Resection Of Common Hepatic Artery Research Articles

Embolize, supercharge, resect: Embolization to enhance hepatic vascularization prior to en-bloc pancreas and arterial resection

IntroductionEmbolization could increase the resectability of pancreatic tumors by supercharging visceral arterial perfusion prior to pancreatic surgery with arterial en-bloc resection. Its indications, however, are controversial. MethodsWe retrospectively analyzed the results of a single-center database of patients undergoing pancreatic surgery with arterial resection (AR) after preoperative arterial embolization (PAE) to increase hepatic vascular flow and spare arterial reconstruction. ResultsPAE was planned in 15 patients with arterial involvement due to pancreatic tumors. Three patients were excluded due to the finding of irresectable disease during surgery. Twelve cases were resected because of pancreatic cancer (10), distal cholangiocarcinoma (1), and pancreatic neuroendocrine tumor (1). Arterial involvement in these cases required embolization of the substitute right hepatic artery (RHA) (5), left hepatic artery (1), and common hepatic artery (CHA) (6) to enhance liver vascularization. Two patients presented migration of the vascular plug after PAE. Six pancreatoduodenectomies and 6 distal pancreatectomies were performed, the latter associated with en-bloc celiac trunk and CHA resection. R0 was achieved in 7 out of 12 patients, and pathological vascular involvement was confirmed in 8. Postoperative complications included one patient who developed gastric ischemia and underwent gastrectomy, and one patient who underwent reoperation for acute cholecystitis with liver abscesses. ConclusionPreoperative arterial embolization before pancreatic surgery with hepatic arterial resection enables surgeons to precondition hepatic vascularization and prevent hepatic ischemia. In addition, this avoids having to perform arterial anastomosis in the presence of pancreatic suture.

Surgical Treatment of Pancreatic Cancer: Currently Debated Topics on Vascular Resection.

Vascular resections involving the superior mesenteric and portal veins (SMV-PV), celiac axis (CA), superior mesenteric artery (SMA) and hepatic artery (HA) have multiplied in recent years, raising the resection rate for pancreatic cancer (PDAC) and the related morbidity and mortality rates. While resection is generally accepted for resectable SMV-PV, the usefulness of associated arterial resection in borderline resectable (BRPC) and locally-advanced PDAC (LAPC) is much debated. Careful selection of splenic vein reconstruction is very important to prevent left-sided portal hypertension (LSPH). During distal pancreatectomy (DP), CA and common HA resection is largely accepted, while there is debate on the value of SMA and proper HA resection and reconstruction. Their resection is useless according to several reviews and meta-analyses, and some international societies, although some high-volume centers have reported good results. Short- and long-term reconstructed vessel patency varies with the type of reconstruction, the material used, and the surgeon's experience. Laparoscopic and robotic pancreaticoduodenectomy and DP are generally accepted if done by surgeons performing at least 10 such procedures annually. The usefulness of associated vascular resection remains highly controversial. Surgeons need to complete numerous minimally-invasive procedures to overcome the learning curve, and prevent an increase in complications and surgical mortality. Higher resectability rates and satisfactory long-term results have been reported after neoadjuvant therapy (NAT) for BRPC and LAPC requiring vascular resection. It is essential to select the most appropriate NAT for a given patient and to assess PDAC resectability preoperatively.

Central pancreatectomy with common hepatic artery resection for a giant pancreatic neuroendocrine tumor

Central pancreatectomy with common hepatic artery resection for a giant pancreatic neuroendocrine tumor

Greater Saphenous Vein Graft Revascularization of the Left Hepatic Artery after Resection of Intrahepatic Cholangiocarcinoma with Common Hepatic Artery Resection

Resection of biliary tract malignancies may require resection of the hepatic vasculature. While immediate revascularization of the liver is necessary, reconstruction is difficult when the original vessels are unavailable. We document a case in which a segment of the common hepatic artery was excised during tumor resection and the remaining proximal vessel displayed intima dissection. A greater saphenous vein was placed as a bridge between the remaining left hepatic artery and gastroduodenal artery for successful revascularization.

