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Maekawa A, Oba A, Inoue Y, Omiya K, Ono Y, Sato T, Watanabe S, Uchino Y, Kobayashi K, Ito H, Sato Y, Tanabe M, Saiura A, Takahashi Y. Technical Strategy for Pancreatic Body Cancers: A Raison d'etre of Distal Pancreatectomy with Portal Resection. Ann Surg Oncol 2024; 31:1347-1357. [PMID: 37952022 DOI: 10.1245/s10434-023-14554-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/22/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Advancements in multiagent chemotherapy have expanded the surgical indications for pancreatic cancer. Although pancreaticoduodenectomy (PD) with portal vein resection (PVR) has become widely adopted, distal pancreatectomy (DP) with PVR remains rarely performed because of its technical complexity. This study was designed to assess the feasibility of DP-PVR compared with PD-PVR for pancreatic body cancers, with a focus on PV complications and providing optimal reconstruction techniques when DP-PVR is necessary. METHODS A retrospective review was conducted on consecutive pancreatic body cancer patients who underwent pancreatectomy with PVR between 2005 and 2020. An algorithm based on the anatomical relationship between the arteries and PV was used for optimal surgical selection. RESULTS Among 119 patients, 32 underwent DP-PVR and 87 underwent PD-PVR. Various reconstruction techniques were employed in DP-PVR cases, including patch reconstruction, graft interposition, and wedge resection. The majority of PD-PVR cases involved end-to-end anastomosis. The length of PVR was shorter in DP-PVR (25 vs. 40 mm; p < 0.001). Although Clavien-Dindo ≥3a was higher in DP-PVR (p = 0.002), inpatient mortality and R0 status were similar. Complete PV occlusion occurred more frequently in DP-PVR than in PD-PVR (21.9% vs. 1.1%; p < 0.001). A cutoff value of 30 mm for PVR length was determined to be predictive of nonrecurrence-related PV occlusion after DP-PVR. The two groups did not differ significantly in recurrence or overall survival. CONCLUSIONS DP-PVR had higher occlusion and postoperative complication rates than PD-PVR. These findings support the proposed algorithm and emphasize the importance of meticulous surgical manipulation when DP-PVR is deemed necessary.
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Affiliation(s)
- Aya Maekawa
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Atsushi Oba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kojiro Omiya
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoshihiro Ono
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takafumi Sato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Shuichi Watanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoshihiro Uchino
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
- Department of Surgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Kosuke Kobayashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hiromichi Ito
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yozo Sato
- Department of Diagnostic Ultrasound and Interventional Radiology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center, Aichi, Japan
| | - Minoru Tanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Akio Saiura
- Department of Hepatobiliary Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.
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2
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Hosokawa I, Kuboki S, Miyazaki M, Ohtsuka M. Portal vein reconstruction using a left renal vein graft in right lobe living donor liver transplantation. Asian J Surg 2023:S1015-9584(22)01807-3. [PMID: 36599724 DOI: 10.1016/j.asjsur.2022.12.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 12/22/2022] [Indexed: 01/03/2023] Open
Affiliation(s)
- Isamu Hosokawa
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan.
