Parietal Peritoneum as an Autologous Substitute for Venous Reconstruction in Hepatopancreatobiliary Surgery

A contemporary view on vascular resections and reconstruction during hepatectomies

Oncological hepatic surgery carries the possibility to perform vascular reconstructions for advanced tumours with vessel invasion since surgery often represents the only potentially curative approach for these tumours. An extended review was conducted in an attempt to understand and clarify the latest trends in hepatectomies with vascular resections. We searched bibliographic databases including PubMed, Scopus, references from bibliographies and Cochrane Library. Information and outcomes from worldwide clinical trials were collected from qualified institutions performing hepatectomies with vascular resection and reconstruction. Careful patient selection and thorough preoperative imaging remain crucial for correct and safe surgical planning. A literature analysis shows that vascular resections carry different indications in different diseases. Despite significant advances made in imaging techniques and technical skills, reports of hepatectomies with vascular resections are still associated with high postoperative morbidity and mortality. The trend of complex liver resection with vascular resection is constantly on the increase, but more profound knowledge as well as further trials are required. Recent technological developments in multiple fields could surely provide novel approaches and enhance a new era of digital imaging and intelligent hepatic surgery.

Ex vivo resection, vessel reconstruction and liver autotransplantation for cholangiocarcinoma: A report of two cases

PURPOSE

Ex vivo liver resection and autotransplantation (ERAT) can be used to treat locally advanced tumors that are conventionally unresectable. Because the procedure is rare, there are very few reports in the literature. Recently, we performed ERAT for two cases of cholangiocarcinoma invading caudate lobe, the retrohepatic vena cava and hepatic veins, and investigated technical variations of this procedure.

METHODS

One patient was a 57-year-old man with liver caudate lobe metastasis from cholangiocarcinoma after pancreaticoduodenal resection five years ago, and the other patient was a 68-year-old man with caudate lobe cholangiocarcinoma. Both cases were considered to be unresectable by conventional resection due to the critical invasion of the retrohepatic vena cava along with the three hepatic veins. Therefore, ERAT was indicated in these two cases.

RESULTS

The liver along with the retrohepatic vena cava was removed, which was replaced by GORE-TEX synthetic artificial vessel grafts with angioplasty to reconstruct the inferior vena cava (IVC), and the GORE-TEX synthetic artificial vessel anastomosed to the right auricular appendage or the IVC to build the continuity of the IVC. Ex vivo caudate lobe hepatectomy was performed, along with the retrohepatic vena cava and hepatic veins, and subsequently the reconstruction outflow of hepatic venous was established using cold-preserved allogeneic vessels and falciform ligament. Finally, remnant of the liver was implanted by Piggyback liver transplantation. The hepatic vein, portal vein, hepatic artery and bile duct were anastomosed, and autotransplantation of the liver was completed. The patients were followed-up for 18 months and showed good liver function, with no recurrence of cancer.

CONCLUSIONS

ERAT should be considered as a therapeutic option for selected patients with cholangiocarcinoma invading caudate lobe, the retrohepatic vena cava and hepatic veins. It is crucial to reconstruct the outflow of hepatic venous according to different situations.

Percutaneous transhepatic stenting for acute superior mesenteric vein stenosis after pancreaticoduodenectomy with portal vein reconstruction: A case report

BACKGROUND

Percutaneous transhepatic stent placement has become a common strategy for the postoperative treatment of portal vein (PV)/superior mesenteric veins (SMV) stenosis/occlusion. It has been widely used after liver transplantation surgery; however, reports on stent placement for acute PV/SMV stenosis after pancreatic surgery within postoperative 3 d are rare.

CASE SUMMARY

Herein, we reported a case of intestinal edema and SMV stenosis 2 d after pancreatic surgery. The patient was successfully treated using stent grafts. Although the stenosis resolved after stent placement, complications, including bleeding, pancreatic fistula, bile leakage, and infection, made the treatment highly challenging. The use of anticoagulants was adjusted multiple times to prevent venous thromboembolism and the risk of bleeding. After careful treatment, the patient stabilized, and stent placement effectively managed postoperative PV/SMV stenosis.

CONCLUSION

Stent placement is effective and feasible for treating acute PV/SMV stenosis after pancreatic surgery even within postoperative 3 d.

Inferior vena cava reconstruction with non-fascial autologous peritoneum: Retrospective study and literature review

BACKGROUND

Inferior vena cava (IVC) resection is essential for complete (R0) excision of some malignancies. However, the optimal material for IVC reconstruction remains unclear. Our objective is to demonstrate the efficacy, safety, and advantages of using Non-Fascial Autologous Peritoneum (NFAP) for IVC reconstruction. To conduct a literature review of surgical strategies for tumors involving the IVC.

METHODS

We reviewed all IVC reconstructions performed at our institution between 2015 and 2023. Preoperative, operative, postoperative, and follow-up data were collected and analyzed.

RESULTS

A total of 33 consecutive IVC reconstructions were identified: seven direct sutures, eight venous homografts (VH), and 18 NFAP. With regard to NFAP, eight tubular (mean length, 12.5 cm) and 10 patch (mean length, 7.9 cm) IVC reconstructions were performed. Resection was R0 in 89% of the cases. Two patients had Clavien-Dindo grade I complications, 2 grade II, 2 grade III and 2 grade V complications. The only graft-related complication was a case of early partial thrombosis, which was conservatively treated. At a mean follow-up of 25.9 months, graft patency was 100%. There were seven recurrences and six deaths. Mean overall survival (OS) was 23.4 months and mean disease-free survival (DFS) was 14.4 months. According to our results, no statistically significant differences were found between NFAP and VH.

CONCLUSIONS

NFAP is a safe and effective alternative for partial or complete IVC reconstruction and has many advantages over other techniques, including its lack of cost, wide and ready availability, extreme handiness, and versatility. Further comparative studies are required to determine the optimal technique for IVC reconstruction.

Resection and reconstruction of the largest abdominal vein system (the inferior vena cava, hepatic, and portal vein): a narrative review

BACKGROUND AND OBJECTIVE

As tumors invade major abdominal veins, surgical procedures are transformed from simple and basic to complicated and challenging. In this narrative review, we focus on what is currently known and not known regarding the technical aspects of major abdominal venous resection and its reconstruction, patency, and oncologic benefit in a cross-cutting perspective.

METHODS

A systematic literature search was performed in PubMed and Semantic Scholar from inception up to October 18, 2023. We reviewed 106 papers by title, abstract, and full text regarding resection or reconstruction of the inferior vena cava, hepatic vein confluence, portal vein (PV), and middle hepatic vein (MHV) tributaries in living donor liver transplantation (LDLT) in a cross-cutting perspective.

KEY CONTENT AND FINDINGS

The oncologic benefit of aggressive hepatic vein resection with suitable reconstruction against adenocarcinoma remains unclear, and further studies are required to clarify this point. A superior mesenteric/PV resection is now a universal, indispensable, and effective procedure for pancreatic ductal adenocarcinoma. Although many case series using tailor-made autologous venous grafts have been reported, not only size mismatch but also additional surgical incisions and a longer operation time remain obstacles for venous reconstruction. The use of autologous alternative tissue remains only an alternative procedure because the patency rate of customized tubular conduit type to interpose or replace the resected vein is not known. Unlike arterial replacement, venous replacement using synthetic vascular grafts is still rarely reported and there are several inherent limitations except for reconstruction of tributaries of MHV in LDLT.

