Gastric Artery Research Articles

A rare case with multiple arterial variations of the liver complicated laparoscopic pancreaticoduodenectomy

BackgroundHepatic arterial variations were fully elaborated in anatomical monographs. Here, we aimed to present a rare case with multiple arterial variations of the liver complicated laparoscopic pancreaticoduodenectomy.Case presentationWe report a 67-year-old woman with a periampullary tumor underwent laparoscopic pancreaticoduodenectomy. Intraoperatively, the aberrant right hepatic artery derived from the gastroduodenal artery (GDA) was observed and had accidentally sacrificed due to untimely ligature of GDA. Three-dimensional reconstruction based on preoperative contrast-enhanced CT performed to better study the anatomy. It demonstrated a replaced right hepatic artery branched from the GDA and supplied right liver lobe. Meanwhile, the middle hepatic artery derived from the common hepatic artery and supplied hepatic segment IV. Additionally, the replaced left hepatic artery emerged from the left gastric artery and fed into left liver lobe.ConclusionsThe origination and course of hepatic arterial anatomy should be thoroughly assessed in planning and performing hepatopancreatobiliary surgeries. Reconstruction images of contrast-enhanced CT are helpful to visualize the vascular variations and its spatial relation with adjacent structures.

Oesophageal reconstruction with a reversed gastric conduit for a complex oesophageal cancer patient: a case report

BackgroundThe gastric conduit is the best replacement organ for oesophageal reconstruction, but a reversed gastric conduit (RGC) is rare. Oesophageal reconstruction for oesophageal cancer patients with a previous history of complicated gastrointestinal surgery is rather difficult. Here, we report a case in which oesophageal reconstruction was successfully managed using RGC based solely on the left gastroepiploic artery supply.Case presentationA 69-year-old man with oesophageal cancer had a history of endoscopic intestinal polypectomy and pylorus-preserving pancreaticoduodenectomy (PPPD). The right gastroepiploic artery and right gastric artery had been completely severed. The only supply artery that could be used for the gastric conduit was just the left gastroepiploic artery. Because of the complex history of abdominal surgery, we had no choice but to use the RGC to complete the oesophageal reconstruction, in which the gastric conduit was passed reversely through the hiatus to the oesophageal bed and layered end-to-side manual intrathoracic anastomosis with the esophagus. The patient had transient feeding problems with postoperative delayed thoracic stomach emptying but no anastomotic stenosis or thoracic stomach fistula. He was satisfied with his life and had no long-term complications. There was no significant effect on gut physiological function, and RGC could work normally.ConclusionsOesophageal reconstruction with RGC is a feasible procedure for complex oesophageal carcinoma that can simplify complicated surgical procedures, has less influence on gut function, is less invasive, and is safe.

Computed tomography assessment of postoperative gastric vascular supply and staple-line leak development after sleeve gastrectomy.

Residual arterial supply of the gastric tube after sleeve gastrectomy (SG) can be damaged by surgery, which can reduce gastric tube perfusion and could promote postoperative leakage. To compare the postoperative vascularization of the gastric tube using early computed tomography (CT) scanning after SG in patients with or without postoperative staple-line leak. University hospital. A retrospective analysis of a prospective database was performed in consecutive patients undergoing SG. Patients who presented with a staple-line leak were matched (1:3) with a control group of patients who underwent surgery without postoperative morbidity during the same period. Gastric tube vascularization was studied on a postoperative day 2 CT scan in both groups of patients. During the study period, 1826 patients underwent SG, including 42 patients (2.3%) who presented with a staple-line leak. Those 42 patients were successfully matched to 126 control patients. Global identification of residual gastric arterial supply in early postoperative CT scans was similar in patients with or without staple-line leak after SG. However, residual vascular supply of the gastroesophageal junction (i.e., terminal and anterior cardiotuberosity branches of the left gastric artery or left inferior phrenic artery) was more frequently interrupted by the staple line in the group of patients who developed a gastric leak. This study suggests a correlation between interruption of the main arteries supplying the gastroesophageal junction by the staple line on early postoperative CT scans and the development of gastric leak after SG. These results support the vascular theory as one of the causes of leak after SG.