| | - Satoshi Kuboki
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Masaru Miyazaki
- Narita Hospital, International University of Health and Welfare, Chiba, Japan; Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Masayuki Ohtsuka
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
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3
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Conticchio M, Salloum C, Allard MA, Golse N, Pittau G, Ciacio O, Vibert E, Sa Cunha A, Cherqui D, Adam R, Azoulay D. The rex shunt for left portal vein reconstruction during hepatectomy for malignancy using of rex-shunt in adults for oncoliver surgery. Surg Endosc 2022; 36:8249-8254. [PMID: 35441315 DOI: 10.1007/s00464-022-09270-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 04/09/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Immediate portal reperfusion is mandatory following hepatectomy combined with portal vein (PV) resection. This retrospective study analyzes the feasibility and the outcomes of the Rex shunt (RS) for reconstruction of the left portal vein (LPV) and reperfusion of the remnant left liver or lobe following hepatectomy for cancer combined with resection of the PV in adult patients. METHODS From 2018 to 2021, an RS was used in the above setting to achieve R0 resection or when the standard LPV reconstruction failed or was deemed technically impossible. RESULTS There were 6 male and 5 female patients (median age, 58 years) with perihilar cancer (5 cases) or miscellaneous cancers invading the PV (6 cases). A major hepatectomy was performed in 10/11 patients. The RS was indicated to achieve R0 resection or for technical reasons in 8 and 3 cases, respectively, and was feasible in all consecutive attempts with (10 cases) or without an interposed synthetic graft (1 case). Two fatal complications (PV thrombosis and pulmonary embolism) and three non-severe complications occurred in four patients within 90 days of surgery. Two patients died of tumor recurrence with a patent RS at 13 and 29 months, and 7 were recurrence free with a patent shunt with a follow-up of 1 to 37 months (median, 15 months). CONCLUSION In case of remnant left liver or lobe following hepatectomy combined with resection of the PV, the RS may help to achieve R0 resection and is a valuable option to perform technically satisfying portal reperfusion of the remnant left liver or lobe.
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Affiliation(s)
- Maria Conticchio
- Centre Hépato-Biliaire, Assistance Publique - Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, 94000, Villejuif, France.,Université Paris-Saclay, Saclay, France
| | - Chady Salloum
- Centre Hépato-Biliaire, Assistance Publique - Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, 94000, Villejuif, France.,Université Paris-Saclay, Saclay, France
| | - Marc Antoine Allard
- Centre Hépato-Biliaire, Assistance Publique - Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, 94000, Villejuif, France.,Université Paris-Saclay, Saclay, France.,Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 935, Villejuif, France
| | - Nicolas Golse
- Centre Hépato-Biliaire, Assistance Publique - Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, 94000, Villejuif, France.,Université Paris-Saclay, Saclay, France.,Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 935, Villejuif, France
| | - Gabriella Pittau
- Centre Hépato-Biliaire, Assistance Publique - Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, 94000, Villejuif, France.,Université Paris-Saclay, Saclay, France.,Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 935, Villejuif, France
| | - Oriana Ciacio
- Centre Hépato-Biliaire, Assistance Publique - Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, 94000, Villejuif, France.,Université Paris-Saclay, Saclay, France.,Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 935, Villejuif, France
| | - Eric Vibert
- Centre Hépato-Biliaire, Assistance Publique - Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, 94000, Villejuif, France.,Université Paris-Saclay, Saclay, France.,Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 935, Villejuif, France
| | - Antonio Sa Cunha
- Centre Hépato-Biliaire, Assistance Publique - Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, 94000, Villejuif, France.,Université Paris-Saclay, Saclay, France.,Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 935, Villejuif, France
| | - Daniel Cherqui
- Centre Hépato-Biliaire, Assistance Publique - Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, 94000, Villejuif, France.,Université Paris-Saclay, Saclay, France.,Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 935, Villejuif, France
| | - René Adam
- Centre Hépato-Biliaire, Assistance Publique - Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, 94000, Villejuif, France.,Université Paris-Saclay, Saclay, France.,Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 935, Villejuif, France
| | - Daniel Azoulay
- Centre Hépato-Biliaire, Assistance Publique - Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, 94000, Villejuif, France. .,Université Paris-Saclay, Saclay, France.
