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.

Antecedent Bile duct Cutting in the Glissonean pedicle technique (ABC technique) for extremely advanced perihilar cholangiocarcinoma

BACKGROUND

In an increasing number of patients undergoing radical surgery for perihilar cholangiocarcinoma [1-3], the intrahepatic bile duct is conventionally transected after the vessels to be preserved or reconstructed are confirmed [3,4]. In patients with extremely advanced perihilar cholangiocarcinoma having massive vascular involvement, it is sometimes difficult to confirm the vessels for reconstruction because of restricted working space and/or anatomical variants, even after liver parenchymal dissection [4]. When the vessels cannot be confirmed, the tumor is usually unresectable [4].

METHODS

We developed a novel technique named "Antecedent Bile duct Cutting in the Glissonean pedicle technique (ABC technique)", in which we directly cut the bile duct in the Glissonean sheath under 5x loupe until the vessels to be reconstructed are secured.

RESULTS

This video demonstrates the case of a 62-year-old man post-gastrectomy with a 47 × 36-mm perihilar cholangiocarcinoma with massive vascular involvement. Trisectionectomy was neither indicated left nor right due to excessively small remnant liver volume estimated even with portal vein embolization; thus, extended left hemihepatectomy with caudate lobectomy was applied using the ABC technique. Using the ABC technique after liver parenchymal dissection enabled us to identify and secure RAHA, RPHA, and RPV in favorable positions, and V5, RPV, RAHA, and RPHA were reconstructed. Finally, hepaticojejunostomy was performed. The operative time and blood transfusion were 1170 min and 1240 ml, respectively. R0 resection was achieved and the postoperative course was uneventful.

CONCLUSION

ABC technique was technically feasible and useful for extremely advanced perihilar cholangiocarcinoma with massive vascular involvement.

3D-laparoscopic pancreaticoduodenectomy with superior mesenteric or portal vein resection for pancreatic cancer

BACKGROUND

Minimally invasive pancreaticoduodenectomy with synchronous vein resection for pancreatic cancer is controversial. The aim of this study was to evaluate outcomes and describe the surgical technique of 3d-laparoscopic pylorus-resecting pancreaticoduodenectomy (3dLPD) with venous resection for pancreatic cancer.

METHODS

A retrospective cohort analysis was performed with 26 patients [male/female 11/15; median age 68 (range 45-83) years] who underwent 3dLPD with stented pancreaticogastrostomy and superior mesenteric or portal vein resection for pancreatic adenocarcinoma between November 2016 and June 2019. Median follow-up time after surgery was 12 months (range 3-32).

RESULTS

Median operating time was 340 min (range 240-420) and intra-operative blood loss was 100 mL (range 0-1000). Type of venous resection and reconstruction was wedge-resection with primary closure (n = 22), wedge-resection with reconstruction using a peritoneal patch (n = 3), and segmental resection with primary end-to-end reconstruction (n = 1). Laparoscopy was converted to open surgery in 4 (15%) patients. Postoperative complications occurred in 10 (38%) patients including severe complications (Clavien-Dindo grade > 2) in 4 (15%). Postoperative mortality was zero. R0 resection was achieved in 21 (81%) patients. Median number of lymph nodes retrieved was 25 (range 10-45). Venous patency was observed in 23 (88%) patients with a median patency duration of 11 months (range 0-31).

CONCLUSIONS

3dLPD with simultaneous venous resection for pancreatic cancer results in acceptable reconstruction patency and adequacy of surgical oncology without compromising clinical outcomes.

[Clinical application of combined hepatic artery resection and reconstruction in surgical treatment for hilar cholangiocarcinoma]

Objective: To clarify whether the surgical treatment for hilar cholangiocarcinoma combined with artery reconstruction is optimistic to the patients with hilar cholangiocarcinoma with hepatic artery invasion. Methods: There were 384 patients who received treatment in the First Affiliated Hospital to Army Medical University from January 2008 to January 2016 analyzed retrospectively. There were 27 patients underwent palliative operation, 245 patients underwent radical operation, radical resection account for 63.8%. Patients were divided into four groups according to different operation method: routine radical resection group(n=174), portal vein reconstruction group (n=47), hepatic artery reconstruction group (n=24), palliative group(n=27). General information of patients who underwent radical operation treatment was analyzed by chi-square test and analysis of variance. The period of operation time, blood loss, the length of hospital stay and hospitalization expenses of the radical operation patients were analyzed by one-way ANOVA. Comparison among groups was analyzed by LSD-t test. Results: The follow-up ended up in June first, 2016. Each of patients followed for 6 to 60 months, the median follow-up period was 24 months. 1-, 3-, and 5-year survival rates were 81.3%, 44.9% and 13.5% of routine radical operation group, and were 83.0%, 44.7% and 15.1% of portal vein reconstruction group, and were 70.8%, 27.7% and 6.9% of hepatic artery reconstruction group, respectively. And 1-, 3-, and 5-year survival rates of hepatic artery reconstruction group was lower than routine radical group and portal vein reconstruction group significantly (P<0.05). However, the rate of postoperative complications of the hepatic artery reconstruction group and the routine radical operation group and the portal vein reconstruction group were 62.5%(15/24), 55.3%(96/174) and 51.5%(24/47), respectively. There was no significant difference among them (P>0.05). The data shows that the ratio of lymphatic metastasis in hepatic artery reconstruction group (70.8%) is much higher than them in routine radical operation group (20.1%) and portal vein reconstruction group (19.1%) significantly (P<0.05). The presented data also indicate that hepatic artery resection prolongs survival time comparing with patients undergoing palliative therapy for hilar cholangiocarcinoma. Cox regression analysis indicate that hepatic artery resection and reconstruction is a protective factor compare with palliative therapy (RR=0.38, 95%CI: 0.22-0.67). The significant reason for shorter survival time is a positive correlation between hepatic artery invasion and lymph node metastasis. Conclusion: Hepatic artery resection and reconstruction has beneficial impact on oncologic long-term outcome in patients with advanced stage hilar cholangiocarcinoma.