Hepatic artery resection in distal cholangiocarcinoma

PURPOSE

This study aimed to elucidate the safety and oncological outcomes of surgery with hepatic artery resection (HAR) for patients with distal cholangiocarcinoma.

METHODS

The clinical data of patients with distal cholangiocarcinoma who underwent curative intent surgery at Hiroshima University between March 2009 and January 2021 were retrospectively analyzed. Eligible patients were classified according to the presence or absence of HAR (HAR and non-HAR group), and clinicopathological features and disease-free survival rates were compared between the two groups.

RESULTS

Among the 60 patients analyzed, eight patients had received HAR, and the remaining 52 patients had not. The rate of portal vein resection, T stage, and the number of metastasized lymph nodes in the HAR group were significantly greater than those in the non-HAR group (p < 0.001, p = 0.00695, and p = 0.0480, respectively). Postoperative severe complication was confirmed in one patient, and there were no in-hospital deaths in the HAR group. Seven of 8 patients in the HAR group showed recurrence during follow-up, and of those, six patients showed early recurrence within 1 year postoperatively. The disease-free survival time in the HAR group was significantly shorter than that in the non-HAR group (median: 7.4 m vs. 34.2 m, respectively) (p < 0.001). Multivariate analysis revealed that lymph node metastasis and HAR were significant risk factors for predicting the adverse disease-free survival time (hazard ratio (HR), 3.21; p = 0.0142; HR, 4.47; p = 0.0346, respectively).

CONCLUSIONS

Patients with distal cholangiocarcinoma who underwent surgery with HAR tended to show early recurrences, although HAR could be performed safely.

Long-term survival after distal pancreatectomy with celiac axis resection and hepatic artery reconstruction in the setting of locally advanced unresectable pancreatic cancer

The long-term survival of patients with locally advanced, unresectable pancreatic cancer is extremely poor. We present our experience with a 67-year-old woman who had a 40-mm mass in the body of the pancreas. Tumor infiltration reached the gastroduodenal artery, celiac artery, common hepatic artery, and splenic artery. After 10 courses of FOLFIRINOX, 2 courses of gemcitabine plus nab-paclitaxel, and 6 courses of gemcitabine alone, we performed distal pancreatectomy with celiac axis resection and hepatic artery reconstruction. The bifurcation of the gastroduodenal artery and the proper hepatic artery had to be resected, after which we created 2 anastomoses: proper hepatic-to-middle colic artery, and second jejunal-to-right gastroepiploic artery. Histopathologic examination revealed an Evans grade IIb histologic response to prior treatment and verified the R0 resection status. The patient was discharged on postoperative day 30 after treatment of a grade B pancreatic fistula and is still alive, without recurrence, more than 5 years after initiation of treatment. This patient with locally advanced, unresectable pancreatic cancer achieved long-term survival through perioperative multidisciplinary treatment, including distal pancreatectomy with celiac axis resection and hepatic artery reconstruction. This aggressive procedure could be a treatment option for patients with locally advanced, unresectable pancreatic cancer.

Effect of hepatic artery resection and reconstruction on the prognosis of patients with advanced hilar cholangiocarcinoma

BACKGROUND

Hilar cholangiocarcinoma (HC) is a good adaptation certificate of hepatic arterectomy, and hepatic arterectomy is conductive to the radical resection of cholangiocarcinoma, which simplifies the operation and helps with a combined resection of the peripheral portal tissue. With continuous development of surgical techniques, especially microsurgical technique, vascular invasion is no longer a contraindication to surgery in the past 10 years. However, hepatic artery reconstruction after hepatic arterectomy has been performed to treat liver tumor in many centers with better results, but it is rarely applied in advanced HC.

AIM

To determine the prognosis of patients with advanced HC after hepatic artery resection and reconstruction.

METHODS

A total of 98 patients with HC who underwent radical operation in our hospital were selected for this retrospective analysis. According to whether the patients underwent hepatic artery resection and reconstruction or not, they were divided into reconstruction (n = 40) and control (n = 58) groups. The traumatic indices, surgical resection margin, liver function tests before and after the operation, and surgical complications were compared between the two groups.