CONCLUSIONS

Various approaches to abdominal vein resection and replacement or reconstruction are technically feasible with satisfactory results. Synthetic vascular grafts may be appropriate but have a certain rate of complications.

The role of vascular resection and reconstruction in pancreaticoduodenectomy

Pancreaticoduodenectomy (PD) is one of the most difficult procedures in general surgery which involves the removal and reconstruction of many organs. PD is the standard surgical method for malignant tumors of the head, uncinate process and even the neck of the pancreas. During PD surgery, it often involves the removal and reconstruction of blood vessels. This is a clinical review about vascular resection and reconstruction in PD surgery.

Parietal Peritoneum Interposition Tube Graft as an Autologous Substitute for the Reconstruction of Inferior Vena cava Following Resection of Retroperitoneal Sarcoma

Complete resection of large retroperitoneal tumors often requires vascular resection and reconstruction, which is frequently performed using prosthetic grafts. We report our experience with inferior vena cava reconstruction utilizing a large peritoneal interposition tube graft performed during en bloc resection of retroperitoneal sarcoma and multiorgan resection. This study aimed to increase the awareness of surgical oncologists about the venous reconstruction technique using a large autologous peritoneal graft. An elderly male presented to our cancer center with a history of persistent abdominal pain. The computed tomography (CT) scan reported a large retroperitoneal mass involving the right kidney and the inferior vena cava (IVC). En bloc tumor resection with right nephrectomy and resection of the IVC extending from just above the bifurcation up to the origin of the renal veins was done. IVC reconstruction was performed using autologous parietal peritoneum tube graft. Harvesting the peritoneum and fashioning a large peritoneal tube graft was challenging. Post-operatively, the patient recovered without any complications and was discharged on oral anticoagulants. The CT scan during the follow-up visit at 6 months revealed that the IVC graft was patent with a good flow. Autologous peritoneal grafts are a safe, valid, and readily available option for venous reconstruction.

Agenesis of Dorsal Pancreas and Solid Pseudopapillary Tumor: Ventral Pancreas Preserving Portal Vein Resection and Reconstruction Using a Peritoneal Graft

A diabetic lady in her 40s was referred to surgical oncologists with epigastric pain associated with vomiting. Computed Tomography (CT) Abdomen with contrast demonstrated a mass arising from the head of the pancreas with the absence of dorsal pancreas, confirmed on magnetic resonance cholangio-pancreatography (MRCP). A core needle biopsy was done, and the tumor was revealed to be a solid pseudopapillary epithelial neoplasm. She underwent sub-total pancreatectomy preserving the duodenum and ventral pancreas as there was adequate free margin; however due to the tumor abutting the anterior wall of the portal vein, it was resected, and reconstruction was done using a peritoneal graft. The patient made a good recovery without any significant post-operative events.

Peritoneal patch in vascular reconstruction during pancreaticoduodenectomy for pancreatic cancer: a single Centre experience

BACKGROUND

Concomitant venous resection during pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma with mesenterico-portal vein involvement is increasingly performed to achieve oncological resection. This study aims to report a single centre experience in peritoneal patch (PP) as autologous graft for vascular reconstruction (VR) during PD.

METHODS

A retrospective analysis of all patients who underwent PD + VR with PP between December 2019 and September 2020 was performed, using a prospective collected database. Postoperative outcome and pathological margins were evaluated. Venous patency was assessed by computed tomography at day 7 and week 12 post surgery.

RESULTS

Fifteen patients underwent PD + VR with PP reconstruction for pancreatic cancer, including one total pancreatectomy. VR consisted of lateral (n = 14) or tubular (n = 1) patch. The median PP length was 30 mm [26.3-33.8] and venous clamping time 30 min [27.5-39.0]. Computed tomography showed a patent VR in 93.3% and 53.3% after 7 days and 12 weeks, respectively; venous patency loss was always asymptomatic. The only postoperative VR-related complication was one mesenteric venous thrombosis. Five other patients experienced VR-unrelated complications: septic shock (n = 3), biliary fistula (n = 1) and post-traumatic subdural hematoma (n = 1). Mortality was nihil. At pathology, R0 resection (≥1 mm) was observed in 40.0% (6/15), venous margin was free in 46.7% (7/15), and venous wall was involved in 40.0% (6/15).

CONCLUSIONS

Use of PP as venous substitute during PD + VR is safe and feasible with an acceptable postoperative morbidity, and a decreased but asymptomatic venous patency after 12 weeks which should question the role of anticoagulation therapy.

Total portal vein replacement with peritoneal interposition graft during Whipple's procedure for extrahepatic cholangiocarcinoma: a technical report

BACKGROUND

Aggressive surgical resection in locally advanced hepatopancreatobiliary (HPB) malignancies is frequently advocated as the only potentially curative treatment. In recent years, advances in chemotherapy regimens and surgical techniques have led to improved oncologic outcomes and overall survival, by increasing the rates of radical (R0) resections. Vascular resections are increasingly reported to further increase disease clearance rates. Within this perspective, the issue of vascular reconstruction has raised growing interest, drawing particular attention to vascular substitutes and surgical techniques for reconstruction.

CASE PRESENTATION

A case of extrahepatic cholangiocarcinoma with high clinical suspicion of vascular infiltration of the portal trunk at preoperative assessment is reported. An autologous interposition graft, harvested from diaphragmatic peritoneum, was chosen as a vascular substitute leading to successful portal trunk reconstruction and overcoming all possible drawbacks associated with cadaveric and artificial grafts reconstructions.

CONCLUSION

This solution was strategic to ensure complete oncologic clearance averting the risk of positive margins (R1) at final pathology.

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.

Tips and tricks for robotic pancreatoduodenectomy with superior mesenteric/portal vein resection and reconstruction

BACKGROUND

Open pancreatoduodenectomy with vein resection (OPD-VR) is now standard of care in patients who responded to neoadjuvant therapies. Feasibility of robotic pancreatoduodenectomy (RPD) with vein resection (RPD-VR) was shown, but no study provided a detailed description of the technical challenges associated with this formidable operation. Herein, we describe the trips and tricks for technically successful RPD-VR.

METHODS

The vascular techniques used in RPD-VR were borrowed from OPD-VR, as well as from our experience with robotic transplantation of both kidney and pancreas. Vein resection was classified into 4 types according to the international study group of pancreatic surgery. Each type of vein resection was described in detail and shown in a video.

RESULTS

Between October 2008 and November 2021, a total of 783 pancreatoduodenectomies were performed, including 233 OPDs-VR (29.7%). RPD was performed in 256 patients (32.6%), and RPDs-VR in 36 patients (4.5% of all pancreatoduodenectomies; 15.4% of all pancreatoduodenectomies with vein resection; 14.0% of all RPDs). In RPD-VR vein resections were: 4 type 1 (11.1%), 10 type 2 (27.8%), 12 type 3 (33.3%) and 10 type 4 (27.8%). Vascular patches used in type 2 resections were made of peritoneum (n = 8), greater saphenous vein (n = 1), and deceased donor aorta (n = 1). Interposition grafts used in type 4 resections were internal left jugular vein (n = 8), venous graft from deceased donor (n = 1) and spiral saphenous vein graft (n = 1). There was one conversion to open surgery (2.8%). Ninety-day mortality was 8.3%. There was one (2.8%) partial vein thrombosis, treated with heparin infusion.

