Artery Resection Research Articles

Borderline or locally advanced pancreatic adenocarcinoma: A single center experience on the FOLFIRINOX induction regimen

IntroductionThis study aimed to determine the impact of FOLFIRINOX neoadjuvant therapy on patients with non-metastatic borderline/locally advanced (BL/LA) pancreatic ductal adenocarcinoma (PDAC), in current practice. Material and methodsFrom 2010 to 2017, 258 patients with BL/LA PDAC from a single high-volume institution received FOLFIRINOX neoadjuvant treatment. ResultsThe 258 patients received a median number of 6 cycles of FOLFIRINOX (range, 3–16); 98 (38%) patients underwent curative surgery, and 160 (62%) continued medical treatment. A venous resection was performed in 57 patients (58%), and an arterial resection in 12 (12%). The postoperative 30- and 90-day mortality rates were 6.1% and 8.2%, respectively. Adjuvant chemotherapy was performed in 57 patients (59%). The median overall survival (OS) in patients who did (n = 98) or did not (n = 160) undergo surgical resection were 39 months and 19 months, respectively (P < 0.001). In resected patients, the ASA 3 score (P < 0.01), venous resection (P < 0.01), hemorrhage (P < 0.01), and R1 margin status (P = 0.03) were found to negatively influence the OS. The median OS was significantly higher in patients who did not require a venous resection (not reached vs. 26.5 months, P < 0.001). ConclusionsNeoadjuvant FOLFIRINOX provided a survival benefit in BL/LA PDAC patients, particularly in those who did not ultimately require venous resection.

Resection or repair of large peripancreatic arteries during robotic pancreatectomy.

Minimally invasive pancreatic surgery is eventually gaining momentum, but concerns remain regarding the ability to manage challenging operative scenarios. A retrospective review of a prospectively maintained database was performed to identify patients who received arterial resection, or required arterial repair, during robot-assisted pancreatic resection (RA-PR). All procedures were video recorded. Between October 2008 and June 2019, a total of 361 RA-PR were performed. Associated vascular procedures were required in 31 patients (8.5%), including resection or repair of arterial segments in five cases (1.3%): celiac trunk (n = 1), hepatic artery (n = 2), splenic artery (n = 1), and superior mesenteric artery (n = 1). In three patients, an arterial resection was required to manage tumor infiltration. In the remaining two patients, an intraoperative injury demanded arterial repair. All procedures were completed without conversion to open surgery and no patient developed severe complications. At the longest follow-up, all vascular reconstructions are patent. Our results do not call for more liberal use of robotic assistance in borderline resectable or locally advanced pancreatic tumors, but rather emphasize the importance of proper preoperative planning and the need for advanced vascular skills for safe implementation of RA-PR.

Management of upper extremity aneurysms: a systematic review.

The aim of this paper is to provide recommendations for diagnosis and management of arterial or venous aneurysms of the upper extremity. A systematic review of the Medline and Cockrane databases was performed from 1988 to 2019 by a combined strategy of MeSh terms. One-hundred-forty-four publications were identified: 111 addressing arterial aneurysms and 33 addressing venous aneurysms. A total of 162 cases of arterial aneurysms, mostly brachial aneurysms (34.0% of cases) and 40 cases of venous aneurysms, mostly located in the forearm (60.0% of cases) were reported. For both types of aneurysms, most common presentation was the perception of a mass (56.3% for arterial one and 87.5% for venous one), but thromboembolic complication (46.7%), paresthesia (16.5%) or rupture (6.4%) could be observed in the setting of arterial aneurysms, while arm swelling (27.5%), neurological symptoms (12.5%), pulmonary embolism (10.0%) or rupture (2.5%) could occur in the setting of venous aneurysms. DUS was performed as first imaging modality for both settings, followed but CTA and MRA, especially in arterial aneurysms, to evaluate distal emboli and surrounding vasculature. Surgical treatment was mostly based on excision of the aneurysms with revascularization for arterial aneurysms (77.2%) and resection without reconstruction for the venous one (85.0%). Complications occurred in 10.5% of the cases of arterial aneurysms, none occurred after venous aneurysm resection. Prompt diagnosis and appropriate preoperative imaging are mandatory in order to offer the best treatment modality. Open resection with revascularization seems to be the treatment of choice for arterial aneurysms, although endovascular procedures became more popular. Venous aneurysms require excision without revascularization.

