Artery-first Approach Research Articles

Pancreatectomies with vein resection: Two large institutions' experience of East and West.

The effectiveness and preferred reconstruction methods of pancreatectomy associated with vein resection (PAVR) for pancreatic cancer, especially for the extensive portal vein/superior mesenteric vein (PV/SMV) resections (more than 4cm), are still subjects of debate. The aim of this study is to evaluate the safety and feasibility of PAVR by analyzing data from two large institutions from different regions. From 2008 to 2018, we identified consecutive series of patients with pancreatic cancer who underwent PAVR at Karolinska University Hospital (KUH), Sweden, and Cancer Institute Hospital, Japanese Foundation of Cancer Research (JFCR), Japan. Both institutions adopted the artery-first approach to enhance surgical precision. This study compared the short- and long-term outcomes, vein resection types, and reconstruction methods between the two centers. A total of 506 patients who underwent PAVR were identified, 211 patients were from KUH and 295 patients were from JFCR. A higher incidence of total pancreatectomy was identified at KUH (24.6% vs 0.3%). There were no significant differences in intraoperative estimated blood loss (KUH: 630ml, JFCR: 600ml), severe complications rate (8.5%, 5.1%), and mortality (2.4%, 0.7%). Primary end-to-end anastomosis was primarily performed even if the length of PV/SMV resection was 5cm or more and achieved successfully with acceptable patency (No thrombus rate: overall cases, 98.0%; 5cm or more, 93.5%). We report favorable outcomes of PAVR for pancreatic cancer from two high-volume centers in the east and west. Primary end-to-end anastomosis was safe and feasible even if the length of PV/SMV resection was 5cm or more.

Technical Guidelines for Safe Mesojejunum Dissection During Pancreaticoduodenectomy: Unveiling Critical Techniques in a Complex Procedure.

Pancreaticoduodenectomy (PD) is a complex procedure involving the dissection of the superior mesenteric artery and vein. However, a safe and standardized technique for dissecting the jejunal veins (JVs) in the mesojejunum during PD remains elusive. We retrospectively analyzed 198 patients who underwent open PD with mesojejunum dissection using an anterior artery-first approach and evaluated anatomical variations in the first JV trunk (FJVT) and its tributaries. This study introduces the concept of a "dangerous crossover vein" (DCV) to describe tributaries that cross the transection line of the mesojejunum. Surgical techniques and perioperative outcomes were assessed. The FJVT drained the territory supplied by the first to second jejunal arteries in 144 patients (75%) and the first to third or more in 50 patients (25%). The FJVT was preserved in 100 patients (50.5%) and sacrificed in 98 (49.5%). Dangerous crossover veins were encountered in 117 patients (59%) and safely managed with standardized mesojejunal dissection. There were no significant differences in blood loss or operative time between patients with or without DCVs. Understanding the anatomy of JVs and the concept of DCVs is critical for safe mesojejunal dissection during PD. Our approach facilitates secure dissection of JVs regardless of their anatomical variations.

Study of variations in the origin and branching of the human dorsal pancreatic artery

In surgical practice, the human pancreas is conventionally divided into two major anatomical and surgical segments: the right (cephalo-cervical) and the left (corpore-caudal). Both of these segments are abundantly supplied with blood. The artery-first approach is widely used in pancreatic resections to avoid venous stasis and achieve reduced blood loss. The dorsal pancreatic artery participates in the blood supply of both segments with its branches, which makes its anatomical study relevant and promising for clinical medicine. The aim was to describe the main branches of the dorsal pancreatic artery and to determine the frequency of their occurrence in the studied cases. Materials and Methods. The work was performed on archival fixed material (n = 60) of duodenum-pancreas-spleen organ complexes with extra-organ vessels taken from the collection of the Department of Anatomy, RyazSMU. All organ complexes belonged to mature age people without pronounced pathology of the organs of the investigated area. The division by sex was not performed. Results. The dorsal pancreatic artery was identified in all cases studied. Most often (n = 40; 67%) it originated from the branches of the ventral trunk, less often (n = 18; 30%) it was a branch of the superior mesenteric artery and in two cases (3%). Despite the place of origin, its trunk diameter averaged 1.8 mm (min 1.6; max 2.0). The branches of this artery were most often directed towards the gland body (85% of cases), less often - towards the head (15%). Conclusion. The dorsal pancreatic artery is the main artery feeding the body and tail of the human pancreas. In the present study, its branches were more frequently recorded towards the body of the gland, despite the origin of the vessel. Despite the accumulated anatomical and clinical knowledge about the peculiarities of the origin and branching of the human dorsal pancreatic artery, the understanding of the principles of the direction of its branches remains open to researchers.

