Complex Vascular Reconstruction Research Articles

Challenges in Pediatric Liver Retransplantation: A Technical Perspective.

Liver retransplantation (reLT) is the only option for pediatric patients experiencing graft loss. Despite recent advancements in surgical techniques and perioperative management, it remains a high-risk procedure. Our aim is to describe our experience in pediatric reLT, focusing on the technical aspects and surgical challenges. We systematically analyzed surgical reports from pediatric reLT performed at our center between 2006 and 2023 to identify recurrent intraoperative findings and specific surgical techniques. We focused on challenges encountered during different phases of reLT, including hepatectomy, vascular, and biliary reconstruction. Additionally, we compared patient and graft survival rates among different groups. During the study period, 23 children underwent 25 reLT procedures at our center. Major surgical challenges included complex hepatectomy and vascular reconstructions, necessitating tailored approaches. Our analysis shows that patient and graft survival were significantly lower for reLT compared to primary transplantation (p = 0.002). Early reLT had a significantly lower graft survival compared to late reLT (p = 0.002), although patient survival was comparable (p = 0.278). Patient and graft survival rates were comparable between the first and second reLT (p = 0.300, p = 0.597). Patient survival tended to be higher after living-donor liver transplantation (LDLT) compared to deceased-donor liver transplantation (DDLT), although the difference was not statistically significant (p = 0.511). Pediatric reLT involves significant technical challenges and lower survival rates. Advances in perioperative management are crucial for improving outcomes. Further research is needed to optimize surgical strategies and evaluate the long-term benefits of LDLT in pediatric reLT.

Anatomical and Biological Considerations to Determine Resectability in Pancreatic Cancer

Pancreatic ductal adenocarcinoma (PDAC) remains associated with poor outcomes with a 5-year survival of 12% across all stages of the disease. These poor outcomes are driven by a delay in diagnosis and an early propensity for systemic dissemination of the disease. Recently, aggressive surgical approaches involving complex vascular resections and reconstructions have become more common, thus allowing more locally advanced tumors to be resected. Unfortunately, however, even after the completion of surgery and systemic therapy, approximately 40% of patients experience early recurrence of disease. To determine resectability, many institutions utilize anatomical staging systems based on the presence and extent of vascular involvement of major abdominal vessels around the pancreas. However, these classification systems are based on anatomical considerations only and do not factor in the burden of systemic disease. By integrating the biological criteria, we possibly could avoid futile resections often associated with significant morbidity. Especially patients with anatomically resectable disease who have a heavy burden of radiologically undetected systemic disease most likely do not derive a survival benefit from resection. On the contrary, we could offer complex resections to those who have locally advanced or oligometastatic disease but have favorable systemic biology and are most likely to benefit from resection. This review summarizes the current literature on defining anatomical and biological resectability in patients with pancreatic cancer.

Abstract 15979: En Bloc Heart-Lung Transplantation and Vascular Reconstruction With Native Tissue in a Patient With Situs Inversus Totalis

Case: A 62-year-old male with primary ciliary dyskinesia, bronchiectasis, dextrocardia, ccTGA, VSD, ASD, and severe ventricular dysfunction was listed for HLTx. Suitable organs became available from a 21-year-old male donor after brain death. The right sided aorta, persistent left superior vena cava (LSVC), RIJ, and LCFV were cannulated for CPB. The bloc was procured in the typical fashion along with the donor’s pericardium and intact innominate vein. During the recipient cardiectomy, the LSVC was transected proximally, and right atrial (RA) tissue preserved in continuity with the left inferior vena cava (LIVC). To achieve situs solitus positioning of the mediastinum, a pericardial sling was created by plicating the right pericardium to the diaphragmatic pericardium, and the left pericardium was augmented with excess donor pericardial tissue to create a neo-pericardium in the left chest. The recipient’s RA tissue was used to extend the LIVC by forming a cavoatrial conduit and anastomosed to the donor RA, which required a slightly counterclockwise rotation of the cardiac axis and facilitated positioning the left phrenic nerve posterior to the apex. The tracheal and aortic anastomoses were performed in the typical fashion. The donor innominate vein was of sufficient caliber and length to complete the anastomosis to the recipient LSVC and the donor RIJ was ligated. Discussion: HLTx remains the only definitive therapy for patients with combined end-stage cardiopulmonary disease. The leading indication for HLTx is congenital heart disease. Accordingly, centers performing HLTx must be experienced in complex vascular reconstructions and concomitant procedures to address a broad spectrum of anatomical variants. With thoughtful pre-operative planning, close communication with the procurement team, and surgical experience, these procedures may be performed without the use of synthetic materials that predispose to infectious and thromboembolic complications.