Robotic Distal Gastrectomy Reduces Drain Amylase Values in Patients With a Small Pancreas-left Gastric Artery Angle.

Purpose:Pancreatic fistula is a severe complication after laparoscopic distal gastrectomy (LDG). We previously evaluated the pancreas-left gastric artery angle (PLA) as a risk indicator for developing a pancreatic fistula after LDG. This study evaluated the incidence of pancreatic fistula with robotic distal gastrectomy (RDG) in comparison to LDG from the view of the PLA.Materials and Methods:An association between the PLA and the incidence of pancreatic fistula in 165 patients who underwent either RDG (n=45) or LDG (n=120) was investigated retrospectively.Results:RDG patients had significantly lower drain amylase values (postoperative day 2) than LDG patients. As opposed to LDG patients, drain amylase values were similar for patients with small (PLA <62 degrees) and large (PLA ≥62 degrees) PLA in RDG patients.Conclusion:Robotic surgery may reduce the risk of postoperative pancreatic fistula in patients with a small PLA.

Hexafurcated coeliac trunks, trifurcated common hepatic artery, and a new variant of the arc of Bühler.

The coeliac trunk (CT) is well-known as trifurcated into the left gastric (LGA), common hepatic (CHA) and splenic (SA) arteries. Scarce reports indicate that the CT could appear quadri-, penta-, hexa-, or even heptafurcated. Reports of CTs with six branches (hexafurcated CT) are few, less than ten. The hexafurcated CT variant was documented by a retrospective study of 93 computed tomography angiograms. Two hexafurcated CTs were found. In one case an arc of Bühler was added to the inferior phrenic arteries, LGA, CHA and SA. In the second case the dorsal pancreatic artery was added to the other five branches. That arc of Bühler descended in front of the aorta to connect with the origin of the third jejunal artery. The CHA in that second case was trifurcated into the left and right hepatic arteries, and the gastroduodenal artery; the proper hepatic artery was absent. Although the hexafurcated CT, as well as the trifurcated CHA, are rarely occurring and reported anatomic variants, this doesn't mean they could not be encountered during surgical or interventional procedures, which they would complicate if not recognised. Moreover, the arc of Bühler, the embryonic remnant, was not reported previously to insert into the CT as an additional branch of it.

Imaging-Guided Percutaneous Puncture and Embolization of Visceral Pseudoaneurysms: Feasibility and Outcomes.

Visceral artery pseudoaneurysms (VAPAs) are the most frequently diagnosed pseudoaneurysms (PSAs). PSAs can be asymptomatic or symptomatic. The aim of our study was to evaluate the safety and effectiveness of percutaneous embolization of VAPAs performed on patients with an unfeasible trans-arterial approach. Fifteen patients with fifteen visceral PSAs, with a median dimension of 21 mm (IQR 20–24 mm), were retrospectively analyzed. No patients were suitable for trans-arterial catheterization and therefore a percutaneous approach was chosen. During percutaneous treatments, two embolic agents were used, either N-butyl cyanoacrylate (NBCA) (Glubran II, GEM Milan, Italy) mixed with Lipiodol (Lipiodol, Guerbet, France) or thrombin. The outcomes of this study were technical success, primary clinical success, and secondary clinical success. In our population the 15 PSA were located as follows: 2 in the left gastric artery, 1 in the right gastric artery, 3 in the right hepatic artery, 2 in a jejunal artery, 1 in left colic artery branch, 1 in a right colic artery branch, 1 in the gastroepiploic artery, 1 in the dorsal pancreatic artery, 1 in an ileocolic artery branch, 1 in an iliac artery branch, and 1 in a sigmoid artery branch. 80% of PSAs (12/15) were treated with a NBCA:lipiodol mixture and 20% of PSAs (3/15) were treated with thrombin. Technical, primary, and secondary clinical successes were obtained in 100% of the cases. No harmful or life-threatening complications were observed. Minor complications were registered in 26.6% (4/15) of the patients. Percutaneous embolization of visceral PSA is a safe and effective treatment and should be considered as an option when the endovascular approach is unsuccessful or unfeasible.