Intraoperative strategies and techniques to achieve surgical radicality in pancreatic cancer

SummaryThe treatment of pancreatic cancer presents a challenging task in surgical oncology, demanding innovative approaches to achieve radical resection and improve patient outcomes. This article provides an overview of state-of-the-art surgical principles and techniques for achieving surgical radicality in localized pancreatic cancer, with a particular emphasis on artery-first approaches, the triangle operation, arterial and venous dissection techniques, including arterial divestment, and the significance of R0 resections with complete lymphadenectomy. By applying these techniques and principles of surgical radicality, surgeons are able to enhance resectability, minimize complications, and potentially extend patient survival in the rapidly evolving field of multimodal pancreatic cancer management.

Intrapancreatic common hepatic artery in pancreatoduodenectomy: a technical note on how to deal with this exceedingly rare arterial variation.

Arterial variations in the liver's blood supply play a pivotal role in the success of pancreatoduodenectomy (PD), impacting both its technical execution and oncological outcomes. Among these variations, a common hepatic artery arising from the superior mesenteric artery (SMA) occurs in about 3% of cases. An exceptionally rare variation is the intrapancreatic common hepatic artery (IPCHA). Preserving or reconstructing the IPCHA is vital during PD to prevent liver and biliary necrosis. Particularly for cases of pancreatic cancer with high rates of intrapancreatic perineural spread, preserving IPCHA without compromising radicality presents challenges. We present a detailed report of the technique used for PD in the presence of IPCHA. Surgical technique details include a pylorus-preserving PD with the Cattell-Braasch maneuver, an artery-first approach, and meticulous dissection using "cold" scissors. We emphasize the importance of strategic surgical planning based on high-quality imaging studies, underscoring the need for pancreatic surgeons to be proficient in managing variations in visceral vessels. In conclusion, this case underscores the significance of navigating rare arterial variations in liver supply during PD, highlighting the necessity for meticulous surgical planning and execution.

Pancreatoduodenectomy combined with intestinal de-rotation as a complete artery-first approach for inexperienced surgeons

Recent technical advances have reduced the incidence of intraoperative complications associated with pancreatoduodenectomy (PD). We aimed to determine whether inexperienced surgeons (ISs) would be as successful as experienced surgeons (ESs) when performing the complete artery-first approach using the intestinal de-rotation method of PD. Seventy patients who underwent PD using the intestinal de-rotation method in Tokushima University Hospital were enrolled in the present study. Intra- and post-operative parameters were compared between patients operated on by ESs (n=20) or ISs (n=50). The surgical procedure lasted longer in the IS group (ES : 402 }68 min vs. IS : 483 }51 min, p<0.0001), but the volume of blood loss was similar (p=0.7304). There was no mortality in either group, and the incidences of postoperative complications with a Clavien-Dindo grade of>III did not differ between the groups. Grade B postoperative pancreatic fistulae developed in 20.0% of patients in the ES group and 22.0% in the IS group (p=0.9569). Finally, the postoperative hospital stay of the IS group (32 }33 days) was equivarent to that of the ES group (33 }16 days) (p=0.9256). ISs were able to perform similarly successful PDs using the intestinal de-rotation method to ESs. J. Med. Invest. 71 : 75-81, February, 2024.

Investigation of the variation of vessels around the pancreatic head based on the first jejunal vein anatomy at pancreaticoduodenectomy.