CONCLUSIONS

We have reported 36 technically successful RPDs-VR. We hope that the tips and tricks provided herein can contribute to safer implementation of RPD-VR. Based on our experience, and according to data from the literature, we strongly advise that RPD-VR is performed by expert surgeons at high volume centers.

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.

In situ repair or reconstruction of the abdominal aorta-iliac artery by autologous fascia-peritoneum with posterior rectus sheath for the treatment of the infected abdominal aortic and iliac artery aneurysms: A case series and literature review

Background

Infected abdominal aortic and iliac artery aneurysms are considered acute and severe diseases with insidious onset, rapid development, and high mortality in vascular surgery. Currently, there is no better treatment, either anatomic or extra-anatomical repair.

Case presentation

From February 2018 to April 2022, 7 patients with infected abdominal aortic and iliac artery aneurysms did not have sufficient autologous venous material for repair. With the consent of the Ethics Committee of the hospital, it uses the autologous peritoneal fascial tissue with rectus sheath to repair or reconstruct the infected vessels in situ. There were 5 cases of infected abdominal aortic aneurysm, 1 case of an infected common iliac aneurysm, and 1 case of the infected internal iliac aneurysm. Aortoduodenal fistula was found in 3 cases, all of them were given duodenal fistula repair and gastrojejunostomy and cholecystostomy. Three cases of infected abdominal aortic aneurysms were repaired with the autologous peritoneal fascial tissue patch, and 2 cases of infected abdominal aortic aneurysms were reconstructed by the autologous peritoneal fascial tissue suture to bifurcate graft in situ, the autologous peritoneal fascial tissue suture reconstructed the rest 2 cases of infected iliac aneurysm to tubular graft in situ. It was essential that Careful debridement of all infected tissue and adequate postoperative irrigation and drainage. Antibiotics were administered perioperatively, and all patients were subsequently treated with long-term antibiotics based on bacterial culture and susceptibility results of infected tissues and blood. All 7 patients had underwent surgery successfully. But there were 2 cases died of anastomotic infection or massive hemorrhage after the operation, the other 5 cases survived. The follow-up time was 2–19 months. The enhanced CT of postoperation showed that the reconstructed arteries were smooth without obvious stenosis or expansion, and no abdominal wall hernia occurred.

Conclusion

In situ repair or reconstruction with autologous peritoneal fascial tissue with rectus sheath is a feasible treatment for the infected aneurysm patients without adequate autologous venous substitute, but it still needs long-term follow-up and a large sample to be further confirmed.

How we do it-the use of peritoneal patches for reconstruction of vena cava inferior and portal vein in hepatopancreatobiliary surgery

PURPOSE

Extended resections in hepatopancreatobiliary (HPB) surgery frequently require vascular resection to obtain tumor clearance. The use of alloplastic grafts may increase postoperative morbidity due to septic or thrombotic complications. The use of suitable autologous venous interponates (internal jugular vein, great saphenous vein) is frequently associated with additional incisions. The aim of this study was to report on our experience with venous reconstruction using the introperative easily available parietal peritoneum, focusing on key technical aspects.

METHODS

All patients who underwent HPB resections with venous reconstruction using peritoneal patches at our department between January 2017 and November 2021 were included in this retrospective analysis with median follow-up of 2 months (IQR: 1-8 months). We focused on technical aspects of the procedure and evaluated vascular patency and perioperative morbidity.

RESULTS

Parietal peritoneum patches (PPPs) were applied for reconstruction of the inferior vena cava (IVC) (13 patients) and portal vein (PV) (4 patients) during major hepatic (n = 14) or pancreatic (n = 2) resections. There were no cases of postoperative bleeding due to anastomotic leakage. Following PV reconstruction, two patients showed postoperative vascular stenosis after severe pancreatitis with postoperative pancreatic fistula and bile leakage, respectively. In patients with reconstruction of the IVC, no relevant perioperative vascular complications occurred.

CONCLUSIONS

The use of a peritoneal patch for reconstruction of the IVC in HPB surgery is a feasible, effective, and low-cost alternative to alloplastic, xenogenous, or venous grafts. The graft can be easily harvested and tailored to the required size. More evidence is still needed to confirm the safety of this procedure for the portal vein regarding long-term results.

Portal vein thrombosis after right hepatectomy: impact of portal vein resection and morphological changes of the portal vein

BACKGROUND

Right hepatectomy occasionally requires portal vein resection (PVR) and causes postoperative portal vein thrombosis (PVT).

METHODS

A total of 247 patients who underwent right hepatectomy were evaluated using a three-dimensional analyzer to identify the morphologic changes in the portal vein (PV). The patients' characteristics were compared between the PVR group (n = 73) and non-PVR group (n = 174), and risk factors for PVT were investigated. The PVR group were subdivided into the wedge resection (WR) group (n = 38) and segmental resection (SR) group (n= 35).

RESULTS

Postoperative PVT occurred in 20 patients (8.1%). Multivariate analyses in all patients revealed that postoperative left PV diameter/main PV diameter (L/M ratio) <0.56 (odds ratio [OR] 4.00, p = 0.009) and PVR (OR 3.31, p = 0.031) were significant risk factors for PVT. In 73 patients who underwent PVR, PVT occurred in 14 (19%) and WR (OR 11.5, p = 0.005) and L/M ratio <0.56 (OR 5.51, p = 0.016) were significant risk factors for PVT.

CONCLUSION

PVR was one of the significant risk factors for PVT after right hepatectomy. SR rather than WR may be recommended for preventing PVT.

Prognostic Analysis of Distal Pancreatectomy for Pancreatic Body and/or Tail Cancer Involving the Portal Vein: Is Pancreatic Body and/or Tail Cancer Involving the Portal Vein Resectable?

OBJECTIVES

To the best of our knowledge, the prognostic impact of distal pancreatectomy (DP) for pancreatic body and/or tail cancer involving portal vein (PV) has not been analyzed.

METHODS

A total of 155 patients with pancreatic body and/or tail cancer who were eligible candidates for resection between 2002 and 2017 were analyzed.

RESULTS

Twenty-seven patients had PV contact ≤180°. Fifteen patients underwent preoperative treatment; finally, 132 patients underwent DP, and 21 underwent DP with celiac axis resection. The overall survival (OS) of the PV contact group (n = 27, median survival time [MST], 25.6 months) was worse than the non-PV contact group (n = 128; MST, 58.4 months; P = 0.002); however, it was better than the unresectable group (MST, 14.2 months; P = 0.011). The OS of the PV contact with preoperative chemotherapy group (MST, not available) was comparable to the non-PV contact group and better than the PV contact without preoperative chemotherapy group (MST, 13.4 months; P = 0.017). The multivariate analysis identified PV contact ( P = 0.046) as one of the independent prognostic factors of OS.

CONCLUSIONS

Pancreatic body and/or tail cancer contact with PV ≤180° should be considered borderline resectable because of poor survival.

Laparoscopic Pancreatoduodenectomy with Resection of the Inferior Vena Cava and Reconstruction with a Peritoneal Patch

BACKGROUND

Laparoscopic resection of the inferior vena cava (IVC) during laparoscopic pancreatoduodenectomy (LPD) has never been described. A 32-year-old male with large solid pseudopapillary neoplasm underwent LPD with resection of the IVC and reconstruction by a peritoneal patch (PP).

