Vascular Resections in Association With Pancreatic Resections for Locally Advanced Pancreatic Cancer

BACKGROUND/AIM

Locally advanced pancreatic cancer has been considered for a long period of time as an unresectable lesion and therefore, all patients have been traditionally addressed to the oncological services for palliative purposes. However, due to the wide usage of newer oncological agents in association with improved surgical techniques, radical surgical procedures became feasible. The aim of this study was to present the different surgical procedures that were performed in locally advanced pancreatic cancer patients in order to achieve radical resections.

PATIENTS AND METHODS

Between 2019 and 2020, six cases were submitted to pancreatic and vascular resections in Fundeni Clinical Hospital.

RESULTS

In all cases, surgery with curative intent was attempted; portal vein resection was performed in five cases, whereas arterial resection was performed in three cases. Reconstruction was performed by direct re-anastomosis, by placing cadaveric or synthetic grafts. The postoperative outcomes were favourable in all cases.

CONCLUSION

Vascular resections can be safely associated with pancreatic resections in cases presenting locally advanced pancreatic lesions, with acceptable morbidity rates.

Major Hepatectomy En Bloc with Cava Vein Resection for Locally Invasive Caudate Lobe Hepatocarcinoma

BACKGROUND/AIM

Locally advanced liver tumours with vascular invasion have been considered for a long period of time as unresectable lesions, so the patient was further deferred to oncology services for palliation. However, improvement of the surgical techniques and the results reported so far came to demonstrate that extended hepatic and vascular resections might be safely performed in such cases and might significantly improve the long-term outcomes.

MATERIALS AND METHODS

A 61-year-old patient was diagnosed with a caudate lobe tumour invading the inferior cava vein and the right hepatic pedicle.

RESULTS

The patient was successfully submitted to surgery, and an extended right hepatectomy en bloc with cava vein resection was performed; the continuity of the cava vein was re-established by the placement of a synthetic graft. The postoperative outcome was uneventful.

CONCLUSIONS

Although initially considered as a formal contraindication for resection, vascular invasion of the greater vessels should not preclude surgery if complete resection is achievable.

Infra-hepatic caval resection en bloc with right nephrectomy followed by caval reconstruction for locally advanced caval leiomyosarcoma: A case report and literature review

Retroperitoneal sarcomas often require complex surgical procedures in order to achieve complete resection; in such cases both vascular and visceral resections are needed. When it comes to the need for vascular reconstruction, the type of graft as well as the type of reconstructive process are chosen according to the length and location of the resected segment. Meanwhile, depending on the location of the resected segment, other vascular reconstructions may be needed such as the reimplantation of the renal veins. However, in certain cases, this reimplantation is not mandatory, an adequate renal outflow being reported through the collateral network at this level. We present the case of a 43-year-old patient diagnosed with a large retroperitoneal sarcoma originating from the cava vein invading the right kidney. Resection of the tumor was performed en bloc with caval resection and right nephrectomy, without reimplantation of the left renal vein at the level of the graft. Extended visceral and vascular resections might be needed in order to achieve complete resection of inferior cava vein sarcomas; re-implantation of the left renal vein being not mandatory if rich collateral circulation is present.

Distal Pancreatectomy En Bloc With Splenectomy, Celiac Axis and Portal Vein Resection Followed by Arterial Reconstruction Using a Cadaveric Graft - A Case Report and Literature Review

BACKGROUND/AIM

Locally advanced pancreatic body tumors invading the celiac axis and the portal vein have been considered since long as unresectable lesions; however, due to improvement of surgical techniques, in certain cases surgery with curative intent might be taken in consideration.

CASE REPORT

We present the case of a 48-year-old female investigated for epigastric pain that was diagnosed with a locally invasive pancreatic body tumor. The patient was submitted to computed tomography which revealed the presence of a locally advanced pancreatic tumor with no demarcation line with the celiac axis and the portal vein. The endoscopic ultrasound raised the suspicion of malignancy and retrieved a biopsy which demonstrated the presence of a pancreatic adenocarcinoma. The patient was submitted to surgery, distal pancreatectomy en bloc with splenectomy, celiac axis and portal vein resection was performed; the hepatic artery was reconstructed by placing a cadaveric graft while the portal vein was sutured per primam by an end to end anastomosis. The postoperative outcome was favorable, and the patient was discharged in the 10^th postoperative day.

CONCLUSION

Multiple vascular resections followed by reconstructions might be needed in order to achieve resection with negative margins in patients with pancreatic body tumors.

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.