Pancreaticoduodenectomy (PD) for pancreatic cancer carries a high risk of massive intraoperative blood loss. The artery first approach (AFA) prevents blood loss during PD, but the optimal approach is unclear. The first jejunal vein (FJV) often comprises multiple veins and broadly supports venous drainage of the proximal jejunum. Its ligation carries a risk of proximal jejunum congestion. Here we investigated the anatomical characteristics of PD-associated vessels and AFA approach selection based on FJV anatomy. This study included 148 Japanese living donors for liver transplantation. We reviewed their computed tomography images and assessed the anatomical pattern of PD-associated vessels in terms of FJV anatomy. The FJV traveled posterior to the superior mesenteric artery in 128 patients (86.5%, dorsal group) and anterior in 20 (13.5%, ventral group). The predominant draining vein of the inferior pancreaticoduodenal vein was the superior mesenteric vein in the ventral group (87.5%) and the FJV in the dorsal group (97.9%). Compared with the dorsal group, the ventral group had a significantly greater percentage with the superior mesenteric vein ventral to the superior mesenteric artery (30.0% versus 10.9%) and a significantly larger posterior superior pancreaticoduodenal vein diameter (3.2 ± 0.9 versus 2.7 ± 0.6mm, p = 0.0029). These results were validated in patients with pancreatic head cancer. The anatomical characteristics of PD-associated vessels differed significantly between groups defined by FJV anatomy. Understanding the venous anatomy, especially the FJV, could support selection of the best approach in AFA for PD.

Contemporary artery-first approaches in pancreatoduodenectomy.

Contemporary artery-first approaches in pancreatoduodenectomy.

Impact of artery-first approach PD on survival

Impact of artery-first approach PD on survival

Modified artery-first approach for distal pancreatectomy with celiac axis resection

The superior mesenteric artery-first approach has been proved superior in pancreatoduodenectomy compared with the standard procedure. It is unclear whether similar benefits could be obtained in distal pancreatectomy with celiac axis resection. Perioperative and survival outcomes of patients who underwent distal pancreatectomy with celiac axis resection with the modified artery-first approach or traditional approach between January 2012 and September 2021 were compared. The entire cohort comprised 106 patients (modified artery-first approach, n = 35; traditional approach, n = 71). The most common complication was postoperative pancreatic fistula (n = 18, 17.0 per cent), followed by ischaemic complications (n = 17, 16.0 per cent) and surgical site infection (n = 15, 14.0 per cent). Intraoperative blood loss (400 versus 600 ml, P = 0.017) and intraoperative transfusion rate (8.6 versus 29.6 per cent, P = 0.015) were lower in the modified artery-first approach group compared with the traditional approach group. A higher number of harvested lymph nodes (18 versus 13, P = 0.030) and R0 resection rate (88.6 versus 70.4 per cent, P = 0.038) and a lower incidence of ischaemic complications (5.7 versus 21.1 per cent, P = 0.042) was observed in the modified artery-first approach group compared with the traditional approach group. In multivariable analysis, the modified artery-first approach (OR 0.006, 95 per cent c.i., 0 to 0.447; P = 0.020) was protective against ischaemic complications. Compared with the traditional approach, the modified artery-first approach was associated with lower blood loss and fewer ischaemic complications, and a higher number of harvested lymph nodes and R0 resection rate. Thus, it might improve the safety, staging and prognosis of distal pancreatectomy with celiac axis resection for pancreatic cancer.

An Innovation in the Technique of Recipient Hepatectomy in Living Donor Liver Transplantation.

Recipient hepatectomy is a challenging surgical procedure. Coagulopathy, multiple collaterals, and dense adhesions secondary to previous spontaneous bacterial peritonitis in cirrhotics are the major contributing factors. However, the appropriate recipient hepatectomy technique can limit the massive blood loss and minimize the operative time. The hepatoduodenal dissection has a key role in recipient hepatectomy. The hilar structures of partial graft in live donor liver transplantation (LDLT) usually have a short length and a small caliber. The concerning task in LDLT recipient hepatectomy is to preserve the integrity, quality, and adequacy of hilar structures for successful implantation. The high hilar dissection technique is usually practiced for getting the adequate length of hilar structures. However, the problems with high hilar dissection inducted the authors to tailor the technique over time. In this report, a modified technique of recipient hepatectomy characterised by the artery-first approach is described. This technique is good in terms of preventing arterial dissection and minimising the anhepatic phase. Key Words: Recipient hepatectomy, Hepatoduodenal dissection, Liver transplantation, Technique.

