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Maino C, Cereda M, Franco PN, Boraschi P, Cannella R, Gianotti LV, Zamboni G, Vernuccio F, Ippolito D. Cross-sectional imaging after pancreatic surgery: The dialogue between the radiologist and the surgeon. Eur J Radiol Open 2024; 12:100544. [PMID: 38304573 PMCID: PMC10831502 DOI: 10.1016/j.ejro.2023.100544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 12/29/2023] [Accepted: 12/29/2023] [Indexed: 02/03/2024] Open
Abstract
Pancreatic surgery is nowadays considered one of the most complex surgical approaches and not unscathed from complications. After the surgical procedure, cross-sectional imaging is considered the non-invasive reference standard to detect early and late compilations, and consequently to address patients to the best management possible. Contras-enhanced computed tomography (CECT) should be considered the most important and useful imaging technique to evaluate the surgical site. Thanks to its speed, contrast, and spatial resolution, it can help reach the final diagnosis with high accuracy. On the other hand, magnetic resonance imaging (MRI) should be considered as a second-line imaging approach, especially for the evaluation of biliary findings and late complications. In both cases, the radiologist should be aware of protocols and what to look at, to create a robust dialogue with the surgeon and outline a fitted treatment for each patient.
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Affiliation(s)
- Cesare Maino
- Department of Diagnostic Radiology, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, MB, Italy
| | - Marco Cereda
- Department of Surgery, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, MB, Italy
| | - Paolo Niccolò Franco
- Department of Diagnostic Radiology, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, MB, Italy
| | - Piero Boraschi
- Radiology Unit, Azienda Ospedaliero-Universitaria Pisana, 56124 Pisa, Italy
| | - Roberto Cannella
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, 90127 Palermo, Italy
| | - Luca Vittorio Gianotti
- Department of Surgery, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, MB, Italy
- School of Medicine, Università Milano-Bicocca, Piazza dell’Ateneo Nuovo, 1, 20100 Milano, Italy
| | - Giulia Zamboni
- Institute of Radiology, Department of Diagnostics and Public Health, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Federica Vernuccio
- University Hospital of Padova, Institute of Radiology, 35128 Padova, Italy
| | - Davide Ippolito
- Department of Diagnostic Radiology, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, MB, Italy
- School of Medicine, Università Milano-Bicocca, Piazza dell’Ateneo Nuovo, 1, 20100 Milano, Italy
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Bilreiro C, Andrade L, Santiago I, Marques RM, Matos C. Imaging of pancreatic ductal adenocarcinoma - An update for all stages of patient management. Eur J Radiol Open 2024; 12:100553. [PMID: 38357385 PMCID: PMC10864763 DOI: 10.1016/j.ejro.2024.100553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 02/02/2024] [Accepted: 02/03/2024] [Indexed: 02/16/2024] Open
Abstract
Background Pancreatic ductal adenocarcinoma (PDAC) is a common and lethal cancer. From diagnosis to disease staging, response to neoadjuvant therapy assessment and patient surveillance after resection, imaging plays a central role, guiding the multidisciplinary team in decision-planning. Review aims and findings This review discusses the most up-to-date imaging recommendations, typical and atypical findings, and issues related to each step of patient management. Example cases for each relevant condition are presented, and a structured report for disease staging is suggested. Conclusion Despite current issues in PDAC imaging at different stages of patient management, the radiologist is essential in the multidisciplinary team, as the conveyor of relevant imaging findings crucial for patient care.
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Affiliation(s)
- Carlos Bilreiro
- Radiology Department, Champalimaud Foundation, Lisbon, Portugal
- Champalimaud Research, Champalimaud Foundation, Lisbon, Portugal
- Nova Medical School, Lisbon, Portugal
| | - Luísa Andrade
- Radiology Department, Champalimaud Foundation, Lisbon, Portugal
| | - Inês Santiago
- Radiology Department, Champalimaud Foundation, Lisbon, Portugal
| | - Rui Mateus Marques
- Nova Medical School, Lisbon, Portugal
- Radiology Department, Hospital de S. José, Lisbon, Portugal
| | - Celso Matos
- Radiology Department, Champalimaud Foundation, Lisbon, Portugal
- Champalimaud Research, Champalimaud Foundation, Lisbon, Portugal
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Fukuda K, Koyama K, Kyoden Y. Successful treatment for pseudoaneurysm following distal pancreatectomy with celiac axis resection without postoperative pancreatic fistula: a case report. Surg Case Rep 2024; 10:113. [PMID: 38714591 PMCID: PMC11076426 DOI: 10.1186/s40792-024-01914-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 04/27/2024] [Indexed: 05/10/2024] Open
Abstract
BACKGROUND Distal pancreatectomy with celiac axis resection (DP-CAR) represents an innovative surgical approach for locally advanced pancreatic body cancer in cases involving celiac axis invasion. However, this procedure carries significant perioperative risks, including arterial aneurysms and organ ischemia. Understanding these risks is crucial for optimizing patient outcomes and guiding treatment decisions. CASE PRESENTATION This case report describes a unique case of a 74-year-old male patient who was diagnosed with locally advanced pancreatic body cancer with invasion of the celiac and splenic arteries. He underwent DP-CAR after six cycles of chemotherapy. His postoperative course was uneventful without any evidence of postoperative pancreatic fistula. However, at the 10-month postoperative follow-up, pseudoaneurysm was incidentally detected in the anterior superior pancreaticoduodenal artery by follow-up computed tomography. It was successfully treated with coil embolization. He had no signs of tumor recurrence or relapse of pseudoaneurysm formation 2 years postoperatively. This case report discusses the potential risks of pseudoaneurysm formation in patients undergoing DP-CAR due to hemodynamic changes. We emphasize the significance of close monitoring in such cases. CONCLUSIONS The case highlights the importance of recognizing and managing potential complications associated with DP-CAR in patients with pancreatic cancer. Despite its effectiveness in achieving complete resection, DP-CAR carries inherent risks, including the development of pseudoaneurysms. Vigilant surveillance and prompt intervention are crucial for optimizing patient outcomes and minimizing postoperative complications.
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Affiliation(s)
- Kaito Fukuda
- Department of Surgery, Ibaraki Prefectural Central Hospital and Cancer Center, 6528 Koibuchi, Kasama, Ibaraki, 309-1793, Japan.
| | - Ken Koyama
- Department of Surgery, Ibaraki Prefectural Central Hospital and Cancer Center, 6528 Koibuchi, Kasama, Ibaraki, 309-1793, Japan
| | - Yusuke Kyoden
- Department of Surgery, Ibaraki Prefectural Central Hospital and Cancer Center, 6528 Koibuchi, Kasama, Ibaraki, 309-1793, Japan
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4
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Ward EP, Vincent-Sheldon S, Tolat P, Kulkarni N, Aldakkak M, Budithi R, Clarke CN, Tsai S, Evans DB, Christians KK. Median arcuate ligament release at the time of pancreaticoduodenectomy or total pancreatectomy. Surgery 2024; 175:1386-1393. [PMID: 38413302 DOI: 10.1016/j.surg.2024.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/27/2023] [Accepted: 01/08/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Celiac artery compression can complicate the performance of pancreaticoduodenectomy or total pancreatectomy due to the need for ligation of the gastroduodenal artery. Median arcuate ligament release restores normal arterial flow to the liver, spleen, and stomach and may avoid complications related to poor perfusion of the foregut. METHODS All patients who underwent median arcuate ligament release for celiac artery compression at the time of pancreatectomy between 2009 and 2023 were reviewed. Pre- and postoperative computed tomography was used to categorize celiac artery compression by the extent of compression (types A [<50%], B [50%-80%], and C [>80%]). RESULTS Of 695 patients who underwent pancreatectomy, 22 (3%) had celiac artery compression, and a majority (17) were identified on preoperative imaging. Median celiac artery compression was 52% (interquartile range = 18); 8 (36%) patients had type A and 14 (64%) had type B compression with a median celiac artery compression of 39% (interquartile range = 18) and 59% (interquartile range = 14), respectively (P < .001). Postoperative imaging was available for 20 (90%) patients, and a reduction in the median celiac artery compression occurred in all patients: type A, 14%, and type B, 31%. Complications included 1 (5%) death after hospital discharge, 1 (5%) pancreatic fistula, 1 (5%) delayed gastric emptying, and 4 (18%) readmissions. No patient had evidence of a biliary leak or liver dysfunction. CONCLUSION Preoperative computed tomography allows accurate identification of celiac artery compression. Ligation of the gastroduodenal artery during pancreaticoduodenectomy or total pancreatectomy in the setting of celiac artery compression requires median arcuate ligament release to restore normal arterial flow to the foregut and avoid preventable complications.
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Affiliation(s)
- Erin P Ward
- Huntsman Cancer Institute, University of Utah Health, Salt Lake City, UT.
| | | | | | | | | | | | | | - Susan Tsai
- Medical College of Wisconsin, Milwaukee, WI
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Lu LY, Eastment JG, Sivakumaran Y. Median Arcuate Ligament Syndrome (MALS) in Hepato-Pancreato-Biliary Surgery: A Narrative Review and Proposed Management Algorithm. J Clin Med 2024; 13:2598. [PMID: 38731126 PMCID: PMC11084382 DOI: 10.3390/jcm13092598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 04/04/2024] [Accepted: 04/22/2024] [Indexed: 05/13/2024] Open
Abstract
Median arcuate ligament syndrome (MALS) is an uncommon condition characterized by the compression of the celiac trunk by the median arcuate ligament. Due to the anatomical proximity to the foregut, MALS has significant implications in hepato-pancreato-biliary (HPB) surgery. It can pose complications in pancreatoduodenectomy and orthotopic liver transplantation, where the collateral arterial supply from the superior mesenteric artery is often disrupted. The estimated prevalence of MALS in HPB surgery is approximately 10%. Overall, there is consensus for a cautious approach to MALS when embarking on complex foregut surgery, with a low threshold for intraoperative median arcuate ligament release or hepatic artery reconstruction. The role of endovascular intervention in the management of MALS prior to HPB surgery continues to evolve, but more evidence is required to establish its efficacy. Recognizing the existing literature gap concerning optimal management in this population, we describe our tertiary center experience as a clinical algorithm to facilitate decision-making. Research question: What is the significance and management of median arcuate ligament syndrome in patients undergoing hepato-pancreato-biliary surgery?