Tipurile de vase asociate tumorilor GIST influenteaza eficienta terapiei antivasculare cu inhibitori de receptor tirozin-kinazic

Gastrointestinal stromal tumors (GIST�sare the most common mesenchymal neoplasms of the alimentary tract. Angiogenesis is an essential condition in the growth and development of tumors, especially in the case of GISTs due to their particular behavior. The aggressive behavior depends on the size and site of the tumor in close relationship with the intratumoral vascular development. The purpose of this study is to investigate, using immunohistochemical stainings, the types of intratumoral vessels in GIST�s, knowing the interrelation between the tumor angiogenesis and the response to the targeted antivascular therapy, influencing directly the prognosis. In our research, in all 37 cases the most numerous vessels were the immature and intermediate ones, signaling an increased angiogenic activity. The perivascular cell free vessels are the most sensitive at antivascular therapy with tyrosine kinase receptor inhibitors, providing a good response and prognosis to the treatment. Immature vessels evaluation especially, could be a an important sign in assessment of the effectiveness of antivascular therapy in GIST.

Management of a Fulminant Upper Gastrointestinal Bleeding Exteriorized Through Hemobilia Due to Arteriobiliary Fistula Between the Common Bile Duct and a Right Hepatic Artery Aneurysm - A Case Report

Right hepatic artery aneurysms are rare events that might remain asymptomatic for a long period of time. However, in cases presenting large lesions, symptoms might develop especially due to the association of compression of the surrounding elements. Most often these symptoms and signs include diffuse abdominal pain, jaundice or portal vein compression signs. In rare cases life-threatening complications might develop due to the aneurysmal erosion of the biliary duct, portal vein or due to the aneurysmal rupture in the peritoneal cavity. In all these cases emergency surgery is imposed. We present the case of a 66-year-old patient diagnosed with a partially thrombosed right hepatic artery aneurysm compressing the common bile duct who was initially submitted to a percutaneous arterial embolization of the aneurysm in association with an external biliary drainage; three weeks later the patient presented a fulminant upper gastrointestinal bleeding exteriorized through the external biliary drainage, hematemesis and hematochezia. The patient was successfully submitted to surgery, intraoperatively a synchronous rupture of the portal vein being revealed. The right hepatic artery aneurysm was resected en bloc with common bile duct resection and segmental portal vein resection. The continuity of the portal vein was re-established through the interposition of a cadaveric allograft, the common bile duct was anastomosed with en Roux en Y limb while the right hepatic artery aneurysm was ligated and resected, the arterial vascularization of the liver being provided by the left hepatic artery.

Successful Resection and Vascular Ligation of a Large Hepatic Artery Aneurysm - A Case Report and Literature Review

The occurrence of hepatic artery aneurysms is rare and might be incidentally diagnosed, as the patient remains asymptomatic for a long period of time. However, due to the fact that these lesions are associated with a high risk of developing life threatening complications, such as intraperitoneal rupture, it has been stated that all cases should be submitted to treatment by endovascular or surgical approach. We present the case of a 68-year-old patient, who presented with recurrent upper digestive tract bleedings and was diagnosed with a large aneurysm of the common and the proper hepatic artery, and the gastroduodenal artery. The preoperative angiography revealed an anatomic variation consisting of the common hepatic artery originating from the celiac trunk, and the left hepatic artery originating from the left gastric artery. A percutaneous right portal vein embolization was performed in order to induce hypertrophy of the left lobe and prepare the patient for a right hepatectomy and aneurysmal resection. However, at the time of surgery, after performing the aneurysmal resection and arterial ligation, the vascular supply of the entire liver was efficiently provided by the left hepatic artery and its collaterals. Concluding, hepatic resection was no longer necessary.

Ante-situm Liver Resection for Giant Hepatic Tumour - Case Report and Review of Literature

Ex-situ liver surgery refers to complex liver resections involving hepatic vascular exclusion and a warm ischemia time (WIT) of more than 90 minutes that allows liver resection and vascular reconstruction in patients with giant liver tumours with a difficult approach . Ante-situm liver resections, otherwise called "œex-situ in-vivo" resections is achieved through externalization of the liver outside of the abdominal cavity by clamping and sectioning of the efferent pedicles (suprahepatic veins) ("ex situ") without cutting the afferent vascular pedicle ("in vivo"), thus leaving the hepatic pedicle intact. We present a case report of a 36 yo male patient diagnosed by MRI scan with giant liver tumor in the left hemiliver. A left "ex-situ in-vivo" hepatectomy was performed by dissecting and ligating the left and middle hepatic veins, clamping and sectioning the right hepatic vein, Pringle maneuver, externalization of the liver followed by the tumor resection and right hepatic vein reimplantation. The short warm ischemia time (hepatic resection + liver reimplantation - 30 minutes) allowed us to perform the procedure without installing a veno-venous or porto-caval shunt otherwise used in all of ex-situ procedures described in the literature reviewed in this presentation. Ex-situ liver resection is a viable procedure for giant liver tumours in highly selected cases. It facilitates resection of large liver tumours that would be otherwise unresectable, extending the indications of surgical treatment.

