Vascular Resection Research Articles

Surgical treatment for perihilar cholangiocarcinoma:a single-center experience

Objective: To investigate surgical strategies and the corresponding benefits for patients with perihilar cholangiocarcinoma(pCCA). Methods: A total of 81 patients with pCCA who underwent radical excision in the Department of Biliary and Pancreatic Surgery of Sun Yat-Sen Memorial Hospital between January 2014 and December 2021 were retrospectively collected.The cohort consisted of 50 male and 31 female patients,with an age of (62.5±11.5)years(range:26 to 83 years).Seventy-five cases were diagnosed with jaundice,60 of whom received preoperative biliary drainage,while 20 patients received portal vein embolization.Their serum bilirubin level within one week before the operation(M(IQR)) was 44.3 (41.9) μmol/L(range:8.0 to 344.2 μmol/L).Preoperative imaging examinations were performed to evaluate the Bismuth-Corlette type of pCCA,showing 3,6,21,27,and 24 cases of Bismuth-Corlette type Ⅰ,Ⅱ,Ⅲa,Ⅲb,and Ⅳ,respectively.The primary outcome was overall survival (OS),and the secondary outcomes were relapse-free survival (RFS),90-day postoperative morbidity and 90-day postoperative mortality.OS and RFS were estimated using the Kaplan-Meier method and compared by the Log-rank test.Significant prognostic factors were determined using univariate and multivariable Cox proportional hazard regression analyses. Results: In the cohort of 81 pCCA patients,67 cases(82.7%) underwent major hepatectomy while 3 cases received major hepatectomy combined with pancreaticoduodenectomy.Thirty-four patients underwent hepatectomy combined with vascular resection and reconstruction(18 cases of portal vein resection and reconstruction alone;9 cases of hepatic artery resection and reconstruction alone;7 cases of combination of portal vein and hepatic artery resection and reconstruction).Margin negative(R0 excision) were achieved in 53.1%(43/81) of these patients.The operation duration was (627±136)minutes(range:565 to 940 minutes),and the intraoperative blood loss was 400(455)ml(range:200 to 2 800 ml).The 90-day postoperative mortality was 3.7%(3/81).Grade 3-4 postoperative morbidity was 23.4% (19/81) according to the Clavien-Dindo classification of surgical complications.Up to the last follow-up at September 2022,the follow-up time was 34.0(24.2)months (range:0.4 to 103.6 months).Three patients who died within 90 days after surgery were excluded from the survival analysis.The median OS was 36.10 months (95%CI:18.23 to 42.97 months) and the 1-,3-and 5-year OS rates were 85.3%,46.8% and 27.3%,respectively.The median OS of 41 patients with negative margins was 47.83 months(95%CI:36.90 to 58.80 months) and that of 37 patients with positive margins was 20.47 months(95%CI:10.52 to 30.58 months).The median RFS of 70 patients with R0 and R1 resection was 24.50 months(95%CI:12.15 to 31.85 months)and the 1-,3-and 5-year RFS rates were 65.2%,45.7% and 29.9%,respectively.The median RFS of 41 patients with R0 resection was 38.57 months(95%CI:21.50 to 55.63 months) and that of 29 patients with R1 resection was 10.83 months(95%CI:2.82 to 19.86 months). Conclusions: The primary therapy for pCCA is radical surgical resection.A precise preoperative evaluation and sufficient preparation can reduce postoperative morbidity.Surgical treatment can achieve a better survival outcome by increasing the radical resection rate.

