Preoperative liver arterial conditioning in patients scheduled for a mayo clinic class IA distal pancreatectomy: Embolization or ligation?

Abstract

Patients who undergo intraoperative ligation of the common hepatic artery in Mayo Clinic class I distal pancreatectomy with en bloc celiac axis resection (DP-CAR) might be exposed to liver ischemia. To avoid serious adverse postoperative outcomes related to arterial reconstruction, preoperative liver arterial conditioning by embolization or ligation is used. Here, we report our experience of preoperative liver conditioning by arterial embolization (AE) or laparoscopic ligation (LL) of the common hepatic artery before Class Ia DP-CAR. From 2014 to 2021, 15 patients were scheduled for a Class Ia DP-CAR after neoadjuvant FOLFIRINOX treatment. Six patients underwent AE, while nine underwent LL. Two procedural complications occurred in the AE group: one patient had an incomplete dissection of the proper hepatic artery, and one patient had distal migration of coils in the right branch of the hepatic artery. None of these complications prevented surgery. The median delay between liver conditioning and DP-CAR was 19 days; this delay decreased to 5 days in the last five patients. Arterial reconstruction was not performed. The severe morbidity and 90-days mortality rates were 26.7% and 13.3%, respectively. No patient developed postoperative liver insufficiency. No differences were noted between the groups in terms of the postoperative course. Preoperative AE and LL were comparable in terms of avoiding arterial reconstruction and postoperative liver insufficiency in patients scheduled for class Ia DP-CAR. However, the possible serious complications that may arise during AE led us to prefer the LL technique.