Incidence of Donor Hepatic Artery Thrombosis in Liver Grafts Recognized During Organ Procurement and Backtable: A Rare but Treacherous Pitfall In Liver Transplantation

Donor hepatic artery thrombosis (dHAT) identified during liver procurement and backtable is a rare and little-reported event that can make liver transplants unfeasible. This is a retrospective study of dHAT identified during liver grafts procurements or backtable procedures. All grafts were recovered from brain-dead donors. The demographic characteristics of the donors and the incidence of dHAT were analyzed. The data were also compared to a cohort of donors without dHAT. There was a total of 486 donors during the study period. The incidence of dHAT was 1.85% (n=9). The diagnosis of dHAT was made during procurement in 5 cases (55.5%) and during the backtable in 4 (44.4%). Most donors were female (n=5), with an average BMI of 28.14 ± 6.9 kg/m2, hypertensive (n=5), and with stroke as cause of brain death (n=8). The most prevalent site of dHAT was a left hepatic artery originating from the left gastric artery (n=4). Of the 9 cases reported, 2 livers were used for transplantation, and 7 were discarded. Comparing those cases to a cohort of 260 donors without dHAT, we found a higher incidence of anatomic variations in the hepatic artery (P=.01) and of stroke as cause of brain death (P=.05). The occurrence of dHAT before liver procurement is a rare event, however it may become a treacherous pitfall if the diagnosis is late. Grafts with anatomic variations recovered from women with brain death due to stroke and with past history of hypertension seem to be at a higher risk of presenting dHAT.

Hepatocellular carcinoma with situs inversus totalis treated by caudate lobectomy: A case report

IntroductionSitus inversus totalis (SIT) is a congenital anatomical variant in which organs and vasculature are positioned in a mirror-image relationship to the normal condition. Therefore, the surgical procedures need to be carefully planned with these factors in mind.Case presentationA 57-year-old man with SIT was diagnosed with a hepatocellular carcinoma (HCC) and was planned for caudate lobectomy. As preoperative preparation, 3D reconstructed images were created based on the contrast-enhanced CT images, and careful simulations were performed on the vascular anomalies and location of the tumor. There was a replaced left hepatic artery forming a common trunk with a left gastric artery. In addition, using media player software, a previous caudate lobectomy video was played in right and left inverted mode to simulate the abdominal surgical field image in SIT. The operative time was 285 min, and the blood loss was 440 ml. The preoperative careful simulation allowed us to proceed with the surgery without significant discomfort.ConclusionEven in the case of hepatocellular carcinoma with SIT, hepatectomy for hepatocellular carcinoma can be safely performed by careful preoperative simulations.

Hepatic Arterial Patterns and Variations: Using CT Data Visualization Software to Decrease Procedural Complications Due to Hepatic Arterial Variations

IntroThree‐dimensional (3D) models have recently been used in pre‐operative planning in rare, complex surgeries in many disciplines. The goal of this study was to determine the efficacy of using 3D models in common procedures that involve increased risk of injury to hepatic arteries in the biliary region. This would allow surgeons to plan around individual variation and prevent intra‐operative complications in these regions. This study focuses on the feasibility of converting computed tomography (CT) scans into 3D models to identify anatomical variation and compares the results to the published rates of anatomical variation for the structures considered.MethodsA total of 27 (n=27) CT scans of healthy individuals were obtained from the Cancer Imaging Archive and digitally segmented with Dragonfly and the 3D Slicer software using the semi‐automated grow from seeds tool. The results were then manually reviewed and edited for accuracy. The liver, gall bladder, and spleen were segmented as well as the associated hepatic arterial vasculature: celiac trunk, splenic artery, left gastric artery, common hepatic artery, gastroduodenal artery, proper hepatic artery, right and left hepatic arteries, and the superior mesenteric artery. The segmented scans were then converted to a 3D model where they were classified using the CRL classification system which has a 99.8% classification rate.ResultsAll 3D models were classified into a CRL classification type. Nineteen (n=19) models were classified as Type 1, two (n=2) models as Type 2, one (n=1) model as Type 3, one (n=1) model as Type 4, two (n=2) models as Type 5, one (n=1) model as Type 9, and one (n=1) model did not fit under the classification system and remained unclassified. Previously published data was used to calculate the statistical expected value of each CRL type. A chi‐square analysis was performed to determine if the dataset fit normal patterns of variation. The results of the statistical test were statistically different χ2=0.0008 than previously published patterns of anatomical variation due to the rare unclassifiable variant.ConclusionThe study showed that it is feasible to use pre‐operative CT scans to reconstruct 3D models that can be used to identify variant anatomy pre‐operatively to assist in the planning of complex surgeries. The 3D slicer software did not require a computer with substantial hardware requirements and is able to be used on a personal computer. This means it is not necessary to purchase special equipment to implement in the hospital and could potentially allow physicians to explain procedures to patients in clinics outside of hospitals. In order to expand on the capabilities of pre‐operative 3D models, it is necessary to investigate more automated methods to accurately segment the appropriate anatomy.