Revival of associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma: An international multicenter study with promising outcomes

BackgroundAssociating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma has been considered to be contraindicated due to the initial poor results. Given the recent reports of improved outcomes, we aimed to collect the recent experiences of different centers performing associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma to analyze factors related to improved outcomes. MethodsThis proof-of-concept study collected contemporary cases of associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma and analyzed for morbidity, short and long-term survival, and factors associated with outcomes. ResultsIn total, 39 patients from 8 centers underwent associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma from 2010 to 2020. The median preoperative future liver remnant volume was 323 mL (155–460 mL). The median future liver remnant increase was 58.7% (8.9% -264.5%) with a median interstage interval of 13 days (6–60 days). Post–stage 1 and post–stage 2 biliary leaks occurred in 2 (7.7%) and 4 (15%) patients. Six patients (23%) after stage 1 and 6 (23%) after stage 2 experienced grade 3 or higher complications. Two patients (7.7%) died within 90 days after stage 2. The 1-, 3-, and 5-year survival was 92%, 69%, and 55%, respectively. A subgroup analysis revealed poor survival for patients undergoing additional vascular resection and lymph node positivity. Lymph node–negative patients showed excellent survival demonstrated by 1-, 3-, and 5-year survival of 86%, 86%, and 86%. ConclusionThis study highlights that the critical attitude toward associating liver partition and portal vein ligation for staged hepatectomy for perihilar cholangiocarcinoma needs to be revised. In selected patients with perihilar cholangiocarcinoma, associating liver partition and portal vein ligation for staged hepatectomy can achieve favorable survival that compares to the outcome of established surgical treatment strategies reported in benchmark studies for perihilar cholangiocarcinoma including 1-stage hepatectomy and liver transplantation.

Comparative analysis of surgical treatment of patients with locally advanced tumors right anatomical segment of pancreas

Radical resection of pancreas during pancreatic ductal adenocarcinoma has a favorable effect on the patient’s survival rate and disease prognosis. Performance of PV/SMV resection during pancreatoduodenectomy is a routine procedure in leading pancreatology centers, increasing the possibility of R0 resections.
 Purpose of the study. Is to evaluate the criteria for the diagnosis of vascular invasion at the preoperative stage, to increase the proportion of R0 resections.The study included 73 patients with locally advanced tumors of the pancreatic head operated on in the pancreatic surgery department from 2019 to 2022. The range of operations included: Whipple pancreatoduodenectomy, pyloruspreserving pancreatoduodenectomy, and total pancreatoduodenectomy.The presence or suspicion of vascular invasion, the size, and the stage of the tumor at the preoperative stage were diagnosed according to the data of MSCT, MRI, ultrasonography, and endosonography. Histological examination was carried out according to the recommendations of the College of American Pathologist 2020.
 The first group 44 of patients who were made pancreatoduodenectomy with resection of PV/SMV, and the second group 29 patients without vascular resection. In the second group, a positive venous (smv) resection margin, R1 resection, had all patients according to the planned histological examination.During the preoperative examination, vascular invasion was suspected in 68,2% of patients in the first group, and 58.6% in the second, 58,6%, (x2 = 0,696; p = 0,403). According to histological examination, damage to the vascular wall was confirmed in 81,8% of cases among the first group of patients.A comparative assessment of the indicators of the two groups indicates that there is no significant difference in tumor size (t = 1,38; p = 0,085), localization, intraoperative data (operation time) (t = 1,19; p = 0,117), the number of postoperative complications (x2 = 0,027; p = 0,869), and the histological type of the tumor. Only intraoperative blood loss had statistical significant.
 Conclusions. The nowaday preoperative examination protocol allows diagnosing vascular or suspicion of it with sufficient probability and planning adequate surgical intervention.
 Performing a resection of PV/SMV during pancreaticoduodenectomy with pre- or intraoperative suspicion of vascular invasion allows to increase the number of R0 resections and improve the prognosis of the disease.

Complex Vascular Resections for Retroperitoneal Soft Tissue Sarcoma

Retroperitoneal sarcomas (RPSs) are locally aggressive tumors that can compromise major vessels of the retroperitoneum including the inferior vena cava, aorta, or main tributary vessels. Vascular involvement can be secondary to the tumor's infiltrating growth pattern or primary vascular origin. Surgery is still the mainstay for curing this disease, and resection of RPSs may include major vascular resections to secure adequate oncologic results. Our improved knowledge in the tumor biology of RPSs, in conjunction with the growing surgical expertise in both sarcoma and vascular surgical techniques, has allowed for major vascular reconstructions within multi-visceral resections for RPSs with good perioperative results. This complex surgical approach may include the combined work of various surgical subspecialties.

