Hepatic Artery Reconstruction Research Articles

Hepatic Artery Anatomic Variations and Reconstruction in Liver Grafts Procured in Greece: The Effect on Hepatic Artery Thrombosis

AimsVariations of the anatomy of donor hepatic arteries increase the number of arterial anastomoses during liver transplantation and, possibly, the incidence of hepatic artery thrombosis (HAT). In this study, we describe the arterial anatomic variations in liver grafts procured and transplanted by a single center in Greece, the techniques of arterial anastomosis, and their effect on the incidence of early HAT. Materials and MethodsFrom January 2013 to December 2017, the arterial anatomy of 116 grafts procured for liver transplantation were recorded, as well as the technique of arterial anastomosis and the incidence of early hepatic artery thrombosis (HAT <30 days). ResultsA single hepatic artery was recorded in 72.41% of the procured grafts, an aberrant left hepatic artery (accessory or replaced) in 18 grafts (15.52%), and an aberrant right hepatic artery (accessory or replaced) in 17 grafts (14.66%), while other variations were observed in less than 1% of the procured livers. Of the 116 primary liver transplantations, 6 patients (5.17%) developed early HAT <30 days. Two of these patients (1.72%) had 1 anastomosis of the hepatic artery and 4 (3.45%) had 2 anastomoses due to anatomic variations. ConclusionsAnatomic variations of the hepatic artery in liver grafts is a common finding and increase the incidence of early HAT but not to a degree to make these grafts unusable.

Comparison of hepatic artery reconstruction using surgical loupe and operating microscope during living donor liver transplantation focusing on the beginner's point.

Backgrounds/AimsHepatic artery (HA) reconstruction during living donor liver transplantation (LDLT) has been performed by experienced microsurgeons with operative microscope in most centers. However, it takes long time to learn the skills and so, to simplify this procedure, transplant surgeons recently performed this procedure using surgical loupe.MethodsThis study retrospectively reviewed outcomes of 237 LDLTs at our institution from January 2012 to October 2016. In group I, HA reconstruction was performed under operative microscope by an experienced microsurgeon and in group II, it was performed using surgical loupe by a transplant surgeon with little experience for arterial anastomosis.ResultsThere was no difference in most perioperative outcomes between two groups except mean time required for HA reconstruction (24.2±4.3 vs. 20.9±6.9 minutes, p=0.001). Multivariable regression modeling to adjust for baseline differences showed that the use of surgical loupe was not associated with either HA thrombosis or intraoperative HA revision rate.ConclusionsHA reconstruction under surgical loupe can be performed simply and yields results as good as with operative microscopy, even when the transplant surgeon has less experience with HA anastomosis.

Why we don’t need hepatic artery reconstruction during DP-CAR? experience of 20 modified appleby procedures

Background: Distal pancreatectomy with celiac artery resection (DPCAR) is in use for borderline-resectable pancreatic cancer. It is believed that considerable reduction of the liver arterial supply after DPCAR may cause severe liver ischemia. Although the artery reconstruction is not a problem anymore the decision to reconstruct artery has to be justified To study liver collateral arterial supply after temporary CHA, right gastroepiploic and accessory/replaced left hepatic arteries (a/rLHA). Methods: Arterial anatomy, diameters of CHA, proper hepatic (PHA), gastroduodenal(GDA) and pancreatoduodenal arteries(PDA) were registered before surgery in 110 consecutive patients with pancreatic body/tail cancer(n35), gastric cancer with pancreatic involvementn30) and liver tumors(n45)by CT. For DPCAR(n20) these data were obtained after surgery as well. Diameters of peripancreatic arteries and mean systolic blood velocity in hepatic arteries before and after CHA clamping were measured intraoperatively by Doppler ultrasound. Results: Pulse disappeared in 19 (17 %) cases after clamping of CHA,RGEA and aLHA/rLPA. Collateral arterial blood flow in the liver parenchyma was revealed in all cases. DPCAR led to increase of GDA, rRHA, PDA and RGEA blood flow in 0,9-12 times Conclusion: Doppler ultrasound is a reliable modality for intraoperative assessment of liver arterial blood supply after DPCAR; Hepatic artery reconstruction may be necessary after DPCAR in case of disappearance of arterial US signal upon the liver parenchyma.