Accuracy of Inflow Inversion Recovery (IFIR) for Upper Abdominal Arteries Evaluation: Comparison with Contrast-Enhanced MR and CTA.

Background: Inflow-sensitive inversion recovery (IFIR) is a recently introduced technique to perform unenhanced magnetic resonance angiography (MRA). The purpose of our study is to determine the accuracy of IFIR-MRA in the evaluation of upper abdominal arteries, compared to standard MRA and computed tomography angiography (CTA). Materials and Methods: Seventy patients undergoing upper abdomen Magnetic Resonance Imaging (MRI) in different clinical settings were enrolled. The MRI protocol included an IFIR-MRA sequence that was intra-individually compared by using a qualitative 4-point scale in the same patients who underwent concomitant or close MRA (n = 65) and/or CTA (n = 44). Celiac trunk (CA), common-proper-left-right hepatic artery (C-P-L-R-HA), left gastric artery (LGA), gastroduodenal artery (GDA), splenic artery (SA), renal arteries (RA) and superior mesenteric artery (SMA) were assessed. Results: IFIR-MRA images were better rated in comparison with MRA. Particularly, all arteries obtained a statistically significant higher qualitative rating value (all p < 0.05). IFIR-MRA and MRA exhibited acceptable intraclass correlation coefficients (ICC) values for CA, C-L-R-HA, and SMA (ICC 0.507, 0.591, 0.615, 0.570, 0.525). IFIR-MRA and CTA showed significant correlations in C-P-L-R-HA (τ = 0.362, 0.261, 0.308, 0.307, respectively; p < 0.05), and in RA (τ = 0.279, p < 0.05). Conclusions: Compared to MRA, IFIR-MRA demonstrated a higher image quality in the majority of upper abdomen arterial vessels assessment. LHA and RHA branches could be better visualized with IFIR sequences, when visualizable. Based on these findings, we suggest to routinely integrate IFIR sequences in upper abdomen MRI studies.

Weight Loss and Gastrointestinal Hormone Variation Caused by Gastric Artery Embolization: An Updated Analysis Study.

ObjectiveMany gastric artery embolizations (GAE) have been performed in recent years. We try to determine whether GAE caused weight loss by decreasing gastrointestinal hormone through the analysis of weight loss and gastrointestinal hormones changes.MethodsThe PubMed and Medline databases, and the Cochrane Library, were searched using the following keywords. A total of 10 animal trials (n=144), 15 human trials (n=270) were included for analysis. After GAE, we mainly evaluated the changes in body weight loss (BWL) and body mass index (BMI), as well as metabolic indexes, such as blood glucose, lipids, and gastrointestinal hormones levels.ResultsAnimal subjects received either chemical or particle embolization, while human subjects only received particle embolization. In animal trials (growing period), the GAE group gained weight significantly slower than the sham-operated group, ghrelin levels decreased. In human trials, GAE brought more weight loss in the early stages, with a trend towards weight recovery after several months that was still lower than baseline levels. Besides weight loss, abnormal metabolic indicators, such as blood glucose and lipids were modified, and the quality of life (QOL) scores of obese patients improved. In addition, weight loss positively correlates with ghrelin.ConclusionGAE may help people lose weight and become a new minimally invasive and effective surgery for the treatment of modest obesity. Physiologic changes in gastrointestinal tract of gastrointestinal hormones level may be one reason for weight loss in GAE.