Utility of Dark-Blood Dual-Energy CT Images for Predicting Vascular Involvement and R0 Resection in Patients With Pancreatic Cancer.

BACKGROUND. Current CT criteria for assessing vascular involvement by pancreatic ductal adenocarcinoma (PDAC) use circumferential contact as an indirect indicator. Dark-blood images derived from dual-energy CT (DECT) provide high lumen-to-wall contrast and may aid assessment. OBJECTIVE. The purpose of this study was to compare the diagnostic performance of 55-keV virtual monoenergetic images (VMIs) assessed using NCCN criteria with that of dark-blood images assessed using wall-based criteria for predicting vascular involvement and surgical resection that achieves microscopically negative margins (i.e., R0 resection) in patients with PDAC who undergo contrast-enhanced DECT. METHODS. This retrospective study included 109 patients (mean age, 62.6 ± 8.8 [SD] years; 66 men, 43 women) with histologically confirmed PDAC who underwent pancreatic parenchymal and portal venous phase DECT within 4 weeks before surgery (including PDAC resection in 73 patients) between July 2020 and June 2022. Dark-blood images were derived using a two-material decomposition algorithm. Two radiologists independently reviewed 55-keV VMIs and dark-blood images in separate sessions to evaluate celiac artery, common hepatic artery, superior mesenteric artery, portal vein, and superior mesenteric vein involvement; a third radiologist resolved discrepancies. On 55-keV VMIs, vessel relationships were classified as no contact, abutment (≤ 180° contact), or encasement (> 180° contact). On dark-blood images, vessel walls were categorized as intact circumferentially, irregular, or discontinuous. Tumor resectability status was classified on the basis of vessel relationships. Surgical observation served as the reference for vascular involvement. Margin status was determined for resected tumors. RESULTS. Across the five vessels, for predicting vascular involvement, abutment or encasement on 55-keV VMIs had sensitivity of 100.0% (all vessels) and specificity of 66.2-92.9%, and an irregular or discontinuous wall on dark-blood images had sensitivity of 80.0-100.0% and specificity of 88.2-98.0%. Specificity was higher for an irregular or discontinuous wall than for abutment or encasement for all vessels (all p < .05); sensitivity was not different for any vessel (all p > .05). Resectable disease classified by dark-blood images, compared with resectable disease classified by 55-keV VMIs, showed no difference in sensitivity (89.5% vs 78.9%, p = .33) but showed higher specificity (75.9% vs 59.3%, p = .01) for predicting R0 resection. CONCLUSION. Dark-blood images showed higher diagnostic performance than 55-keV VMIs for predicting vascular involvement and R0 resection in patients with PDAC. CLINICAL IMPACT. Dark-blood images may aid decisions regarding neoadjuvant therapy and surgical planning for PDAC.

Chinese expert consensus on minimally invasive radical surgery for pancreatic ductal adenocarcinoma (version 2022)

Although there are still controversies over the efficiency and safety of minimally invasive radical surgery for pancreatic ductal adenocarcinoma (PDAC), most available studies have suggested a promising application of minimally invasive radical surgery. This consensus, referring to Chinese expert opinions and worldwide researches, aimed to discuss the related issues on minimally invasive radical surgery for PDAC to ensure the perioperative and oncological outcomes. Quality of evidence and strength of recommendations were evaluated based on the GRADE approach. The 15 recommendations covered 5 topics: oncological outcomes and patient safety of laparoscopic and robotic pancreatoduodenectomy, left-side pancreatectomy for PDAC, learning curve, safety of neoadjuvant therapy, and vascular resection in minimally invasive radical surgery for PDAC. This consensus gives reference and guidance to surgeons on the use of minimally invasive radical surgery for PDAC. Although this consensus is not sufficient to answer all the questions about minimally invasive radical surgery for PDAC, it represents the current consensus on the application of the techniques in the treatment of PDAC on the Chinese mainland.