Vascular Reconstruction and Limb Loss in Military Tibial Artery Injuries

Selective operative management of injuries to the tibial arteries is controversial, with the necessity of revascularization in the face of multiple tibial arteries debated. Tibial artery injuries are frequently encountered in military trauma, but revascularization practices and outcomes are poorly defined. We aimed to investigate associations between the number of injured vessels and reconstruction and limb loss rates in military casualties with tibial arterial trauma. A US military database of lower extremity vascular injuries from Iraq and Afghanistan (2004-2012) was queried for limbs sustaining at least 1 tibial artery injury. Injury, intervention characteristics, and limb outcomes were analyzed by the number of tibial arteries injured (1, T1; 2, T2; 3, T3). Two hundred twenty one limbs were included (194 T1, 22 T2, 5 T3). The proportions with concomitant venous, orthopedic, nerve, or proximal arterial injuries were similar between groups. Arterial reconstruction (versus ligation) was performed in 29% of T1, 63% of T2, and universally in T3 limbs (P<0.001). Arterial reconstruction was via vein graft (versus localized repair) in 62% of T1, 54% of T2, and 80% of T3 (P=0.59). T3 received greater blood transfusion volume (P=0.02), and fasciotomy was used universally (versus 34% T1 and 14% T2, P=0.05). Amputation rates were 23% for T1, 26% for T2, and 60% for T3 (P=0.16), and amputation was not significantly predicted by arterial ligation in T1 (P=0.08) or T2 (P=0.34) limbs. Limb infection was more common in T3 (80%) than in T1 (25%) or T2 (32%, P=0.02), but other limb complication rates were similar. In this series of military lower extremity injuries, an increasing number of tibial arteries injured was associated with the increasing use of arterial reconstruction. Limbs with all 3 tibial arteries injured had high rates of complex vascular reconstruction and eventual amputation. Limb loss was not predicted by arterial ligation in 1-vessel and 2-vessel injuries, suggesting that selective reconstruction in these cases is advisable.

Extended Right Hepatectomy to Inferior Vena Cava Under Total Vascular Exclusion, Veno-Venous Bypass and In Situ Hypothermic Perfusion of the Future Liver Remnant.

Venous obstruction at the hepatic veins-inferior vena cava confluence can be particularly challenging to manage if an associated liver resection is needed. Total vascular exclusion (TVE) with veno-venous bypass (VVB) and hypothermic in situ perfusion (HP) of the future liver remnant can be used in these conditions.1,2 METHODS: The patient was a 58-year-old with a voluminous adrenal cancer invading the kidney, the right liver and the retrohepatic inferior vena cava with intraluminal thrombus extending up to the hepatic veins confluence. A right hepatectomy, extended to segment 1, the right kidney, and the retrohepatic inferior vena cava was planned. The parenchymal liver transection was performed under a TVE, VVB, and HP of the left liver to decrease blood losses and risk of postoperative liver failure. Vena cava reconstruction was achieved by a ringed Gore-Tex prosthesis with reimplantation of the left renal vein. Total duration of veno-venous bypass and liver vascular exclusion were 2 h 40 min and 2 h 10 min, respectively. The patient was discharged on postoperative day 17. Total vascular exclusion with veno-venous bypass and in-situ liver hypothermic perfusion increases the safety of major liver resection requiring complex vascular reconstruction.1,2 TVE under VVB and HP of the future liver remnant is used at our institution when: (1) TVE will last more than 30 min; (2) vascular reconstruction is needed; (3) in the presence of venous obstruction; (4) in the presence of injured liver parenchyma; and (5) in the presence of cardiovascular comorbidities.