RESULTS

Operation time, blood loss, hospital stay, and gastrointestinal function recovery time were higher in the reconstruction group than in the control group (P < 0.05); The R0 resection rates were 90.00% and 72.41% in the reconstruction and control groups, respectively (P < 0.05). Serum alanine aminotransferase was lower in the reconstruction group on day one and three postoperatively, whereas serum aspartate aminotransferase was lower on the third day (P < 0.05). Preoperatively, the Karnofsky performance status scores were similar between the groups (P > 0.05), but was higher in the reconstruction group (P < 0.05) two weeks postoperatively. There was no difference in the complication rate between the two groups (27.50% vs 32.67%, P > 0.05). Two-year survival rate (42.50% vs 39.66%) and two-year survival time (22.0 mo vs 23.0 mo) were similar between the groups (P > 0.05).

CONCLUSION

Radical surgery combined with reconstruction after hepatic artery resection improves R0 resection rate and reduces postoperative liver injury in advanced HC. However, the operation is difficult and the effect on survival time is not clear.

Effect of vascular resection for perihilar cholangiocarcinoma: a systematic review and meta-analysis

OBJECTIVE

To evaluate the effect of vascular resection (VR), including portal vein resection (PVR) and hepatic artery resection (HAR), on short- and long-term outcomes in patients with perihilar cholangiocarcinoma (PHC).

BACKGROUND

Resection surgery and transplantation are the main treatment methods for PHC that provide a chance of long-term survival. However, the efficacy and safety of VR, including PVR and HAR, for treating PHC remain controversial.

METHODS

This study was registered at the International Prospective Register of Systematic Reviews (CRD42020223330). The EMBASE, PubMed, and Cochrane Library databases were used to search for eligible studies published through November 28, 2020. Studies comparing short- and long-term outcomes between patients who underwent hepatectomy with or without PVR and/or HAR were included. Random- and fixed-effects models were applied to assess the outcomes, including morbidity, mortality, and R0 resection rate, as well as the impact of PVR and HAR on long-term survival.

RESULTS

Twenty-two studies including 4,091 patients were deemed eligible and included in this study. The meta-analysis showed that PVR did not increase the postoperative morbidity rate (odds ratio (OR): 1.03, 95% confidenceinterval (CI): [0.74-1.42], P = 0.88) and slightly increased the postoperative mortality rate (OR: 1.61, 95% CI [1.02-2.54], P = 0.04). HAR did not increase the postoperative morbidity rate (OR: 1.32, 95% CI [0.83-2.11], P = 0.24) and significantly increased the postoperative mortality rate (OR: 4.20, 95% CI [1.88-9.39], P = 0.0005). Neither PVR nor HAR improved the R0 resection rate (OR: 0.70, 95% CI [0.47-1.03], P = 0.07; OR: 0.77, 95% CI [0.37-1.61], P = 0.49, respectively) or long-term survival (OR: 0.52, 95% CI [0.35-0.76], P = 0.0008; OR: 0.43, 95% CI [0.32-0.57], P < 0.00001, respectively).

CONCLUSIONS

PVR is relatively safe and might benefit certain patients with advanced PHC in terms of long-term survival, but it is not routinely recommended. HAR results in a higher mortality rate and lower overall survival rate, with no proven benefit.

Hepatic artery resection and reconstruction using the right gastroepiploic artery during pancreaticoduodenectomy in advanced pancreatic cancer

PURPOSE

Surgical resection is the only curative treatment for pancreatic cancer. Arterial resection and reconstruction during pancreaticoduodenectomy for advanced pancreatic cancer remain controversial due to a high rate of complications.

METHODS

We report two cases of pancreatic cancer with hepatic artery resection and reconstruction using the right gastroepiploic artery during pancreaticoduodenectomy after neoadjuvant therapy.