Segmental resection with partial mesopancreatic and mesojejunal excision (pMME) for duodenal carcinoma of the third or fourth portion.

Pancreatoduodenectomy is the standard procedure for duodenal carcinoma of the third or fourth portion. As an alternative option, we developed a novel segmental resection (SR) with partial mesopancreatic and mesojejunal excision (pMME) that enhances radicality. In this report, the surgical technique with video and outcomes are described. We performed SR with pMME on seven consecutive patients with third or fourth duodenal carcinoma between 2009 and 2021. We divided the procedure into four sections, including (1) wide Kocher's maneuver, (2) supracolic anterior artery-first approach, (3) dissection of the mesopancreas and mesojejunum, and (4) devascularization of the uncinate process and dissection of duodenum. Median operative time was 348min (range, 222-391min), and median blood loss was 100mL (range, 30-580mL). Major complications of Clavien-Dindo classification grade 3a or more occurred in one patient. All patients achieved R0 resections with 10mm or more proximal margin. Six cases (85%) were alive without recurrence. We developed a radical and safe procedure of SR with pMME as an alternative and less invasive approach for duodenal carcinoma of the third or fourth portion.

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy with Anterocranial Splenic Artery-First Approach for Left-Sided Resectable Pancreatic Cancer (with Videos)

Laparoscopic radical antegrade modular pancreatosplenectomy (Lap-RAMPS) for left-sided pancreatic cancer remains a technically challenging procedure. How to approach the splenic artery in laparoscopic surgery has not been discussed in adequate detail, and the implications of an artery-first approach in left-sided pancreatic cancer remain unclear. Forty-five consecutive patients with left-sided resectable pancreatic cancer underwent Lap-RAMPS between July 2018 and September 2020. They were divided according to whether Lap-RAMPS was performed using an anterocranial splenic artery-first (ASF) approach (ASF group, n = 23) or via another approach (non-ASF group, n = 22). Clinical, pathological, and short-term outcomes were reviewed and compared between the groups. The ASF approach was performed safely in all patients with resectable left-sided pancreatic cancer, and none required conversion to laparotomy. The ASF group had better outcomes in terms of conspicuous bleeding from the spleen during splenic mobilization (P = 0.016) and blood pooling during posterior dissection (P = 0.035). Consequently, blood loss was significantly less and operation time was significantly shorter in the ASF group than in the non-ASF group. There was no significant between-group difference in other short-term outcomes, including mortality, length of hospital stay, or Clavien-Dindo classification. The ASF approach was safe when performed for resectable left-sided pancreatic cancer and may help to prevent congestion of the pancreas and lessen intraoperative blood loss.

Pancreatico-Duodenectomy for Pancreatic Ductal Adenocarcinoma: from Artery-First Approaches toTRIANGLE Operation.

Pancreatico-duodenectomy (PD) is the single hope for long-term survival in a patient with pancreatic head ductal adenocarcinoma (PDAC). Unfortunately, even after curative intent PD, the long-term survival of patients with PDAC remains under expectations, with high recurrence rates, including the loco-regional ones. Positive resection margins after resection of PDAC are frequent, and they have a detrimental effect on both recurrence and long-term survival rates, particularly the R1 (direct) ones, toward the mesopancreas. In the last years, there were made increased efforts by surgeons to introduce in clinical practice several technical refinements to the standard technique of PD better to resect the tumor, including an accurate lymph node dissection, hoping to increase the rate of negative resection margins, to decrease local recurrence rates and to improve prognosis. Furthermore, to extend the number of patients with resectable disease, a few surgical techniques were also intended to convert to resectability the patients with the regional disease (i.e., anatomical borderline resectable and locally advanced PDAC) in the context of multimodal therapies, particularly neoadjuvant therapies. With this, we briefly discuss a few technical refinements addressing the resection time of PD, like the artery-first approaches and the Triangle operation. Both surgical techniques aim for better clearance of the retroperitoneal space for nerves, lymphatic nodes, and vessels, including total mesopancreas excision.