Why we don’t need hepatic artery reconstruction during DP-CAR? Experience of 20 modified Appleby procedures

Why we don’t need hepatic artery reconstruction during DP-CAR? Experience of 20 modified Appleby procedures

Surgical outcomes of left trisectionectomy combined with vascular reconstruction for perihilar cholangiocarcinoma

Introduction: Left risectionectomy for perihilar cholangiocarcinoma (PHC) is a complicated and extensive surgical procedure with high morbidity and mortality rates. Hence thorough regional extirpation including combined resection of adjacent vasculature is often required for curative surgical treatment of PHC. In the present study, we elucidate whether left trisectionectomy is efficacious in surgery for PHC. Method: Between April 1992 and December 2017, our department surgically treated 252 cases of PHC. These included 19 cases for which we performed left trisectionectomy (Tri) and 71 cases that underwent left hemihepatectomy (Hemi). Curative resection rates, incidences of Clavien-Dindo grade III or higher complications, in-hospital mortality rates, and long-term results were analyzed. Result: Preoperative patients’ background of the two group is almost similar except Bismuth type (Bismuth type IV; 94.7% in Tri, 22.5% in Hemi, p<0.001). Although PD was added 11.2% (8/71) in Hemi and only one patient in Tri (5.2%: 1/19) (p=0.730). Hepatic artery reconstruction was performed 39.4% (28/71) in Hemi and 73.6% (14/19) in Tri (p=0.007). Curative resection rates were almost same in both groups: 73.6% (14/19) in Tri and 80.2% (57/71) in Hemi (p=0.531). No Tri cases showed a positive bile duct surgical margin. Incidences of complications were similar in both groups, at 73.6% in Tri, and 54.9% in Hemi (p=0.140). In-hospital mortality rates in Tri were statistically higher than those in Hemi (26.3% (5/19) vs 8.4% (6/71), p=0.034). Five-year survival rates were 30.1% in Tri and 34.9% in Hemi. In Tri, the resection afforded good long-term results even with advanced cancers. Conclusion: Left trisectionectomy proved useful in securing the bile duct margin. However, as left trisectionectomy remains a challenging procedure with high in-hospital mortality rates, surgeons need to pay close attention to anatomical variations in order to perform left trisectionectomy safely and successfully.

Results of portal vein and hepatic artery resection for surgical treatment of Klatskin tumor

Background: Portal vein invasion is most often cause of portal vein resection and reconstruction combine with hepatectomy for surgical treatment of Klatskin tumor at nowadays. The reported rate of morbidity and mortality still high (more then 10%). 5-year survival is possible. Special complexity is represented by cases with a tumor invasion of a portal vein and a hepatic artery. Results of combine resection portal vein and hepatic artery still controversial. Methods: The aim of this study to observe results of surgical treatment of Klatskin tumor with portal vein and hepatic artery invasion. Between 2002 and 2016 major and extended resections of the liver to 183 patients with Klatskin tumor was made. Results: 183 patients underwent resection for pCCA. Median age was 61,2 ±/12 years. More than in 45 % of cases there was a necessity of a separate drainage of three sections of a liver. A liver resection carried out at level of bilirubin of a blood not above 60 mcmol/l. From 183 patients in 96 cases have executed a resection of a portal vein with the subsequent reconstruction. At 13 patients it is made hepatoduodenoligamentectomy with resection and reconstruction of portal vein and hepatic artery. The postoperative mortality has made 9,3 %, 5-year survival rate – 18,8 %. Conclusion: Aggressive surgical treatment for cholangiocarcinoma the confluence of bile duct with portal vein resection can be performed safely with acceptable mortality and long-term survival rate.