RESULTS

The patients underwent pancreaticoduodenectomy with resection of the right hepatic and common hepatic arteries. Achieving direct anastomosis was difficult; therefore, we planned hepatic artery reconstruction using the right gastroepiploic artery. We performed the reconstruction using an interrupted suture with end-to-end anastomosis. The first patient developed a postoperative pancreatic fistula, while the postoperative course of the second patient was uneventful. However, there were no adverse events related to the arterial reconstruction. R0 resection was achieved, and postoperative computed tomography revealed good patency of the reconstructed artery.

CONCLUSION

Hepatic artery reconstruction using the right gastroepiploic artery in pancreatic cancer might be technically safe and might become one of the alternative options.

Short- and Long-Term Outcomes of Simultaneous Hepatic Artery Resection and Reconstruction for Perihilar Cholangiocarcinoma

Introduction

Because surgical resection with simultaneous hepatic artery (HA) resection and reconstruction for perihilar cholangiocarcinoma (PHC) is technically demanding, the surgical indication for this challenging procedure is controversial. Thus, this study aimed to evaluate the efficacy of simultaneous HA resection and reconstruction for PHC.

Methods

Between January 2002 and January 2018, 13 patients with PHC underwent surgical intervention with simultaneous resection and reconstruction of the HA at Yamaguchi University Hospital (Ube, Japan) and Osaka University Hospital (Suita, Japan).

Results

There were 2 cases (15.4%) of 90-day postoperative mortality. Nine patients (69.2%) developed major postoperative complications (Clavien-Dindo classification ≥IIIa). Curative resections (R0) were achieved in 8 cases (61.5%). The median survival time (MST) and 1- and 3-year survival rates after resection (including in-hospital deaths) were 20.9 months and 61.5 and 10.3%, respectively. The MST and 1- and 2-year survival rates of 8 patients who underwent R0 resection were significantly better than those of the other 5 patients (24.2 vs. 10.2 months, 75.0 vs. 40.0%, and 50.0 vs. 0.0%, respectively, p = 0.0228).

Conclusions

Simultaneous HA resection and reconstruction is technically possible and may provide long-term survival in selected patients with locally advanced PHC.

Distal pancreatectomy with celiac axis resection (DP-CAR): Optimal perioperative outcome in a patient with locally advanced pancreas adenocarcinoma

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DP-CAR: A rare, technically demanding operation with significant morbidity & mortality.

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DP-CAR may provide curative (R0) resection of an otherwise unresectable cancer.

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Our patient had optimal perioperative outcome and excellent histology result.

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To the best of our knowledge this is the first DP-CAR case in Greece.

Introduction

Distal pancreatectomy with en bloc celiac axis resection (DP-CAR) is an operation technically demanding, uncommonly performed, even in high-volume pancreatic centers, which may offer a curative resection in patients with locally advanced cancer of the body of the pancreas, otherwise considered unresectable.

Presentation of case

We present, in clinical and technical detail, a patient with DP-CAR with a very good intraoperative and postoperative course, no complications, short hospital stay, and histology consistent with a curative resection.

Discussion

Because of the scarcity of DP-CAR, even high-volume individual centers have been able to gather relatively limited experience, and only in a time frame of more than a decade each.

Conclusion

DP-CAR can be curative for a minority of patients with pancreatic adenocarcinoma and is performed only in centers with a long, dedicated interest in advanced pancreatic surgery with a well-known track record in resection of borderline and locally advanced pancreatic cancer involving major peripancreatic veins.

Pancreatectomy With Arterial and Portal Vein Reconstruction for Locally Advanced Pancreatic Cancer - A Case Report and Literature Review

BACKGROUND/AIM

Pancreatic cancer is still associated with poor survival rates due to the fact that it is most often diagnosed at advanced stages of the disease when local invasion is present. However, improvements of surgical techniques have enabled extended resections with curative intent. We present the case of a 43-year-old patient diagnosed with locally invasive pancreatic adenocarcinoma invading the portal vein and the common hepatic artery.

CASE REPORT

Surgery with curative intent consisting of pancreatoduodenectomy en bloc with hepatic artery resection and portal vein resection was successfully performed. The right hepatic artery was further anastomosed with the remaining common hepatic artery while the left hepatic artery was reconstructed using a reversed splenic artery patch. The continuity of the portal vein was re-established by placing a synthetic prosthesis.