METHODS

In this indication, the dissection is achieved by resection of the IVC. Kocher maneuver is difficult owing to the caval invasion, and section of the retroportal lamina tissue, before Kocher maneuver, is needed to control the left side of the IVC. Extended lymphadenectomy is not needed because the risk of lymph node invasion is low, and venous resection may be required for severe tumor adhesions without necessary histological invasion, to avoid tumor rupture at high risk of recurrence.1,2 The IVC was clamped by a laparoscopic vascular clamp and reconstructed (5-6 cm) with a PP.

RESULTS

The operative duration was 430 min, including IVC clamping for 27 min. The outcome was marked by biliary fistula and 24 days of hospital stay. Histology showed 6 cm tumor without histological invasion of the IVC wall. After 15 months of follow-up, there was no recurrence and no stenosis of the IVC. In our experience, reconstruction of the IVC with a PP is a safe procedure, with no PP-related complications and high patency rate (> 90%).3 CONCLUSION: Laparoscopic resection of the IVC is feasible in highly selected centers. The harvesting of the PP is easier than that of other autologous venous grafts, especially when done by the laparoscopic approach.

Vascular Resection in Pancreatectomy-Is It Safe and Useful for Patients with Advanced Pancreatic Cancer?

Pancreatic ductal adenocarcinoma (PDAC) is a lethal disease with poor prognosis and increased incidence. Surgical resection R0 remains the most important treatment to prolong survival in PDAC patients. In borderline and locally advanced cancer, vascular resection and reconstruction during pancreatectomy enables achieving R0 resection. This study is a comprehensive review of the literature regarding the role of venous and arterial resection with vascular reconstruction in the treatment of pancreatic cancer. The literature review is focused on the use of venous and arterial resection with immediate vascular reconstruction in pancreaticoduodenectomy. Different types of venous and arterial resections are widely described. Different methods of vascular reconstructions, from primary vessel closure, through end-to-end vascular anastomosis, to interposition grafts with use autologous veins (internal jugular vein, saphenous vein, superficial femoral vein, external or internal iliac veins, inferior mesenteric vein, and left renal vein or gonadal vein), autologous substitute grafts constructed from various parts of parietal peritoneum including falciform ligament, cryopreserved and synthetic allografts. The most attention was given to the most common venous reconstructions, such as end-to-end anastomosis and interposition graft with the use of an autologous vein. Moreover, we presented mortality and morbidity rates as well as vascular patency and survival following pancreatectomy combined with vascular resection reported in cited articles.

Falciform ligament tubular graft for mesenteric-portal vein reconstruction during pancreaticoduodenectomy

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.

Protective peritoneal patch for arteries during pancreatoduodenectomy: good value for money

PURPOSE

This study proposes and details a simple and inexpensive protective technique of wrapping the hepatic and gastroduodenal artery stumps with a peritoneal patch during pancreatoduodenectomy (PD) in order to decrease post-pancreatectomy hemorrhage (PPH).

METHODS

Among the 85 patients who underwent PD between July 2020 and March 2021, 16 patients with high-risk pancreatic anastomosis received a peritoneal patch. The Updated Alternative Fistula Risk Score (ua-FRS) was calculated. Post-operative pancreatic fistula (POPF) and PPH were diagnosed and graded according to the International Study Group of Pancreatic Surgery. The mortality rate was calculated up to 90 days after PD.

RESULTS

The mean ua-FRS of the 16 patients was 43% (range: 21-63%). Among them, 6 (38%) experienced clinically relevant-POPF, and a PPH was observed in two patients (13%). In these two patients who required re-intervention, the peritoneal patch was remarkably intact, and neither the gastroduodenal stump nor hepatic artery was involved. None of the patients experienced 90-day mortality.

CONCLUSION

Although the outcomes are encouraging, the evaluation of a larger series to assess the effectiveness of the peritoneal protective patch for arteries in a high-risk pancreatic anastomosis is ongoing.

Vascular surgery in liver resection

Vascular surgery in liver resection is a standard part of liver transplantation, but is also used in oncological liver surgery. Malignant liver tumors with vascular involvement have a poor prognosis without resection. Surgery is currently the only treatment to provide long-term survival in advanced hepatic malignancy. Even though extended liver resections are increasingly performed, vascular involvement with need of vascular reconstruction is still considered a contraindication for surgery in many institutions. However, vascular resection and reconstruction in liver surgery-despite being complex procedures-are safely performed in specialized centers. The improvements of the postoperative results with reduced postoperative morbidity and mortality are a result of rising surgical and anesthesiological experience and advancements in multimodal treatment concepts with preconditioning measures regarding liver function and systemic treatment options. This review focuses on vascular surgery in oncological liver resections. Even though many surgical techniques were developed and are also used during liver transplantation, this special procedure is not particularly covered within this review article. We provide a summary of vascular reconstruction techniques in oncological liver surgery according to the literature and present also our own experience. We aim to outline the current advances and standards in extended surgical procedures for liver tumors with vascular involvement established in specialized centers, since curative resection improves long-term survival and shifts palliative concepts to curative therapy.

Vascular Resection for Intrahepatic Cholangiocarcinoma: Current Considerations

Intrahepatic cholangiocarcinoma (iCCA) accounts for approximately 10% of all primary liver cancers. Surgery is the only potentially curative treatment, even in cases of macrovascular invasion. Since resection offers the only curative chance, even extended liver resection combined with complex vascular or biliary reconstruction of the surrounding organs seems justified to achieve complete tumour removal. In selected cases, the major vascular resection is the only change to try getting the cure. The best results are achieved by the referral centre with a wide experience in complex liver surgery, such as ALPPS procedure, IVC resection, and ante-situ and ex-situ resections. However, despite aggressive surgery, tumour recurrence occurs frequently and long-term oncological results are very poor. This suggests that significant progress in prognosis cannot be expected by surgery alone. Instead, multimodal treatment including neoadjuvant chemotherapy, radiotherapy, and subsequent adjuvant treatment for iCCA seem to be necessary to improve results.

Individualized tissue-engineered veins as vascular grafts: A proof of concept study in pig

Personalized tissue engineered vascular grafts are a promising advanced therapy medicinal product alternative to autologous or synthetic vascular grafts utilized in blood vessel bypass or replacement surgery. We hypothesized that an individualized tissue engineered vein (P-TEV) would make the body recognize the transplanted blood vessel as autologous, decrease the risk of rejection and thereby avoid lifelong treatment with immune suppressant medication as is standard with allogenic organ transplantation. To individualize blood vessels, we decellularized vena cava from six deceased donor pigs and tested them for cellular removal and histological integrity. A solution with peripheral blood from the recipient pigs was used for individualized reconditioning in a perfusion bioreactor for seven days prior to transplantation. To evaluate safety and functionality of the individualized vascular graft in vivo, we transplanted reconditioned porcine vena cava into six pigs and analyzed histology and patency of the graft at different time points, with three pigs at the final endpoint 4-5 weeks after surgery. Our results showed that the P-TEV was fully patent in all animals, did not induce any occlusion or stenosis formation and we did not find any signs of rejection. The P-TEV showed rapid recellularization in vivo with the luminal surface covered with endothelial cells. In summary, the results indicate that P-TEV is functional and have potential for use as clinical transplant grafts.