Robot-assisted transhiatal lower esophagectomy and proximal gastrectomy for Siewert type II advanced esophagogastric junction cancer with situs inversus totalis: a case report

BackgroundSitus inversus totalis (SIT) is a rare congenital abnormality in which the thoracic and abdominal organs are reversed or mirrored from their usual positions. We herein report the first case of robot-assisted transhiatal lower esophagectomy and proximal gastrectomy with esophagogastrostomy for treatment of Siewert type II advanced esophagogastric junction (EGJ) cancer with SIT.Case presentationA 62-year-old man with SIT and intestinal malrotation was diagnosed with T3N0M0 Stage IIA EGJ cancer. Three-dimensional reconstruction of a computed tomography angiogram showed that the common hepatic artery was absent, the proper hepatic artery was derived from the superior mesenteric artery through the gastroduodenal artery, and an accessary left hepatic artery arose from the left gastric artery. The patient underwent robot-assisted transhiatal lower esophagectomy and proximal gastrectomy with D2 lymph node dissection, including lower mediastinal lymphadenectomy. Intraoperative examination revealed minor vascular abnormalities, including three branches of the left gastric artery and two left gastric veins, that had not been recognized preoperatively. The surgery was performed safely, and the patient had an uneventful postoperative course.ConclusionsRobotic-assisted surgery is efficient even for complex conditions, such as Siewert type II advanced EGJ cancer with SIT.

En bloc mesoesophageal esophagectomy through thoracoscopy combined with laparoscopy based on the mesoesophageal theory.

To investigate the effectiveness and clinical significance of thoracolaparoscopic esophagectomy with mesoesophagus excision. Patients who underwent en bloc mesoesophageal esophagectomy through thoracoscopy combined with laparoscopy were retrospectively enrolled. Carbon nanoparticles were used in some patients to label the esophageal drainage lymph nodes. The clinical data were analyzed. En bloc mesoesophageal esophagectomy was successfully performed in 135 patients (100%). The carbon nanoparticles were used in 10 patients, among which the left gastric arterial lymph nodes were labeled in all patients and excised together with the left gastric mesentery, mesoesophagus, esophageal cancer, lymph nodes, vessels, nerves, and adipose tissues as one intact package. The mean operation time was 182.5 ± 26.4min, intraoperative blood loss 45.9 ± 17.6ml, mean number of lymph nodes dissected 20.9 ± 8.12, extubation time of drainage tubes 7.5 ± 3.8days, first oral feeding time 7.5 ± 1.8days, and postoperative hospital stay 13 ± 5.11days. Postoperatively, anastomotic leakage occurred in six patients (4.4%), anastomotic stenosis in eight (5.9%), hoarseness in seven (5.2%), and inflammation of the remnant stomach in four (3.0%), with a complication rate of 18.5%. Patients were followed up for 13-34months (median 23). Eighteen patients presented with organ metastasis. No local recurrence or death during follow-up. Based on the membrane anatomy or mesoesophagus theory, thoracolaparoscopic en bloc mesoesophageal esophagectomy is safe, with decreased blood loss, and it is necessary to resect the left gastric artery lymph nodes together with the left gastric mesentery and its contents to completely remove the cancer.