Robot-Assisted Versus Laparoscopic Distal Pancreatectomy in Patients with Resectable Pancreatic Cancer: An International, Retrospective, Cohort Study

BackgroundRobot-assisted distal pancreatectomy (RDP) is increasingly used as an alternative to laparoscopic distal pancreatectomy (LDP) in patients with resectable pancreatic cancer but comparative multicenter studies confirming the safety and efficacy of RDP are lacking.MethodsAn international, multicenter, retrospective, cohort study, including consecutive patients undergoing RDP and LDP for resectable pancreatic cancer in 33 experienced centers from 11 countries (2010–2019). The primary outcome was R0-resection. Secondary outcomes included lymph node yield, major complications, conversion rate, and overall survival.ResultsIn total, 542 patients after minimally invasive distal pancreatectomy were included: 103 RDP (19%) and 439 LDP (81%). The R0-resection rate was comparable (75.7% RDP vs. 69.3% LDP, p = 0.404). RDP was associated with longer operative time (290 vs. 240 min, p < 0.001), more vascular resections (7.6% vs. 2.7%, p = 0.030), lower conversion rate (4.9% vs. 17.3%, p = 0.001), more major complications (26.2% vs. 16.3%, p = 0.019), improved lymph node yield (18 vs. 16, p = 0.021), and longer hospital stay (10 vs. 8 days, p = 0.001). The 90-day mortality (1.9% vs. 0.7%, p = 0.268) and overall survival (median 28 vs. 31 months, p = 0.599) did not differ significantly between RDP and LDP, respectively.ConclusionsIn selected patients with resectable pancreatic cancer, RDP and LDP provide a comparable R0-resection rate and overall survival in experienced centers. Although the lymph node yield and conversion rate appeared favorable after RDP, LDP was associated with shorter operating time, less major complications, and shorter hospital stay. The specific benefits associated with each approach should be confirmed by multicenter, randomized trials.

Perioperative Outcomes and Long-Term Survival of Laparoscopic Pancreaticoduodenectomy: A Retrospective Study of 653 Cases in a Single Institution.

Introduction: Laparoscopic pancreaticoduodenectomy (LPD) is gaining wide acceptance within pancreatic surgery. However, longitudinal data are lacking. The aim of this study was to analyze and assess the short-term outcomes and long-term survival of LPD over a duration of 8 years. Methods: Patients who underwent LPD in our institution between November 2013 and September 2021 were included in this study. The perioperative outcomes were statistically analyzed. The long-term survival was studied over a median follow-up duration of 13 months. Results: In total, 653 consecutive patients treated at our institution were included, of which 617 cases underwent standard LPD and 36 cases underwent LPD with vascular resection. The rate of death in hospital, reoperation, postpancreatectomy hemorrhage, postoperative pancreatic fistula, and delayed gastric emptying were 4.4%, 10.3%, 11.9%, 12.9%, and 6.1% respectively. There were statistical differences in the intraoperative blood loss and transfusion, operation time, and the R0 resection rate between the LPD cases and LPD with vascular resection cases. A total of 526 cases were pathologically diagnosed of cancer. The 1-, 3-, and 5-year survival rates were 49.2%, 17.9%, and 17.9%, respectively, for pancreatic cancer with the median survival time of 12 months. The 1-, 3-, and 5-year survival rates were 76.9%, 60.8%, and 52.5%, respectively, for bile duct cancer with the median survival time of 35 months. The 1-, 3-, and 5-year survival rates were 80.2%, 62.2%, and 52.9%, respectively, for duodenal cancer with the median survival time of 53 months. The 1-, 3-, and 5-year survival rates were 72.5%, 54.5%, and 50%, respectively, for ampullary cancer with the median survival time of 55 months. Conclusion: LPD is a feasible and oncologically acceptable procedure with satisfying perioperative outcomes and long-term survival in a high-volume institution.