Parietal Peritoneum as a Novel Substitute for Middle Hepatic Vein Reconstruction During Living Donor Liver Transplantation

BACKGROUND

Although autologous, cryopreserved, or artificial vascular grafts can be used as interpositional vascular substitutes for middle hepatic vein (MHV) reconstruction during living donor liver transplantation (LDLT), they are not always available, are limited in size and length, and are associated with risks of infection. This study aimed to evaluate the parietal peritoneum as a novel substitute for MHV reconstruction during LDLT.

METHODS

Prospectively collected data of 15 patients who underwent LDLT using the right liver with reconstruction of MHV using the recipients' own parietal peritoneum graft were retrospectively reviewed.

RESULTS

The 1-, 2-, 3-, and 5-mo patency rates were 57.1%, 57.1%, 57.1%, and 28.6%, respectively. Among the 15 cases assessed, the most recent 6 cases showed patent graft flow until discharge with 1-, 2-, 3-, and 5-mo patency rates of 80.0%, 80.0%, 80.0%, and 20.0%, respectively. All patients survived with tolerable liver function tests. There were no significant congestion-related problems, except for 1 patient who experienced MHV thrombosis requiring aspiration thrombectomy and stent insertion. There were no infection-related complications. All patients survived to the final follow-up, with a minimum follow-up duration of 8 mo. When comparing the latter 6 cases of peritoneal grafts and the recent 28 cases of conventional polytetrafluorethylene graft, the overall patency rate of the polytetrafluorethylene group was higher (P = 0.002). There were no major differences other than long-term patency rate.

CONCLUSIONS

Parietal peritoneum may be a novel autologous substitute for MHV reconstruction during LDLT.

Vascular Involvements in Cholangiocarcinoma: Tips and Tricks

Cholangiocarcinoma (CCA) is an aggressive malignancy of the biliary tract. To date, surgical treatment remains the only hope for definitive cure of CCA patients. Involvement of major vascular structures was traditionally considered a contraindication for resection. Nowadays, selected cases of CCA with vascular involvement can be successfully approached. Intrahepatic CCA often involves the major hepatic veins or the inferior vena cava and might necessitate complete vascular exclusion, in situ hypothermic perfusion, ex situ surgery and reconstruction with autologous, heterologous or synthetic grafts. Hilar CCA more frequently involves the portal vein and hepatic artery. Resection and reconstruction of the portal vein is now considered a relatively safe and beneficial technique, and it is accepted as a standard option either with direct anastomosis or jump grafts. However, hepatic artery resection remains controversial; despite accumulating positive reports, the procedure remains technically challenging with increased rates of morbidity. When arterial reconstruction is not possible, arterio-portal shunting may offer salvage, while sometimes an efficient collateral system could bypass the need for arterial reconstructions. Keys to achieve success are represented by accurate selection of patients in high-volume referral centres, adequate technical skills and eclectic knowledge of the various possibilities for vascular reconstruction.

Feasibility of using the homologous parietal peritoneum as a vascular substitute for venous reconstruction during abdominal surgery: An animal model

BACKGROUND

The interest in vascular substitutes has recently increased. We evaluated the feasibility of using a homologous parietal peritoneum as a vascular substitute for venous reconstruction during abdominal surgery.

METHODS

The inferior vena cava was replaced with a homologous parietal peritoneum after cross-linking with glutaraldehyde in 36 rabbits. At 7, 14, and 28 days, the patency rate, outer and inner graft diameters, histology, and immunohistochemistry were evaluated.

RESULTS

Both the 7- and 14-day groups maintained vascular patency. Vascular patency was maintained in 3 rabbits in the 28-day group. The inner diameters of the anastomotic sites were 6.23 ± 0.18, 5.64 ± 0.16, and 2.34 ± 0.21 mm in the 7-day, 14-day, and 28-day groups, respectively. The midpoint inner diameters of the homologous parietal peritoneum grafts were 624 ± 0.46, 5.74 ± 0.26, and 2.14 ± 0.28 mm in each group, respectively. Endothelial cell proliferation on the homologous parietal peritoneum graft surfaces in all groups was based on the histological findings from the first group. Multiple neovascularizations of the homologous parietal peritoneum graft were found in the 14- and 28-day groups, indicating neo-media formation. Acute inflammation appeared to progress to the entire layer of the homologous parietal peritoneum graft without an intraluminal thrombus, but the graft was patent in the 14-day group. In the 28-day group, 6 rabbits showed near-total occlusion and a thrombus formed in the homologous parietal peritoneum graft at the anastomosis site with severe stricture; however, the rabbits were alive and had collateral vessel formation.

CONCLUSION

Using homologous parietal peritoneum is feasible for venous reconstruction in abdominal surgery.

Complete and partial replacement of the inferior vena cava with autologous peritoneum in cancer surgery

Resection of the inferior vena cava may be required in the courses of oncological surgeries for the tumors originating from or invading it. Management of the remaining defect depends on the extension of the resection. Partial or complete replacement of the inferior vena cava, with a patch or interposition graft, may be required. Standard techniques for the reconstruction with a prosthetic material or the autologous veins can be associated with the prosthetic graft infection, high cost, long-standing anticoagulation, technical difficulties, and/or need for extra incisions. The use of the autologous peritoneum represents an easy and inexpensive alternative for the partial and complete inferior vena cava reconstructions.

Technical advances in surgery for pancreatic cancer

BACKGROUND

Multimodal treatment concepts enhance options for surgery in locally advanced pancreatic ductal adenocarcinoma (PDAC). This review provides an overview of technical advances to facilitate curative-intent resection in PDAC.

METHODS

A review of the literature addressing current technical advances in surgery for PDAC was performed, and current state-of-the-art surgical techniques summarized.

RESULTS

Artery-first and uncinate-first approaches, dissection of the anatomical triangle between the coeliac and superior mesenteric arteries and the portomesenteric vein, and radical antegrade modular pancreatosplenectomy were introduced to enhance the completeness of resection and reduce the risk of local recurrence. Elaborated techniques for resection and reconstruction of the mesenteric-portal vein axis and a venous bypass graft-first approach frequently allow resection of PDAC with venous involvement, even in patients with portal venous congestion and cavernous transformation. Arterial involvement does not preclude surgical resection per se, but may become surgically manageable with recent techniques of arterial divestment or arterial resection following neoadjuvant treatment.

CONCLUSION

Advanced techniques of surgical resection and vessel reconstruction provide a toolkit for curative-intent surgery in borderline resectable and locally advanced PDAC. Effects of these surgical approaches on overall survival remain to be proven with high-level clinical evidence.

The impact of standardized methods of hepatic vein reconstruction with an external iliac vein graft

Background

Liver tumors that invade the hepatic vein are surgically challenging, especially in patients with liver dysfunction. Preservation of as much of the parenchyma as possible is important; thus, when feasible, we perform hepatectomy with hepatic vein reconstruction (HVR) using an external iliac vein (EIV) graft. We conducted a retrospective study to investigate the benefit of HVR and to evaluate our procedure.

Methods

The study included patients treated by hepatectomy with HVR using EIV grafts and vascular clips. We reviewed the surgical outcomes, including total operation and HVR times, postoperative complications, and postoperative liver function.