Abstract 14290: Implementation of a Comprehensive STEMI Protocol Improves Key Process Metrics for Transfer STEMI Patients

Introduction: Despite improvements in STEMI door-to-balloon time (D2BT), the majority of patients who present to US hospitals without PCI capability do not achieve the national goal D2BT of ≤ 120 minutes for transfer STEMI patients. We sought to determine the impact of a comprehensive STEMI protocol (CSP) on key process and outcome metrics in transfer STEMI patients. Methods: The CSP is a 4-step STEMI protocol aimed at minimizing STEMI care variability. The protocol streamlines STEMI care by (1) allowing catheterization lab activation by emergency physicians without cardiology consultation, (2) standardizing early administration of guideline-directed medical therapy (GDMT), (3) ensuring immediate transfer to a PCI-capable facility, and (4) implementing a radial artery-first approach (RAFA). We evaluated outcomes in 499 STEMI patients transferred to our hospital from January 1, 2011 to July 14, 2014 prior to implementation of CSP (control group) and 775 patients presenting from July 15, 2014 to July 15, 2019, after implementation of the CSP. Results: Compared to the control group, after implementation of CSP there was a significant increase in the number of STEMI patients transferred to our hospital who received GDMT (84.6% vs 93.9%, p&lt;0.001). There was a significant increase in the use of RAFA (19.0% vs 77.7%, p&lt;0.001). The median D2BT decreased from 114 minutes prior (IQR 94.0-146.0min, p&lt;0.001) to 97 minutes (IQR 82.0-115.0min) after CSP implementation, with substantially more patients reaching the target D2BT of 120 minutes (55.7% vs 80.1%, p&lt;0.001). There was a trend towards lower in-hospital mortality after CSP implementation (4.4% vs 2.8%, p=0.180) though the results were not powered to show statistical significance. Conclusion: The CSP significantly improved STEMI care key process metrics (GDMT, RAFA, and D2BT) with a trend to lower mortality for patients presenting with STEMI to outside facilities who are transferred to a CCF PCI-capable hospital.

Pancreaticoduodenectomy at a Non-high-volume Center and Efforts to Perform Safe Surgery.

The aim of the current study was to investigate whether the artery-first approach (AFA) improved surgical outcomes of pancreaticoduodenectomy (PD) at our non-high-volume center. We retrospectively reviewed data on 121 consecutive patients who underwent PD between January 2009 and December 2018. The perioperative data of 49 patients who underwent conventional PD (conventional group) and 72 patients who underwent PD via artery-first approach were analyzed and compared to assess the effectiveness of the AFA. Although no significant difference was observed between the two groups overall, in those with pancreatic cancer, the duration of surgery, intraoperative blood loss and transfusion rate in the AFA group (n=33) were significantly lower than those for the conventional group (n=11) (p=0.011, p=0.021 and p=0.038 respectively). AFA can be used to reduce the operative time, intraoperative blood loss, and transfusion rate in patients with pancreatic cancer.

"Mesopancreas-first" radical resection of pancreatic head cancer following the Cattell-Braasch-Valdoni maneuver: Appreciating the legacy of pioneers in visceral surgery.

The “artery-first” approach pancreaticoduodenectomy, with maximal mesopancreas excision and central vascular ligation, represents the current principal determinants of radicality in pancreatic head cancer resection. However, these modifications at the resection stage of pancreaticoduodenectomy constitute extremely demanding and technically complicated procedures. Among the most critical contributing factors in the difficulty of artery-first approaches is the spiral configuration of the mesoduodenum and proximal mesojejunum around the superior mesenteric artery axis. This creates complicated tridimensional anatomy, making surgical dissection in the inferior peripancreatic anatomic area extremely challenging and demanding. The Cattell–Braasch–Valdoni maneuver (right-sided medial visceral mobilization and intestinal derotation maneuver) restores the embryological twist of the duodenojejunal junction, which demystifies the distorted peripancreatic vascular anatomy and facilitates a safe and radical “mesopancreas-first” pancreatic head cancer resection. The aim of this paper was to present the advantages, efficacy, and safety of the Cattell–Braasch–Valdoni maneuver in artery-first approach radical pancreaticoduodenectomy and provide a detailed description of its surgical technique.

Robotic Artery-First Approach During Pancreatoduodenectomy.

