Precision vascular anatomy for minimally invasive distal pancreatectomy: A systematic review

BACKGROUND

Minimally invasive distal pancreatectomy (MIDP) is increasingly performed worldwide; however, the surgical anatomy required to safely perform MIDP has not yet been fully considered. This review evaluated the literature concerning peripancreatic vascular anatomy, which is considered important to conduct safe MIDP.

METHODS

A database search of PubMed and Ichushi (Japanese) was conducted. Qualified studies investigating the anatomical variations of peripancreatic vessels related to MIDP were evaluated using SIGN methodology.

RESULTS

Of 701 articles yielded by our search strategy, 76 articles were assessed in this systematic review. The important vascular anatomy required to recognize MIDP included the pancreatic parenchymal coverage on the root and the running course of the splenic artery, branching patterns of the splenic artery, confluence positions of the left gastric vein and the inferior mesenteric vein, forms of pancreatic veins including the centro-inferior pancreatic vein, characteristics of the left renal vein, and collateral routes perfusing the spleen following Warshaw's technique. Very few articles evaluating the relationship between the anatomical variations and surgical outcomes of MIDP were found.

CONCLUSIONS

The precise knowledge of peripancreatic vessels is important to adequately complete MIDP. More detailed anatomic analyses and descriptions will benefit surgeons and their patients who are facing these operations.

Performance of Comprehensive Complication Index and Clavien-Dindo Complication Scoring System in Liver Surgery for Hepatocellular Carcinoma

BACKGROUND

We aimed to assess the ability of comprehensive complication index (CCI) and Clavien-Dindo complication (CDC) scale to predict excessive length of hospital stay (e-LOS) in patients undergoing liver resection for hepatocellular carcinoma.

METHODS

Patients were identified from an Italian multi-institutional database and randomly selected to be included in either a derivation or validation set. Multivariate logistic regression models and ROC curve analysis including either CCI or CDC as predictors of e-LOS were fitted to compare predictive performance. E-LOS was defined as a LOS longer than the 75th percentile among patients with at least one complication.

RESULTS

A total of 2669 patients were analyzed (1345 for derivation and 1324 for validation). The odds ratio (OR) was 5.590 (95%CI 4.201; 7.438) for CCI and 5.507 (4.152; 7.304) for CDC. The AUC was 0.964 for CCI and 0.893 for CDC in the derivation set and 0.962 vs. 0.890 in the validation set, respectively. In patients with at least two complications, the OR was 2.793 (1.896; 4.115) for CCI and 2.439 (1.666; 3.570) for CDC with an AUC of 0.850 and 0.673, respectively in the derivation cohort. The AUC was 0.806 for CCI and 0.658 for CDC in the validation set.

CONCLUSIONS

When reporting postoperative morbidity in liver surgery, CCI is a preferable scale.

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy with Venous Tangential Resection: Focus on Periadventitial Dissection of the Superior Mesenteric Artery for Obtaining Negative Margin and a Safe Vascular Resection

BACKGROUND

Due to its technical complexity, laparoscopic (L-) radical antegrade modular pancreatosplenectomy (RAMPS) for left-sided pancreatic ductal adenocarcinoma (PDAC) has been described in a few series.1-4 In addition, splenomesenteric junction tumor involvement is considered a formal contraindication to L-RAMPS.

METHODS

The video shows posterior L-RAMPS with a left approach to the superior mesenteric artery (SMA) for a left-sided PDAC with suspected involvement of the splenomesenteric junction.

RESULTS

The patient was a 61-year-old woman affected by a cT3N0M0 pancreatic body PDAC. Following dissection of the superior mesenteric vein (SMV), proper/common hepatic artery, and gastroduodenal artery, the pancreatic neck is encircled and the celiac trunk (CT) skeletonized. The treitz ligament is opened, and the SMA is identified and dissected on its left anterior margin. Pancreatic mobilization en bloc with the Gerota fascia and left adrenal gland is followed by splenic artery transection and suprapancreatic lymphadenectomy completion. The mesopancreas is dissected from the right margin of the SMA and CT and the pancreas is transected. The portal vein and SMV are cross-clamped and a venous tangential resection/closure is performed. Cryostate histological examination of the venous and pancreatic stumps showed absence of tumor cells. Final pathology revealed a pT2N0(0+/42)R0G2 PDAC of the pancreatic body.

CONCLUSION

During L-RAMPS, periadvential SMA dissection through the left-anterior approach, specular to the right posterior SMA approach described for laparoscopic pancreatoduodenectomy,5^,6 has a primary role in maximizing the vascular surgical margin and, allowing for complete mobilization of the specimen before vein resection, may make a splenomesenteric junction tangential resection/closure easier and safer in case of tumor involvement of the splenomesenteric venous axis.