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Affiliation(s)
- Lawrence Y. Lu
- Critical Care Research Group, The Prince Charles Hospital, Chermside, QLD 4032, Australia
- Faculty of Medicine, University of Queensland, Herston, QLD 4006, Australia
- Department of General Surgery, Princess Alexandra Hospital, Woolloongabba, QLD 4120, Australia
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
| | - Jacques G. Eastment
- Faculty of Medicine, University of Queensland, Herston, QLD 4006, Australia
- Department of General Surgery, Princess Alexandra Hospital, Woolloongabba, QLD 4120, Australia
| | - Yogeesan Sivakumaran
- Faculty of Medicine, University of Queensland, Herston, QLD 4006, Australia
- Department of Vascular Surgery, Princess Alexandra Hospital, Woolloongabba, QLD 4120, Australia
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Doita S, Aoki H, Kajioka H, Tanakaya K, Kawamoto K. The combination of preoperative celiac axis stenting and neoadjuvant chemotherapy in an elderly patient with pancreatic cancer: a case report. Surg Case Rep 2024; 10:59. [PMID: 38467960 PMCID: PMC10928057 DOI: 10.1186/s40792-024-01857-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 03/03/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Celiac axis stenosis (CAS) is frequently observed in patients undergoing pancreaticoduodenectomy (PD). This poses challenges because of the potential disruption of the hepatic arterial blood flow. CASE PRESENTATION We present the case of an 81-year-old woman diagnosed with pancreatic head cancer and severe CAS caused by calcification. The patient received neoadjuvant chemotherapy (NAC) and underwent preoperative endovascular stenting of the celiac axis to restore blood flow. After two cycles of NAC, subtotal stomach-preserving PD was performed. An intraoperative assessment of the hepatic arterial blood flow determined that it was well maintained. PD was performed using the standard technique; specialized techniques were not necessary. Importantly, no ischemic complications were encountered. CONCLUSION This case report describes the successful combination of preoperative celiac axis stenting, NAC, and surgical intervention for the management of CAS in an elderly patient with pancreatic cancer. This approach offers a potential solution for maintaining the hepatic arterial blood flow in the presence of CAS without vascular reconstruction, particularly in elderly individuals.
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Affiliation(s)
- Susumu Doita
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, 1-1-1 Atago-Machi, Iwakuni-City, Yamaguchi, 740-8510, Japan.
| | - Hideki Aoki
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, 1-1-1 Atago-Machi, Iwakuni-City, Yamaguchi, 740-8510, Japan
| | - Hiroki Kajioka
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, 1-1-1 Atago-Machi, Iwakuni-City, Yamaguchi, 740-8510, Japan
| | - Kohji Tanakaya
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, 1-1-1 Atago-Machi, Iwakuni-City, Yamaguchi, 740-8510, Japan
| | - Kenji Kawamoto
- Department of Cardiovascular Medicine, National Hospital Organization Iwakuni Clinical Center, 1-1-1 Atago-Machi, Iwakuni-City, Yamaguchi, 740-8510, Japan
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Uraoka M, Funamizu N, Sogabe K, Shine M, Honjo M, Tamura K, Sakamoto K, Ogawa K, Takada Y. Novel embryological classifications of hepatic arteries based on the relationship between aberrant right hepatic arteries and the middle hepatic artery: A retrospective study of contrast-enhanced computed tomography images. PLoS One 2024; 19:e0299263. [PMID: 38416748 PMCID: PMC10901311 DOI: 10.1371/journal.pone.0299263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 02/06/2024] [Indexed: 03/01/2024] Open
Abstract
BACKGROUND Variations in hepatic arteries are frequently encountered during pancreatoduodenecomy. Identifying anomalies, especially the problematic aberrant right hepatic artery (aRHA), is crucial to preventing vascular-related complications. In cases where the middle hepatic artery (MHA) branches from aRHAs, their injury may lead to severe liver ischemia. Nevertheless, there has been little information on whether MHA branches from aRHAs. This study aimed to investigate the relationship between aRHAs and the MHA based on the embryological development of visceral arteries. METHODS This retrospective study analyzed contrast-enhanced computed tomography images of 759 patients who underwent hepatobiliary-pancreatic surgery between January 2011 and August 2022. The origin of RHAs and MHA courses were determined using three-dimensional reconstruction. All cases of aRHAs were categorized into those with or without replacement of the left hepatic artery (LHA). RESULTS Among the 759 patients, 163 (21.4%) had aRHAs. Five aRHAs patterns were identified: (Type 1) RHA from the gastroduodenal artery (2.7%), (Type 2) RHA from the superior mesenteric artery (SMA) (12.7%), (Type 3) RHA from the celiac axis (2.1%), (Type 4) common hepatic artery (CHA) from the SMA (3.5%), and (Type 5) separate branching of RHA and LHA from the CHA (0.26%). The MHA did not originate from aRHAs in Types 1-3, whereas in Type 4, it branched from either the RHA or LHA. CONCLUSIONS Based on the developmental process of hepatic and visceral arteries, branching of the MHA from aRHAs is considered rare. However, preoperative recognition and intraoperative anatomical assessment of aRHAs is essential to avoid injury.
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Affiliation(s)
- Mio Uraoka
- Department of Hepatobiliary-Pancreatic Surgery and Breast Surgery, Ehime University Hospital, Shitsukawa Toon City, Ehime, Japan
| | - Naotake Funamizu
- Department of Hepatobiliary-Pancreatic Surgery and Breast Surgery, Ehime University Hospital, Shitsukawa Toon City, Ehime, Japan
| | - Kyosei Sogabe
- Department of Hepatobiliary-Pancreatic Surgery and Breast Surgery, Ehime University Hospital, Shitsukawa Toon City, Ehime, Japan
| | - Mikiya Shine
- Department of Hepatobiliary-Pancreatic Surgery and Breast Surgery, Ehime University Hospital, Shitsukawa Toon City, Ehime, Japan
| | - Masahiko Honjo
- Department of Hepatobiliary-Pancreatic Surgery and Breast Surgery, Ehime University Hospital, Shitsukawa Toon City, Ehime, Japan
| | - Kei Tamura
- Department of Hepatobiliary-Pancreatic Surgery and Breast Surgery, Ehime University Hospital, Shitsukawa Toon City, Ehime, Japan
| | - Katsunori Sakamoto
- Department of Hepatobiliary-Pancreatic Surgery and Breast Surgery, Ehime University Hospital, Shitsukawa Toon City, Ehime, Japan
| | - Kohei Ogawa
- Department of Hepatobiliary-Pancreatic Surgery and Breast Surgery, Ehime University Hospital, Shitsukawa Toon City, Ehime, Japan
| | - Yasutsugu Takada
- Department of Hepatobiliary-Pancreatic Surgery and Breast Surgery, Ehime University Hospital, Shitsukawa Toon City, Ehime, Japan
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Lazzarotto-da-Silva G, Santos LM, Lucena IRS, Rabolini BB, Hallal CP, Feier FH, Grezzana-Filho TJM, Chedid MF, Leipnitz I, Chedid AD, de Araujo A, Alvares-da-Silva MR, Kruel CRP. Celiac trunk stenosis by median arcuate ligament in orthotopic liver transplantation: a potential hidden foe to the biliary tree. HPB (Oxford) 2024; 26:137-144. [PMID: 37722997 DOI: 10.1016/j.hpb.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 08/16/2023] [Accepted: 09/04/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Celiac trunk compression by the median arcuate ligament (MAL) increases the risk of ischemic complications following gastrointestinal surgical procedures. Previous studies suggest increased risk of hepatic artery thrombosis (HAT) in orthotopic liver transplant (OLT) recipients. The aim of this study is to investigate the impact of untreated MAL compression (MAL-C) on biliary complications in OLT. METHODS Contrast-enhanced imaging was used to classify celiac trunk stenosis by MAL-C. Medical records were reviewed to extract pre-transplant, transplant and post-transplant data. Patients were divided into two groups: no MAL compression (nMAL-C) and MAL-C. The primary endpoint was biliary complications. Secondary endpoints were HAT and graft survival. RESULTS 305 OLT were performed from 2010 to 2021, of which 219 were included for analysis: 185 (84.5%) patients without and 34 (15.5%) with MAL-C. The incidence of HAT was 5.9% in both groups. Biliary complications were more common in the MAL-C group (35.3% vs. 17.8%, p = 0.035). Graft survival was decreased in patients with MAL-C (p = 0.035). CONCLUSIONS MAL-C of the celiac trunk was associated with increased risk of biliary complications and inferior graft survival in OLT patients. These findings highlight the importance of preoperative screening and treatment of MAL in this population.