Vascular Resection for Pancreatic Cancer: 2019 French Recommendations Based on a Literature Review From 2008 to 6-2019

Introduction: Vascular resection remains a subject of debate in the management of Pancreatic Ductal Adenocarcinoma (PDAC). These French recommendations were drafted on behalf of the French National Institute of Cancer (INCA-2019).Material and Methods: A systematic literature search, with PubMed, Medline® (OvidSP), EMBASE, the Cochrane Library, was performed for abstracts published in English from January 2008 to June 2019, and identified systematic reviews/metaanalyses, retrospective analyses and case series dedicated to vascular resections in the setting of PDAC. All selected articles were graded for level of evidence and strength of recommendation was given according to the GRADE system.Results: Neoadjuvant treatment should be performed rather than direct surgery in borderline and locally advanced non-metastatic PDAC with venous and/or arterial infiltration (T4 stage). Patients who respond or those with stable disease and good performance status should undergo surgical exploration to assess resectability because cross-sectional imaging often fails to identify the extent of the remaining viable tumor. Combining vascular resection with pancreatectomy in these cases increases the feasibility of curative resection which is still the only option to improve long-term survival. Venous resection (VR) is recommended if resection is possible in the presence of limited lateral or circumferential involvement but without venous occlusion and in the absence of arterial contact with the celiac axis (CA; cephalic tumors) or the superior mesenteric artery (SMA; all tumor locations) (Grade B). The patients should be in good general condition because mortality and morbidity are higher than following pancreatectomy without VR (Grade B). In case of planned VR, neoadjuvant treatment is recommended since it improves both rate of R0 resections and survival compared to upfront surgery (Grade B). Due to their complexity and specificities, arterial resection (AR; mainly the hepatic artery (HA) or the CA) must be discussed in selected patients, in multidisciplinary team meetings in tertiary referral centers, according to the tumor location and the type of arterial extension. In case of invasion of a short segment of the common HA, resection with arterial reconstruction may be proposed after neoadjuvant therapy. In case of SMA invasion, neoadjuvant therapy may be followed by laparotomy with dissection and biopsy of peri-arterial tissues. A pancreaticoduodenectomy (PD) with SMA-resection is not recommended if the frozen section examination is positive (Grade C). In case of distal PDAC with invasion of the CA, a distal pancreatectomy with CA-resection without arterial reconstruction may be proposed after neoadjuvant therapy and radiologic embolization of the CA branches (expert opinion).Conclusion: For PDAC with vascular involvement, neoadjuvant treatment followed by pancreatectomy with venous resection or even arterial resection can be proposed as a curative option in selected patients with selected vascular involvement.

Risk model for severe postoperative complications after total pancreatectomy based on a nationwide clinical database.

Total pancreatectomy is required to completely clear tumours that are locally advanced or located in the centre of the pancreas. However, reports describing clinical outcomes after total pancreatectomy are rare. The aim of this retrospective observational study was to assess clinical outcomes following total pancreatectomy using a nationwide registry and to create a risk model for severe postoperative complications. Patients who underwent total pancreatectomy from 2013 to 2017, and who were recorded in the Japan Society of Gastroenterological Surgery and Japanese Society of Hepato-Biliary-Pancreatic Surgery database, were included. Severe complications at 30 days were defined as those with a Clavien-Dindo grade III needing reoperation, or grade IV-V. Occurrence of severe complications was modelled using data from patients treated from 2013 to 2016, and the accuracy of the model tested among patients from 2017 using c-statistics and a calibration plot. A total of 2167 patients undergoing total pancreatectomy were included. Postoperative 30-day and in-hospital mortality rates were 1·0 per cent (22 of 2167 patients) and 2·7 per cent (58 of 167) respectively, and severe complications developed in 6·0 per cent (131 of 2167). Factors showing a strong positive association with outcome in this risk model were the ASA performance status grade and combined arterial resection. In the test cohort, the c-statistic of the model was 0·70 (95 per cent c.i. 0·59 to 0·81). The risk model may be used to predict severe complications after total pancreatectomy.