Abdominal apoplexy: rupture of short gastric artery after retching

Abdominal apoplexy, or idiopathic spontaneous intraperitoneal hemorrhage (ISIH), is a rare but often fatal condition resulting from a variety of disease processes affecting abdominal vasculature. A 30-year-old woman presented with acute abdominal pain and breathlessness and was in class II hypovolemic shock. She had a history of multiple episodes of retching with non-bilious vomiting prior to that. Computed tomography (CT) reported a non-rotation of the gut, gross intraperitoneal free fluid with debris, and possible perforated appendicitis. Laparoscopy revealed a gross hemoperitoneum of 2.5 L, with bowel findings consistent with non-rotation of the gut, but technical difficulty in identifying the source of bleeding led to conversion to laparotomy. A ruptured short gastric artery was ascertained to be the source of bleeding and was successfully ligated. A retrospective review of the preoperative CT showed intraperitoneal free fluid with Hounsfield unit measurements of 48 and 52, suggestive of acute hemoperitoneum. ISIH is often a delayed diagnosis or missed diagnosis due to its low incidence. The presence of vomiting and abdominal pain with hypovolemic shock, especially in a young individual, should raise the suspicion of ISIH, which can be confirmed via early CT imaging to facilitate achieving hemostasis during surgery.

Hemodynamic, Surgical and Oncological Outcomes of 40 Distal Pancreatectomies with Celiac and Left Gastric Arteries Resection (DP CAR) without Arterial Reconstructions and Preoperative Embolization.

Simple SummaryDistal pancreatectomy with the celiac artery resection (DPCAR) is an oncologically justified procedure for locally advanced pancreatic ductal adenocarcinoma (PDAC). The results of its use in our selective group of 40 consecutive patients demonstrated a high rate of R0-resections, acceptable morbidity, and survival better than that for resectable PDAC. The unsolved problems of this procedure are the liver and stomach ischemic complications, which can be lethal or lead to prolonged hospital stay and deterioration in survival. The existing clinical data do not explain the mechanisms of these specific complications in sufficient detail and can’t be used for their prognosis and prevention. We have studied the correlation of clinical data and hemodynamic changes of the collateral arteries in a series of technically homogeneous procedures. The geometrical changes of the pancreatoduodenal arcade elements after DPCAR could explain the causes of ischemic complications after surgery and determine the directions for their prevention.DPCAR’s short- and long-term outcomes are highly diverse, while the causes and prevention of ischemic complications are unclear. To assess oncological, surgical, and hemodynamic outcomes of 40 consecutive DPCARs for pancreatic (n37) and gastric tumors (n3) (2009–2021), retrospective analyses of mortality, morbidity, survival, and hemodynamic consequences after DPCAR were undertaken using case history data, IOUS, and pre- and postoperative CT measurements. In postoperative complications (42.5%), the pancreatic fistula was the most frequent event (27%), 90-day mortality was 7.5. With 27 months median follow-up, median overall (OS) and progression-free survival (PFS) for PDAC were 29 and 18 months, respectively; with 1-, 3-, and 5-years, the OS were 90, 60, and 28%, with an R0-resection rate of 92.5%. Liver and gastric ischemia developed in 0 and 5 (12.5%) cases. Comparison of clinical and vascular geometry data revealed fast adaptation of collateral circulation, insignificant changes in proper hepatic artery diameter, and high risk of ischemic gastropathy if the preoperative diameter of pancreaticoduodenal artery was <2 mm. DP CAR can be performed with acceptable morbidity and survival. OS and RFS in this super-selective cohort were compared to those for resectable cancer. The changes in the postoperative arterial geometry could explain the causes of ischemic complications and determine directions for their prevention.

Endovascular management of HIV vasculopathy.

HIV is a multisystem disease process that can affect the cardiovascular system resulting in vasculopathy. As highly active anti-retroviral therapy has allowed patients to live longer with the disease, vascular complications such as aneurysms, occlusive disease, spontaneous arteriovenous fistulae, and arterial dissections have been described. The pathogenesis of vascular-related complications in HIV is poorly understood but is thought to involve an interplay between viral-induced inflammation, vascular smooth muscle changes, endothelial alterations, and circulating blood factors. The most well-described management strategies for symptomatic aneurysm-related complications are surgical in nature, with mostly anecdotal reports of endovascular intervention. We present a case of a 24-year-old male who was found to have findings consistent with HIV vasculopathy on angiography after presenting with acute GI hemorrhage secondary to left gastric artery bleeding. Our patient was managed with endovascular embolization. Although studies have shown promise regarding the endovascular management of HIV-related aneurysmal complications in the short term, more research is needed to evaluate the long-term success of these interventions.