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Affiliation(s)
| | | | - Iara R S Lucena
- Radiology Unit, Hospital de Clínicas de Porto Alegre, Brazil
| | - Bruno B Rabolini
- Post-Graduate Program in Surgical Sciences, Medical School of UFRGS, Brazil
| | - Celina P Hallal
- Post-Graduate Program in Surgical Sciences, Medical School of UFRGS, Brazil
| | - Flavia H Feier
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Brazil
| | | | - Marcio F Chedid
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Brazil
| | - Ian Leipnitz
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Brazil
| | - Aljamir D Chedid
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Brazil
| | - Alexandre de Araujo
- Gastroenterology and Hepatology Unit, Hospital de Clínicas de Porto Alegre, Brazil
| | | | - Cleber R P Kruel
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Brazil
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Nguyen TK, Nguyen HH, Luong TH, Chantha P, Ngo GK, Le VD, Dang KK, Tran DH, Nguyen CT. Pancreaticoduodenectomy combined gastroduodenal collateral reconstruction and preservation due to median arcuate ligament syndrome: technical notes with two surgical cases report (with video). World J Surg Oncol 2023; 21:206. [PMID: 37461042 DOI: 10.1186/s12957-023-03096-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/29/2023] [Indexed: 07/20/2023] Open
Abstract
INTRODUCTION Pancreaticoduodenectomy in patients with CA stenosis due to median arcuate ligament often required carefully collateral pathways management to avoid hepatic ischemic complications. CASES PRESENTATION Case 1: A 63-year-old man was referred to our department because of jaundice with distal common bile duct tumor. Pancreaticoduodenectomy with left posterior SMA first approach and circumferential lymphadenectomy was performed. Case 2: A 48-year-old man was referred to our department because of right-upper-quadrant abdominal pain with Vater tumor. Laparoscopic pancreaticoduodenectomy with left posterior SMA first approach and circumferential lymphadenectomy was performed. Postoperatively, in all two cases, three-dimensional reconstruction images showed developed collateral pathways around the pancreatic head, and the CA was stenosis in 75% and 70% due to MAL, respectively. Intraoperatively, in all two cases, we confirmed poor blood flow in the common hepatic artery (CHA) by palpation and observation. So that in the first case, we have decided to proceed a no-touch technique of GDA segmental resection en bloc with the tumor and reconstructed with an end-to-end GDA anastomosis; in the second cases, we have decided to proceed gastroduodenal collateral preservation. When preserving these collateral pathways, we confirmed that the PHA flow remained pulsatile as an indicator that the blood flow was adequate. CONCLUSION Celiac axis stenosis was a rare but difficult-to-managed condition associated with pancreaticoduodenectomy. Collateral pathways management depends on variety of collateral pathways.
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Affiliation(s)
- Thanh Khiem Nguyen
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Ham Hoi Nguyen
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Tuan Hiep Luong
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgery, Bach Mai Hospital, Hanoi, Vietnam.
| | - Pisey Chantha
- Department of Surgery, Hanoi Medical University, Hanoi, Vietnam
| | - Gia Khanh Ngo
- Department of Thoracic & Vascular Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Van Duy Le
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgery, Bach Mai Hospital, Hanoi, Vietnam
| | | | - Duc Huy Tran
- Center of Diagnostic Imaging and Intervention, Bach Mai Hospital, Hanoi, Vietnam
| | - Cuong Thinh Nguyen
- 108 Institute of Clinical Medical and Pharmaceutical Sciences, Hanoi, Vietnam
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10
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Bieniek PA, Katou S, Kraehling H, Masthoff M, Morgul H, Pascher A, Struecker B. Clinical impact of a celiac axis stenosis in patients undergoing hepatobiliary surgery. Langenbecks Arch Surg 2023; 408:279. [PMID: 37454337 PMCID: PMC10350437 DOI: 10.1007/s00423-023-03003-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 06/26/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Celiac axis stenosis (CAS) often is an incidental finding in terms of diagnostic for hepatobiliary surgery since most cases remain asymptomatic. It remains unclear whether CAS is a risk factor for postoperative complications after hepatobiliary surgery. Therefore, the aim of this study was to evaluate the impact of an asymptomatic CAS on the postoperative morbidity and survival of patients undergoing hepatobiliary surgery. METHODS We retrospectively analyzed CT scans and clinicopathological data of 250 consecutive patients undergoing hepatobiliary surgery between 2011 and 2018 in our tertiary center. We compared the postoperative course between patients with and without an incidental CAS as well as their overall survival. RESULTS CAS was caused by atherosclerotic stenosis in 16 (64%) patients, by ligamentous stenosis in 4 (16%) and by combined conditions in 5 cases (20%). Mean age of patients in the CAS group was significantly higher in comparison to patients of the non-CAS group (71.0 vs. 59.1 years, p < 0.001). Major hepatectomy was conducted in 40% of the CAS patients and 19.6% of non-CAS patients, respectively (p = 0.036). Interestingly, no statistically significant differences in postoperative morbidity (40 vs. 46.2%, p = 0.673) or in overall survival between the groups (41.3 vs. 51.9 months, p = 0.611) were observed. CONCLUSION Our analysis found no correlation between an asymptomatic celiac axis stenosis and postoperative complications or overall survival after hepatobiliary surgery. Which impact the incidental CAS may have in highly complex cases remains unclear. Further studies are needed to identify patients who benefit from CAS treatment before hepatobiliary surgery.
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Affiliation(s)
- Pawel A Bieniek
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Waldeyerstrasse 1, 48149, Münster, Germany
| | - Shadi Katou
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Waldeyerstrasse 1, 48149, Münster, Germany
| | - Hermann Kraehling
- Clinic for Radiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Max Masthoff
- Clinic for Radiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Haluk Morgul
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Waldeyerstrasse 1, 48149, Münster, Germany
| | - Andreas Pascher
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Waldeyerstrasse 1, 48149, Münster, Germany
| | - Benjamin Struecker
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Waldeyerstrasse 1, 48149, Münster, Germany.
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Al-Saeedi M, Sauer HB, Ramouz A, Koch JM, Frank-Moldzio L, Bruckner T, Loos M, Mayer P, Klauss M, Kulu Y, Berchtold C, Hoffmann K, Mehrabi A, Schneider M, Müller-Stich B, Hackert T, Büchler MW, Strobel O. Celiac Axis Stenosis is an Underestimated Risk Factor for Increased Morbidity After Pancreatoduodenectomy. Ann Surg 2023; 277:e885-e892. [PMID: 35129468 PMCID: PMC9994807 DOI: 10.1097/sla.0000000000005383] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assesses the prevalence and severity of CAS in patients undergoing PD/total pancreatectomy and its association with major postoperative complications after PD. SUMMARY OF BACKGROUND DATA CAS may increase the risk of ischemic complications after PD. However, the prevalence of CAS and its relevance to major morbidity remain unknown. METHODS All patients with a preoperative computed tomography with arterial phase undergoing partial PD or TP between 2014 and 2017 were identified from a prospective database. CAS was assessed based on computed tomography and graded according to its severity: no stenosis (<30%), grade A (30%-<50%), grade B (50%-≤80%), and grade C (>80%). Postoperative complications were assessed and uni- and multivariable risk analyses were performed. RESULTS Of 989 patients, 273 (27.5%) had CAS: 177 (17.9%) with grade A, 83 (8.4%) with grade B, and 13 (1.3%) with grade C. Postoperative morbidity and 90-day mortality occurred in 278 (28.1%) patients and 41 (4.1%) patients, respectively. CAS was associated with clinically relevant pancreatic fistula ( P =0.019), liver perfusion failure ( P =0.003), gastric ischemia ( P =0.001), clinically relevant biliary leakage ( P =0.006), and intensive care unit ( P =0.016) and hospital stay ( P =0.001). Multivariable analyses confirmed grade B and C CAS as independent risk factors for liver perfusion failure; in addition, grade C CAS was an independent risk factor for clinically relevant pancreatic fistula and gastric complications. CONCLUSIONS CAS is common in patients undergoing PD. Higher grade of CAS is associated with an increased risk for clinically relevant complications, including liver perfusion failure and postoperative pancreatic fistula. Precise radiological assessment may help to identify CAS. Future studies should investigate measures to mitigate CAS-associated risks.
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Affiliation(s)
- Mohammed Al-Saeedi
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Hendrik B Sauer
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Ali Ramouz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Julian M Koch
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Leonie Frank-Moldzio
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Tom Bruckner
- Institute of Medical Biometry and Informatics, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Loos
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Philipp Mayer
- Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Miriam Klauss
- Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Yakup Kulu
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Christoph Berchtold
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Katrin Hoffmann
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Schneider
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Beat Müller-Stich
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
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12
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Aru RG, Deery SE, Kavousi Y, Black JH, Burns WR, Hicks CW. Retrograde Open Celiac Stenting for Ischemic Hepatitis following Pancreaticoduodenectomy. J Vasc Surg Cases Innov Tech 2023; 9:101136. [PMID: 37168707 PMCID: PMC10164893 DOI: 10.1016/j.jvscit.2023.101136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 02/03/2023] [Indexed: 03/06/2023] Open
Abstract
A 74-year-old man with pancreatic cancer had undergone pancreaticoduodenectomy and subsequently developed ischemic hepatitis secondary to high-grade celiac artery stenosis. Celiac antegrade stenting via brachial artery access was unsuccessful, and open antegrade bypass would have required takedown of the pancreatic and/or biliary anastomoses for adequate exposure. Retrograde open celiac stenting was, therefore, successfully performed via the gastroduodenal artery stump. His ischemic hepatitis resolved, and he was ultimately discharged with dual antiplatelet therapy. Computed tomography angiography at 6 months demonstrated a widely patent celiac stent. Retrograde open celiac stenting via the gastroduodenal artery stump is an alternative to open bypass for celiac revascularization not amenable to percutaneous antegrade stenting in patients who have undergone pancreaticoduodenectomy.