Surgical resection with adjuvant or neoadjuvant chemotherapy is the only curative modality for treatment of patients with pancreatic and periampullary tumors. With the increasing use of minimally invasive techniques, laparoscopic and robotic pancreatoduodenectomy (PD) has become more common, but laparoscopic artery-first techniques have been described in few studies. The aim of this study is to describe our robotic artery-first technique. Video clips were compiled from several robotic PDs to demonstrate the artery-first technique. This technique consists of early retroperitoneal dissection of the superior mesenteric artery from the pancreatic head. Overall, 73 patients underwent robotic PD at our center between March 2018 and August 2020. Of these, 24 patients underwent the robotic artery-first approach. Indication for its use included proximity of the tumor to the portal vein or SMV in six cases. In three cases, partial resection of the portomesenteric axis was necessary, and the artery-first approach allowed for safe venous resection and reconstruction. In three other cases, the tumor was in close contact with the vein, but it could be resected with free margins without venous resection. In the remaining 18 patients, the approach was systematically used regardless of tumor proximity to the portomesenteric axis. This robotic artery-first approach is feasible and safe for PD. The approach could facilitate robotic PD, and its systematical use could provide some important advantages during the resection phase. The videos could also help oncological surgeons to perform this complex yet important maneuver.

The standardized technique in robotic radical antegrade modular pancreatosplenectomy using the flip-up approach.

Radical antegrade modular pancreatosplenectomy (RAMPS) was first introduced in 2003. It has been accepted as an alternative technique for pancreatic cancer of the body and tail. However, robotic RAMPS is not yet popular because of its technical difficulty and lack of standardized technique. This study describes in detail the standard steps of robotic RAMPS using the flip-up approach with the benefit of a robotic view when treating pancreatic cancer of the body and tail. We took advantage of our single-center experience to provide a step-by-step technique of robotic RAMPS procedure using the da Vinci Si system. We divided the procedure into 11 key steps. The surgical steps are optimized to achieve margin-negative curative resection and sufficient regional lymphadenectomy. The artery-first approach is usually used to determine tumor resectability early before performing an irreversible operative step. We also determine the borders of surgical resection and divide the splenic artery after dividing the pancreatic neck and the splenic vein, which facilitates a complete lymphadenectomy around the celiac axis with a bottom-up view. Robotic RAMPS using the flip-up approach is safe and feasible in performing curative resection for well-selected pancreatic cancer of the body and tail. A randomized controlled trial comparing open and robotic RAMPS is needed in the future.

Impact of artery-first pancreaticoduodenectomy including whole lymphadenectomy around superior mesenteric artery but preserving whole nerve plexus for resectable T3 ductal adenocarcinoma of the pancreatic head

Introduction: Artery-first pancreatoduodenectomy (AF-PD) has a positive impact on short- and long-term outcome as compared to the conventional PD (C-PD). However, appropriate AF-PD may be still unclear when focusing on extent of lymphadenectomy, or that of nerve plexus dissection around the superior mesenteric artery (SMA). Methods: We investigated recurrence and survival in 88 patients with pancreatic ductal adenocarcinoma of the head (PDAC-H) who underwent PD. Forty-five patients underwent AF-PD with the lymphadenectomy around the SMA but without nerve plexus dissection around SMA (AF-PD group), and forty-three patients underwent PD without artery-first approach, i.e., without left side lymphadenectomy at the SMA (C-PD group). Results: The median amounts of blood loss were significantly lower in the AF-PD group than in the C-PD group (P=0.0210). The numbers of totally dissected lymph nodes were significantly greater in the AF-PD group than in the C-PD group (P=0.0165). The incidence of recurrence rate of the lymph node (LN) around SMA (No. 14 LN) was significantly lower in the AF-PD group (20%) than in the C-PD group (39.5%, p=0.045). The median survival after PD was significantly higher in the AF-PD group (40.3 months) than in the C-PD group (22.6 months, p=0.014). Conclusions: The present data showed that PD based on artery-first approach and lymphadenectomy whole around SMA but preserving whole nerve plexus in patients with T3 PDAC-H may prevent LN recurrence around the SMA and may result in longer survival.