Results

The surgeries included right HVR (n=13), left HVR (n=3), and middle HVR (n=1). The total operation time was 277±72 minutes (155-400 minutes), and the HVR time was 27±5 minutes (19-40 minutes). Graft patency was confirmed in 14 (82%) of the patients. One patient who underwent HVR with running sutures required emergency surgery due to graft thrombosis. Clavien-Dindo > grade IIIa postoperative complications occurred in 4 (23.5%) patients, but there were no treatment-related deaths.

Conclusions

In conclusion, our hepatic resections with HVR using the same techniques and graft materials showed acceptable surgical outcomes. From our experience, we believe that preparatory hepatic resection with HVR is an effective treatment, especially for patients with decreased liver function or with a small residual liver parenchyma.

Graft type for superior mesenteric and portal vein reconstruction in pancreatic surgery - A systematic review

BACKGROUND

Contemporary practice for superior mesenteric/portal vein (SMV-PV) reconstruction during pancreatectomy with vein resection involves biological (autograft, allograft, xenograft) or synthetic grafts as a conduit or patch. The aim of this study was to systematically review the safety and feasibility of the different grafts used for SMV-PV reconstruction.

METHODS

A systematic search was performed in PubMed and Embase according to the PRISMA guidelines (January 2000-March 2020). Studies reporting on ≥ 5 patients undergoing reconstruction of the SMV-PV with grafts during pancreatectomy were included. Primary outcome was rate of graft thrombosis.

RESULTS

Thirty-four studies with 603 patients were included. Four graft types were identified (autologous vein, autologous parietal peritoneum/falciform ligament, allogeneic cadaveric vein/artery, synthetic grafts). Early and overall graft thrombosis rate was 7.5% and 22.2% for synthetic graft, 5.6% and 11.7% for autologous vein graft, 6.7% and 8.9% for autologous parietal peritoneum/falciform ligament, and 2.5% and 6.2% for allograft. Donor site complications were reported for harvesting of the femoral, saphenous, and external iliac vein. No cases of graft infection were reported for synthetic grafts.

CONCLUSION

In selected patients, autologous, allogenic or synthetic grafts for SMV-PV reconstruction are safe and feasible. Synthetic grafts seems to have a higher incidence of graft thrombosis.

Single-Centre Experience of Supra-Renal Vena Cava Resection and Reconstruction

BACKGROUND

Tumours involving the supra-renal segment of IVC have dismal prognosis if left untreated. Currently, aggressive surgical management is the only potentially curative treatment but is associated with relatively high morbidity and mortality. This study aims to evaluate perioperative factors, associated with adverse postoperative outcomes, based on the perioperative characteristics and type of IVC reconstruction.

METHODS

We identified 44 consecutive patients, who underwent supra-renal IVC resection with a mean age of 57.3 years. Isolated resection of IVC was performed in four patients, concomitant liver resection was performed in 27 patients and other associated resection in 13 patients. Total vascular exclusion was applied in 21 patients, isolated IVC occlusion in 11 patients. Neither venovenous bypass (VVB) nor hypothermic perfusion was used in any of the cases.

RESULTS

The mean operative time was 205 min (150-324 min) and the mean estimated blood loss was 755 ml (230-4500 ml). Overall morbidity was 59% and major complications (Dindo-Clavien ≥ III) occurred in 11 patients (25%). The 90-day mortality was 11% (5pts). Intraoperative haemotransfusion was significantly associated with postoperative general complications (p < 0,001). With a mean follow-up of 26.2 months, the actuarial 1-, 3- and 5-year survival is 69%, 34%, and 16%, respectively.

CONCLUSIONS

IVC resection and reconstruction in the aspect of aggressive surgical management of malignant disease confers a survival advantage in patients, often considered unresectable. When performed in experienced centres it is associated with acceptable morbidity and mortality.

Vascular Resection During Hepatectomy for Liver Malignancies. Results from a Tertiary Center using Autologous Peritoneal Patch for Venous Reconstruction

BACKGROUND

To evaluate early outcomes of venous reconstruction with peritoneal patch (PP) during resection for hepatic malignancies.

METHODS

Since May 2015, PP was considered as the first option for venous reconstruction in the case of lateral resection. Between May 2015 and June 2019, 579 consecutive hepatectomies for malignancies were performed at our institution. Among 27 patients requiring venous resection, PP was used in 22, who were included in the present study. Data from a prospectively collected database were analysed.

RESULTS

Tumour types were ten colorectal metastases (CRLM), six intrahepatic cholangiocarcinomas, four hilar cholangiocarcinomas, one hepatocellular carcinoma and one gallbladder carcinoma. Hepatectomies were major in 50% of cases. Eleven patients had hepatic vein resections, eight portal vein and three inferior vena cava. Venous reconstruction enabled resection in 12 (54.5%) patients, otherwise non-resectable. Among CRLM, the venous reconstruction allowed avoidance of major resection in eight (80%) cases. Median operative time was 456 min (range 270-960). Blood loss was a median 300 cc (range 40-1500), and blood transfusions were required in three patients (13.6%). At pathological examination, venous infiltration was confirmed in 14 (63.6%) patients. No vascular complications related to the patch were recorded. Post-operative major (Dindo III/IV) complications were observed in two (9%) patients. One patient died because of liver failure without vascular thrombosis and one due to biliary fistula complicated by arterial bleeding. Overall, post-operative mortality was 9% (2/22).

CONCLUSIONS

Venous reconstruction with peritoneal patch during hepatectomy for malignancies can feasibly allow resection in otherwise unresectable patients and decrease the rate of major resection in colorectal liver metastases.

What Should Guide the Performance of Venous Resection During Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma with Venous Contact?

Complete surgical resection, most often associated with perioperative chemotherapy, is the only way to offer a chance of cure for patients with pancreatic cancer. One of the most important factors in determining survival outcome that can be influenced by the surgeon is the R0 resection. However, the proximity of mesenteric vessels in cephalic pancreatic tumors, especially the mesenterico-portal venous axis, results in an increased risk of vein involvement and/or the presence of malignant cells in the venous bed margin. A concomitant venous resection can be performed to decrease the risk of a positive margin. Given the additional technical difficulty that this implies, many surgeons seek a path between the tumor and the vein, hoping for the absence of tumor infiltration into the perivascular tissue on pathologic analysis, particularly in cases with administration of neoadjuvant therapy. The definition of optimal surgical margin remains a subject of debate, but at least 1 mm is an independent predictor of survival after pancreatic cancer surgical resection. Although preoperative radiologic assessment is essential for accurate planning of a pancreatic resection, intraoperative decision-making with regard to resection of the mesenterico-portal vein in tumors with a venous contact remains unclear and variable. Although venous histologic involvement and perivascular infiltration are not accurately predictable preoperatively, clinicians must examine the existing criteria and normograms to guide their surgical management according to the integration of new imaging techniques, preoperative chemotherapy use, tumor biology and molecular histopathology, and surgical techniques.

Applications of hepatic round ligament/falciform ligament flap and graft in abdominal surgery-a review of their utility and efficacy

BACKGROUND AND PURPOSE

Despite their ubiquitous presence, easy availability and diverse possibilities, falciform ligament and hepatic round ligament have been used less frequently than their potential dictates. This article aims to comprehensively review the applications of hepatic round ligament/falciform ligament flap and graft in abdominal surgery and assess their utility and efficacy.

METHODS

Medical literature/indexing databases were searched, using internet search engines, for pertinent articles and analysed.