Pancreatoduodenectomy en bloc with portal and superior mesenteric artery resection--a case report and literature review

BACKGROUND

Pancreatic cancer is one of the most lethal malignancies and is associated with a very poor overall survival. However, it seems that the only curative option remains an aggressive surgical approach capable of obtaining a radical resection. Unfortunately, this desiderate is even harder to be obtained when it comes to pancreatic tumors with vascular invasion.

CASE REPORT

We present the case of a 65-year-old patient who was diagnosed with a cephalopancreatic tumor invading both the portal vein and the superior mesenteric artery.

RESULTS

Whipple procedure was performed with portal and superior mesenteric artery resection; the continuity of the portal vein was established by an end-to-end anastomosis, while the superior mesenteric artery was re-implanted in the infra-renal aorta.

CONCLUSION

Due to improvements of surgical techniques and postoperative management, the postoperative morbidity and early mortality significantly decreased and enabled the surgeon to perform ultra-radical surgery with better outcome.

Technical aspects of biliary reconstruction correlated with biliary complications in 46 consecutive right lobe liver transplantations from living donors

INTRODUCTION

Biliary complications contribute to a high morbidity rate in patients with right lobe liver transplant from a living donor. We retrospectively evaluated biliary reconstructions and complications in a number of recipients with liver transplant from a living donor, in a single center.

PATIENTS AND METHODS

A number of 46 patients (23 males and 23 females aged 9-63) received a right lobe liver graft between 2009 and 2013, with the following types of biliary reconstruction:duct-to-duct choledochocholedochal anastomosis (n=24)or Roux-en-Y hepaticojejunoanastomosis, with or without an external transanastomotic biliary stent.

RESULTS

The rate of biliary complications (leakage 15.21%,anastomotic stenosis 4.34%, overall 17.39%) was not statistically significantly influenced by the demographics of the studied lot, by the etiology of the liver disease or by the characteristics of the biliary reconstruction; the only risk factor which showed a statistically significant influence in terms of biliary complications was MELD.

CONCLUSION

The type and technique of the biliary reconstruction in LDLT should be adapted depending on the anatomy of the biliary tree of both the donor and recipient, as well as the clinical and laboratory findings of the recipient.

A case report of pancreatic transection by blunt abdominal trauma

Posttraumatic pancreatic rupture is associated with high morbidity and mortality. Various management strategies are described, but due to the relative rarity of this pathology no standards exist. We reported a 21 years old male with post traumatic complete rupture of the pancreatic isthmus,devascularization lesion of descending duodenum, right renal artery posttraumatic thrombosis and left lobe of the liver laceration. Laparotomy for hemostasis was initially performed in a different hospital and the patient was then referred to us.Pancreaticoduodenectomy and right nephrectomy were performed. Postoperatively the patient had a pancreaticojejunal anastomosis fistula spontaneously resolved at 45 days.Pancreaticoduodenectomy can in selected cases be a solution in pancreatic trauma.

Status of the Southern Carpathian forests in the long-term ecological research network

Air pollution, bulk precipitation, throughfall, soil condition, foliar nutrients, as well as forest health and growth were studied in 2006-2009 in a long-term ecological research (LTER) network in the Bucegi Mountains, Romania. Ozone (O(3)) was high indicating a potential for phytotoxicity. Ammonia (NH(3)) concentrations rose to levels that could contribute to deposition of nutritional nitrogen (N) and could affect biodiversity changes. Higher that 50% contribution of acidic rain (pH < 5.5) contributed to increased acidity of forest soils. Foliar N concentrations for Norway spruce (Picea abies), Silver fir (Abies alba), Scots pine (Pinus sylvestris), and European beech (Fagus sylvatica) were normal, phosphorus (P) was high, while those of potassium (K), magnesium (Mg), and especially of manganese (Mn) were significantly below the typical European or Carpathian region levels. The observed nutritional imbalance could have negative effects on forest trees. Health of forests was moderately affected, with damaged trees (crown defoliation >25%) higher than 30%. The observed crown damage was accompanied by the annual volume losses for the entire research forest area up to 25.4%. High diversity and evenness specific to the stand type's structures and local climate conditions were observed within the herbaceous layer, indicating that biodiversity of the vascular plant communities was not compromised.