Results of portal vein and hepatic artery resection for surgical treatment of Klatskin tumor

Background: Portal vein invasion is most often cause of portal vein resection and reconstruction combine with hepatectomy for surgical treatment of Klatskin tumor at nowadays. The reported rate of morbidity and mortality still high (more then 10%). 5-year survival is possible. Special complexity is represented by cases with a tumor invasion of a portal vein and a hepatic artery. Results of combine resection portal vein and hepatic artery still controversial. Methods: The aim of this study to observe results of surgical treatment of Klatskin tumor with portal vein and hepatic artery invasion. Between 2002 and 2016 major and extended resections of the liver to 183 patients with Klatskin tumor was made. Results: 183 patients underwent resection for pCCA. Median age was 61,2 ±/12 years. More than in 45 % of cases there was a necessity of a separate drainage of three sections of a liver. A liver resection carried out at level of bilirubin of a blood not above 60 mcmol/l. From 183 patients in 96 cases have executed a resection of a portal vein with the subsequent reconstruction. At 13 patients it is made hepatoduodenoligamentectomy with resection and reconstruction of portal vein and hepatic artery. The postoperative mortality has made 9,3 %, 5-year survival rate – 18,8 %. Conclusion: Aggressive surgical treatment for cholangiocarcinoma the confluence of bile duct with portal vein resection can be performed safely with acceptable mortality and long-term survival rate.

The impact of extra-anatomical hepatic artery reconstruction during living donor liver transplantation on biliary complication, graft and patient survival.

Introduction: This study is designed to analyze the feasibility of extra-anatomical hepatic artery reconstruction in living donor liver transplantation. Method: Patients who underwent their first living donor liver transplantation in our center from January 2008 to December 2017 were reviewed. Hepatic artery reconstruction was classified as anatomical or extra-anatomical reconstruction. Comparisons of the background characteristics and post-transplantation outcome including complications, biliary complications, graft survival and overall survival were performed. Potential risk factors for bile leakage was analyzed using multivariable logistic regression analysis. Potential risk factor for biliary stricture-free survival, graft survival, and overall survival were analyzed using multivariable Cox proportional hazard models. Result: Among 800 patients, 35 (4.4%) underwent extra-anatomical reconstruction. Extra-anatomical reconstruction (n=2/35, 5.7%) showed similar rate of hepatic artery complication to anatomical reconstruction. (n=46/772, 5.9%, P=0.699) Seven patients (7/35, 20.0%) with extra-anatomical reconstruction experienced hepatic artery complication after anatomical reconstruction and changed to extra-anatomical reconstruction. Extra-anatomical reconstruction showed significant risk of increased bile leakage (OR=4.167, CI 1.928-9.006, P<0.001) along with multiple bile duct (OR=1.606, CI=1.022-2.526, P=0.040) and hepaticojejunostomy (OR=4.108, CI=2.190-7.707, P<0.001). However, extra-anatomical reconstruction showed no statistical relationship to poor biliary stricture-free survival (HR=1.602, CI=0.982-2.613, P=0.059), graft survival (HR=1.745, CI=0.741-4.109, P=0.203) and overall survival. (HR=1.405, CI=0.786-2.513, P=0.251) Hepatic artery complication was related to poor biliary stricture-free survival (HR=2.060, CI=1.329-3.193, P=0.001), graft survival (HR=5.549, CI=2.883-10.681, P<0.001) and overall survival. (HR=1.958, CI=1.195-3.206, P=0.008) Conclusion: Extra-anatomical hepatic artery reconstruction during living donor liver transplantation was not a risk factor of biliary stricture, graft failure and overall survival.

Arterial blood gas test to decide whether to reconstruct single or both the arteries in living donor liver transplantation.