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13
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Shimbara K, Shintakuya R, Honmyo N, Nakagawa N, Kohashi T. Median arcuate ligament resection for a patient with ruptured pancreaticoduodenal artery aneurysm: A case report. Int J Surg Case Rep 2023; 106:108041. [PMID: 37030161 PMCID: PMC10119882 DOI: 10.1016/j.ijscr.2023.108041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 03/14/2023] [Accepted: 03/17/2023] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Median arcuate ligament syndrome (MALS) is a rare disease characterized by compression of the celiac artery (CA) by the median arcuate ligament (MAL). A small proportion of pancreaticoduodenal artery (PDA) aneurysms are caused by compression of the CA by the MAL. Here, we report a case of rupture of a PDA aneurysm associated with MALS that was treated with coil embolization followed by MAL resection. CASE PRESENTATION A 49-year-old man lost consciousness due to hypovolemic shock in the hospital two days after appendectomy. Contrast-enhanced multi-detector row computed tomography (MD-CT) showed a retroperitoneal hematoma and extravasation from the pancreaticoduodenal arcade vessels, therefore emergency angiography was performed. An aneurysm was detected in the anterior inferior PDA and coil embolization was performed for the inferior PDA. Three months after embolization, MAL resection was performed to prevent rebleeding from the PDA. Six months have passed after the surgery, the patient had no CA restenosis or PDA aneurysms. CLINICAL DISCUSSION MALS is a rare disease that results from the compression of the CA by the MAL. PDA aneurysms are associated with CA stenosis, and compression of the CA by the MAL is the most frequently reported cause of CA stenosis. There is no established treatment for CA stenosis after a PDA aneurysm rupture due to MALS. CONCLUSION It is suggested that MAL resection may be effective in reducing shear stress in the pancreaticoduodenal arcade. Improving blood flow through the CA by MAL resection might reduce risk of PDA aneurysm recurrence.
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14
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Colella M, Mishima K, Wakabayashi T, Fujiyama Y, Al-Omari MA, Wakabayashi G. Preoperative blood circulation modification prior to pancreaticoduodenectomy in patients with celiac trunk occlusion: Two case reports. World J Gastrointest Surg 2022; 14:1310-1319. [PMID: 36504517 PMCID: PMC9727574 DOI: 10.4240/wjgs.v14.i11.1310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/24/2022] [Accepted: 10/19/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Celiac trunk stenosis or occlusion is a common condition observed in patients undergoing pancreaticoduodenectomy (PD). The risk of upper abdominal organ ischemia or failure increases if the blood circulation in the celiac arterial system is not maintained after the surgery.
CASE SUMMARY We present two cases of elderly patients with distal cholangiocarcinoma and celiac trunk occlusion who underwent PD. We performed blood circulation modification preoperatively with transcatheter coil embolization of the arterial arcades of the pancreatic head via the superior mesenteric artery to develop collateral communication between the superior mesenteric artery and the common hepatic or splenic arteries to ensure arterial blood flow to the upper abdominal organs. The postoperative course was marked by delayed gastric emptying, but no major surgical complications, such as biliary or pancreatic fistula, or clinical, biochemical, or radiological evidence of ischemic disease, was observed.
CONCLUSION Preoperative blood circulation modification may be a valid alternative procedure for elderly patients with celiac trunk occlusion who are ineligible for interventional or surgical revascularization.
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Affiliation(s)
- Marco Colella
- Center for Advanced Treatment of HBP Diseases, Ageo Central General Hospital, Ageo 362-8588, Saitama, Japan
| | - Kohei Mishima
- Center for Advanced Treatment of HBP Diseases, Ageo Central General Hospital, Ageo 362-8588, Saitama, Japan
| | - Taiga Wakabayashi
- Center for Advanced Treatment of HBP Diseases, Ageo Central General Hospital, Ageo 362-8588, Saitama, Japan
| | - Yoshiki Fujiyama
- Center for Advanced Treatment of HBP Diseases, Ageo Central General Hospital, Ageo 362-8588, Saitama, Japan
| | - Malek A Al-Omari
- Center for Advanced Treatment of HBP Diseases, Ageo Central General Hospital, Ageo 362-8588, Saitama, Japan
| | - Go Wakabayashi
- Center for Advanced Treatment of HBP Diseases, Ageo Central General Hospital, Ageo 362-8588, Saitama, Japan
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15
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Onishi Y, Shimizu H, Isoda H, Shinozuka K, Ohtsuru S, Nakamoto Y. Transcatheter arterial embolization for bleeding from the pancreaticoduodenal artery in patients with celiac artery stenosis: A technical report. Acta Radiol Open 2022; 11:20584601221135180. [PMID: 36313861 PMCID: PMC9597204 DOI: 10.1177/20584601221135180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 10/09/2022] [Indexed: 11/12/2022] Open
Abstract
Background Transcatheter arterial embolization (TAE) is widely accepted as a treatment for bleeding from the pancreaticodoudenal artery (PDA) in patients with celiac artery stenosis. However, the technical aspect of TAE has not received much attention. Purpose To report the technical details and success rate of TAE for bleeding from the PDA in patients with CA stenosis. Material and Methods Between 2015 and 2021, nine TAE procedures were performed in eight patients (five women, three men; one woman underwent TAE twice). The cause of CA stenosis was compression by the median arcuate ligament in eight cases and CA dissection in one case. The cause of bleeding was flow-related aneurysm rupture in six cases. Pre-TAE CT showed a pseudoaneurysm in all cases. The technical details of TAE were recorded, and the success rate was evaluated. Results The technical and clinical success rates were 100%. In six cases, both the CA and superior mesenteric artery (SMA) were cannulated using two parent catheters: a microcatheter advancing to the pseudoaneurysm from the CA (the CA approach) to achieve embolization and another catheter for angiography advancing from the SMA to map the vascular anatomy. In five cases, the CA approach was successfully performed after failed attempts of advancing a microcatheter from the SMA. Conclusion TAE is an effective treatment for bleeding from the PDA in patients with CA stenosis. Using two parent catheters, one for CA cannulation and microcatheter advancement and another for SMA cannulation and vascular mapping, may be a useful technique.
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Affiliation(s)
- Yasuyuki Onishi
- Department of Diagnostic Imaging
and Nuclear Medicine, Graduate School of Medicine,
Kyoto
University, Kyoto, Japan,Yasuyuki Onishi, MD, Department of
Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto
University, 54 Shogoin-kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan.
| | - Hironori Shimizu
- Department of Diagnostic Imaging
and Nuclear Medicine, Graduate School of Medicine,
Kyoto
University, Kyoto, Japan
| | - Hiroyoshi Isoda
- Department of Diagnostic Imaging
and Nuclear Medicine, Graduate School of Medicine,
Kyoto
University, Kyoto, Japan
| | - Ken Shinozuka
- Department of Primary Care and
Emergency Medicine, Graduate School of Medicine,
Kyoto
University, Kyoto, Japan
| | - Shigeru Ohtsuru
- Department of Primary Care and
Emergency Medicine, Graduate School of Medicine,
Kyoto
University, Kyoto, Japan
| | - Yuji Nakamoto
- Department of Diagnostic Imaging
and Nuclear Medicine, Graduate School of Medicine,
Kyoto
University, Kyoto, Japan
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16
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Miura Y, Ohgi K, Sugiura T, Okamura Y, Ashida R, Yamada M, Otsuka S, Yasunaga Y, Nakagawa M, Uesaka K. Resectability Status of Pancreatic Cancer Having Tumor Contact with an Aberrant Right Hepatic Artery: Is Upfront Surgery Justified? Ann Surg Oncol 2022; 29:4979-4988. [PMID: 35362841 DOI: 10.1245/s10434-022-11624-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 02/27/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND The NCCN guidelines define pancreatic cancer that has contact with an aberrant right hepatic artery (A-RHA) as a borderline-resectable tumor. However, the impact of tumor contact with an A-RHA on surgical and survival outcomes has not been well discussed. METHODS A total of 541 patients who underwent pancreatoduodenectomy for resectable and borderline-resectable pancreatic cancer between 2002 and 2019 were retrospectively analyzed. The presence of an A-RHA and tumor contact with an A-RHA were evaluated based on the preoperative computed tomography findings. Patients with resectable tumors and tumors with A-RHA-contact (having contact with an A-RHA without involvement of the major arteries) were generally treated by upfront surgery, whereas those with borderline-resectable tumors generally underwent neoadjuvant therapy and subsequent resection. RESULTS Among the 541 patients, 116 (21.4%) had an A-RHA and 15 (2.8%) had tumor with A-RHA-contact. The A-RHA was resected in 12, and arterial reconstruction was performed in 8. The rates of morbidity and R1 resection in patients with an A-RHA (32.8 and 10.3%, respectively) were comparable to those without an A-RHA (27.3 and 11.3%, respectively). The overall survival in patients with A-RHA-contact was significantly worse than that in patients with borderline-resectable tumors (median survival time, 14.6 vs. 35.3 months, p = 0.048). CONCLUSIONS Although upfront resection was safely performed and led to a high R0 resection rate in patients with A-RHA-contact, the survival outcome was dismal. A tumor with A-RHA-contact should be regarded as technically resectable but oncologically borderline-resectable. Upfront surgery may not be appropriate for patients with A-RHA-contact.