The findings of the contrast-enhanced CT and risk factors for hepatic infarction after pancreatoduodenectomy.

Hepatic infarction is a relatively rare life-threatening complication after pancreatoduodenectomy (PD). Computed tomography (CT) findings and risk factors for hepatic infarctions after PD were investigated. One hundred-fifty three patients who underwent contrast-enhanced CT (CECT) after PD between January 2011 and August 2016 were retrospectively analyzed. Hepatic infarction was defined as the non-contrast enhanced area expanding to the liver surface without mass effect on CECT. The relationships between infarctions and preoperative laboratory data or surgical procedures using uni- and multivariate analyses were examined. Twenty-nine patients showed 47 hepatic infarctions on CT. Infarctions most commonly appeared in segment 7 (S7) (17 lesions, 36.2%). Lesions were wedge-shaped in 12 patients and spread over multiple hepatic segments in 11 patients. Univariate analysis identified celiac artery (CA) or common hepatic artery (CHA) resection (p = 0.0029) and portal vein (PV) resection (p = 0.013) as risk factors for infarctions. CA or CHA resection (p = 0.038) remained as a significant factor after multivariate logistic analysis. Hepatic infarctions after PD were most frequently seen in S7 and PV penetrating sign was characteristic CT findings. CA or CHA resection or PV resection were revealed as risk factors for hepatic infarctions.

The surgical outcomes of borderline resectable or locally advanced pancreatic cancer.

691 Background: Advances in multidisciplinary treatment for pancreatic cancer (PC) have increased surgical opportunities for initially unresectable locally advanced (UR-LA) or borderline resectable PC. In order to obtain a high rate of R0 resection, it is important to select an appropriate approach according to the infiltration site of the artery that can determine whether curative surgery is possible or not at early phase of the operation. Methods: From April 2012 to December 2018, 81 patients who were scheduled for curative resection for UR-LA or borderline resectable PC that contact the main artery (BR-A). In our institution, if a tumor is in contact with the superior mesenteric artery (SMA), we select the mesenteric approach. And if a tumor is in contact with the common hepatic artery (CHA) and/or celiac artery (CA), we open the lesser omentum and then dissect from the cranial side of pancreas to the diaphragm leg to judge the resectability before dividing the stomach. When arterial plexus infiltration is observed during surgery, we abandoned curative surgery or we performed combined resection of CHA and reconstruction if possible. Results: There were 69 BR-A and 12 UR-LA patients. Macroscopic curative resection was performed in 67 (83%) of 81 patients, and 14 patients were unresectable. Pancreatoduodenectomy was performed in 54 patients, distal pancreatectomy (DP) in 8, and DP with celiac axis resection in 7. There were 67 patients with vascular resection / reconstruction. R0 resection was obtained in 64 of 67 patients among curative resection. The median blood loss, operation time, and length of hospital stay were 714 mL, 439 minutes, and 19 days, respectively. The complications of Clavien-Dindo grade 3a or higher were observed in 18 patients (27%). There were no post-operative deaths. The 3-year survival rate after surgery was 70.3%, and there was no significant difference between BR-A and UR-LA (P = 0.701). The 3-year recurrence-free survival rate after surgery was 34.4%, which was not significantly different between the two groups (P = 0.816). Conclusions: A high R0 resection rate (96%) was obtained by an appropriate approach that can determine the resectability at early stage of operation, and high R0 rate leads to good outcomes.

Anastomoses between major hepatic arteries. How one can use this knowledge in pancreatic and liver surgery? Experience of 9 cases