Vascular Resections for Pancreatic Ductal Adenocarcinoma: Vascular Resections for PDAC.

It has become clear that vein resection and reconstruction for pancreatic ductal adenocarcinoma (PDAC) is the standard of care as supported by multiple guidelines. However, resection of large peri-pancreatic arteries remains debatable. This review examines the current state of vascular resection with curative intent for PDAC in the last 5 years. Herein, we consider venous (superior mesenteric vein, portal vein), as well as arterial (superior mesenteric artery, celiac trunk, hepatic artery) resection or both with or without reconstruction. Improvement of multidrug chemotherapy has revolutionized care for PDAC that should shift traditional surgical thinking from an anatomical classification of resectability to a prognostic and biological classification. The present review gives an overview on the results of pancreatectomy associated with vascular resection, with consideration of new perspectives offered by the availability of better systemic therapies.

The surgeon's contribution to long term survival for peri-hilar cholangiocarcinoma

Background: Surgery for peri-hilar cholangiocarcinoma (PCC) is still demanding and long-term prognosis is still dismal. We sought to investigate the factors related to long term survival. Methods: Data regarding PCC patients who underwent surgical resection with radical intent from January 1990 to December 2017 were analysed from a prospectively maintained database. Clinicopathological characteristics were investigated to identify long-term survival predictors. Patients were staged according to the AJCC/UICC 8th ed. TNM staging system. Results: Among 162 patients submitted to surgical exploration, 123 who underwent radical intent surgery were included in this study. In this group of patients, 102 (82.9%) underwent major liver resections, portal vein resection was conducted in 17.1%, arterial resection in 4.1%, median number of lymph nodes retrieved was 8 [IQR 5-13]. Negative margin resection (R0) was achieved in 69,9% of cases and positive lymph nodes were observed in 45.5% of cases. Overall 3- and 5-year survival (OS) was 54.2% and 26.7% respectively, while 3- and 5-year disease free survival (DFS) were 32.5% and 22.1%, respectively. Multivariable Cox analysis for OS identified that pN stage 8th ed. (HR 1.62; P = 0.006), positive resection margins (HR 1.72; P = 0.027), portal vein resection (HR 1.95; P = 0.016) and number of lymph nodes retrieved ≥ 4 (HR 0.5; P = 0.027) are associated with OS. Interestingly, 5 years OS for R0 and pN0 patients was 40.3% compared to 24.4% for R1 and pN1-2 patients (P = 0.037). Conclusion: The surgeon’s contribution to long term survival in the treatment of PCC is still of great importance by means of oncological radicality and adequate lymph node dissection, which should be the current goal of treatment.