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Affiliation(s)
- Yuya Miura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Katsuhisa Ohgi
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan.
| | - Teiichi Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yukiyasu Okamura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Ryo Ashida
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Mihoko Yamada
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Shimpei Otsuka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yoshichika Yasunaga
- Division of Plastic and Reconstructive Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Masahiro Nakagawa
- Division of Plastic and Reconstructive Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
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17
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KIROV KG. Central pancreatectomy with common hepatic artery resection for a giant pancreatic neuroendocrine tumor. Chirurgia (Bucur) 2022. [DOI: 10.23736/s0394-9508.21.05294-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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18
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Sakamoto A, Funamizu N, Ito C, Iwata M, Shine M, Uraoka M, Nagaoka T, Matsui T, Nishi Y, Tamura K, Sakamoto K, Ogawa K, Takada Y. Postoperative arterial lactate levels can predict postoperative pancreatic fistula following pancreaticoduodenectomy: A single cohort retrospective study. Pancreatology 2022; 22:651-655. [PMID: 35487869 DOI: 10.1016/j.pan.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/18/2022] [Accepted: 04/04/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND /Objectives: Postoperative pancreatic fistula (POPF) is a serious complication after pancreaticoduodenectomy (PD). Thus, identification of the risk factors for POPF is urgently needed. In this study, we aimed to identify whether arterial lactate (LCT) levels following PD might be a marker of the potential risk of POPF. METHODS Between September 2009 and December 2020, 151 patients who underwent elective PD were retrospectively enrolled. Patient characteristics, perioperative clinicopathological variables, postoperative blood biochemistry data were analyzed in univariable and multivariable analyses. Pancreatic fistula of Grade B and C was considered as POPF. RESULTS Patients were divided into the POPF group (n = 33, 21.9%) and non-POPF group (n = 118, 78.1%). Higher body mass index (p = 0.017), increased estimated blood loss (p = 0.047), soft textured pancreas (p = 0.007), smaller main pancreatic duct (p = 0.016), higher LCT levels (p < 0.001), higher aspartate aminotransferase levels (p = 0.023) and higher procalcitonin levels (p = 0.024) were significantly associated with POPF. Receiver operating characteristic curve analysis revealed that 2.1 mmol/L was the optimal cut-off value of LCT (sensitivity = 78.8%, specificity = 61.2%) for predicting POPF occurrence. Univariate and multivariate analyses confirmed that an LCT of ≥2.1 mmol/L was independently associated with the risk of POPF following PD (odds ratio = 6.78, 95% confidence interval = 2.22-20.74; p = 0.001). CONCLUSIONS Higher LCT is a predictive marker for POPF following PD.
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Affiliation(s)
- Akimasa Sakamoto
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, Japan
| | - Naotake Funamizu
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, Japan.
| | - Chihiro Ito
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, Japan
| | - Miku Iwata
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, Japan
| | - Mikiya Shine
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, Japan
| | - Mio Uraoka
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, Japan
| | - Tomoyuki Nagaoka
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, Japan
| | - Takashi Matsui
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, Japan
| | - Yusuke Nishi
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, Japan
| | - Kei Tamura
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, Japan
| | - Katsunori Sakamoto
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, Japan
| | - Kohei Ogawa
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, Japan
| | - Yasutsugu Takada
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, Japan
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19
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Xu YC, Yang F, Fu DL. Clinical significance of variant hepatic artery in pancreatic resection: A comprehensive review. World J Gastroenterol 2022; 28:2057-2075. [PMID: 35664036 PMCID: PMC9134138 DOI: 10.3748/wjg.v28.i19.2057] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 03/16/2022] [Accepted: 04/09/2022] [Indexed: 02/06/2023] Open
Abstract
The anatomical structure of the pancreaticoduodenal region is complex and closely related to the surrounding vessels. A variant of the hepatic artery, which is not a rare finding during pancreatic surgery, is prone to intraoperative injury. Inadvertent injury to the hepatic artery may affect liver perfusion, resulting in necrosis, liver abscess, and even liver failure. The preoperative identification of hepatic artery variations, detailed planning of the surgical approach, careful intraoperative dissection, and proper management of the damaged artery are important for preventing hepatic hypoperfusion. Nevertheless, despite the potential risks, planned artery resection has become acceptable in carefully selected patients. Arterial reconstruction is sometimes essential to prevent postoperative ischemic complications and can be performed using various methods. The complexity of procedures such as pancreatectomy with en bloc celiac axis resection may be mitigated by the presence of an aberrant right hepatic artery or a common hepatic artery originating from the superior mesenteric artery. Here, we comprehensively reviewed the anatomical basis of hepatic artery variation, its incidence, and its effect on the surgical and oncological outcomes after pancreatic resection. In addition, we provide recommendations for the prevention and management of hepatic artery injury and liver hypoperfusion. Overall, the hepatic artery variant may not worsen surgical and oncological outcomes if it is accurately identified pre-operatively and appropriately managed intraoperatively.
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Affiliation(s)
- Ye-Cheng Xu
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai 200040, China
| | - Feng Yang
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai 200040, China
| | - De-Liang Fu
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai 200040, China
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20
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Pancreatoduodenectomy in a patient with celiac axis stenosis and a replaced common hepatic artery: A case report. Int J Surg Case Rep 2022; 94:107088. [PMID: 35462147 PMCID: PMC9046802 DOI: 10.1016/j.ijscr.2022.107088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/12/2022] [Accepted: 04/12/2022] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Evaluation of anatomical variations is important in pancreatoduodenectomy (PD) because an arterial anomaly is a risk factor for morbidity. Herein, we report a rare case of PD for lower bile duct cancer in which celiac axis stenosis and a replaced common hepatic artery (rCHA) coexisted. PRESENTATION OF CASE An 84-year-old woman presented with epigastric pain. She was diagnosed with a lower bile duct cancer and underwent PD. Preoperative computed tomography showed celiac axis stenosis, and the deformed celiac artery had a "hooked appearance," suggesting compression by the median arcuate ligament (MAL). The rCHA branched from the superior mesenteric artery. The gastroduodenal artery (GDA) diverged from the rCHA, forming a developed arterial arcade of the pancreatic head. There was an oncological safety margin between the rCHA and common bile duct; however, a part of the collateral artery was close to the common bile duct. Therefore, we planned to preserve the rCHA and resect the GDA to form collateral circulation. The MAL was divided and we evaluated the blood flow of the left upper abdominal organs using indocyanine green fluorescence imaging with a near-infrared camera system. We considered that perfusion of organs was preserved, and PD was performed without vessel reconstruction. No ischemic complication occurred in the postoperative course. DISCUSSION The coexistence of these arterial anomalies made the procedure of PD more complicated. CONCLUSION Precise preoperative diagnosis of arterial anomalies is necessary to avoid postoperative complications that may be induced by intraoperative arterial injury and organ ischemia.
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21
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Takeuchi S, Ambo Y, Kodama Y, Takada M, Kato K, Nakamura F, Hirano S. Preoperative embolization strategy for the combined resection of replaced right hepatic artery in pancreaticoduodenectomy: a small case series. Surg Case Rep 2022; 8:49. [PMID: 35316851 PMCID: PMC8941043 DOI: 10.1186/s40792-022-01403-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 03/17/2022] [Indexed: 11/22/2022] Open
Abstract
Background Replaced right hepatic artery (rRHA) is a common vascular variation, and combined resection of this vessel is sometimes needed for the curative resection of pancreatic head malignancy. Safe surgical management has not been established, and there is a small number of reported cases. Here, we reported five cases, wherein preoperative embolization of rRHA was performed for combined resection. Case presentation All patients had pancreatic head malignancies that were in contact with rRHA. We performed a preoperative embolization of the rRHA before the scheduled pancreaticoduodenectomy for the combined resection. Arterial embolization was safely accomplished, and the communicating arcade from the left hepatic artery via the hilar plate was clearly revealed in all cases. Four patients underwent the operative procedure, except for one patient who had liver metastasis at laparotomy. No patient suffered from a severe abnormal liver function during the management; however, one patient had multiple liver infarctions during the postoperative course. Conclusions Preoperative embolization for the combined resection of rRHA in pancreaticoduodenectomy can be a management option for the precise evaluation of hemodynamics after sacrificing rRHA. In our cases, arterial flow to the right liver lobe was supplied by the left hepatic artery via the bypass route, including the communicating arcade of the hilar plate.
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Affiliation(s)
- Shintaro Takeuchi
- Department of Surgery, Teine Keijinkai Hospital, 1-12-1-40, Maeda, Teine-ku, Sapporo, Hokkaido, 006-8555, Japan.
| | - Yoshiyasu Ambo
- Department of Surgery, Teine Keijinkai Hospital, 1-12-1-40, Maeda, Teine-ku, Sapporo, Hokkaido, 006-8555, Japan
| | - Yoshihisa Kodama
- Department of Radiology, Teine Keijinkai Hospital, 1-12-1-40, Maeda, Teine-ku, Sapporo, Hokkaido, 006-8555, Japan
| | - Minoru Takada
- Department of Surgery, Teine Keijinkai Hospital, 1-12-1-40, Maeda, Teine-ku, Sapporo, Hokkaido, 006-8555, Japan
| | - Kentaro Kato
- Department of Surgery, Teine Keijinkai Hospital, 1-12-1-40, Maeda, Teine-ku, Sapporo, Hokkaido, 006-8555, Japan
| | - Fumitaka Nakamura
- Department of Surgery, Teine Keijinkai Hospital, 1-12-1-40, Maeda, Teine-ku, Sapporo, Hokkaido, 006-8555, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Faculty of Medicine, Hokkaido University, West-7, North-15, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
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22
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Yoshida E, Kimura Y, Kyuno T, Kawagishi R, Sato K, Kono T, Chiba T, Kimura T, Yonezawa H, Funato O, Kobayashi M, Murakami K, Takagane A, Takemasa I. Treatment strategy for pancreatic head cancer with celiac axis stenosis in pancreaticoduodenectomy: A case report and review of literature. World J Gastroenterol 2022; 28:868-877. [PMID: 35317096 PMCID: PMC8900579 DOI: 10.3748/wjg.v28.i8.868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 10/07/2021] [Accepted: 01/22/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND During pancreaticoduodenectomy in patients with celiac axis (CA) stenosis due to compression by the median arcuate ligament (MAL), the MAL has to be divided to maintain hepatic blood flow in many cases. However, MAL division often fails, and success can only be determined intraoperatively. To overcome this problem, we performed endovascular CA stenting preoperatively, and thereafter safely performed pancreaticoduodenectomy. We present this case as a new preoperative treatment strategy that was successful.