CONCLUSION

Combined arterial and venous resections might be useful in order to achieve a good local control of disease in patients with locally advanced pancreatic cancer.

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

OBJECTIVE

The objective of the study is to examine the feasibility of hepatic artery resection (HAR) without subsequent reconstruction (RCS) in specified patients of Bismuth type III and IV hilar cholangiocarcinoma.

METHODS

We retrospectively reviewed 63 patients who underwent hepatic artery resection for Bismuth type III and IV hilar cholangiocarcinoma. These patients were subsequently enrolled into two groups based on whether the artery reconstruction was conducted. Postoperative morbidity and mortality, and long-term survival outcome were compared between the two groups.

RESULTS

There were 29 patients in HAR group and 34 patients in the HAR + RCS group. Patients with hepatic artery reconstruction tended to have longer operative time (545.6 ± 143.1 min vs. 656.3 ± 192.8 min; P = 0.013) and smaller tumor size (3.0 ± 1.1 cm vs. 2.5 ± 0.9 cm; P = 0.036). The R0 resection margin was comparable between the HAR group and HAR + RCS group (86.2 vs. 85.3%; P > 0.05). Twelve patients (41.4%) with 24 complications in HAR group and 13 patients (38.2%) with 25 complications in HAR + RCS group were recorded (P = 0.799). The postoperative hepatic failure rate (13.8 vs. 5.9%) and postoperative mortality rate (3.4% vs. 2.9%) were also comparable between the two groups. In the HAR group, the overall 1-, 3-, and 5-year survival rates were 72, 41, and 19%, respectively; while in the HAR + RCS group, the overall 1-, 3-, and 5-year survival rates were 79, 45, and 25%, respectively (P = 0.928).

CONCLUSIONS

Hepatic artery resection without reconstruction is also a safe and feasible surgical procedure for highly selected cases of Bismuth type III and IV hilar cholangiocarcinoma.

Assessment of clinical outcomes of advanced hilar cholangiocarcinoma

BACKGROUND

Low resectability and poor survival outcome are common for hilar cholangiocarcinoma (HCCA), especially in advanced stages. The present study was to assess the clinical outcome of advanced HCCA, focusing on therapeutic modalities, survival analysis and prognostic assessment.

METHODS

Clinical data of 176 advanced HCCA patients who had been treated in our hospital between January 2013 and December 2015 were analyzed retrospectively. Prognostic effects of clinicopathological factors were explored by univariate and multivariate analysis. Survival predictors were evaluated by the receiver operating characteristic (ROC) curve.

RESULTS

The 3-year overall survival rate was 13% for patients with advanced HCCA. Preoperative total bilirubin (P = 0.009), hepatic artery invasion (P = 0.014) and treatment modalities (P = 0.020) were independent prognostic factors on overall survival. A model combining these independent prognostic factors (area under ROC curve: 0.748; 95% CI: 0.678-0.811; sensitivity: 82.3%, specificity: 53.5%) was highly predictive of tumor death. After R0 resection, the 3-year overall survival was up to 38%. Preoperative total bilirubin was still an independent negative factor, but not for hepatic artery invasion.

CONCLUSIONS

Surgery is still the best treatment for advanced HCCA. Preoperative biliary drainage should be performed in highly-jaundiced patients to improve survival. Prediction of survival is improved significantly by a model that incorporates preoperative total bilirubin, hepatic artery invasion and treatment modalities.

Right hepatectomy for a detoured left hepatic artery in hilar cholangiocarcinoma-report of a rare but rational resection

Background

Curative hepatectomy with bile duct resection is the treatment for perihilar cholangiocarcinoma. A locally advanced tumor necessitates hepatectomy with simultaneous vascular resection, and reconstruction remains an obstacle for surgeons. Studies have focused on the variations of hepatic arteries. Nevertheless, the anatomical alignment of the portal veins, bile ducts, and hepatic arteries are equally critical in surgical planning of curative resection for advanced tumors. We have reported promising outcomes of hepatectomy with simultaneous resection and reconstruction of the hepatic artery. With respect to the type of surgery, most patients undergo left hepatectomy with right hepatic artery resection and reconstruction in contrast to right hepatectomy with left hepatic artery resection and reconstruction. We present two patients who showed detoured left hepatic arteries that were invaded by the perihilar tumors.