Pancreaticoduodenectomy in octogenarians: A UK multicentre case-control study

Presenter: Joseph Attard MD, MSc, MRCSEd | Queen Elizabeth Hospital Background: As a result of the ageing population, pancreaticoduodenectomy is increasingly being offered as curative therapy for periampullary tumours in patients 80 years of age and older. Our aim was to evaluate clinical outcomes and provide evidence on current UK practice in the elderly population after pancreaticoduodenectomy. Methods: A multicentre retrospective case-control analysis of prospectively-maintained databases was performed. This included pancreaticoduodenectomies undertaken between January 2008 and December 2017. Octogenarians who underwent pancreaticoduodenectomy were matched with consecutively-operated younger patients with 1:1 ratio, based on extent of surgery (venous, arterial or additional resection). Pre-operative comorbidities, intra-operative variables, post-operative complications and mortality were compared. Chi-Square, Fisher’s Exact and Mann-Whitney U tests were used as appropriate to compare variables and outcomes between the two groups, with statistical significance set at p<0.05. A survival analysis, using Kaplan-Meier estimators, was also performed to determine overall survival as well as disease-free survival. Results: Six UK specialist HPB centres participated in this study. 181 octogenarians (median age 81 years, range: 80 - 90) who underwent pancreaticoduodenectomy (either classical or pylorus-preserving) were compared to the same number of controls (median age 67 years, range: 31 - 79). Gender and ASA (octogenarians median grade 2 [range: 1 - 4] versus median grade 2 [range: 1 - 3] for controls) were comparable (p=0.75 and p=0.82 respectively). The distribution of performance status scores (octogenarian median score 0 [range: 0 - 3] versus median score 0 [range: 0 - 2] for non-octogenarians) was found to be significantly different (p=0.02). Similarly, Charlson Comorbidity Index scores were significantly higher overall for octogenarians (median 7 [range: 6 - 11] versus 5 [range: 2 -9], p=0.001). Ninety-nine percent of octogenarians and 97% of controls were offered upfront resection. The remainder underwent neoadjuvant treatment prior to surgery. Median length of hospital stay was longer in octogenarians, 17 days (range: 3 – 120 days) compared to 13 days (range: 5 – 81 days) for controls (p=0.001). Negative resection margin (R0) rates were comparable for the two groups, 61% for octogenarians and 58% for controls (p=0.57), as were lymph node ratios, median 0.1 (range: 0 – 0.8) for octogenarians and 0.095 (range: 0 – 1) for controls, p=0.77. Complication rates across the Clavien-Dindo classification categories were not statistically significant (p>0.05 in all categories). Thirty-day mortality was 3 % for octogenarians and 2% for controls (p=0.54). Ninety-day mortality was 7% for octogenarians versus 3% for controls. This difference was not statistically significant (p=0.1). A survival analysis revealed that, while median overall survival was significantly longer for controls, 59 months versus 23 months for octogenarians, (p=0.006); disease-free survival was not statistically different between both groups, with a median of 19 months for octogenarians and 28 months for controls (p=0.22). Median follow-up was 13 months (range: 0 – 100) for octogenarians and 17 months (0 – 111) for controls. Conclusion: Despite the higher ninety-day mortality, pancreaticoduodenectomy outcomes in octogenarians are comparable to their younger counterparts. Pancreaticoduodenectomy should therefore be offered as a curative surgical option in this cohort, in specialised centres after meticulous preoperative assessment.

Surgical treatment of perihilar cholangiocarcinoma with vascular invasion

Introduction: Vascular invasion is a main cause irresectability of perihilar cholangiocarcinoma. However innovative surgical technologies allow resecting involved portal vein with acceptable mortality. Invasion of the hepatic artery, often combined with invasion of portal vein, still remains the most serious obstacle in resection of this disease. Aim: The aim of our study was to asses Results of surgical treatment of perihilar cholangiocarcinoma with portal vein and hepatic artery invasion. Materials and Methods: We studied Results of surgical treatment 141 patients with Klatskin tumor period 2002-2018. T2a TNM stage had 3% patients, T2b – 8,4% patients, T3 – 71,8% patients, and T4 stage TNM had 16,8% patients. Bismuth type B2 had 4,6% patients, B3a – 37,4% patients, B3b – 46,6% patients, B4 – 11,4% patients. For patients with small remnant liver volume, less than 40 %, we did preoperative PV embolization of a resected part of the liver. RPV embolization we did in 71% right hemyhepatectomy, RPVE with Sg4 embolization – for 31,8% right trisectionectomy, LPVE and RAPVE for 25% left trisectionectomy. PV resection was made 61 (46,6%) patients, combined PV and HA resection and reconstruction we did for 8 cases, liver transplantation – 2 cases. In all cases we made extended lymphadenectomy. Mortality was 11,5% (15 patients). 1-, 3- and 5-years survival was higher in group with portal vein resection 86,8%, 58% and 50% respectively, for patients without portal vein resection– 85,6%, 56% and 42%. Conclusion: Aggressive surgical treatment for cholangiocarcinoma the confluence of bile duct with hepatic artery and portal vein resection can be performed safely with acceptable lethality and long-term survival rate.