Synchronous double primary malignancies of the pancreatic body and extrahepatic bile duct treated with pancreatoduodenectomy and splenic artery resection following neoadjuvant chemotherapy with gemcitabine plus nab-paclitaxel: a case report

BackgroundPrimary pancreatic cancer with synchronous primary tumors in other organs is a rare condition, and its treatment largely depends on the progression of pancreatic cancer. Here, we describe a rare case of double primary malignancies involving borderline resectable pancreatic body and extrahepatic bile duct cancers that were successfully resected after neoadjuvant chemotherapy (NAC), subsequently avoiding total pancreatectomy.Case presentationA 61-year-old Japanese male was referred to our hospital by his general practitioner after presenting with elevated liver enzymes during a routine check-up for type 2 diabetes mellitus. He was diagnosed with synchronous borderline resectable pancreatic cancer in the body of the pancreas and lower extrahepatic bile duct cancer with obstructive jaundice. Abdominal computed tomography (CT) confirmed a hypovascular mass in the pancreatic body with partial encasement of the common hepatic artery, left gastric artery, celiac artery, and splenic artery and invasion of the splenic vein. Endoscopic retrograde cholangiopancreatography and bile duct biopsy confirmed lower bile duct cancer. Following multidisciplinary discussion, endoscopic retrograde biliary drainage was performed, and neoadjuvant chemotherapy comprising gemcitabine plus nanoparticle albumin-bound paclitaxel (GEM + nab-PTX) was administered. After a total of seven cycles of chemotherapy, follow-up CT showed that the size of the pancreatic lesion reduced, following which the patient underwent pancreatoduodenectomy with splenic artery resection. The postoperative course was uneventful without any surgical complications or intensive hypoglycemic treatment. The pathological diagnosis was pancreatic ductal adenocarcinoma (ypT3N1aM0 ypStage IIB/UICC 8th) with synchronous extrahepatic cholangiocarcinoma (ypT2N1M0 ypStage IIB/UICC 8th). R0 pancreatic resection was performed with an Evans grade III response to neoadjuvant chemotherapy. The patient was followed up and had no tumor recurrence at 22 months after surgery with adjuvant S-1 chemotherapy, however, died after 32 months after surgery due to multiple liver metastasis and para-aortic lymph node metastasis despite salvage GEM + nab-PTX chemotherapy.ConclusionIn our case, neoadjuvant chemotherapy for borderline resectable pancreatic cancer and function-preserving pancreatoduodenectomy (R0 resection) for double primary malignancies achieved balanced patient survival and postoperative quality of life.

A locally advanced pancreatic body cancer presenting common bile duct invasion resected via distal pancreatectomy after gemcitabine plus nab-paclitaxel chemotherapy: A case report.

IntroductionThe locally advanced pancreatic cancer has been steadily recognized as a potentially curable disease by a combination of chemotherapy and surgery. The remarkable effect of advanced chemotherapy would help surgeons do a function-preserving operation for advanced pancreatic cancer.Presentation of caseA 73-year-old woman presenting with obstructive jaundice was diagnosed to have a 3-cm pancreatic body cancer invading the celiac axis (CA), superior mesenteric artery (SMA), portal/splenic vein confluence, and the common bile duct (CBD). A plastic internal stent tube was placed endoscopically. After 11 cycles (231 days) of a weekly doublet chemotherapy with 1000 mg/m2 of gemcitabine and 125 mg/m2 of albumin-bound paclitaxel, the tumor shrunk based on imaging done every four months during chemotherapy, with residual periarterial high-density area around CA and proximal SMA and the patient was referred for surgery. During the operation, the absence of cancer cells was confirmed at (1) the origin of the proper hepatic artery, gastroduodenal artery and the left gastric artery, and (2) pancreatic cut stump along the right border of the portal vein; thus, distal pancreatectomy with coeliac axis resection was done. The patient had postoperative adjuvant chemotherapy with 100 mg/day of tegafur/gimeracil/oteracil for half a year and is currently alive and well, without signs of recurrence and diabetes mellitus a year after surgery.DiscussionAlthough surgical techniques aimed at local radicality are important, especially for conversion surgery for locally advanced pancreatic cancer, surgeons should consider the balance between radicality, safety, and functional preservation of surgery.