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Balzan SMP, Gava VG, Rieger A, Magalhães MA, Schwengber A, Ferreira F. Falciform ligament tubular graft for mesenteric-portal vein reconstruction during pancreaticoduodenectomy. J Surg Oncol 2021; 125:658-663. [PMID: 34862611 DOI: 10.1002/jso.26762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 11/14/2021] [Accepted: 11/22/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Portal vein resection and reconstruction in locally advanced pancreatic cancer represents a potentially curative treatment in selected patients without increasing surgical mortality. However, vascular reconstruction after segmental venous resection is challenging. The parietal peritoneum has emerged as a venous substitute but few reports include its use as a tubular graft. We report a retrospective series of portal vein reconstruction using a falciform ligament tubular graft during pancreaticoduodenectomy. MATERIAL AND METHODS Technical aspects and short-term morbidity and mortality after pancreaticoduodenectomy with falciform ligament tubular graft interposition were analyzed. RESULTS Among 21 patients who used parietal peritoneum for venous substitution between 2015 and 2019, eight underwent pancreaticoduodenectomy with venous resection and reconstruction using interposition of falciform ligament tubular graft. The mean duration of surgery and clamping time were 350 and 27 min, respectively. No perioperative blood transfusion was required. All the grafts were patent the day after surgery. No complication related to venous obstruction was detected during the hospital stay. Two patients had postoperative pancreatic fistula. No further intervention was needed. The 90-day mortality was null. CONCLUSIONS The use of interposition of falciform ligament tubular graft for portal venous reconstruction during pancreaticoduodenectomy seems to be a reliable, inexpensive, and safe procedure.
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Affiliation(s)
- Silvio M P Balzan
- Postgraduate Program in Health Promotion (PPGPS), University of Santa Cruz do Sul (UNISC), Santa Cruz do Sul, Brazil.,Cancer League, Life Sciences Department, University of Santa Cruz do Sul (UNISC), Santa Cruz do Sul, Brazil.,Oncology Center Lydia Wong Ling, Moinhos de Vento Hospital, Porto Alegre, Brazil.,Surgical Department, Ana Nery Hospital, Santa Cruz do Sul, Brazil
| | - Vinicius G Gava
- Oncology Center Lydia Wong Ling, Moinhos de Vento Hospital, Porto Alegre, Brazil
| | - Alexandre Rieger
- Postgraduate Program in Health Promotion (PPGPS), University of Santa Cruz do Sul (UNISC), Santa Cruz do Sul, Brazil.,Cancer League, Life Sciences Department, University of Santa Cruz do Sul (UNISC), Santa Cruz do Sul, Brazil
| | | | - Alex Schwengber
- Surgical Department, Ana Nery Hospital, Santa Cruz do Sul, Brazil
| | - Fagner Ferreira
- Surgical Department, Ana Nery Hospital, Santa Cruz do Sul, Brazil
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Garnier J, Traversari E, Ewald J, Marchese U, Delpero JR, Turrini O. Venous Reconstruction During Pancreatectomy Using Polytetrafluoroethylene Grafts: A Single-Center Experience with Standardized Perioperative Management. Ann Surg Oncol 2021; 28:5426-5433. [PMID: 33655364 DOI: 10.1245/s10434-021-09716-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/26/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Although primary end-to-end anastomosis is preferred for portal vein-superior mesenteric vein (PV-SMV) reconstruction, interposition graft use may be required in some situations. We investigated the efficacy of polytetrafluoroethylene (PTFE) grafts when used during pancreatectomy in this context. METHODS From 2014 to 2019, 19 patients who underwent pancreatectomy requiring PV-SMV reconstruction using ringed PTFE grafts were entered prospectively into a clinical database (NCT02871336, CNIL No. Sy50955016U). Unfractionated heparin was used during the first 24 h postoperatively. The administration of low-molecular-weight heparin was initiated twice a day (two injections of 1 mg/kg enoxaparin) on postoperative day 2 and was continued until the first clinical follow-up. Patency was assessed by CT scan before home discharge. Patients were switched to antiplatelet therapy (75 mg of aspirin-based drug Kardegic®) without a deadline. RESULTS Pancreatoduodenectomy was the most commonly performed procedure (15 patients, 79%), and pancreatic duct adenocarcinoma was the predominant etiology (17 patients, 89%). The median PTFE graft diameter and length were 10 mm and 8 cm, respectively. The median clamping time was 25 min. The overall severe morbidity and 90-day mortality values were 21% and 10%, respectively. None of the patients experienced anticoagulation-related morbidity or PTFE graft-related infection. The 6-month PTFE graft patency rate was 68%. Patients who underwent distal pancreatectomy showed a higher late thrombosis rate than those who underwent a pancreaticoduodenectomy (50% vs. 8%, p = 0.049). The median long-term PTFE graft patency duration was 37 months. CONCLUSIONS PTFE reconstruction can be safely performed with simple perioperative management in cases requiring interposition graft use.