Surgical outcomes after neoadjuvant ablative dose radiation among patients with borderline resectable and locally advanced pancreas cancer from the multi-institutional phase 2 Stereotactic MR-Guided Adaptive Radiation Therapy (SMART) trial.

718 Background: Acute grade 3+ toxicity was rare in the multi-institutional phase 2 stereotactic MR-guided on-table adaptive radiation therapy (SMART) trial (NCT03621644) for locally advanced and borderline resectable pancreatic cancer (LAPC/BRPC). Surgery may be considered after ablative SMART although the feasibility and safety of this is not well understood. Postoperative outcomes of the subset of patients in the SMART trial are examined here. Methods: Trial eligibility included BRPC or LAPC without metastases after a minimum of 3 months of induction chemotherapy. All patients received SMART prescribed to 50 Gy in 5 fractions using an integrated 0.35T MR-radiation therapy device equipped with cutting edge soft tissue tracking, automatic beam gating, and on-table adaptive replanning. Surgery was permitted after SMART, often after multi-disciplinary review. Perioperative details and postoperative outcomes, including morbidity, mortality, and overall survival (OS), were analyzed. Results: 136 patients across 13 sites were enrolled between 2019-2022. 44 patients (32.4%) had surgery after SMART (33 BRPC, 11 LAPC). Surgical procedures included pancreaticoduodenectomy (81.8%), distal pancreatectomy with splenectomy (9.1%), total pancreatectomy (6.8%), and distal pancreatectomy with celiac axis resection (2.3%). 52.3% required vascular resection/reconstruction, a majority of which were venous resections (65.2%), with a smaller proportion needing both venous/arterial (21.7%), or arterial (13%). Surgery was performed after a mean 51.4 ± 52.8 days from SMART. Postoperative hospitalization was 10.5 ± 8.9 days. Nine patients (20.5%) had Clavien-Dindo complications of grade III or higher; 3 deaths resulted from post-pancreatectomy hemorrhage in patients who had portal vein resection. One-year OS in patients who had surgery versus no surgery after SMART was 66% vs. 43%, respectively. Conclusions: These are the first prospectively evaluated surgical outcomes after 5-fraction ablative SMART for BRPC/LAPC. The rate of surgery for BRPC compares favorably to radiated patients on the Alliance A021501 trial. Despite the use of ablative radiation dose and frequent need for vascular resection, the incidence of serious surgical complications was similar to what is reported after non-ablative radiation therapy. However, several deaths occurred after surgery and we therefore we urge caution when considering surgery after ablative radiation therapy. Further analysis of other variables such as the time between SMART and surgery, approaches to vascular resections, and discrete events such as delayed gastric emptying, operative duration, and post-operative pancreatic fistula are needed to better understand the surgical morbidity seen in these patients. Clinical trial information: NCT03621644 .

Laparoscopic Ultrasound-Guided R1 Vascular Liver Resection for Colorectal Liver Metastases at Caval Confluence.

Patients with tumors involving the hepatic vein (HV) at the caval confluence (CC) usually receive major hepatectomies or HV grafting. For colorectal liver metastases (CLM), tumor-vessel detachment (R1vasc) has proven to be oncologically adequate.1-3 However, parenchyma-sparing R1vasc surgery has usually been confined to the open approach. The technical tricks for accomplishing this kind of surgery in laparoscopy are disclosed. A patient with a CLM in contact with the middle HV (MHV) and left HV (LHV) at the CC underwent liver resection. No signs of vascular invasion were observed at preoperative imaging. On the basis of the low rate of tumor-vesselregression after chemotherapy,4 technical feasibility, and low tumor burden, patient was considered for upfront surgery. Surgery consisted in: (1) left liver mobilization with full exposure of the CC; (2) identification of the common trunk's root and its encirclement by tape; (3) the use of ultrasound to rule out HV invasion and to define a resection area favoring a transection plane smoothly approaching the point of vascular contact; and (4) careful vascular detachment by blunt dissection in a caudocranial fashion to separate the lesion from HVs. A limited resection of segments, four superior and two with MHV-LHV detachment, was performed. Operation time was 285min, with 52min of cumulative Pringle time and 20ml of blood loss. Postoperative course was uneventful. The in-hospital stay was 6days. Similarly to open surgery, laparoscopic R1vasc surgery for CLM at CC is feasible and represents an alternative to major hepatectomy. HV control by tape is recommended to manage any bleeding that may occur during tumor-vessel detachment.