Background: The resources of anastomoses between major hepatic arteries are underestimated and do not used by HPB surgeons. It is supposed that this is only theoretical knowledge Methods: Analysis of 9 cases of liver survival due to communicating interlobar artery after major pancreatic and gastric resections and hepatic artery embolization, accompanied by dearterialization of one of the liver lobes. Monitoring of liver arterial supply intraoperatively was carried out by US Doppler of liver parenchima, and after surgery - by CT angiography(CTA) and angiography. Results: Distal pancreatectomy with celiac (CA) and gastroduodenal artery resection (Michels IV), total duodenopancreatectomy with CA resection (Michels III), pancreaticoduodenectomy with common hepatic artery resection (Michels IX), total gastrectomy with resection of right hepatic artery originated from the CA (Michels I), total duodenopancreatectomy with resection of the left hepatic and embolization of the right hepatic artery and embolysatioembolization of the right hepatic arteries for multiple gunshot injuries (Michels I) and for huge hepatocellular carcinoma (Michels I) were performed without vascular reconstructions and ischemic sequelae. Postsurgical CTAs have shown that arterial supply is provided through the anastomoses between major hepatic arteries Conclusion: Capability of anastomoses between major hepatic arteries allows to resect the main feeding lobar hepatic artery without reconstruction under intraoperative monitoring by ultrasound Doppler

Anastomoses between major hepatic arteries. How one can use this knowledge in pancreatic and liver surgery? Experience of 9 cases

Background: The resources of anastomoses between major hepatic arteries are underestimated and do not used by HPB surgeons. It is supposed that this is only theoretical knowledge. Methods: Analysis of 9 cases of liver survival due to communicating interlobar artery after major pancreatic and gastric resections and hepatic artery embolization, accompanied by dearterialization of one of the liver lobes. Monitoring of liver arterial supply intraoperatively was carried out by US Doppler of liver parenchima, and after surgery - by CT angiography(CTA) and angiography. Results: Distal pancreatectomy with celiac (CA) and gastroduodenal artery resection (Michels IV), total duodenopancreatectomy with CA resection (Michels III), pancreaticoduodenectomy with common hepatic artery resection (Michels IX), total gastrectomy with resection of right hepatic artery originated from the CA (Michels I), total duodenopancreatectomy with resection of the left hepatic and embolization of the right hepatic artery and embolysatioembolization of the right hepatic arteries for multiple gunshot injuries (Michels I) and for huge hepatocellular carcinoma (Michels I) were performed without vascular reconstructions and ischemic sequelae. Postsurgical CTAs have shown that arterial supply is provided through the anastomoses between major hepatic arteries. Conclusion: Capability of anastomoses between major hepatic arteries allows to resect the main feeding lobar hepatic artery without reconstruction under intraoperative monitoring by ultrasound Doppler.

Clinical efficacy of pancreaticoduodenectomy combined with venous resection via inferior mesenteric vein pathway for resectable pancreatic cancer