The graft used in living donor liver transplantation (LDLT) sometimes has two hepatic arteries. This study aimed to introduce arterial-blood gas (ABG) test on the decision on whether to reconstruct a single or both arteries in LDLT. Patients with a right lobe graft with two hepatic arteries were enrolled from the prospectively maintained database of our institution. After anastomosis of one of two arteries, the back-bleeding from the second hepatic artery was taken for ABG test. Depending on the results, the second artery was anastomosed or ligated. Between January 2012 and December 2017, a total of 372 patients underwent LDLT, and 21 living donors had two right hepatic arteries. Based on ABG test results, a single anastomosis was created in 15 recipients while double anastomoses were performed in the remaining 6 recipients. All the patients had an uneventful recovery and were discharged in good conditions. Neither hepatic artery thrombosis nor liver dysfunction was observed during the median follow-up of 26 months (range, 6-71 months). The overall incidence of biliary complications was 9.5% (2/21). Bile leakage arose in one patient with two hepatic artery reconstructions, and the patient subsequently developed biliary stricture. Biliary stricture occurred in another patient with one hepatic artery reconstruction. The biliary complications were successfully managed with endoscopic or percutaneous intervention. ABG test provides a good measure for deciding whether to reconstruct single or both arteries in LDLT.

Clinical Course of Hepatic Artery Thrombosis After Living Donor Liver Transplantation Using the Right Lobe.

Hepatic artery thrombosis (HAT) can result in biliary tree necrosis and graft loss, necessitating retransplantation. The most effective treatment approach is still controversial. This study was performed to review the outcomes of HAT after living donor liver transplantation (LDLT) and to clarify the feasibility of different strategies. From May 1996 to August 2017, LDLT using the right lobe was performed in 827 adult patients in our center. Our technique of hepatic artery (HA) reconstruction is end-to-end anastomosis under a microscope (10×). Diagnosis of HAT was performed using Doppler sonography and computed tomography (CT) angiography. HAT was initially treated with surgical or endovascular procedure, and retransplantation was considered according to the graft condition. Among the 827 cases of LDLT using the right lobe, HAT occurred in 16 (1.9%) cases within 1 month after transplantation. Within the first week, 7 of these HAT cases (43.8%) occurred (early HAT), while the remaining 9 cases (56.2%) occurred between the first week and 1 month (late HAT). The incidence of graft failure was high in early HAT (42.9%), and the frequency of biliary complications was high in late HAT (77.8%). The success rate of HA recanalization was 62.5% (10/16): 100% (5/5) after reoperation and 45.5% (5/11) after the endovascular procedure. Of the patients in whom treatment failed in late HAT (n = 5), 4 underwent neovascularization during observation. A total of 5 patients underwent graft failure, and 3 of these patients underwent repeat liver transplantation (LT). Mortality occurred in 3 patients, including 1 in the surgical group and 2 in the endovascular group. In conclusion, early diagnosis and aggressive treatment of HAT are necessary to avoid graft failure, and the choice of treatment depends on various factors. Although further studies are required, early HAT requires preparation for graft failure, while late HAT requires treatment for biliary complications.

Left Hepatectomy with Combined Resection and Reconstruction of Right Hepatic Artery for Bismuth Type I and II Perihilar Cholangiocarcinoma.

Right hepatectomy with caudate lobectomy (RHx) is considered an appropriate procedure for Bismuth type I/II perihilar cholangiocarcinoma in terms of its anatomical and oncological aspect. However, validity of left hepatectomy with caudate lobectomy (LHx) concomitant with arterial resection and reconstruction (AR) is not fully evaluated. The patients who underwent surgical resection for Bismuth type I/II perihilar cholangiocarcinoma between 2002 and 2013 were studied. The standard procedure for Bismuth type I/II cholangiocarcinoma in the institute was RHx, while in patients who had insufficient functional reserve of the left liver, LHx was selected, irrespective of the necessity of AR. The clinicopathologic and perioperative outcomes after LHx + AR were compared with those after RHx. The surgical procedures comprised LHx + AR in 12 and RHx in 24. The left liver volume and left liver functional reserve were significantly lower with LHx + AR than with RHx (left liver volume: 28.0 vs. 33.7%, p = 0.026; estimated indocyanine green clearance of the left liver: 0.036 vs. 0.046, p < 0.001). The rate of surgical morbidity was almost identical between the two procedures. No arterial reconstruction-related complications occurred. The overall 3- and 5-year survival rates and median survival time were 66.7%, 41.7% and 44months for LHx + AR and 70.8%, 49.0% and 57months for RHx (p = 0.640). LHx + AR for Bismuth type I/II perihilar cholangiocarcinoma is considered to be a valid alternative to RHx in patients with an insufficient left liver functional reserve.