Vascular resection in minimally invasive vs open pancreaticoduodenectomy

Presenter: Roheena Panni MD, MPHS | Washington University, St. Louis Background: Pancreaticoduodenectomy is associated with high morbidity and the complexity of the procedure increases with vascular resection. Vascular resection during pancreaticoduodenectomy is associated with increased operative time, perioperative transfusion, DVT, septic shock, and length of stay, but the overall mortality is similar. With the advancement in minimally invasive surgical techniques, laparoscopic and robotic pancreatic surgery is becoming more common. A growing body of evidence exists demonstrating the equivalence or benefit of minimally invasive pancreaticoduodenectomy (MIPD) when compared to open pancreaticoduodenectomy (OPD) regarding the short term outcomes and safety. The purpose of this study is to determine the postoperative outcomes of patients undergoing vascular resection with OPD or MIPD approach using a large, multicenter cohort. Methods: All patients undergoing elective pancreaticoduodenectomy, including OPD and MIPD (robotic and laparoscopic, including open-assisted and unplanned open conversion), with vascular resection in the ACS NSQIP database were included in the study. Patients were stratified into those who underwent OPD vascular resection and those who underwent MIPD vascular resection. Patient covariates and outcomes were compared using standard statistical methods. Results: 2233 patients underwent OPD with vascular resection (17.8%) and 149 patients underwent MIPD with vascular resection (13.8%). The frequency of artery, vein, and combined artery and vein resection was (10.3%, 69.9%, and 19.6%) in OPD and (16.1%, 62.4%, and 21.47%) in MIPD, respectively. Patients undergoing MIPD vascular resection were more likely to have BMI < 25 (34.2% vs 42.5%, p-value 0.0143). The mean OR time was significantly longer in patients undergoing MIPD and vascular resection compared to OPD and vascular resection (485.4 ± 13.30 vs. 427 ± 152.90, p-value < 0.0001). We next compared postoperative complications and found that patients undergoing OPD vascular resection were more likely to have postoperative sepsis compared to MIPD vascular resection (10.17% vs. 4.70%, p-value= 0.0299). There was a trend towards a decrease in superficial surgical site infection, organ space infection and length of stay and an increase in 30-day readmission in the MIPD vascular resection group; however, these differences were not statistically significant. On multivariate analysis, postoperative sepsis was independently associated with OPD (p-value= 0.0446). Conclusion: MIPD with vascular resection is safe and feasible. Future studies are needed to determine the effect of MIPD with vascular resection on long term outcomes and survival.

Perihilar cholangiocarcinoma with and without portal vein and hepatic artery resection: Comparative analysis of early and late outcomes

Background: Surgical resection is the only radical of curative-intent therapy for patients with perihilar cholangiocarcinoma (PHC). In this study, we compared the early and long-term outcomes in Moscow Clinical Scientific Center(MCSC) after resection for PHC with and without portal and hepatic artery resection. Patients and Methods: From December 2013 to December 2018 in MCSC was performed 100 radical hepatic resections for PHC. Since January 2015 (82 patients) the more aggressive approaches (en bloc liver resection, portal vein resection(PVR) and hepatic artery resection(HAR)) was indroduced if necessary for a complete removal of the tumor. The data of 30 patients with vascular resection (group A) were compared with those of 62 patients with a curative-intent surgery for PHC without vascular resection (group B). Perioperative morbidity, mortality, R0 rate and overall survival rate were compared between the groups. Results: 19 patients (23,1%) underwent PVR alone and 11 patients (13,4%) underwent HAR either with (n = 5) or without PVR (n = 6). R0 rate was 90 % in the group A and 87,7% in the group B (p>0.05). III-IV complications by Clavien-Dindo classification were significantly different between groups (66,7% for group A versus 45% for group B; (p<0,05). No differences between the groups were observed regarding the postoperative mortality rates(13,3% in the group A and 12,9% in the group B). The 3-year overall survival rate was 30% in the group A and 40% in the group B (p>0,05). Conclusion: No significant differences were seen in mortality and late outcomes by involving en bloc liver combined with vascular resection. An aggressive approach provides high R0 rates that increase resectability of PHC.