The ISCON-trial protocol: laparoscopic ischemic conditioning prior to esophagectomy in patients with esophageal cancer and arterial calcifications

BackgroundAnastomotic leakage is the most important surgical complication following esophagectomy. A major cause of leakage is ischemia of the gastric tube that is used for reconstruction of the gastrointestinal tract. Generalized cardiovascular disease, expressed by calcifications of the aorta and celiac axis stenosis on a pre-operative CT scan, is associated with an increased risk of anastomotic leakage. Laparoscopic ischemic conditioning (ISCON) aims to redistribute blood flow and increase perfusion at the anastomotic site by occluding the left gastric, left gastroepiploic and short gastric arteries prior to esophagectomy. This study aims to assess the safety and feasibility of laparoscopic ISCON in selected patients with esophageal cancer and concomitant arterial calcifications.MethodsIn this prospective single-arm safety and feasibility trial based upon the IDEAL recommendations for surgical innovation, a total of 20 patients will be included recruited in 2 European high-volume centers for esophageal cancer surgery. Patients with resectable esophageal carcinoma (cT1-4a, N0–3, M0) with “major calcifications” of the thoracic aorta accordingly to the Uniform Calcification Score (UCS) or a stenosis of the celiac axis accordingly to the modified North American Symptomatic Carotid Endarterectomy Trial (NASCET) score on preoperative CT scan, who are planned to undergo esophagectomy are eligible for inclusion. The primary outcome variables are complications grade 2 and higher (Clavien-Dindo classification) occurring during or after laparoscopic ISCON and before esophagectomy. Secondary outcomes include intra- and postoperative complications of esophagectomy and the induction of angiogenesis by biomarkers of microcirculation and redistribution of blood flow by measurement of indocyanine green (ICG) fluorescence angiography.DiscussionWe hypothesize that in selected patients with impaired vascularization of the gastric tube, laparoscopic ISCON is feasible and can be safely performed 12–18 days prior to esophagectomy. Depending on the results, a randomized controlled trial will be needed to investigate whether ISCON leads to a lower percentage and less severe course of anastomotic leakage in selected patients.Trial registrationClinicaltrials.gov, NCT03896399. Registered 4 January 2019.

Indocyanine green fluorescence angiography-guided simultaneous laparoscopic distal gastrectomy and spleen-preserving distal pancreatectomy for conserving the gastrosplenic ligament: A case report.

Introduction and importanceIndocyanine green (ICG) fluorescence angiography is being increasingly performed intraoperatively to detect restricted blood flow intraoperatively for the prevention of postoperative organ ischemia and anastomotic leakage. This is the first case report of simultaneous laparoscopic distal gastrectomy (LDG) and spleen-preserving distal pancreatectomy (LSPDP) involving ICG angiography use to avoid the remnant stomach ischemia.Case presentationA 55-year-old man was diagnosed with early cancer of the stomach body and intraductal papillary mucinous neoplasms of the pancreatic tail. We performed simultaneous LDG with D2 dissection and LSPDP to conserve the gastrosplenic ligament and preserve blood supply to the remnant stomach. Intraoperatively, blood flow to the remnant stomach was visualized using ICG fluorescence angiography, after which Roux-en-Y reconstruction was performed. There was no perioperative remnant stomach ischemia.Clinical discussionDespite the preserved splenic artery and vein, complete splenic infarction occurs after LSPDP possibly due to thrombus formation during surgical procedures. In this patient, we conserved the gastrosplenic ligament for the short gastric artery, which supplied blood to the remnant stomach; however, remnant stomach ischemia may occur. Therefore, we performed ICG fluorescence angiography during this operation to ensure that sufficient blood supply to the remnant stomach was maintained.ConclusionOur experience demonstrates that ICG angiography may be useful for the prevention of remnant stomach ischemia.