Objective To investigate clinical efficacy of pancreaticoduodenectomy combined with venous resection via inferior mesenteric vein (IMV) pathway for resectable pancreatic cancer with superior mesenteric vein (SMV) and / or anterior wall of portal vein (PV) involvements. Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 38 resectable pancreatic cancer patients who underwent pancreaticoduodenectomy with venous resection via IMV pathway in the West China Hospital of Sichuan University between January 2013 and January 2017 were collected. The tumors of 25 patients were BR-PV type (simplex SMV and / or PV involvements), and tumors of 13 patients were BR-A type (SMV, celiac trunk and / or hepatic artery involvements). The pancreaticoduodenectomy via IMV pathway was the same as traditional surgery in organs resection and lymph node dissection, the difference was cutting off the pancreas at a junction between IMV and splenic vein when using IMV pathway. Observation indicators: (1) intraoperative and postoperative situations; (2) results of postoperative pathological examination; (3) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival up to January 2018. Measurement data with skewed distribution were described as M (range). The survival curve was drawn by the Kaplan-Meir method, and Log-rank test was used for survival analysis. Results (1) Intraoperative and postoperative situations: 38 patients underwent intraoperative segmental resection of PV and / or SMV, including 30 with end-to-end anastomosis in situ and 8 with artificial vessel interposition anastomosis. Two of 38 patients were intraoperatively combined with common hepatic artery resection and end-to-end anastomosis in situ. There was no intraoperative celiac trunk resection. The operation time and volume of intraoperative blood loss of 38 patients were respectively 320 minutes (range, 280-520 minutes) and 530 mL (range, 420-650 mL). The incidence of total complications (Clavien-Dindo Ⅲ and above) of 38 patients was 18.4%(7/38), and some patients were combined with multiple complications, including 6 with pulmonary infection, 4 with pancreatic fistula (B and C grade), 4 with intra-abdominal infection, 3 with delayed gastric emptying, 2 with postoperative bleeding and 2 with venous thrombosis. Five patients were cured by postoperative symptomatic treatment, and 2 with postoperative bleeding died of worsened condition after reoperation. The mortality at 90 days postoperatively and duration of hospital stay were respectively 5.3%(2/38) and 12 days (range, 9-52 days). (2) Results of postoperative pathological examination: the R0 resection rate of 38 patients was 81.6%(31/38). The R0 resection rate of 25 patients in BR-PV type was 92.0%(23/25), and resection margin of pancreatic leading edge < 1 mm was in 2 patients without R0 resection; R0 resection rate of 13 patients in BR-A type was 8/13, and resection margin of pancreatic leading edge < 1 mm was in 2 patients and resection margin of SMV < 1 mm was in 4 patients (1 margined with resection margin of multiple sites < 1 mm) of patients without R0 resection. The resection margins of pancreatic trailing edge, venous cut edge and pancreatic cut edge in patients with BR-PV type and BR-A type were more than and equal to 1mm. The venous infiltration rate in patients with BR-PV type and BR-A type was respectively 100.0%(25/25) and 9/13. (3) Follow-up and survival situations: 38 patients were followed up for 6-40 months, with a median time of 15 months, and survival time was 18 months (range, 6-40 months). The survival time and 1-, 2- and 3-year cumulative survival rates were respectively 23 months (range, 8-40 months), 89.5%, 33.1%, 22.1% in 25 patients with BR-PV type and 16 months (range, 6-25 months), 83.9%, 16.8%, 0 in 13 patients with BR-A type. The tumor-free survival time and 1- and 2-year cumulative tumor-free survival rates were respectively 15 months (range, 5-30 months), 63.0%, 7.5% in patients with BR-PV type and 9 months (range, 4-18 months), 11.5%, 0 in patients with BR-A type. Conclusion For resectable pancreatic cancer with SMV and / or anterior wall of PV involvements, pancreaticoduodenectomy combined with venous resection via IMV pathway could avoid injury of SMV and / or PV, and increase negative rates of venous and pancreatic resection margins. Key words: Pancreatic neoplasms; Borderline resectable pancreatic cancer; Resectable pancreatic neoplasms; Pancreaticoduodenectomy; Combined venous resection; Inferior mesenteric vein pathway

Pancreaticoduodenectomy with common hepatic artery and portal vein resection for locally advanced pancreatic cancer

Background: Major arterial involvement used to be considered as a contraindication for resection for locally advanced pancreatic cancer because of its poor long-term outcomes. However, in the era of modern effective chemotherapeutic regimens, the role of arterial resection is to be evaluated. Herein, we illustrate the case of the patients with locally advanced pancreatic cancer with both common hepatic artery (CHA) and portal vein (PV) involved, who underwent successful pancreaticoduodenectomy (PD) with CHA resection and PV resection/reconstruction following preoperative systemic chemotherapy. Methods: The patient was a 74-year-old woman who presented with back pain and elevated CA19.9. The work-up revealed locally advanced pancreatic cancer with CHA involvement. The tumor was deemed unresectable and she received systemic chemotherapy with gemcitabine and nab-paclitaxel with partial response. Given the lack of disease progression, radical resection with major vascular resection/reconstruction was planned. Results: She had a abberant replaced left hepatic artery branching off the left gastric artery and thus CHA was embolized preoperatively to allow collateral arterial flow to the right liver to develop. The radical resections included subtotal stomach preserving PD with CHA resection and PV/splenic vein resection with reconstruction. Splenic venous drainage was reestablished by creating splenorenal shunt. The operative time was 544 minutes and the estimated blood loss was 690 cc. The final pathological stage was pT3N1M0 and all the surgical margins were negative for cancer. Her post-operative course was uneventful. Conclusion: PD with arterial resection for locally advanced pancreatic cancer is technically feasible and the selection criteria for this aggressive operation should be re-defined in the era of modern effective chemotherapy.