Vascular Reconstruction and Limb Loss in Military Tibial Artery Injuries

Selective operative management of injuries to the tibial arteries is controversial, with the necessity of revascularization in the face of multiple tibial arteries debated. Tibial artery injuries are frequently encountered in military trauma, but revascularization practices and outcomes are poorly defined. We aimed to investigate associations between the number of injured vessels and reconstruction and limb loss rates in military casualties with tibial arterial trauma. A US military database of lower extremity vascular injuries from Iraq and Afghanistan (2004-2012) was queried for limbs sustaining at least one tibial artery injury. Injury and intervention characteristics and limb outcomes were analyzed by the number of tibial arteries injured (one, T1; two, T2; three, T3). We included 221 limbs (194 T1, 22 T2, 5 T3). The proportions with concomitant venous, orthopedic, nerve, or proximal arterial injuries were similar between groups. Arterial reconstruction (vs ligation) was performed in 29% of T1, 63% of T2, and universally in T3 limbs (P < .001) (Figure). Arterial reconstruction was via vein graft (vs localized repair) in 62% of T1, 54% of T2, and 80% of T3 (P = .59). T3 received greater blood transfusion volume (P = .02) and fasciotomy was used universally (vs 34% T1 and 14% T2; P = .05). Amputation rates were 23% for T1, 26% for T2, and 60% for T3 (P = .16), and amputation was not significantly predicted by arterial ligation in T1 (P = .08) or T2 (P = .34) limbs. Infection was more common in T3 (80%) than T1 (25%) or T2 (32%, P = .02), but other limb complication rates were similar. In this series of military lower extremity injuries, an increasing number of tibial arteries injured was associated with increasing use of arterial reconstruction. Limbs with all three tibial arteries injured had high rates of complex vascular reconstruction and eventual amputation. Limb loss was not predicted by arterial ligation in one- and two-vessel injuries, suggesting that selective reconstruction in these cases is advisable.

Abstract 13000: The Effect of Flow Dynamics on the Neotissue Formation of 3D Printed Tissue Engineered Vascular Graft

Introduction: Complex vascular reconstruction such as that of the right ventricle to pulmonary artery (RVPA) and the aortic arch remains challenging due to the various 3D geometry of each patient. Tissue-engineered vascular grafts (TEVG) possess not only excellent antithrombotic and anti-infective properties but also the ability to grow as the patient matures. 3D printed patient-specific TEVG can maintain optimal hemodynamics with the growth of the patient and may improve surgical outcomes. We applied our unique 3D printing technology to create patient-specific TEVG for RVPA and the aortic arch. Methods: We acquired MRI and 4-dimensional flow data for the native anatomy of pigs (n=8) to design a patient-specific TEVG of the pulmonary artery (n=5) and the aortic arch (n=3) 4 weeks prior to surgery. The optimal shape of the branched vascular graft (n=8) was designed using a computer-aided design informed by computational flow dynamics analysis. We manufactured and implanted the grafts into the RVPA or aortic arch in the porcine model. The grafts were explanted after surgery at 8 - 12 weeks for evaluation. Pre- and post-op implant flow dynamics data in MRI and histology were analyzed. Results: The local neointimal thickness of TEVG in histology and the corresponding area of wall shear stress in 4D MRI were measured. Low wall shear stress, an aspect of MRI flow analysis, demonstrated a significant correlation with decreased neointimal thickness through histology (R2=0.65, P=0.016), which suggested optimal shape and design is important for appropriate neotissue formation. Conclusions: Our 3D printed custom designed TEVG demonstrated optimal anatomical fit maintaining ideal flow dynamics can attenuate neointimal hyperplasia and appropriate neovessel formation.

Surgical management strategy for leiomyosarcoma of Zone I-II inferior vena cava: A case series.

Objectives:Leiomyosarcoma of inferior vena cava (IVC) is a rare clinical entity with severe vascular involvement. Surgical management of leiomyosarcoma is still challenging.Methods:This a retrospective study of consecutive patients referred to our hospital from January 2017 to June 2019. Depending on the anatomical site of affected IVC, leiomyosarcomas were categorized into zone I-II. The clinical data including baseline information, surgical parameters, peri-operative management, short- and mid-term outcomes were observed.Results:Four patients with leiomyosarcoma of zone I-III underwent radical resection without intraoperative mortality. Prosthetic grafts were interpositioned in all patients to instruct vena cava. Renal vein reconstruction was perfumed in two patients due to involvement to renal veins. Median blood loss was 450 mL (200–600 mL), median operative time was 215 minutes (150–240 minutes). No Clavien-Dindo IIIa or higher complication was observed. No organ dysfunction and recurrence were observed with median follow-up of 25.5 months.Conclusions:Curative resection of zone I-II leiomyosarcoma is associated with longer survival in selected cases, en-bloc resection with complex vascular reconstruction could be considered.