Outcomes of Arterial and Caval Resection During Post-Chemotherapy Retroperitoneal Lymph Node Dissection in Metastatic Testicular Cancer

Background/Objective:In the United States, testicular cancer is the most common solid tumor in men aged 15 to 34. Fortunately, testicular cancer has a cure rate greater than 90% and a 97% five-year survival rate. For the men not cured, a relapse to the retroperitoneum (RP) is most common. Of the patients with RP metastases, a minimal number may require post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) with resection of the aorta, external iliac, or inferior vena cava (IVC). We hypothesized this procedure would yield reasonable cure rates with acceptable levels of postoperative complications to warrant the indication for surgery.&#x0D; Methods:Between 2000 and 2020, 2,054 patients with metastatic testicular cancer underwent a PC-RPLND; of those men, 39 also underwent an aortic, external iliac, and/or IVC resection. For the men with a PC-RPLND and vascular resection, demographic, clinical, pathologic, and operative information were reviewed. Next, a Kaplan-Meier curve was created to determine overall survival&#x0D; Results:In this retrospective cohort study of 39 patients, PC-RPLND and vascular resection occurred at a median age of 40. The median follow-up of the cohort was 9 months. The median pre-operative mass size was 9 cm and 19 cm in the RP and pelvis, respectively. At PC-RPLND, 54%, 13%, 18%, and 15% of patients demonstrated cancer, teratoma, teratoma and cancer, and necrosis, respectively. Following PC-RPLND and vascular resection, 22 (56%) patients recurred. The median (IQR) time to relapse was 4.2 (2.5 – 8.2) months. Recurrence to the lung was most common, followed by the RP and liver. In total, 17 (44%) patients died of disease with a median overall survival of 14.8 months.&#x0D; Conclusion:With an overall survival rate of 45% at two years in this heavily pretreated patient population, PC-RPLND with resection of the aorta, external iliac, and/or IVC is reasonable in very select cases.

Pancreatectomy After Neoadjuvant FOLFIRINOX Chemotherapy: Identifying Factors Predicting Long-Term Survival.

We aimed to evaluate the long-term outcomes of the association of neoadjuvant chemotherapy with pancreatectomy with vascular resection in patients with locally advanced pancreatic cancer. Clinical data from patients who underwent pancreatic resection after neoadjuvant FOLFIRINOX were retrospectively reviewed. Cox analyses were used to identify factors prognostic of overall survival (OS). FOLFIRINOX protocol was administered pre-operatively with a median number of nine cycles (range 2-18) in 98 patients. Types of resections included pancreaticoduodenectomy (n = 53), total pancreatectomy (n = 17), and distal spleno-pancreatectomy (n = 28). Venous resection and arterial resections were performed in 85 (86.7%) and 64 patients (65.3%), respectively. The overall 90-day mortality and morbidity rates were 6.1% (n = 6) and 47% (n = 47), respectively. The median OS was 31.08months after surgery. OS rates at one, three, five, and 10years were 82%, 47%, 28%, and 21%, respectively. According to the type of vascular resection, median OS and 5-year survival rates were exclusive venous resection (31.08months; 23%) and arterial resections (24.7months; 27%). Multivariate Cox analysis found lymph node involvement, venous invasion, and total pancreatectomy as independent prognostic factors for OS. According to the presence of 0 or 1-3 risk factors, 5-year survival (85% vs 16%) and median overall survival rates (not reached versus 24.7months, respectively) were statistically significantly different (p < 0.0001). A multimodal treatment, including neoadjuvant FOLFIRINOX combined with pancreatectomy with venous and arterial resection, achieves long term survival rates in patients with locally advanced disease. Surgery, in experienced centers, should be integrated into the treatment of patients with locally advanced pancreatic adenocarcinomas.