Immediate results of surgical treatment of advanced age patients with non-small cell lung cancer

To study the immediate results of surgical treatment of advanced age patients with non-small cell lung cancer (NSCLC). We included 190 elderly and senile patients with NSCLC who underwent surgery at the thoracic department of the Tomsk Regional Clinical Hospital in 2010-2018. There were 149 men and 41 women. Cancer stage I was observed in 67 (35%) cases, stage II - 49 (26%) patients, stage III - 69 (37%) patients, stage IV - 5 (2%) patients. Squamous cell cancer was diagnosed in 94 patients, adenocarcinoma - 78 patients, large cell lung cancer - 18 patients. Paraneoplastic inflammatory complications occurred in 26% of patients, concomitant diseases - in 99% of patients. The research included anatomic lung resection with systematic mediastinal lymph node dissection and the absence of tumor at the resection line. There were 118 lobectomies and 47 pneumonectomies. In 74 cases, combined procedures were carried out. Lobectomy with pulmonary artery resection was performed in 18 patients, lobectomy with bronchial resection - in 10 cases. Twenty-five patients underwent video-assisted lobectomy. An acceptable morbidity and mortality allow you to expand the indications for radical surgery in geriatric patients with NSCLC. However, we must establish strict indications for pneumonectomy. Bronchial and angioplastic lobectomy may be an alternative to pneumonectomy in NSCLC patients.

Evaluation of the Blood Flow in the Remnant Pancreas Using ICG Fluorescence Imaging during Pancreaticoduodenectomy with Splenic Artery Resection and without Pancreatico-jejunostomy for Pancreatic Cancer—Report of a Case—

Evaluation of the Blood Flow in the Remnant Pancreas Using ICG Fluorescence Imaging during Pancreaticoduodenectomy with Splenic Artery Resection and without Pancreatico-jejunostomy for Pancreatic Cancer—Report of a Case—

Implications of Arterial Variations in Pancreatoduodenectomy for Cancer

Pancreatoduodenectomy for cancer is a complex surgical procedure with significant morbidity and mortality. Technical aspects of this procedure typically comprise dissection of celiac trunk, the common and the proper hepatic arteries. The presence of hepatic arterial anomalies is not uncommon and influences surgical technique. An aberrant right hepatic artery (replaced or accessory) or a common hepatic artery originating from the superior mesenteric artery are present in nearly 13% of cases and usually run in contact with the posterior aspect of the head of the pancreas. These anomalous arteries are at risk of iatrogenic injury and tumor involvement. Iatrogenic vascular lesions can lead to bleeding and/or ischemic complications, such as anastomotic stenosis, hepatic abscess and liver failure. Also, vascular tumor involvement might require arterial resection and reconstruction. The presence of arterial variations should not affect the radicalness of pancreatic resection as the involvement of aberrant arteries does not seem to affect postoperative outcomes or overall survival. These vascular variations should be, preferably, recognized pre-operatively in order to define possible surgical strategies. Preoperative contrast enhanced computed tomography provides accurate arterial anatomy evaluation. Lastly, aberrant hepatic arteries require proper dissection and/or occasionally resection and reconstruction during pancreatoduodenectomy to achieve a safe resection with proper radicalness. Knowledge of arterial variations is crucial for pancreatic cancer surgery.