Pancreaticoduodenectomy with Complex Vascular Reconstruction Is Safe and Oncologically Justified

Introduction: The aim of this study was to analyze the experience in two transplant centers of patients undergoing pancreaticoduodenectomy (PD) with or without vascular reconstruction. Method: We retrospectively reviewed prospectively collected data of all consecutive patients undergoing pancreaticoduodenectomy (PD) for cancer, between 1/1/2013 and 1/31/2018. The overall cohort (n=197) was divided into those with vascular reconstruction (Group1, n=38) and without vascular reconstruction (Group2, n=159). Results: The two groups were similar in terms of age, sex distribution, and pre-operative ASA score. One post-operative portal vein thrombosis was seen in each group (NS). Peri-operative mortality occurred in one patient in Group 2 due to post-op bleeding. Hospital length of stay (8d vs 7d, p=0.14), ICU length of stay (2d vs 1d, p=0.47), and blood loss (350cc vs 300cc) were similar in both groups. The length of surgery was longer in Group 1 (438 minutes vs 341, p<0.0001). Both groups had similar rates of Clavien grade 3 or higher morbidity (15.8% in Group1 and 15.7% in Group2, p=0.83). R0 resection rate was lower in Group 1 (73.7% vs 92.5%, p=0.001). However, the local recurrence rates did not differ between the two groups - 17 (44.7%) in Group 1 and 71 in Group 2 (44.7%, p=0.992). Kaplan-Meier analysis showed no difference in overall and disease-free survival, and also when limiting the pathology to only pancreatic ductal adenocarcinoma. Conclusions: Our experience shows that complex vascular reconstruction in PD can be achieved safely when done by experienced teams, and with comparable cancer outcomes in selected patients.

Gallbladder carcinoma and extrahepatic cholangiocarcinoma

Gallbladder carcinoma and extrahepatic cholangiocarcinoma Abstract. In this article, we focus on three entities of malignant biliary tumors: gallbladder carcinoma, distal and perihilar cholangiocarcinoma. Those are rare malignant tumors which require an extensive interdisciplinary expertise in the treatment of hepato-pancreato-biliary conditions in order to provide an appropriate diagnostic work-up, correctly assess resectability and come up with a clear-cut multimodal treatment plan. Perihilar cholangiocarcinoma (Klatskin-tumour) usually requires the most complex evaluation of resectability, which involves not only the assessment of vascular in- and outflow and an adequate biliary drainage, but also aims to ensure that enough functional liver tissue is left after resection. To this end, preoperative portal vein embolization may be used to increase the size the future liver remnant. In highly selected, unresectable cases of perihilar cholangiocarinoma, or if a primary sclerosing cholangitis is present, neoadjuvant chemoradiotherapy followed by liver transplantation can be evaluated as a curative option. Distal cholangiocarcinomas usually are treated by a partial pancreaticoduodenectomy (Whipple operation). The surgical treatment of gallbladder cancer ranges from simple cholecystectomy to major liver resection with complex biliary and vascular reconstruction, dependent on tumour stage. The surgical treatment is usually followed by an adjuvant regimen of Capecitabine which can significantly improve survival, while a combination Cisplatin and Gemcitabine is used in the palliative setting.

Early Outcomes of Complex Vascular Reconstructions in Lower Extremities Using Spiral and Panel Vein Grafts

Spiral saphenous vein grafts (SSVG) or paneled vein grafts (PVG) can be used when the diameter of the autologous great saphenous vein does not match the vessel that needs to be repaired. This study aimed to present early results of complex vascular reconstruction with SSVGs and PVGs in the lower extremities. From May 2019 through January 2021, 6 SSVGs and 3 PVGs were used for vascular reconstruction in 9 patients. Patient data were collected retrospectively, including age, gender, cause of vascular pathology, target vessels, concomitant injury, surgical method, additional surgical methods, and hemodynamic status. The Kaplan-Meier method was used to calculate the rate of freedom from reintervention. Among these patients, 7 had trauma, 1 had graft infection, and 1 had vascular reconstruction after tumor excision. The mean duration of follow-up was 6 ± 6.6 months (range 1-19 months). The rate of freedom from reintervention for any reason was 77.8% at 1 year. Two patients underwent amputation after vascular reconstruction with patent vascular reconstructions. One of the 2 amputations was performed because of infection, and the other was due to ischemia >24 hr. The success rate of reconstruction was 100%, and the primary patency rate was 100%. The rate of limb salvage was 77.8%. There was no death, bleeding, embolism, skin ulcers, graft-related complication, or aneurysmal dilation during follow-up. SSVG and PVG were associated with low infection rates and satisfactory short-term patency rates. Both 2 grafts may be good choices when there is a diameter mismatch in vascular reconstructions.