Case presentation

A 78-year-old man who presented with epigastric pain and abnormal liver function was referred to our clinic for further examination. Serial examination resulted in the diagnosis of Bismuth type II hilar cholangiocarcinoma. The left hepatic artery ran a detoured course and was invaded by the tumor. The second patient was a 76-year-old woman who presented with jaundice and the Bismuth type II hilar cholangiocarcinoma. The left hepatic artery was along the right-lateral position of the left portal vein and was invaded by the tumor. The variant anatomical relationship of the vessel was identified preoperatively in both patients, and they underwent right hepatectomy with concomitant left hepatic artery resection and reconstruction without any major complications or recurrence.

Conclusions

The largely biased selection of patients is based on the following anatomical relationship: the left hepatic artery usually runs left lateral to the portal vein, which spares invasion by the perihilar cholangiocarcinoma. On the contrary, the right hepatic artery mostly runs behind the bile duct and is invaded by the tumor. This aforementioned anatomy is one of the reasons for the relatively rare left hepatic artery resections and reconstructions in right hepatectomies. By meticulous preoperative evaluation with images, we identify the anatomical variation and performed right hepatectomy with concomitant left hepatic artery resection and reconstruction without any major complications and mortalities.

Major hepatopancreatoduodenectomy with simultaneous resection of the hepatic artery for advanced biliary cancer

BACKGROUND

Major hepatopancreatoduodenectomy (HPD) with simultaneous resection of the hepatic artery (HA) for biliary cancer is the most extended surgery for obtaining curative resection, and its clinical significance is unclear. The aim of this study was to appraise the clinical value of this extended procedure as a treatment for biliary cancer.

METHODS

We retrospectively reviewed the medical records of 38 patients with biliary cancer who underwent major HPD from 1994 to 2014. Clinicopathological factors and survival following HPD were compared between patients with and without simultaneous resection of the HA.

RESULTS

Of the 38 study patients, 12 patients (32 %) underwent major HPD with HA. There was no significant difference in major complications between the two groups. The overall 2-year survival rate and the median survival time following major HPD with HA were 71 % and 42.3 months. The survival of the patients with gallbladder cancer was significantly worse than that of the patients with bile duct cancer (p = 0.001).

CONCLUSIONS

Major HPD with simultaneous resection of the HA can be a preferable treatment option for bile duct cancer that offers acceptable perioperative morbidity and mortality, as well as long-term survival. However, this procedure for gallbladder cancer should not be performed.

Surgical technique of hepatectomy combined with simultaneous resection of hepatic artery and portal vein for perihilar cholangiocarcinoma (with video)

Perihilar cholangiocarcinomas often involve the bifurcation of the portal vein and the hepatic artery at initial presentation. Previously, vascular invasion was a major obstacle for R0 resection; therefore, such tumors were regarded as locally advanced, unresectable disease. Recently, in leading centers, these tumors have been resected using a specific technique, vascular resection and reconstruction. Vascular resection is classified into three types: portal vein resection alone, hepatic artery resection alone, and simultaneous resection of both the portal vein and hepatic artery. Of these, portal vein resection is widely performed, whereas hepatic artery resection remains controversial. Therefore, hepatectomy combined with simultaneous resection of the portal vein and hepatic artery represents one of the most complicated and challenging procedures in hepatobiliary surgery. The survival benefit of this extended procedure remains unproven, and there is only a single study reporting an unexpectedly favorable outcome in 50 patients. Considering the dismal survival in patients with unresectable disease, hepatic artery resection and/or portal vein resection may be a promising option of choice. However, the technique is highly demanding and has not been standardized. Therefore, this extended surgery may be allowed only in selected hepatobiliary centers.