CASE SUMMARY A 77-year-old man with a diagnosis of pancreatic head cancer presented to our department for surgery. Preoperative assessment revealed CA stenosis caused by MAL. We performed endovascular stenting in the CA preoperatively because we knew that going into the operation without a strategy could lead to ischemic complications. Double-antiplatelet therapy (DAPT) – which is needed when a stent is inserted – was then administered in parallel with neoadjuvant chemotherapy (NAC). This allowed us to administer DAPT for a sufficient period before the main pancreaticoduodenectomy procedure while obtaining therapeutic effects from NAC. Subtotal stomach-preserving pancreaticoduodenectomy was then performed. The operation did not require any unusual techniques and was performed safely. Postoperatively, the patient progressed well, without any ischemic complications. Histopathologically, curative resection was confirmed, and the patient had no recurrence or complications due to ischemia up to six months postoperatively.
CONCLUSION Preoperative endovascular stenting, with NAC and DAPT, is effective and safe prior to pancreaticoduodenectomy in potentially resectable pancreatic cancer.
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Affiliation(s)
- Eiji Yoshida
- Department of Surgery, Hakodate Goryoukaku Hospital, Hakodate City 040-8611, Japan
| | - Yasutoshi Kimura
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo City 060-8543, Hokkaido, Japan
| | - Takuro Kyuno
- Department of Surgery, Hakodate Goryoukaku Hospital, Hakodate City 040-8611, Japan
| | - Ryoko Kawagishi
- Department of Surgery, Hakodate Goryoukaku Hospital, Hakodate City 040-8611, Japan
| | - Kei Sato
- Department of Surgery, Hakodate Goryoukaku Hospital, Hakodate City 040-8611, Japan
| | - Tsuyoshi Kono
- Department of Surgery, Hakodate Goryoukaku Hospital, Hakodate City 040-8611, Japan
| | - Takehiro Chiba
- Department of Surgery, Hakodate Goryoukaku Hospital, Hakodate City 040-8611, Japan
| | - Toshimoto Kimura
- Department of Surgery, Hakodate Goryoukaku Hospital, Hakodate City 040-8611, Japan
| | - Hitoshi Yonezawa
- Department of Surgery, Hakodate Goryoukaku Hospital, Hakodate City 040-8611, Japan
| | - Osamu Funato
- Department of Surgery, Hakodate Goryoukaku Hospital, Hakodate City 040-8611, Japan
| | - Makoto Kobayashi
- Department of Surgery, Hakodate Goryoukaku Hospital, Hakodate City 040-8611, Japan
| | - Kenji Murakami
- Department of Diagnostic Radiology, Hakodate Goryoukaku Hospital, Hakodate City 040-8611, Japan
| | - Akinori Takagane
- Department of Surgery, Hakodate Goryoukaku Hospital, Hakodate City 040-8611, Japan
| | - Ichiro Takemasa
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo City 060-8543, Hokkaido, Japan
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Hanada K, Tsunoda S, Ogiso S, Nishigori T, Hisamori S, Obama K. McKeown esophagectomy with concomitant median arcuate ligament release in a case of esophageal cancer with celiac artery stenosis. Surg Case Rep 2022; 8:5. [PMID: 34993694 PMCID: PMC8738834 DOI: 10.1186/s40792-022-01359-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 01/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The celiac artery stenosis due to compression by median arcuate ligament (MAL) has been reported in many cases of pancreaticoduodenectomy, but not in cases of esophagectomy. Recently, the celiac artery stenosis due to MAL or arteriosclerosis has been reported to be associated with the gastric tube necrosis or anastomotic leakage following Ivor-Lewis esophagectomy. Herein, we present the first reported case of esophageal cancer with celiac artery stenosis due to compression by the MAL successfully treated by McKeown esophagectomy and gastric tube reconstruction following prophylactic MAL release. CASE PRESENTATION A 72-year-old female patient was referred to our department for esophagectomy. The patient had received two courses of neoadjuvant chemotherapy with 5-FU and cisplatin for T2N0M0 squamous cell carcinoma of the middle esophagus. Preoperative contrast-enhanced computed tomography (CECT) showed celiac artery stenosis due to compression by the MAL. The development of collateral arteries around the pancreatic head was observed without evidence of aneurysm formation. The patient reported no abdominal symptoms. After robot-assisted esophagectomy with mediastinal lymphadenectomy, gastric mobilization, supra-pancreatic lymphadenectomy, and preparation of the gastric tube were performed under laparotomy. Subsequently, the MAL was cut, and released to expose the celiac artery. Improved celiac artery blood flow was confirmed by decreased pulsatility index on intraoperative Doppler sonography. The operation was completed with the cervical esophagogastric anastomosis following cervical lymphadenectomy. Postoperative CECT on postoperative day 7 demonstrated increased celiac artery patency. The patient had an uncomplicated postoperative course thereafter. CONCLUSIONS Prophylactic MAL release may be considered in patients with celiac artery stenosis due to compression by the MAL on preoperative CECT for esophagectomy.
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Affiliation(s)
- Keita Hanada
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin- Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Shigeru Tsunoda
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin- Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Satoshi Ogiso
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin- Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Tatsuto Nishigori
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin- Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Shigeo Hisamori
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin- Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kazutaka Obama
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin- Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
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24
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Marichez A, Turrini O, Fernandez B, Garnier J, Lapuyade B, Ewald J, Adam JP, Marchese U, Chiche L, Delpero JR, Laurent C. Does pre-operative embolization of a replaced right hepatic artery before pancreaticoduodenectomy for pancreatic adenocarcinoma affect postoperative morbidity and R0 resection? A bi-centric French cohort study. HPB (Oxford) 2021; 23:1683-1691. [PMID: 33933344 DOI: 10.1016/j.hpb.2021.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 03/06/2021] [Accepted: 04/06/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Sacrificing a replaced right hepatic artery (rRHA) from the superior mesenteric artery is occasionally necessary to obtain an R0 resection after pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PA). Preoperative embolization (PEA) of the rRHA has been proposed to avoid the onset of postoperative biliary and ischemic liver complications. METHODS Eighteen patients with cephalic PA with an rRHA underwent PEA of the rRHA from 2013 to 2019. The monitoring after embolization and PD was systematic and included a clinical-biological evaluation and a computed tomography scan. This study aimed to determine the feasibility of PEA of the rRHA, postoperative morbidity at 90 days, and quality of oncologic resection after PD. RESULTS Feasibility of PEA was 100% without complications. A PD was performed in 16/18 patients. Mortality was 2/16 with one death after septic shock with hepatic ischemia without an arterial obstruction. Overall morbidity was 44% including one hepatic abscess after hepatic ischemia (6%). Two resections were R1 (<1 mm) in contact with the origin of the rRHA (2/4 R1). CONCLUSION PEA of the rRHA before PD was safe and reproducible. PEA of the rRHA followed by en bloc PD resection seems to limit the risk of bilio-hepatic ischemia and could facilitate oncologic resection.
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Affiliation(s)
- Arthur Marichez
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation, Haut Lévêque Hospital, CHU de Bordeaux, Bordeaux, France
| | - Olivier Turrini
- Department of Surgery, Aix-Marseille University, Institut Paoli-Calmettes, Marseille, France
| | - Benjamin Fernandez
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation, Haut Lévêque Hospital, CHU de Bordeaux, Bordeaux, France
| | - Jonathan Garnier
- Department of Surgery, Aix-Marseille University, Institut Paoli-Calmettes, Marseille, France
| | - Bruno Lapuyade
- Department of Radiology, Haut Lévêque, CHU de Bordeaux, Hospital Bordeaux University, Bordeaux, France
| | - Jacques Ewald
- Department of Surgery, Aix-Marseille University, Institut Paoli-Calmettes, Marseille, France
| | - Jean-Philippe Adam
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation, Haut Lévêque Hospital, CHU de Bordeaux, Bordeaux, France
| | - Ugo Marchese
- Department of Surgery, Aix-Marseille University, Institut Paoli-Calmettes, Marseille, France
| | - Laurence Chiche
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation, Haut Lévêque Hospital, CHU de Bordeaux, Bordeaux, France; Department of Research, INSERM UMR 1035, CHU Bordeaux, France
| | - Jean-Robert Delpero
- Department of Surgery, Aix-Marseille University, Institut Paoli-Calmettes, Marseille, France
| | - Christophe Laurent
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation, Haut Lévêque Hospital, CHU de Bordeaux, Bordeaux, France; Department of Research, INSERM UMR 1035, CHU Bordeaux, France.
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25
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Dilek ON, Atay A. Dealing with hepatic artery traumas: A clinical literature review. World J Clin Cases 2021; 9:8425-8440. [PMID: 34754851 PMCID: PMC8554434 DOI: 10.12998/wjcc.v9.i28.8425] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/05/2021] [Accepted: 08/11/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The hepatic artery (HA) is one of the most threatened vascular structures during hepatopancreatobiliary (HPB) surgeries and interventional procedures. It can be affected by many clinical pictures, especially tumors, due to its anatomical position and neighborhood.
AIM To reveal the evolution and recent developments in the management of HA traumas in the light of the literature.
METHODS In this article, 100 years of MEDLINE (PubMed) literature and articles including cases and series of HA injuries were reviewed, and the types of injury occurrence, treatment, and related complications and their management were compiled.
RESULTS The risk of HA injury increases during cholecystectomies and pancreatoduodenectomies, among the most common operations. HA anatomy shows anomalies in approximately 15%-25% of the cases, further increasing this risk. The incidence of HA injury is not precisely known. Approaches that have evolved in recent years in managing patients with HA injury (laceration, transection, ligation, resection) with severe morbidity and mortality risk are reviewed in light of the current literature.