Vascular Resection for Intrahepatic Cholangiocarcinoma: Current Considerations.

Intrahepatic cholangiocarcinoma (iCCA) accounts for approximately 10% of all primary liver cancers. Surgery is the only potentially curative treatment, even in cases of macrovascular invasion. Since resection offers the only curative chance, even extended liver resection combined with complex vascular or biliary reconstruction of the surrounding organs seems justified to achieve complete tumour removal. In selected cases, the major vascular resection is the only change to try getting the cure. The best results are achieved by the referral centre with a wide experience in complex liver surgery, such as ALPPS procedure, IVC resection, and ante-situ and ex-situ resections. However, despite aggressive surgery, tumour recurrence occurs frequently and long-term oncological results are very poor. This suggests that significant progress in prognosis cannot be expected by surgery alone. Instead, multimodal treatment including neoadjuvant chemotherapy, radiotherapy, and subsequent adjuvant treatment for iCCA seem to be necessary to improve results.

Liver Resection for Intrahepatic Cholangiocarcinoma-Single-Center Experience with 286 Patients Undergoing Surgical Exploration over a Thirteen Year Period.

Background: Intrahepatic cholangiocarcinoma (iCCA) accounts for about 10% of primary liver cancer. Surgery is the only potentially curative treatment. We report on our current series of 229 consecutive hepatic resections for iCCA, which is one of the largest Western single-center series published so far. Methods: Between January 2008 to December 2020, a total of 286 patients underwent 307 surgical explorations for intended liver resection of iCCA at our department. Data were analyzed with regard to (1) preoperative treatment of tumor, (2) operative details, (3) perioperative morbidity and mortality, (4) histopathology, (5) outcome measured by tumor recurrence, treatment of recurrence and survival and (6) prognostic factors for overall and disease-free survival. Results: the resectability rate was 74.6% (229/307). In total, 202 primary liver resections, 21 repeated, 5 re-repeated, and 1 re-re-repeated liver resections were performed. In primary liver resections there were 77% (155/202) major hepatectomies. In 39/202 (20%) of patients additional hepatic wedge resections and in 87/202 (43%) patients additional 119 other surgical procedures were performed next to hepatectomy. Surgical radicality in first liver resections was 166 R0-, 33 R1- and 1 R2-resection. Following the first liver resection, the calculated 1-, 3- and 5-year-survival is 80%, 39%, and 22% with a median survival of 25.8 months. Until the completion of data acquisition, tumors recurred in 123/202 (60.9%) patients after a median of 7.5 months (range 1–87.2 months) after resection. A multivariate cox regression revealed tumor size (p < 0.001), T stage (p < 0.001) and N stage (p = 0.003) as independent predictors for overall survival. N stage (p = 0.040), preoperative therapy (p = 0.005), T stage (p = 0.004), tumor size (p = 0.002) and M stage (p = 0.001) were independent predictors for recurrence-free survival. Conclusions: For complete surgical removal, often extended liver resection in combination with complex vascular or biliary reconstruction is required. However, despite aggressive surgery, tumor recurrence is frequent and long-term oncological results are poor. This indicated that surgery alone is unlikely to make great strides in improving prognosis of patients with iCCA, instead clearly suggesting that liver resection should be incorporated in multimodal treatment concepts.

3D preoperative assessment for locally advanced pancreatic cancer undergoing modified-Appleby procedure with reversed autologous arterial graft reconstruction: A case report

Advanced pancreatic ductal adenocarcinoma represents one of the most challenging oncologic diseases nowadays for many reasons: it is burdened by one of the poorest prognoses, it is often diagnosed when in an advanced stage and it demands a multimodal approach which is necessary to assign the proper patient-specific treatment. When feasible, surgical resection combined with systemic treatment is still the best curative choice and can require complex vascular resections and reconstructions to obtain R0 margins. In these cases, a detailed preoperative assessment made of blood tests, thoracoabdominal imaging and histological definition of the tumor is fundamental. Unfortunately, the current imaging techniques are not completely reliable in defining the extension of the contact between the neoplasm and the surrounding arteries and veins, especially when considering borderline and locally advanced diseases. The use of 3D reconstructions can improve the perception of crucial anatomical details for the diagnostic evaluation and the surgical procedure.