Thrombosis prophylaxis in pediatric liver transplantation: A systematic review.

AIMTo review current literature of thrombosis prophylaxis in pediatric liver transplantation (PLT) as thrombosis remains a critical complication.METHODSStudies were identified by electronic search of MEDLINE, EMBASE and Cochrane Library (CENTRAL) databases until March 2018. The search was supplemented by manually reviewing the references of included studies and the references of the main published systematic reviews on thrombosis and PLT. We excluded from this review case report, small case series, commentaries, conference abstracts, papers which describing less than 10 pediatric liver transplants/year and articles published before 1990. Two reviewers performed study selection independently, with disagreements solved through discussion and by the opinion of a third reviewer when necessary.RESULTSNine retrospective studies were included in this review. The overall quality of studies was poor. A pooled analysis of results from studies was not possible due to the retrospective design and heterogeneity of included studies. We found an incidence of portal vein thrombosis (PVT) ranging from 2% to 10% in pediatric living donor liver transplantation (LDLT) and from 4% to 33% in pediatric deceased donor liver transplantation (DDLT). Hepatic artery thrombosis (HAT) was observed mostly in mixed LDLT and DDLT pediatric population with an incidence ranging from 0% to 29%. In most of the studies Doppler ultrasonography was used as a first line diagnostic screening for thrombosis. Four different surgical techniques for portal vein anastomosis were reported with similar efficacy in terms of PVT reduction. Reduced size liver transplant was associated with a low risk of both PVT (incidence 4%) and HAT (incidence 0%, P < 0.05). Similarly, aortic arterial anastomosis without graft interposition and microsurgical hepatic arterial reconstruction were associated with a significant reduced HAT incidence (6% and 0%, respectively). According to our inclusion and exclusion criteria, we did not find eligible studies that evaluated pharmacological prevention of thrombosis.CONCLUSIONPoor quality retrospective studies show the use of tailored surgical strategies might be useful to reduce HAT and PVT after PLT; prospective studies are urgently needed.

Alternative hepatic arterial reconstruction technique in case of total pancreaticoduodenectomy after celiac artery resection in pancreas cancer: Iliac-hepatic bypass.

Surgery is the only treatment method in pancreatic cancer. Unfortunately, metastatic diseases or invasion of the main vascular structures are observed in a majority of cases at the time of diagnosis; these structures originate from the body, neck, and tail of the pancreas and are considered inoperable. The first celiac artery resection for the treatment of cancer was described by Appleby in 1953. Here, we describe our hepatic artery reconstruction technique in a case with pancreatic body cancer. A 37-year-old male patient was admitted to our emergency department owing to syncope. The patient was diagnosed with acute renal failure secondary to fluid loss. Thereafter, his general condition was stable and laboratory results improved. Abdominal computed tomography was performed. Pancreatic cancer originating from the pancreatic body was detected. A pancreatic biopsy was performed and neoadjuvant gemcitabine and paclitaxel chemoradiotherapy were initiated. Surgical treatment was recommended for the identification of regression after neoadjuvant chemoradiotherapy. Following intraoperative Doppler ultrasonography, en bloc distal pancreatectomy and splenectomy involving the celiac artery trunk and total gastrectomy were performed. However, the surgical margin reliability in a frozen section revealed that the tumor was still present. Therefore, the surgical procedure was replaced with total pancreaticoduodenectomy. The hepatic artery reconstruction was performed from the left main iliac artery using a 4-mm ringed GORE-TEX® graft. The iliac-hepatic bypass for hepatic artery reconstruction in pancreatic cancer could be an alternative surgical technique.