CONCLUSION In conclusion, complications and deaths due to HA injury are less common today. The risk of complications increases in patients with hemodynamic instability, jaundice, cholangitis, and sepsis. Revealing the variations in the preoperative radiological evaluation will reduce the risks. In cases where HA injury is detected, arterial flow continuity should be tried to maintain with primary anastomosis, arterial transpositions, or grafts. In cases where bile duct injury develops, patients should be directed to HPB surgery centers, considering the possibility of accompanying HA injury. Large-scale and multicentric studies are needed to understand better the early and long-term results of HA ligation and determine preventive procedures.
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Affiliation(s)
- Osman Nuri Dilek
- Department of General Surgery, Division of Hepatopancreatobiliary Surgery, İzmir Katip Celebi University School of Medicine, İzmir 35150, Turkey
| | - Arif Atay
- Department of Surgery, İzmir Katip Celebi University School of Medicine, İzmir 35150, Turkey
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26
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Vascular resections in minimally invasive surgery for pancreatic cancer. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2021. [DOI: 10.1016/j.lers.2021.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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27
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Appanraj P, Mathew AP, Kandasamy D, Venugopal M. CT reporting of relevant vascular variations and its implication in pancreatoduodenectomy. Abdom Radiol (NY) 2021; 46:3935-3945. [PMID: 33738555 DOI: 10.1007/s00261-021-02983-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/20/2021] [Accepted: 02/09/2021] [Indexed: 01/09/2023]
Abstract
Pancreatoduodenectomy (PD) also known as Whipple procedure is done for malignant lesions involving the distal CBD, duodenum, ampulla and pancreatic head. In the absence of peritoneal and distant metastases, resectability of the lesion is mainly determined by the relationship of the lesion with the vascular structures in the vicinity. Vascular variations of the celiac artery branches are common and PD, a complex surgical procedure, becomes more challenging if the vascular variations are present. In borderline resectable lesions advances in neoadjuvant therapies and refined surgical techniques are pushing the boundaries of resection. Extended PD is done in borderline resectable lesions when resection and reconstruction of portal vein involved by the primary mass and dissection of extended lymph nodal stations are intended. In this era where more borderline cases are undergoing surgery, it is essential for the radiologist to understand the procedure and the implications of variations in vascular anatomy. Though there are many radiology literatures available on the diagnostic and resectability criteria related to normal vessel anatomy there are very few on the importance of the variant arterial anatomy. The purpose of this review is to familiarize the readers with these variant vessels which can help the surgeons in their intraoperative identification and consequently improve surgical outcomes.
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28
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Shintakuya R, Kohashi T, Nakashima A, Oishi K, Honmyo N, Hihara J, Kagawa E, Mukaida H. How to do it: Endovascular stent and ligament resection during pancreaticoduodenectomy for coeliac axis stenosis in median arcuate ligament syndrome. ANZ J Surg 2021; 91:2824-2826. [PMID: 34180573 DOI: 10.1111/ans.17007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 06/03/2021] [Accepted: 06/03/2021] [Indexed: 11/29/2022]
Abstract
To decrease complications associated with the treatment of coeliac axis (CA) stenosis due to median arcuate ligament (MAL) syndrome in pancreaticoduodenectomy, we performed combined preoperative endovascular stenting and intraoperative MAL resection. This technique can secure the CA blood flow to the hepatic artery before surgery in one stage and prevent CA restenosis and stent dislocation because there is no extrinsic compression of the CA after MAL resection.
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Affiliation(s)
- Ryuta Shintakuya
- Department of Surgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Toshihiko Kohashi
- Department of Surgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan.,Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Akira Nakashima
- Department of Surgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Koichi Oishi
- Department of Surgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Naruhiko Honmyo
- Department of Surgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Jun Hihara
- Department of Surgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Eisuke Kagawa
- Department of Cardiology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Hidenori Mukaida
- Department of Surgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
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29
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Moulla Y, Buchloh DC, Köhler H, Rademacher S, Denecke T, Meyer HJ, Mehdorn M, Lange UG, Sucher R, Seehofer D, Jansen-Winkeln B, Gockel I. Hyperspectral Imaging (HSI)-A New Tool to Estimate the Perfusion of Upper Abdominal Organs during Pancreatoduodenectomy. Cancers (Basel) 2021; 13:cancers13112846. [PMID: 34200412 PMCID: PMC8201356 DOI: 10.3390/cancers13112846] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 05/20/2021] [Accepted: 05/25/2021] [Indexed: 01/16/2023] Open
Abstract
Simple Summary Novel intraoperative imaging systems may have a critical impact on intraoperative decision-making. Hyperspectral imaging (HSI) is one of the leading new imaging systems, providing color pictures of tissue characterization, such as oxygen saturation (StO2) and Near-Infrared Perfusion Index (NIR-PI). Several surgical disciplines have already used HSI in detecting tissue perfusion with a proven record of success. To the best of our knowledge, HSI has not been used in the field of pancreatic surgery yet. Abstract Hyperspectral imaging (HSI) in abdominal surgery is a new non-invasive tool for the assessment of the perfusion and oxygenation of various tissues and organs. Its benefit in pancreatic surgery is still unknown. The aim of this study was to evaluate the key impact of using HSI during pancreatoduodenectomy (PD). In total, 20 consecutive patients were included. HSI was recorded during surgery as part of a pilot study approved by the local Ethics Committee. Data were collected prospectively with the TIVITA® Tissue System. Intraoperative HS images were recorded before and after gastroduodenal artery (GDA) clamping. We detected four patients with celiac artery stenosis (CAS) caused by a median arcuate ligament (MAL). In two of these patients, a reduction in liver oxygenation (StO2) was discovered 15 and 30 min after GDA clamping. The MAL was divided in these patients. HSI showed an improvement of liver StO2 after MAL division (from 61% to 73%) in one of these two patients. There was no obvious decrease in liver StO2 in the other two patients with CAS. HSI, as a non-invasive procedure, could be helpful in evaluating liver and gastric perfusion during PD, which might assist surgeons in choosing the best surgical approach and in improving patients’ outcomes.
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Affiliation(s)
- Yusef Moulla
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebigstr. 20, D-04103 Leipzig, Germany; (D.C.B.); (S.R.); (M.M.); (U.G.L.); (R.S.); (D.S.); (B.J.-W.); (I.G.)
- Correspondence: ; Tel.: +49(0)341-9717211; Fax: +49(0)341/9717209
| | - Dorina Christin Buchloh
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebigstr. 20, D-04103 Leipzig, Germany; (D.C.B.); (S.R.); (M.M.); (U.G.L.); (R.S.); (D.S.); (B.J.-W.); (I.G.)
| | - Hannes Köhler
- Innovation Center Computer Assisted Surgery (ICCAS), University of Leipzig, D-04103 Leipzig, Germany;
| | - Sebastian Rademacher
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebigstr. 20, D-04103 Leipzig, Germany; (D.C.B.); (S.R.); (M.M.); (U.G.L.); (R.S.); (D.S.); (B.J.-W.); (I.G.)
| | - Timm Denecke
- Department of Diagnostic and Interventional Radiology, University Hospital of Leipzig, D-04103 Leipzig, Germany; (T.D.); (H.-J.M.)
| | - Hans-Jonas Meyer
- Department of Diagnostic and Interventional Radiology, University Hospital of Leipzig, D-04103 Leipzig, Germany; (T.D.); (H.-J.M.)
| | - Matthias Mehdorn
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebigstr. 20, D-04103 Leipzig, Germany; (D.C.B.); (S.R.); (M.M.); (U.G.L.); (R.S.); (D.S.); (B.J.-W.); (I.G.)
| | - Undine Gabriele Lange
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebigstr. 20, D-04103 Leipzig, Germany; (D.C.B.); (S.R.); (M.M.); (U.G.L.); (R.S.); (D.S.); (B.J.-W.); (I.G.)
| | - Robert Sucher
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebigstr. 20, D-04103 Leipzig, Germany; (D.C.B.); (S.R.); (M.M.); (U.G.L.); (R.S.); (D.S.); (B.J.-W.); (I.G.)
| | - Daniel Seehofer
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebigstr. 20, D-04103 Leipzig, Germany; (D.C.B.); (S.R.); (M.M.); (U.G.L.); (R.S.); (D.S.); (B.J.-W.); (I.G.)
| | - Boris Jansen-Winkeln
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebigstr. 20, D-04103 Leipzig, Germany; (D.C.B.); (S.R.); (M.M.); (U.G.L.); (R.S.); (D.S.); (B.J.-W.); (I.G.)
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebigstr. 20, D-04103 Leipzig, Germany; (D.C.B.); (S.R.); (M.M.); (U.G.L.); (R.S.); (D.S.); (B.J.-W.); (I.G.)
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30
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Balachandran G, Bharathy KGS, Sikora SS. Median Arcuate Ligament Syndrome: an Important Consideration in Pancreaticoduodenectomy. Indian J Surg Oncol 2021; 12:439-441. [PMID: 34295093 DOI: 10.1007/s13193-021-01308-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 03/02/2021] [Indexed: 11/26/2022] Open
Abstract
Pancreaticoduodenectomy (PD) is a common surgery performed with curative intent for periampullary and pancreatic head neoplasms. In the presence of intrinsic celiac artery narrowing due to atherosclerosis or extrinsic compression due to median arcuate ligament syndrome (MALS), division of the gastroduodenal artery during PD can result in liver ischemia. This report describes a patient who had MALS which was treated by intraoperative median arcuate ligament release during PD, resulting in restoration of hepatic artery pulsations. Preventive, management strategies for MALS and the communicating vascular arcades between the celiac and superior mesenteric arterial systems are discussed in the context of PD.
