Surgical strategies for restoring liver arterial perfusion in pancreatic resections

Intraoperative celiac axis flow measurement and dynamic surgical strategies in robotic distal pancreatectomy

Locally advanced pancreatic ductal adenocarcinoma (LA-PDAC) involving the body and neck of the pancreas often necessitates complex resections in selected cases, such as the Appleby procedure, also known as distal pancreatectomy with en bloc celiac axis resection (DP-CAR). A 75-year-old female with LA-PDAC, confirmed by endoscopic ultrasound-guided biopsy and treated with neoadjuvant chemotherapy, was initially planned for a robotic DP-CAR. During surgery, transit-time flow measurement (TTFM) showed an inverted and threefold increase in the gastroduodenal artery flow after clamping of the common hepatic artery (CHA), ensuring adequate liver perfusion and avoiding unnecessary preoperative CHA embolization to enhance collateral arterial circulation to the liver. Intraoperative findings revealed only fibrosis without evidence of tumor infiltration around the celiac axis, as confirmed by intraoperative frozen sections. This led to a shift from the planned DP-CAR procedure to an anterior radical antegrade modular pancreatosplenectomy (RAMPS). Final histopathological examinations revealed chronic pancreatitis and complete tumor regression (tumor regression grade 0, ypT0N0). This case underscores the role of robotic platforms and intraoperative tools like TTFM in real-time decision making, enabling tailored surgical strategies for complex pancreatic resections, ensuring oncological adequacy, and optimizing patient outcomes.

Technical Implications for Surgical Resection in Locally Advanced Pancreatic Cancer

Pancreatic ductal adenocarcinoma remains a global health challenge and is predicted to soon become the second leading cause of cancer death in developed countries. Currently, surgical resection in combination with systemic chemotherapy offers the only chance of cure or long-term survival. However, only 20% of cases are diagnosed with anatomically resectable disease. Neoadjuvant treatment followed by highly complex surgical procedures has been studied over the last decade with promising short- and long-term results in patients with locally advanced pancreatic ductal adenocarcinoma (LAPC). In recent years, a wide variety of complex surgical techniques that involve extended pancreatectomies, including portomesenteric venous resection, arterial resection, or multi-organ resection, have emerged to optimize local control of the disease and improve postoperative outcomes. Although there are multiple surgical techniques described in the literature to improve outcomes in LAPC, the comprehensive view of these strategies remains underdeveloped. We aim to describe the preoperative surgical planning as well different surgical resections strategies in LAPC after neoadjuvant treatment in an integrated way for selected patients with no other potentially curative option other than surgery.

How to deal with hepatic artery injury during pancreaticoduodenectomy. A systematic review

BACKGROUND

Operative injury to the hepatic artery is a serious complication of pancreaticoduodenectomy and guidelines to manage this complication are lacking.

METHODS

A systematic search performed in PubMed database identified eleven studies overall including 20 patients having sustained injury to the hepatic artery during pancreaticoduodenectomy (n=18) or total pancreatectomy (n=2). One further unpublished personal observation following pancreaticoduodenectomy was also included.

RESULTS

Sixteen of 21 patients (76%) experienced serious complications including liver necrosis/abscess (n=14), acute liver failure (n=3), and biliary anastomotic dehiscence (n=6). Eleven patients (52%) were reoperated and 5 patients died (24%). Arterial injury was recognized and repaired immediately in five patients, four recovering uneventfully and one dying from acute liver failure (20%). In contrast delayed or conservative treatment in 16 patients was associated with serious early morbidity in 15 patients (94%), leading to death in 4 patients and late biliary complications in four others.

CONCLUSIONS

Accidental interruption of arterial flow to the liver during pancreaticoduodenectomy often results in serious short and long-term consequences. Immediate restoration of arterial flow is indicated whenever technically feasible and may prevent early life-threatening complications as well as late biliary stenosis.