The stand of portal vein arterialization in hepatobiliary surgery: a systematic review

Introduction: Hepatic artery (HA) reconstruction during liver resection can be impossible due to arterial infiltration or anatomical limitations. Portal vein arterialization (PVA) is discussed to improve the hepatic oxygenation and provide a new chance for the patients with dearterialized liver. The aim of this study is to review the clinical application of PVA in hepatobiliary surgeries. Methods: The systematic review was performed according to the PRISMA guidelines. MEDLINE, Embase, and Web of Science databases were systematicly searched. Experimental studies, review articles, letters, and also articles published in languages other than English were excluded. Results: A total of 20 studies, involving 57 patients, were included. According to the anatomical location, hilar lesions (38 patients, 70.4%) were the most common indication of the surgery. The reasons for performing PVA were excision of lesions abutting HA (32 patients, 56.1%), HA ligation (11 patients, 19.3%), HA thrombosis (six patients, 10.5%), iatrogenic injury (four patients, 7.0%), and failure of HA reconstruction (four patients, 7.0%). An end-to-side anastomosis between celiac trunk branches and portal vein (PV) was the main performing technique for PVA (35 patients, 59.3%). The most common complication of PVA was portal hypertension (12 of 57, 21.1%). Thirty-five patients (61.4 %) survived during the follow-up period of 1 to 87 months. Conclusion: PVA may provide a chance of cure for patients with the unresectable lesions. To prevent portal hypertension and liver injuries due to thrombosis or over-arterialization, calibrating and timely closure of PVA should be considered.

Reconstruction of hepatic artery with a transposed splenic artery

Introduction: Reconstruction of hepatic artery following its excision requires a prosthetic graft or saphenous vein graft. We report a case of hepatic artery reconstructed by a transposed splenic artery. Methods: We report a case of true hepatic artery aneurysm managed in our department. Results: A 65 yr old gentleman presented with pain abdomen of 1 month duration.He had 1 episode of hematemesis. CT angiography showed fusiform dilatation of distal 2/3rd of common hepatic artery.We took him for surgery as stent graft could not be placed.We excluded the aneurysm as the aneurysm was densely adherent to portal vein.After taking proximal control from celiac axis, the aneurysm was partially excised. The hepatic artery was cut just below the bifurcation. The splenic artery was mobilised for 6cm from pancreas. Thedistal end was cut and transposed to reconstruct the hepatic artery. There was no twist as splenic artery was mobilised till its origin from celiac axis. He had an uneventful postoperative course. Conclusion: Transposed Splenic artery can be used to reconstruct hepatic artery.

A case of haemosuccus pancreaticus treated with a technically challenging pancreatico-duodenectomy and a novel reconstruction of proper hepatic artery

A case of haemosuccus pancreaticus treated with a technically challenging pancreatico-duodenectomy and a novel reconstruction of proper hepatic artery

A systematic review and meta-analysis of rescue revascularization with arterial conduits in liver transplantation.

Although aortohepatic conduits (AHCs) provide an effective technique for arterialization in liver transplantation (LT) when the native recipient artery is unusable, various publications report higher occlusion rates and impaired outcome compared to conventional anastomoses. This systematic review and meta-analysis investigates the published evidence of outcome and risk of AHCs in LT using bibliographic databases and following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Primary and secondary outcome were artery occlusion as well as graft and patient survival. Twenty-three retrospective studies were identified with a total of 22113 patients with LT, of whom 1900 patients (9%) received an AHC. An AHC was used in 33% of retransplantations. Early artery occlusion occurred in 7% (3%-16%) of patients with AHCs, compared to 2% (1%-3%) without conduit (OR 3.70; 1.63-8.38; P=.001). The retransplantation rate after occlusion was not significantly different in both groups (OR 1.46; 0.67-3.18; P=.35). Graft (HR 1.38; 1.17-1.63; P<.001) and patient (HR 1.57; 1.12-2.20; P=.009) survival was significantly lower in the AHC compared to the nonconduit group. In contrast, graft survival in retransplantations was comparable (HR 1.00; 0.82-1.22; P=.986). Although AHCs provide an important rescue option, when regular revascularization is not feasible during LT, transplant surgeons should be alert of the potential risk of inferior outcome.