Complex Vascular Reconstruction following Resection of a Large Retroperitoneal Teratoma

Germ cell tumors (GCTs) are a common malignancy in males, with variations in differentiation making different therapeutic strategies necessary. Generally, GCTs show good curation rates due to their good response to radiotherapy or chemotherapy. However, certain subtypes are resistant to these therapies and require surgery. We present a case of a 25-year-old patient with a large retroperitoneal GCT with somatic malignant transformation, where resection of large abdominal blood vessels with complex reconstruction was necessary to completely remove the tumor. The tumor was completely resected, and the patient has since been recurrence-free in the follow-up period. GCTs with somatic transformation show high resistance rates to chemo- and radiotherapy, and the patient in the presented case study did indeed show only a limited response to carboplatin-based chemotherapy. Patients suffering from these conditions should be resected whenever possible, as curation can be achieved by complete tumor resection. Infiltration of neighboring structures is no contraindication to surgery. The case presented here shows that interdisciplinary surgical planning including vascular and general surgeons as well as radiologists is vital to ensure successful tumor resection.

Late Re-transplantation of the Liver in Adulthood Following Successful Paediatric Transplantation'

Introduction: The survival outcomes of paediatric liver transplantation (LT) have improved from 30% in the 1970's to over 90% in the current era. Therefore a huge number of paediatric LT recipients are reaching adulthood. Non-compliance, chronic rejection and vascular related complications are common reasons for late allograft failure after a successful paediatric LT. Methods: In this case series we specifically reviewed the outcomes of 11 patients who underwent a successful paediatric LT and underwent re-transplantation as an adult, due to primary graft failure at Queen Elizabeth Hospital Birmingham, UK. Results: The mean age at the time of primary LT was 7.3 (+6.2) years and the most common indication was biliary atresia (36.4%). Chronic rejection was the most common reason for primary graft failure (77%) followed by hepatic artery thrombosis. The mean graft survival after paediatric LT was 13.1 (± 4.4) years. Re-transplantation of liver as adults was performed at a mean age of 23.3 (+4.2) years. Vascular related complications were observed in 36% of patients and overall postoperative morbidity rate was 88.9%. After re-transplantation the median graft survival was 34 months (2-91 months). There was only 1 ninety-day mortality. One, three and five year survival rates were 82%, 73% and 73% respectively. A third transplant was needed in 18% of patients. Conclusion: Re-transplantation of liver in paediatric patients as adults is technically very challenging. High morbidity and mortality rates are not unexpected as these patients are already immunosuppressed and undergoing a very complex vascular and biliary reconstruction.

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy with Vascular Resection for Pancreatic Cancer: Tips and Tricks

BackgroundLaparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) with vascular resection for pancreatic cancer has been rarely reported in the literature. Several critical steps are required to achieve a safe radical resection under laparoscopy while respecting oncologic principles of radicality. MethodsProspectively collected data on a consecutive series of patients undergoing radical antegrade modular pancreatosplenectomy (RAMPS) were retrospectively reviewed for the purpose of this study. Patients were divided into two groups based on the surgical approach and the need for vascular resection, and data were compared. The surgical technique is reported in detail focusing on the different modalities of vascular resection. ResultsTwenty-three patients (male/female ratio, 12/11; mean age, 73 years) underwent RAMPS between July 2014 and October 2018 at our institution. Of these, 17 had a laparoscopic approach and six a standard open approach. All patients in the open group underwent complex vascular reconstructions while four out of 17 (23.5%) underwent laparoscopic vascular resection. One patient in the laparoscopic approach required a vascular reconstruction with graft interposition, which combined the two approaches. There was no mortality, and the complication rate and the duration of surgery were comparable between the two groups. ConclusionL-RAMPS with vascular resection is feasible and safe in selected cases when performed by advanced pancreatic surgeons with experience in laparoscopic surgery.