Substance MCS-18 Isolated from Helleborus Purpurascens Is a Potent Antagonist of the Capsaicin Receptor, TRPV1, in Rat Cultured Sensory Neurons

Extracts of Helleborus roots were traditionally used in the Balkan area for their analgesic action. We report that the pure natural product MCS-18 isolated from this source is a potent, specific and reversible antagonist of the capsaicin receptor, TRPV1, expressed in rat dorsal root ganglion (DRG) neurons. TRPV1 is a nonselective cation channel expressed in a subset of cutaneous and visceral sensory nerve endings and activated by noxious heat, acidity and fatty acid metabolites of arachidonic acid, with a decisive role in inflammatory heat hyperalgesia. MCS-18 inhibited the increase in intracellular calcium concentration evoked in DRG neurons by capsaicin (300 nM) and low pH (5.5) but not by heat (43 ºC). The substance had no effect on the responses mediated by acid-sensing ion channels (ASICs) or the irritant receptor TRPA1. Whole-cell patch-clamp was used to confirm the inhibition of capsaicin-induced currents by MCS-18 which was dose-dependent. The mechanism of inhibition does not require an intact cell, as capsaicin-induced currents were also inhibited in the excised outside-out configuration. The antagonism of the capsaicin and proton action on native TRPV1 by MCS-18 may be of interest for pain therapy.

Wavelength-sized, tunable nanocavity in deeply etched InP/InGaAsP/InP photonic crystals

Wavelength-sized point defect cavities coupled to access waveguides are reported for deeply etched InP/InGaAsP/InP two-dimensional photonic crystals. The observed quality factor of 60 is comparable to those found for one-row defect Fabry-Perot cavities and for simple point defect cavities in membranes. The quality factor was changed by varying the number of rows of holes. Upon infiltration of the holes with liquid crystal, frequency tuning was demonstrated.

New international long-term ecological research on air pollution effects on the Carpathian Mountain forests, Central Europe

An international cooperative project on distribution of ozone in the Carpathian Mountains, Central Europe was conducted from 1997 to 1999. Results of that project indicated that in large parts of the Carpathian Mountains, concentrations of ozone were elevated and potentially phytotoxic to forest vegetation. That study led to the establishment of new long-term studies on ecological changes in forests and other ecosystems caused by air pollution in the Retezat Mountains, Southern Carpathians, Romania and in the Tatra Mountains, Western Carpathians on the Polish-Slovak border. Both of these important mountain ranges have the status of national parks and are Man & the Biosphere Reserves. In the Retezat Mountains, the primary research objective was to evaluate how air pollution may affect forest health and biodiversity. The main research objective in the Tatra Mountains was to evaluate responses of natural and managed Norway spruce forests to air pollution and other stresses. Ambient concentrations of ozone (O(3)), sulfur dioxide (SO(2)), nitrogen oxides (NO(x)) as well as forest health and biodiversity changes were monitored on densely distributed research sites. Initial monitoring of pollutants indicated low levels of O(3), SO(2), and NO(x) in the Retezat Mountains, while elevated levels of O(3) and high deposition of atmospheric sulfur (S) and nitrogen (N) have characterized the Tatra Mountains. In the Retezat Mountains, air pollution seems to have little effect on forest health; however, there was concern that over a long time, even low levels of pollution may affect biodiversity of this important ecosystem. In contrast, severe decline of Norway spruce has been observed in the Tatra Mountains. Although bark beetle seems to be the immediate cause of that decline, long-term elevated levels of atmospheric N and S depositions and elevated O(3) could predispose trees to insect attacks and other stresses. European and US scientists studied pollution deposition, soil and plant chemistry, O(3)-sensitive plant species, forest insects, and genetic changes in the Retezat and Tatra Mountains. Results of these investigations are presented in a GIS format to allow for a better understanding of the changes and the recommendations for effective management in these two areas.

[Clinical syndrome of convulsive cough of adenoviral etiology in a children's collective]

Bacteriological, viral and serological investigators were carried out in a community with 100 prescholar children (Kindergarden), 34 of whom presented a clinical syndrome of whooping cough, in order to establish the bacteriologic or viral etiology of the syndrome. The etiologic role of organisms of the Bordetella, B. pertussis and B. parapertussis was invalidated by the bacteriologic and serological tests. Viral and serological tests, performed to demonstrate the participation of viral agents in the causation of this clinical syndrome, established an adenoviral diagnosis in 13 (43.3%) of the 30 children. Adenovirus type 6 was isolated and there was a significant increase in the titers of antibodies to adenoviruses.