A Comparison of Hepatic Artery Reconstruction Using a Surgical Loupe and Operating Microscope During Living Donor Liver Transplantation

Adequate hepatic artery (HA) flow is the most important contributor to proper graft function in living donor liver transplantation (LDLT). Therefore, in most centers, this is performed by an experienced microsurgeon with an operating microscope. However, it takes a long time to learn the skills involved in this microsurgical reconstruction and to gain experience to achieve good outcomes. To simplify this procedure, a transplant surgeon recently performed the procedure using a surgical loupe. This study retrospectively reviewed the outcomes of 218 LDLTs performed in our institution from January 2012 to October 2016. Before September 2014, an experienced microsurgeon reconstructed the HA under an operating microscope and, after that period, a hepatobiliary surgeon with little experience in arterial anastomosis during LDLT performed it using a surgical loupe. A total of 237 LDLTs were performed: 136 in the first period and 101 in the second. The mean time required for the HA reconstruction was shorter in the second period (20.9± 6.9 vs. 24.2 ± 4.3 minutes, P =0.001), while there was no difference in intraoperative arterial revision between the two groups. The incidence of arterial or bile duct complications did not differ significantly between the two groups. In conclusion, HA reconstruction under a surgical loupe can be performed simply by the transplant surgeon with a low complication rate and yields results as good as with operative microscopy, even when the surgeon has less experience with HA anastomosis.

Hepatic Artery Resection for Bismuth Type III and IV Hilar Cholangiocarcinoma: Is Reconstruction Always Required?

ObjectiveThe objective of the study is to examine the feasibility of hepatic artery resection (HAR) without subsequent reconstruction (RCS) in specified patients of Bismuth type III and IV hilar cholangiocarcinoma. MethodsWe retrospectively reviewed 63 patients who underwent hepatic artery resection for Bismuth type III and IV hilar cholangiocarcinoma. These patients were subsequently enrolled into two groups based on whether the artery reconstruction was conducted. Postoperative morbidity and mortality, and long-term survival outcome were compared between the two groups. ResultsThere were 29 patients in HAR group and 34 patients in the HAR + RCS group. Patients with hepatic artery reconstruction tended to have longer operative time (545.6±143.1 min vs. 656.3±192.8 min; P=0.013) and smaller tumor size (3.0±1.1 cm vs. 2.5±0.9 cm; P=0.036). The R0 resection margin was comparable between the HAR group and HAR+RCS group (86.2 vs. 85.3%; P>0.05). Twelve patients (41.4%) with 24 complications in HAR group and 13 patients (38.2%) with 25 complications in HAR+RCS group were recorded (P=0.799). The postoperative hepatic failure rate (13.8 vs. 5.9%) and postoperative mortality rate (3.4% vs. 2.9%) were also comparable between the two groups. In the HAR group, the overall 1-, 3-, and 5-year survival rates were 72, 41, and 19%, respectively; while in the HAR+RCS group, the overall 1-, 3-, and 5-year survival rates were 79, 45, and 25%, respectively (P=0.928). ConclusionsHepatic artery resection without reconstruction is also a safe and feasible surgical procedure for highly selected cases of Bismuth type III and IV hilar cholangiocarcinoma.

Modified Appleby procedure for locally advanced pancreatic cancer

Locally advanced pancreas cancer (LAPC) involving the celiac axis is typically considered unresectable and carries a poor prognosis. We present a case of a patient with LAPC who underwent a modified Appleby procedure for tumor clearance following neoadjuvant therapy. Technical aspects include diagnostic laparoscopy to exclude occult metastatic disease followed by complete mobilization of the pancreas and spleen, preservation of the left gastric artery, and resection and reconstruction of the common hepatic artery. With proper patient selection and preparation, LAPC with celiac axis involvement can be safely resected with favorable outcomes.