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Affiliation(s)
- Jonathan Garnier
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France.
| | - Eddy Traversari
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Jacques Ewald
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Ugo Marchese
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Jean-Robert Delpero
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Olivier Turrini
- Department of Surgical Oncology, CRCM, Institut Paoli-Calmettes, Aix-Marseille University, Marseille, France
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6
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Cao MT, Higuchi R, Yazawa T, Uemura S, Izumo W, Matsunaga Y, Sato Y, Morita S, Furukawa T, Egawa H, Yamamoto M. Narrowing of the remnant portal vein diameter and decreased portal vein angle are risk factors for portal vein thrombosis after perihilar cholangiocarcinoma surgery. Langenbecks Arch Surg 2021; 406:1511-1519. [PMID: 33409580 DOI: 10.1007/s00423-020-02044-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 11/24/2020] [Indexed: 12/20/2022]
Abstract
PURPOSE To evaluate the incidence, risk factors, management options, and outcomes of portal vein thrombosis following major hepatectomy for perihilar cholangiocarcinoma. METHODS A total of 177 perihilar cholangiocarcinoma patients who (1) underwent major hepatectomy and (2) underwent investigating the portal vein morphology, which was measured by rotating the reconstructed three-dimensional images after facilitating bone removal using Aquarius iNtuition workstation between 2002 and 2018, were included. Risk factors were evaluated using the Kaplan-Meier method and Cox proportional hazard models. RESULTS Six patients developed portal vein thrombosis (3.4%) within a median time of 6.5 (range 0-22) days. Portal vein and hepatic artery resection were performed in 30% and 6% patients, respectively. A significant difference in the probability of the occurrence of portal vein thrombosis (PV) within 30 days was found among patients with portal vein resection, a postoperative portal vein angle < 100°, remnant portal vein diameter < 5.77 mm, main portal vein diameter > 13.4 mm, and blood loss (log-rank test, p = 0.003, p = 0.06, p < 0.0001, p = 0.01, and p = 0.03, respectively). Decreasing the portal vein angle and narrowing of the remnant PV diameter remained significant predictors on multivariate analysis (p = 0.027 and 0.002, respectively). Reoperation with thrombectomy was performed in four patients, and the other two patients were successfully treated with anticoagulants. All six patients subsequently recovered and were discharged between 25 and 70 days postoperatively. CONCLUSION Narrowing of the remnant portal vein diameter and a decreased portal vein angle after major hepatectomy for perihilar cholangiocarcinoma are significant independent risk factors for postoperative portal vein thrombosis.
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Affiliation(s)
- Manh-Thau Cao
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.,Department of Oncology, Viet Duc University Hospital, 40 Trang Thi, Hang Bong, Hoan Kiem, Hanoi, 100000, Vietnam
| | - Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Takehisa Yazawa
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Shuichiro Uemura
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Wataru Izumo
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Yutaro Matsunaga
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Yasuto Sato
- Department of Public Health, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Satoru Morita
- Department of Diagnostic Imaging & Nuclear Medicine, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Toru Furukawa
- Department of Histopathology, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai, Japan
| | - Hiroto Egawa
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Masakazu Yamamoto
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
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A Novel Cardiovascular Prosthesis Made from Woven Ultrahigh-Molecular-Weight Polyethylene Fibers, Proof of Concept in a Sheep Model. Ann Vasc Surg 2018; 52:244-254.e1. [DOI: 10.1016/j.avsg.2018.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 04/23/2018] [Accepted: 04/25/2018] [Indexed: 11/24/2022]
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