The evolution of oncovascular pelvic surgery: A historical perspective

Pelvic exenteration surgery has evolved dramatically in recent decades and now represents the standard of care for many patients with advanced pelvic malignancy. Most recently the use of complex vascular resection and reconstructive techniques have been applied in advanced pelvic oncology surgery at specialist units and these oncovascular techniques are considered one of the frontiers in this field. This article summaries the historical evolution of oncovascular surgery in the pelvis and sets the scene for where this treatment is going. The role of vascular resection and reconstruction in curative treatment of advanced pelvic malignancy is an evolving area that is redefining the boundaries of what was historically thought possible.

Laparoscopic pancreaticoduodenectomy with portal or superior mesenteric vein resection and reconstruction for pancreatic cancer: A single-center experience

BackgroundOpen pancreaticoduodenectomy (OPD) with portal or superior mesenteric vein resection and reconstruction has been applied in pancreatic cancer patients with tumor infiltration or adherence. However, it is controversial whether laparoscopic pancreaticoduodenectomy (LPD) with major vascular resection and reconstruction is feasible. This study aimed to evaluate the safety and feasibility of LPD with major vascular resection compared with OPD with major vascular resection. MethodsWe reviewed data for all pancreatic cancer patients undergoing LPD or OPD with vascular resection at Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, between February 2018 and May 2022. We compared the preoperative, intraoperative, and postoperative clinicopathological data of the two groups to conduct a comprehensive evaluation of LPD with major vascular resection. ResultsA total of 63 patients underwent pancreaticoduodenectomy (PD) with portal or superior mesenteric vein resection and reconstruction, including 25 LPDs and 38 OPDs. The LPD group had less intraoperative blood loss (200 vs. 400 mL, P < 0.001), lower proportion of intraoperative blood transfusion (16.0% vs. 39.5%, P = 0.047), longer operation time (390 vs. 334 min, P = 0.004) and shorter postoperative hospital stay (11 vs. 14 days, P = 0.005). There was no perioperative death in all patients. There was no significant difference in the incidence of total postoperative complications, grade B/C postoperative pancreatic fistula, delayed gastric emptying and abdominal infection between the two groups. No postpancreatectomy hemorrhage nor bile leakage occurred during perioperative period. There was no significant difference in R0 resection rate and number of lymph nodes harvested between the two groups. Patency of reconstructed vessels in the two groups were 96.0% and 92.1%, respectively (P = 0.927). ConclusionsLPD with portal or superior mesenteric vein resection and reconstruction was safe, feasible and oncologically acceptable for selected patients with pancreatic cancer, and it can achieve similar or even better perioperative results compared to open approach.

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

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

Pancreatectomy with vascular resection is not associated with increased mortality

Background: Given increased effectiveness and adoption of neoadjuvant chemotherapy (NAT) for pancreatic adenocarcinoma (PDAC), there has been increased willingness to explore borderline and locally advanced patients for resection that may include venous and/or arterial resection. We hypothesized that with careful patient selection, and a team approach including transplant surgery and vascular surgery, perioperative outcomes would be comparable to reported outcomes. The aim of the study was to examine our recent indications and outcomes for pancreatectomy with vascular resection.

Neoadjuvant chemotherapy prior to vascular resection in pancreaticoduodenectomy for pancreas cancer

Background: Neoadjuvant chemotherapy (NC) is given in pancreatic ductal adenocarcinoma (PDAC) prior to pancreaticoduodenectomy to increase the R0 resection rate and improve survival. Vascular resection (VR) is associated with more aggressive disease and adds considerable morbidity to pancreaticoduodenectomy. This study evaluated the impact of NC and VR on outcomes after pancreaticoduodenectomy.