Neurological Complications Following Resection and Synthetic Interposition of the Carotid Arteries on the Occasion of Infiltrating Advanced Tumor of the Neck

Introduction - Tumors of the head and neck represent 6-10% of all malignancies. Carotids are engaged by the tumor process in 5-10%. The goal of oncological surgery is to achieve a full tumor resection (R- 0). When the carotid artery is infiltrated by the tumor process the therapeutic options are resection followed by ligation, peeling the tumor of the adventitia or resection with reconstruction of the carotids.

Laparoscopic surgery for colorectal cancer with persistent descending mesocolon

BackgroundPersistent descending mesocolon (PDM) is caused by the absence of fusion of the descending colon to the retroperitoneum. We herein report two colorectal cancer cases with PDM that were treated with laparoscopic surgery.Case presentationCase 1: a 50-year-old man with sigmoid colon cancer and synchronous liver metastasis. After neoadjuvant chemotherapy, he underwent laparoscopic sigmoidectomy with lymph node dissection cutting the root of the inferior mesenteric artery (IMA) and synchronous liver resection. He experienced postoperative stenosis of the reconstructed colon possibly due to an impaired arterial blood flow in the reconstructed colon.Case 2: a 77-year-old man with rectal cancer. Laparoscopic low anterior resection preserving the left colic artery (LCA) was performed. Intraoperative infrared ray (IR) imaging using indocyanine green (ICG) showed good blood flow of the reconstructed colon. He had no postoperative complications. In cases of PDM, the mesentery of the descending and sigmoid colon containing the LCA is often shortened, and the marginal artery of the reconstructed colon is located close to the root of the LCA. Lymph node dissection accompanied by cutting the LCA carries a risk of marginal artery injury. Therefore, we recommend lymph node dissection preserving the LCA in colorectal cancer patients with PDM in order to maintain the blood flow of the reconstructed colon. If the IMA and LCA absolutely need to be cut for complete lymph node dissection, the marginal artery should be clearly identified and preserved. In addition, intraoperative IR imaging is extremely useful for evaluating colonic perfusion and reducing the risk of anastomotic complications.ConclusionIn colorectal cancer surgery in patients with PDM, surgeons should be aware of these tips for maintaining the blood flow of the reconstructed colon and thereby avoid postoperative complications caused by an impaired blood flow.

Quantitative Analysis of Near-Infrared Indocyanine Green Videoangiography for Predicting Functional Outcomes After Spinal Intramedullary Ependymoma Resection.

One of the most critical steps in surgery for spinal intramedullary ependymomas is the resection of small feeding arteries from the anterior spinal artery with anatomical preservation of the normal circulation of the ventral spinal cord. To quantitatively analyze the microcirculation of the ventral spinal cord by near-infrared indocyanine green videoangiography (ICG-VA) after the spinal intramedullary ependymoma resection. This retrospective study included 12 patients (7 male and 5 female; average age 55.2 years, range 36-79 years). Patients' neurological conditions were assessed based on the modified McCormick functional schema of grade 1 (neurologically normal) to 5 (severe deficit). Postoperative functional assessment was conducted at least 3 months after surgery. Quantitative analysis of vascular flow dynamics was carried out following spinal intramedullary ependymoma resection. Fluorescence intensities were measured and the indocyanine green (ICG) intensity-time curves were analyzed and compared with the functional outcomes after surgery. Microscopically total or subtotal resection of the intramedullary ependymoma was achieved in all cases. Average peak time on ICG-VA was significantly shorter in the postoperative functional grade 1 to 2 group than in the postoperative functional grade 3 to 5 group, but there was no significant difference in average peak intensity between the 2 groups. Postoperative functional grade and the peak time of ICG, but not peak intensity, appeared correlated. To the best of our knowledge, this is the first report showing that quantitative analysis of ICG-VA may predict functional outcomes after spinal intramedullary ependymoma resection.