RESULTS

The studied flap and graft have found utility predominantly in the management of diaphragmatic hernias, gastro-oesophageal reflux disease, peptic perforations, biliary reconstruction, venous reconstruction, post-operative pancreatic fistula, post-pancreatectomy haemorrhage, hepatic cyst cavity obliteration, liver bleed, sternal dehiscence, splenectomy, reinforcement of aortic stump, feeding access, diagnostic/therapeutic access into portal system, composite tissue allo-transplant and ventriculo-peritoneal shunting where they have exhibited the desired efficacy.

CONCLUSIONS

Hepatic round ligament/falciform ligament flap and graft are versatile and have multifarious applications in abdominal surgery with some novel and unique uses in hepatopancreaticobiliary surgery including liver transplantation. Their evident efficacy needs wider adoption to realise their true potential.

Feasibility of mesentericoportal vein reconstruction by autologous falciform ligament during pancreaticoduodenectomy-cohort study

BACKGROUND

Mesentericoportal vein (MPV) resection in pancreatic ductal adenocarcinoma (PDAC) surgery has become a common procedure. A few studies had described the use of falciform ligament (FL) for MPV reconstruction and received encouraging preliminary effects.

AIMS

This study was designed to explore the feasibility and efficacy of this technique compared with others.

METHODS

Patients who underwent pancreaticoduodenectomy (PD) with MPV resection for PDAC from 2009 to 2018 were enrolled. Medical records were retrospectively reviewed, MPV reconstructions using FL were distinguished and compared with other techniques.

RESULTS

146 patients underwent MPV reconstruction, and 13 received FL venoplasty. Other reconstruction techniques included primary end-to-end anastomosis (primary, n = 30), lateral venorrhaphy (LV, n = 19), polytetrafluoroethylene conduit interposition (PTFE, n = 24), iliac artery (IA) allografts interposition (n = 47), and portal vein (PV) allografts interposition (n = 13). FL group holds the advantages of shortest operation time (p = 0.023), lowest blood loss (p = 0.109), and shortest postoperative hospital stay (p = 0.125). The grouped patency rates of FL, primary, LV, PTFE, IA, and PV were 100%, 90%, 68%, 54%, 68%, and 85% respectively. Comparison displayed that FL had the highest patency rate (p = 0.008) and lowest antiplatelet/anticoagulation proportion (p = 0.000). Complications and long-term survival were similar among different techniques. The median survival time of patent group (24.0 months, 95% CI: 22.0-26.0) was much longer than that of the thrombosed (17.0 months, 95% CI: 13.7-20.3), though without significant difference (P = 0.148).

CONCLUSIONS

PD with MPV resection and reconstruction by FL is safe, feasible, and efficacious, it might provide a potential benefit for patients.

Staged Double Hepatectomy, Double Total Vascular Exclusion, and Double Venous Reconstruction by Peritoneal Patches in One Patient with Colorectal Liver Metastases

BACKGROUND

Surgical resection is the best treatment for colorectal liver metastases with good response to chemotherapy and in the absence of extrahepatic disease.1 With the amelioration of surgical technique, primary and recurrent colorectal liver metastases with venous invasion can be resected safely under short total vascular exclusion (TVE), and associated right thoracotomy can have a major benefit if resection at the hepato-caval junction is planned.2 The availability of the peritoneum as an autologous graft for venous reconstruction considerably facilitates the task of the surgeon.3 In this video, we present a patient who had staged double liver resection, double TVE, and double venous reconstruction by a peritoneal graft on the vena cava and the hepatic vein.

METHODS

In March 2017, a 47-year-old female was diagnosed with rectal cancer and synchronous liver metastases, microsatellite stability, and Kras mutation. The patient received folinic acid, fluorouracil, and oxaliplatin (FOLFOX) chemotherapy, with good response and a decrease in tumor markers. After chemotherapy, a computed tomography (CT) scan showed one lesion located on the right liver with lateral invasion of the vena cava, and another lesion located in segment I. A liver-first strategy was decided and, in October 2017, the patient had a right hepatectomy extended to segment I and partially on the diaphragm, with lateral resection of the vena cava under isolated clampage of the vena cava and reconstruction with a peritoneal graft (60 mm). The patient received FOLFOX adjuvant chemotherapy for 3 months, and, while under radiotherapy for the rectal cancer, recurrence was diagnosed on the left liver lobe (two lesions), with lateral invasion of the left hepatic vein. Chemotherapy was shifted to folinic acid, fluorouracil, and irinotecan (FOLFIRI)-Avastin, with good response, allowing resection of the primary (T3N0M1), followed by adjuvant chemotherapy. In May 2019, the patient underwent two large resections on the left liver, including one under TVE, with opening of the diaphragm and intrathoracic control of the vena cava. The left hepatic vein was reconstructed laterally with a peritoneal graft (30 mm).

RESULTS

Postoperative outcome was uneventful and the two hospital stays were 12 and 15 days, respectively. For the first hepatectomy, pathological examination showed two lesions (80 and 50 mm) with a residual tumor at 10% and R0 resection, and, for the second resection, pathological examination showed two lesions (18 and 20 mm) with residual tumor at 40-60% and R0 resection. In both cases, the tumor was in contact with the resected vein without wall infiltration. The reconstructed vena cava and hepatic vein were patent without stenosis. The patient is disease-free 3 years after the diagnosis.

CONCLUSION

Improvements in surgical technique combined with short TVE and associated thoracotomy allow some complicated liver resections to be performed safely. The use of the peritoneum for venous reconstruction is of great benefit in relation to safety and availability, especially in 'redo' liver surgery where intense adhesions can be encountered.

Mesoportal bypass, interposition graft, and mesocaval shunt: Surgical strategies to overcome superior mesenteric vein involvement in pancreatic cancer

BACKGROUND

In pancreatic cancer, extensive tumor involvement of the mesenteric venous system poses formidable challenges to operative resection. Such involvement can result from cavernous collateral veins leading to increased intraoperative blood loss or long-segment vascular defects of not only just the superior mesenteric vein but also even jejunal/ileal branches. Strategies to facilitate margin-free resection and safe vascular reconstruction in pancreatic surgery are important, particularly because systemic control of the tumor is improving with multi-agent chemotherapy regimens.

METHODS

We describe a systematic, multidisciplinary assessment for patients with pancreatic cancer that involves the superior mesenteric vein, as well as the preoperative planning of those undergoing operative resection. In addition, detailed descriptions of operative approaches and technical strategies, which evolved with increasing experience at a high-volume center, are presented.

RESULTS

For the preoperative evaluation of tumor-free, vascular locations for potential reconstruction and collateralization, computed tomographic imaging with high-resolution of vascular structures (used with 3-dimensional or cinematic rendering) allows a precise calibration of radiographic data with intraoperative findings. From an operative perspective, we identified 5 potential strategies to consider for resection: collateral preservation, mesoportal bypass (preresection), mesoportal interposition graft (postresection), mesocaval shunt, and various combinations of these strategies. Many of these techniques use interposition grafts, making it essential to assess autologous veins (preferred conduit for reconstruction) or to prepare cryopreserved vascular allografts (an alternative conduit, which must be thawed and should be matched for size and blood type).

CONCLUSION

Herein we share operative strategies to overcome involvement of the superior mesenteric vein in pancreatic cancer. Improvements in preoperative planning and operative technique can address common barriers to resection with curative intent.