The infrequent large pelvi-perineal tumors as a surgical dilemma: en bloc resection and long-term results

To assess long-term results of surgical resections of the sporadic extra-large pelvi-perineal soft tissue tumors, a retrospective series of patients referred to the National Cancer Institute 2001–2022 (tertiary care cancer university hospital in Egypt) was designed. Thirteen patients (3 males) averaged age 57 years had large 29 cm (18–38) pelvi-perineal tumors (10 to the paraanal ischiorectal spaces and 3 to the vulva) plus upper intra-abdominal extensions in 9 patients (69%). Symptoms were nonspecific with delayed presentation that averaged 22-month. The entire underwent combined open abdomino-perineal approach to widely en masse resect tumors plus infiltrated organs. No downsizing hormonal treatment was offered preoperative. Main outcome measures were disease free survival, recurrence pattern and salvage. Extensive pelvic and perineal tumor resection is tough and meticulous but straightforward with minor (Clavien-Dindo Classification (CDC) grade I &amp; II) early and delayed morbidity. Resection extends to hysterectomy, vaginectomy and vascular resection. Histopathology plus immunohistochemistry showed 9-aggressive angiomyxoid tumors (AA), 2-fibromatosis and 2-neurofibromas (NF). Margins of resection are all adequate (R0) except for 2 (Resection margin 1 (R1)). After 50-month median follow up, 8/13 total series (61.5%) were surviving free of disease. 4/9 of AA (44%) had local perineal and/or pelvic recurrences (13–37 months) and all were amenable to curative salvage resections; while, 1/2 patients with fibromatosis died of disseminated peritoneal relapses. No systemic metastases are noticed. Extensive tumors meticulous surgery with experienced pelvic dissection and resection could offer alone long term cure even after recurrences with minor morbidity in a good percent. Fertility sparing resection is not oncologically safe because of the frequent uterine and ovarian invasions.

Outcome comparisons of laparoscopic distal pancreatectomy vs open in pancreas cancer

Background: As minimally invasive (MIS) approaches continue to advance within the field of hepato-pancreato-biliary (HPB) surgery, it is imperative to ensure that equivalent oncologic outcomes can be achieved as compared to open surgery. In the setting of left sided pancreatic adenocarcinoma (PDAC), limited long-term data is available regarding the oncologic outcomes of patients undergoing laparoscopic resection, particularly in patients necessitating multivisceral or vascular resection. The purpose of this study was to compare the oncologic outcomes of patients undergoing laparoscopic distal pancreatectomy (LDP) to open distal pancreatectomy (ODP for PDAC.

Vascular reconstructions and transplant technologies in liver surgery (part I)

To systematize technical aspects of liver resections with reconstruction of afferent and efferent liver blood supply and/or inferior vena cava, as well as to analyze the results of surgical treatment in patients with focal liver lesions. The study included 413 patients with parasitic lesions, primary and secondary liver tumors with great vessel invasion (portal vein, hepatic artery, hepatic veins, inferior vena cava, right atrium). These features excluded radical liver resections without vascular resection and reconstruction, as well as liver autotransplantation in vivo, liver autotransplantation ante situ (ex situ in vivo), extracorporeal liver resections with autotransplantation (ex vivo). Surgical interventions were systematized depending of surgical tactics and techniques, technical complexity, type and number of reconstructed vessels, the use of total vascular isolation and cold preservation techniques, resection and reconstruction of great vessels. Thus, 4 gradations were allocated (Grade I-IV). The definition of transplantation technologies in liver surgery was proposed. Transplantation technologies in liver surgery include liver resections supplemented with vascular reconstruction of afferent and efferent liver blood supply, inferior vena cava including total vascular isolation of liver under normo- or hypothermia. These measures can significantly extend the possibilities of resection.