TRIANGLE operation for borderline resectable pancreatic cancer in total pancreatectomy

Background: Pancreatic cancer is a highly aggressive cancer featured by early metastasis and multiple chemoresistance. Surgical resection remains the only way for the radical cure of pancreatic cancer. The aim of this study was to assess the safety, feasibility and oncological effect of the Heidelberg TRIANGLE operation in total pancreatectomy (TP) for borderline resectable pancreatic cancer (BRPC). Methods: Patients with BRPC eligible for TP were selected and underwent total pancreatectomy with Heidelberg TRIANGLE operation. Sharp dissection was applied to separate tumor and involved artery. Then we completely dissected the soft tissues surround celiac axis (CA) and superior mesenteric artery (SMA) in each case. If superior mesenteric vein (SMV) or portal vein (PV) were invaded by the tumor, resection and reconstruction of veins were performed. Operation time, blood loss, post-operative complications, perioperative mortality, number of lymph node examined and R0 resection rate were collected and analyzed. Results: Nine BRPC patients underwent TRIANGLE operation in TP. No perioperative death occurred. 3 cases developed postoperative complications: biliary leakage and colon fistula in 1 case and lymphatic leakage in 2 cases. The R0 resection rate of operation was 88.89% (8/9). Conclusions: For patients with BRPC, upfront surgery should be encouraged when they were unwilling or unable to received neoadjuvant therapy. Especially for those patients with artery involvement eligible for TP, TRIANGLE operation can help to achieve arterial sparing resection. Thus, the risk of postoperative hemorrhage for vascular reconstruction and skeletonization can be reduced. After postoperative adjuvant therapy, the prognosis is acceptable.

Advances of the combined superior mesenteric artery resection and reconstruction in surgical treatment of pancreatic head cancer in the era of neoadjuvant chemotherapy

胰腺癌侵犯肠系膜上动脉后，直接手术难以获得R0切除，而同时联合动脉切除与重建的并发症发生率和死亡率均较高，因此该术式一直是胰腺外科的禁区。随着对胰腺癌生物学行为认识的提高和新辅助化学治疗的发展，胰腺癌诊疗模式逐步走向多学科综合治疗，外科技术的进步也提高了联合动脉切除与重建手术的安全性。胰腺癌侵犯肠系膜上动脉不再是手术绝对禁忌证。通过新辅助化学治疗使部分侵犯肠系膜上动脉的胰腺癌降期，再联合动脉切除与重建，有望改善部分患者的手术切除率与预后。

Arterial resection and reconstruction in pancreatectomy: surgical technique and outcomes

BackgroundThe outcomes in patients with pancreatic or ampulla tumors remain unsatisfactory, especially with invasion into the hepatic artery (HA) or the superior mesenteric artery (SMA). In this setting, pancreatectomy combined with arterial resection and reconstruction may offer the possibility of an en-block resection with negative margins and acceptable morbidity and mortality.MethodsA six year retrospective review of pancreatectomies performed at our institution, included 21 patients that underwent a pancreatectomy combined with arterial resection and reconstruction. Arterial reconstruction was performed under an operating microscope. The types of arterial reconstruction included direct anastomosis, arterial transposition, and arterial bypass with a vascular graft.ResultsThe surgical procedures consisted of 19 pancreaticoduodenectomies and 2 total pancreatectomies. The tumors were located at the pancreatic head (n = 10), whole pancreas (n = 2), distal common bile duct (n = 5), ampulla (n = 2) and retroperitoneum with pancreatic head involvement (n = 2). All operations achieved R0 resection successfully, with no intraoperative complication. Eighteen patients recovered without complications while three patients died from intra-abdominal hemorrhage due to a pancreatic fistula, though notably the bleeding was not at the arterial anastomosis site. All reconstructed arteries showed adequate patency at follow-up. The median postoperative survival was 11.6 months in all the 11 patients with pancreatic adenocarcinoma.ConclusionPancreatectomy combined with arterial resection and reconstruction is a feasible treatment option. The microsurgical technique is critically important to achieving a successful and patent arterial anastomosis.