膵癌術前の血流改変 （特殊な症例，肝動脈合併膵頭十二指腸切除術前血流改変）

膵癌術前の血流改変 （特殊な症例，肝動脈合併膵頭十二指腸切除術前血流改変）

Advanced gastric cancer with a duplicated hepatic artery: preoperative diagnostic value of multidetector-row computed tomography for surgical resection

A 63-year-old woman with appetite loss and general fatigue underwent gastrointestinal fiberscopy, which revealed type 2 advanced gastric cancer. Multidetector-row computed tomography revealed a massive gastric cancer invading the left hepatic lobe, pancreatic head, and common hepatic artery, as well as revealing a duplicated hepatic artery in which the right hepatic artery branched directly from the celiac axis, and ran behind the splenic vein. On the other hand, the common hepatic artery ran anterior to the splenic vein. We were able to perform pancreaticoduodenectomy with common hepatic artery resection and left lobectomy as curative surgery because her duplicated hepatic artery enabled us to ligate the common hepatic artery. Her postoperative clinical course was uneventful, and she is in good health 3 years after the surgery, without recurrence. We consider that multidetector-row computed tomography is very useful for the diagnosis of vascular anomaly, preoperative staging and decision making on the appropriate surgical strategy.

Clinical evaluation of 21 cases of total pancreatectomy

To evaluate the clinical outcome of 21 cases of total pancreatectomy. The clinical data of 21 cases of total pancreatectomy performed from April 2003 to June 2006 was retrospectively analyzed. Among the 21 patients, 1 case combined with transverse colon resection, 1 case with total gastrectomy, 9 cases with portal-superior mesentery vein resection with end-to-end anastomosis, 9 cases with portal-superior mesentery vein resection and grafts implantation, 8 cases with concomitant celiac axis resection, 4 cases with concomitant celiac axis and common hepatic artery resection, 1 case with concomitant celiac axis, portal vein and superior mesentery artery resection and reconstruction. Complications occurred in 12 cases (57.1%) post the operation and 5 cases (23.8%) died in 30 days after the operation. Insulin was given at the dose of 18 - 28 U daily post operation and blood glucose was maintained normal effectively. Sixteen cases were followed-up and median survival was 9.2 months (1.2 - 13.0 months). The median survival of tubular adenocarcinoma and intraductal papillary mucinous neoplasms of the pancreas (IPMNs) were 7 months (1.2 - 9.0 months) and 11.3 months (10.0 - 13.0 months), respectively. Total pancreatectomy could not improve survival and it increases the complications and death, but it could improve the quality of life. It's an operation of choice for IPMNs, but with pancreatic carcinoma, the warranty of operation should be considered. The blood glucose level could be maintained normal effectively after the operation.

A CASE OF ADVANCED GASTRIC CANCER COMPLICATED WITH POSTOPERATIVE LIVER ABSCESS AFTER THE RESECTION OF COMMON HEPATIC ARTERY

A 32-year-old man was admitted to the hospital because of epigastralgia and back pain. A diagnosis of gastric cancer with para-aortic lymph node metastasis was made. After chemotherapy, an operation was performed. Common hepatic artery was completely involved in metastatic lymph nodes. It was diagnosed as advanced gastric cancer (S0H0P0N2, Stage 4) and total gastrectomy, total pancreatectomy, splenectomy, cholecystectomy, lymph node dissection of R3 and para-aortic lymph nodes and resection of common hepatic artery were performed followed by its reconstruction. On the 23rd postoperative day, he was died of sepsis caused by the rupture of liver abscess.Although the effectiveness of para-aortic lymph node dissection in advanced gastric cancer has been recognized recently, the increasing rate of complication is also considered. In the case of a patient undergoing extended operation with reconstruction of hepatic artery for the gastric cancer, the possibility of liver abscess should be kept in mind, though that condition is rare.