Robotic-assisted pancreaticoduodenectomy with vascular resection. Description of the surgical technique and analysis of early outcomes

BACKGROUND

Despite the potential benefits, the adoption of the minimally invasive surgery for the treatment of borderline resectable pancreatic cancer is still in the initial phase. We investigated the safety and feasibility of the robotic pancreaticoduodenectomy with venous resection/reconstruction (RPD SMV/PV).

METHODS

Since March 2013 to October 2019, a total of 73 RPD and 10 RPD SMV/PV were performed. The two groups were case-matched according to the preoperative characteristics.

RESULTS

Mean operative times and estimated blood loss were less in the RPD group in comparison to that in the RPD with SMV-PV group (525 vs 642 min, p = 0.003 and 290 vs 620 ml, p = 0.002, respectively). The mean length of hospital stay was similar in the RPD group in comparison to that in the RPD with SMV-PV group (10 days vs 13 days, p = 0.313). The two groups had similar overall postoperative morbidity rate (57.5% vs 60%, p = 0.686), although the severe complication rate was lower in the RPD group (11% vs 40%, p = 0.004).

CONCLUSIONS

RPD with SMV-PV is associated with increased operative time, estimated blood loss, higher major complication rate compared with RPD.

Glutaraldehyde-fixed parietal peritoneum graft conduit to replace completely the portal vein during pancreaticoduodenectomy: A case report

•

Pancreatic ductal adenocarcinoma often displays major vascular invasion.

•

Portal vein and superior mesenteric artery resection can be performed safely.

•

Venous end-to-end anastomosis is not always feasible during pancreaticoduodenectomy.

•

Directly available peritoneum graft conduit doesn’t require anticoagulation.

•

Glutaraldehyde solidifies and improves handling of peritoneum graft conduit.

Introduction

Combined total portal vein (PV) and superior mesenteric artery (SMA) resection during pancreaticoduodenectomy (PD) is a challenging task that is no longer considered as a contra-indication to achieve R0 in borderline resectable (BR) and locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC).

Presentation of case

We report a 66-year-old female with BR-PDAC of the head of the pancreas in whom PV and SMA were replaced with a glutaraldehyde-fixed autologous peritoneo-fascial graft (APG) and a splenomesenteric arterial bypass, respectively, during the PD.

Discussion

When PV venorraphy or end-to-end anastomosis is not feasible, APG conduit, immediately available without extra-incision, does not need postoperative anticoagulation and is associated with a low risk of infection and thrombosis. If fixed in glutaraldehyde, handling, risk of compression when placed intra-peritoneally and long-term patency of the graft are improved.

Conclusion

Glutaraldehyde-fixed APG is a strategy that every surgeon should bear in mind for PV replacement during PD and other HBP surgical procedures, especially if a vascular resection is unforeseen.

Portal vein stent placement after hepatobiliary and pancreatic surgery

Purpose

To evaluate the long-term outcomes of percutaneous transhepatic stent placement for portal vein (PV) stenosis after liver transplantation (LT) and hepato-pancreato-biliary (HPB) surgery.

Methods

Retrospective study of 455 patients who underwent LT and 522 patients who underwent resection of the pancreatic head between June 2011 and February 2016. Technical success, clinical success, patency, and complications were evaluated for both groups.

Results

A total of 23 patients were confirmed to have postoperative PV stenosis and were treated with percutaneous transhepatic PV stent placement. The technical success rate was 100%, the clinical success rate was 80%, and the long-term stent patency was 91.3% for the entire study population. Two procedure-related hemorrhages and two early stent thromboses occurred in the HPB group while no complications occurred in the LT group. A literature review of selected studies reporting PV stent placement for the treatment of PV stenosis after HPB surgery and LT showed a technical success rate of 78–100%, a clinical success rate of 72–100%, and a long-term patency of 57–100%, whereas the procedure-related complication rate varied from 0–33.3%.

Conclusions

Percutaneous transhepatic PV stent is a safe and effective treatment for postoperative PV stenosis/occlusion in patients undergoing LT regardless of symptoms. Due to increased risk of complications, the indication for percutaneous PV stent placement after HPB surgery should be limited to patients with clinical symptoms after an individual assessment.

Case series of extended liver resection associated with inferior vena cava reconstruction using peritoneal patch

INTRODUCTION

Among various reported techniques for inferior vena cava (IVC) reconstruction, the superiority of one technique over another has not been clearly established. This study aimed at reporting the technical aspects of caval reconstruction using peritoneal patch during extended liver resections.

METHODS

All consecutive patients who underwent extended liver resection associated with anterolateral caval reconstruction using a peritoneal patch from 2016 to 2019 were included in this study. Technical insights, intra-operative details, short and long-term results were reported.

RESULTS

Overall six patients underwent caval reconstruction using peritoneal patch under total vascular exclusion. Half of them required veno-venous bypass. Caval involvement ranged from 30 to 50% of the circumference and from 5 to 7 cm of the length of the IVC. Caval reconstructions was performed using a peritoneal patch harvested from the falciform ligament in four cases and from the right pre-renal peritoneum and right part of the diaphragm in one Case each. Three cases underwent associated reimplantation the remnant hepatic vein. Median intra-operative blood loss and TVE duration were 500 ml and 41 min, respectively. One case experienced a severe complication (liver failure leading to death). R₀ resection was achieved in all patients. All patients had patent IVC and remnant hepatic vein at last follow-up and none was on long-term therapeutic anticoagulation.

CONCLUSION

Caval reconstruction using a peritoneal patch in patients undergoing extended liver resection is feasible and cost-effective and associated with excellent long-term results.

Inferior vena cava resection and reconstruction with a peritoneal patch for a leiomyosarcoma: A case report

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Leiomyosarcoma of the inferior vena cava are very rare neoplasm with a limited responsiveness to medical therapy.

•

Surgery seems to be the only chance of cure.

•

Complex vascular resection are often necessary and required accurate reconstruction technique.

•

Peritoneal patch is an efficient and safe option to repair venous defects and it is gaining great attention in recent years.

Introduction

Leiomyosarcomas (LMs) of the inferior vena cava (IVC) are very rare neoplasms seldom reported in the literature. The majority of patients does not present with specific abdominal pain and IVC LMs are used to become symptomatic with the increase of tumor volume. The role of chemotherapy or radiotherapy is not yet defined and surgical resection seems to be the only chance to improve survival rates.

Presentation of case

We present a case of a 58-year-old female with a recent diagnosis of IVC LM who underwent surgery with a partial resection of the anterior wall of the vein using a lateral and partial vein clamping. The primary repair of the defect could result in stricture of the vein, so a parietal peritoneum patch was used for the vein reconstruction. The postoperative course was uneventful.

Discussion

Actual evidence suggests that vascular sarcomas have limited responsiveness to cytotoxic chemotherapy and chemoradiotherapy, so surgery is the treatment of choice. Major surgery entailing multivisceral and complex vascular resection is usually necessary to achieve negative margins and accurate vascular reconstruction techniques are mandatory to avoid serious circulatory complications. Different kinds of graft (biological or synthetics) are available for the reconstruction, with intrinsic advantages and limitations. The use of peritoneal patches seems a valid and cheap option for vascular reconstruction and it is gaining great attention in recent years.

Conclusion

This case demonstrates that peritoneal graft could be a safe option to manage IVC defects in expert hands. A brief review of literature is also included.