Role of ultrasonography in assessment of postoperative vascular complications in recipients of living donor liver transplantation

Objective The aim was to evaluate the role of color Doppler ultrasonography (CDUS) in the evaluation of vascular complications detected in recipients of living donor liver transplantation (LDLT). Background Post-transplant-related vascular complications remain threat to the recipients' survival. A higher risk for vascular complications was found in LDLT recipients because of complex vascular reconstruction and slender vessels. CDUS acted as a first-modality imaging technique to detect vascular complications in the early and late follow-up period. Patients and methods A total of 60 liver transplant recipients who underwent LDLT in National Liver Institute Menoufia University were included. The study was done over a period of 25 months from January 2016 to January 2018. These recipients underwent serial color Doppler sonographic evaluation of hepatic arteries, portal vein, and hepatic veins after surgery. Patients with abnormal sonographic finding underwent subsequent angiography. Results The study was done by gray-scale, CDUS and included 47 patients of 60 recipients who showed suspicious vascular complications as follows: 26, 13, and eight patients had suspected arterial, portal, and hepatic venous complications, respectively. All these patients underwent conventional angiography. The sensitivity and specificity of CDUS in the evaluation of arterial, portal, and hepatic venous complications were 95, 87.5, and 87%, respectively, and 86, 91, and 96%, respectively, and for the latest complications was 87 and 96%, respectively. Conclusion CDUS was the preferred postoperative screening method; it was an initial recipient workup for post-LDLT. Providing a perfect evaluation of hepatic vasculature and assessment of early and lately presented vascular complications.

Salvage resection of advanced mediastinal tumors.

The surgical treatment of locally advanced mediastinal tumors invading the great vessels and other nearby structures still represent a tricky question, principally due to the technical complexity of the resective phase, the contingent need to carry out viable vascular reconstructions and, therefore, the proper management of pathophysiologic issues. Published large-number series providing oncologic outcomes of patients who have undergone extended radical surgery for invasive mediastinal masses are just a few. Furthermore, the wide variety of different histologies included in some of these studies, as well as the heterogeneity of chemo and radiation therapies employed, did not allow for the development of clear oncologic guidelines. Usually in the past, surgical resections of large masses along with the neighbouring structures were not offered to patients because of related morbidity and mortality and limited information available on the prognostic advantage for long term. However, in the last decades, advances in surgical technique and perioperative management, as well as increased oncologic experience in this field, have allowed radical exeresis in selected patients with invasive tumors requiring resections extended to the surrounding structures and complex vascular reconstructions. Such aggressive surgical treatment has been proposed in association or not with adjuvant chemo- or radiotherapy regimens, achieving encouraging oncologic results with limited morbidity and mortality in experienced institutions. Congestive heart failure or impending cardiovascular collapse due to the compression by the large mass are the most frequent immediately life-threatening problems that some of these patients can experience. In this setting, medical palliation is usually ineffective and an aggressive salvage surgical treatment may remain the only therapeutic option.

Hepatic malignancies infiltrating the hepatocaval confluence – A single center experience with ante situm liver resection

Background: The ante situm-technique allows for luxation of the liver in front of the situs, enabling the experienced HPB-surgeon to resect liver malignancies invading the hepatic veins/inferior vena cava. Single-center experience with ante-situm liver resection over the past 10 years is presented. Methods: Retrospective analysis on patients receiving ante situm liver resection comprising demographical and basic clinical data as well as perioperative courses. Results: Ante situm liver resection was performed on 7 patients suffering from primary (n=5) or secondary (n=2) liver tumors. Patients received trisegmentectomy (n=4), extended left hemihepatectomy (n=1) or atypical liver resection (segments 8/4a; n=2) combined with dissection of the suprahepatic vena cava/liver veins. Venous reconstruction was performed as reinsertion of liver veins (n=3) or vascular replacement with allogeneic donor veins (n=3) or PTFE-graft (n=1) in total vascular occlusion (mean of 29.6 min.). Severe morbidity defined as Dindo Clavien >3a was found in 3 patients; one patient died due to small-for-size syndrome. Mean length of stay at ICU and hospital were 9.0 and 34.3 days, respectively. R0-resection was achieved in 5 cases (twice a R1-situation). Disease-free survival was 24.6 months with an overall survival of 34.4 months. Conclusion: Ante situm liver resection offers the opportunity to achieve surgical cure in otherwise unresectable tumors. Nevertheless, this approach remains challenging with need for complex vascular reconstruction.