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Affiliation(s)
- Gayatri Balachandran
- Department of Surgical Gastroenterology & Liver Transplantation, Institute of Digestive & HPB Sciences, Sakra World Hospital, SY No.52/2 & 52/3, Devarabeesanahalli, Oppsite Intel, VarthurHobli, Bengaluru, Karnataka 560103 India
| | - Kishore G S Bharathy
- Department of Surgical Gastroenterology & Liver Transplantation, Institute of Digestive & HPB Sciences, Sakra World Hospital, SY No.52/2 & 52/3, Devarabeesanahalli, Oppsite Intel, VarthurHobli, Bengaluru, Karnataka 560103 India
| | - Sadiq S Sikora
- Department of Surgical Gastroenterology & Liver Transplantation, Institute of Digestive & HPB Sciences, Sakra World Hospital, SY No.52/2 & 52/3, Devarabeesanahalli, Oppsite Intel, VarthurHobli, Bengaluru, Karnataka 560103 India
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31
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Yamaguchi T, Hasegawa K, Sauvain MO, Passoni S, Kazami Y, Kokudo T, Cristaudi A, Melloul E, Uldry E, Kobayashi K, Akamatsu N, Kaneko J, Arita J, Sakamoto Y, Demartines N, Kokudo N, Halkic N. An aberrant right hepatic artery arising from the gastroduodenal artery: a pitfall encountered during pancreaticoduodenectomy. Surg Today 2021; 51:1577-1582. [PMID: 33575949 DOI: 10.1007/s00595-021-02242-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 01/13/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE Among the variations of the right hepatic artery (RHA), the identification of an aberrant RHA arising from the gastroduodenal artery (GDA) is vital for avoiding damage to the RHA during surgery, since ligation of the GDA is necessary during pancreaticoduodenectomy (PD). However, this variation is not frequently reported. The purpose of this study was to focus on an aberrant RHA arising from the GDA, which was not noted in the classifications reported by Michels and Hiatt. METHODS A total of 574 patients undergoing a PD between Jan 2001 and Dec 2015 at a tertiary care hospital in Switzerland (n = 366) and between Jan 2009 and May 2015 at a hospital in Japan (n = 208) were included in the analysis. Of these, preoperative CT angiography or/and MRI angiography findings were available for 532 patients. We retrospectively analyzed the hepatic artery variations, patient demographics, and surgical outcomes. RESULTS Among the 532 patients who received a PD, an RHA originating from the GDA was observed in 19 cases (3.5%). Eleven patients (2.1%) had both an aberrant RHA and an aberrant left hepatic artery (LHA) (Hiatt Type 4). Six patients (1.2%) had a replaced CHA arising from the SMA (Hiatt Type 5). We could, therefore, correctly identify the aberration in all cases. CONCLUSIONS We observed rarely reported but important aberrant RHA variations arising from the GDA. To prevent injury during PD in patients with this type of aberrant RHA, intensive preparations using CT and/or MRI imaging before surgery and intraoperative liver Doppler ultrasonography are considered to be essential.
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Affiliation(s)
- Takamune Yamaguchi
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan.,Department of Visceral Surgery, University Hospital of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan.
| | - Marc-Olivier Sauvain
- Department of Visceral Surgery, University Hospital of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Stefano Passoni
- Department of Visceral Surgery, University Hospital of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Yusuke Kazami
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Takashi Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Alessandra Cristaudi
- Department of Visceral Surgery, University Hospital of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Emmanuel Melloul
- Department of Visceral Surgery, University Hospital of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Emilie Uldry
- Department of Visceral Surgery, University Hospital of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Kosuke Kobayashi
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Nobuhisa Akamatsu
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Junichi Kaneko
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Junichi Arita
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Yoshihiro Sakamoto
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Nicolas Demartines
- Department of Visceral Surgery, University Hospital of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan.,National Center for Global Health and Medicine, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Nermin Halkic
- Department of Visceral Surgery, University Hospital of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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Nakata K, Higuchi R, Ikenaga N, Sakuma L, Ban D, Nagakawa Y, Ohtsuka T, Asbun HJ, Boggi U, Tang CN, Wolfgang CL, Nishino H, Endo I, Tsuchida A, Nakamura M. Precision anatomy for safe approach to pancreatoduodenectomy for both open and minimally invasive procedure: A systematic review. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 29:99-113. [PMID: 33533158 DOI: 10.1002/jhbp.901] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/19/2020] [Accepted: 01/18/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Minimally invasive pancreatoduodenectomy (MIPD) has recently gained popularity. Several international meetings focusing on the existing literature on MIPD were held; however, the precise surgical anatomy of the pancreas for the safe use of MIPD has not yet been fully discussed. The aim of this study was to carry out a systematic review of available articles and to show the importance of identifying the anatomical variation in pancreatoduodenectomy. METHODS In this review, we described variations in surgical anatomy related to MIPD. A systematic search of PubMed (MEDLINE) was conducted, and the references were identified manually. RESULTS The search strategy yielded 272 articles, with 77 retained for analysis. The important anatomy to be considered during MIPD includes the aberrant right hepatic artery, first jejunal vein, first jejunal artery, and dorsal pancreatic artery. Celiac artery stenosis and a circumportal pancreas are also important to recognize. CONCLUSIONS We conclude that only certain anatomical variations are associated directly with perioperative outcomes and that identification of these particular variations is important for safe performance of MIPD.
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Affiliation(s)
- Kohei Nakata
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Naoki Ikenaga
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Leon Sakuma
- Professor with Special Assistant, Kawasaki Medical School, Okayama, Japan
| | - Daisuke Ban
- Department of Hepatobiliary and Pancreatic Surgery Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Takao Ohtsuka
- First Department of Surgery, Kagoshima University School of Medicine, Kagoshima, Japan
| | - Horacio J Asbun
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, FL, USA
| | - Ugo Boggi
- Division of General and Transplant Surgery, Pisa University Hospital, Pisa, Italy
| | - Chung-Ngai Tang
- Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China
| | | | - Hitoe Nishino
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Akihiko Tsuchida
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Dembinski J, Robert B, Sevestre MA, Freyermuth M, Yzet T, Dokmak S, Regimbeau JM. Celiac axis stenosis and digestive disease: Diagnosis, consequences and management. J Visc Surg 2020; 158:133-144. [PMID: 33191149 DOI: 10.1016/j.jviscsurg.2020.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Arterial blood flow to the organs of the upper abdomen is provided by the celiac axis (CA) and the superior mesenteric artery (SMA) that communicate between each other via the gastro-duodenal artery, the anterior and posterior pancreatico-duodenal arcades, the branches of the dorsal pancreatic artery and inconsistently, though a supplementary arcade that connects the CA and the SMA (arcade of Bühler). Celiac axis stenosis may or may not have a hemodynamic impact on the splanchnic circulation. Hemodynamically significant CA stenosis can be asymptomatic, or symptomatic with variables clinical consequences. Management depends on whether the mechanism of stenosis is extrinsic or intrinsic. When upper gastrointestinal interventional radiology or surgery is indicated, stenosis can pose technical difficulties or create severe ischemia requiring good understanding of this entity in the planning of operative steps and adapted management. Management of CA stenosis is therefore multidisciplinary and may involve interventional radiologists, gastrointestinal surgeons, vascular surgeons as well as medical physicians. Even though the prevalence of CA stenosis is relatively low (between 5 and 10%) and irrespective of its etiology, surgeons, radiologists and physicians must be aware of it because it can intervene in the management of upper gastrointestinal disease. It must be sought, and treatment must be adapted to each particular situation to avoid potentially severe complications.
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Affiliation(s)
- J Dembinski
- Department of Digestive Surgery, University Hospital of Amiens Picardie et Université de Picardie Jules Verne, 1, rue du Professeur Christian Cabrol, 80054 Amiens, France; Clinical research unit SSPC (Simplifications des Soins des Patients Complexes) UR UPJV 7518, University of Picardie Jules Verne, Amiens, France
| | - B Robert
- Radiology Department, University Hospital of Amiens Picardie and Picardie Jules Verne University, Amiens, France
| | - M-A Sevestre
- Vascular Medicine Department, University Hospital of Amiens Picardie and Picardie Jules Verne University, Amiens, France
| | - M Freyermuth
- Vascular Surgery Department, University Hospital of Amiens Picardie and Picardie Jules Verne University, Amiens, France
| | - T Yzet
- Radiology Department, University Hospital of Amiens Picardie and Picardie Jules Verne University, Amiens, France
| | - S Dokmak
- Department of Hepatobiliary Surgery and Liver Transplantation, Assistance Publique-Hôpitaux de Paris and Paris University, Clichy, France
| | - J-M Regimbeau
- Department of Digestive Surgery, University Hospital of Amiens Picardie et Université de Picardie Jules Verne, 1, rue du Professeur Christian Cabrol, 80054 Amiens, France; Clinical research unit SSPC (Simplifications des Soins des Patients Complexes) UR UPJV 7518, University of Picardie Jules Verne, Amiens, France.
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Minagawa M, Ichida H, Yoshioka R, Gyoda Y, Mizuno T, Imamura H, Mise Y, Yoshimatsu H, Fukumura Y, Kato K, Kajiyama Y, Saiura A. Pancreaticoduodenectomy with reconstructing blood flow of the gastric conduit after esophagectomy with concomitant celiac axis stenosis: a case report. Surg Case Rep 2020; 6:267. [PMID: 33030640 PMCID: PMC7544791 DOI: 10.1186/s40792-020-01019-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/21/2020] [Indexed: 11/10/2022] Open
Abstract
Background Pancreaticoduodenectomy after esophageal resection is technically difficult, because blood flow of the gastric conduit should be preserved. Celiac axis stenosis (CAS) is also a problem for pancreaticoduodenectomy, because arterial blood supply for the liver comes mainly through the collateral route from the superior mesenteric artery (SMA) via the gastroduodenal artery (GDA). Herein, we report the case of a patient with pancreatic head cancer who underwent a pancreaticoduodenectomy after esophagectomy with concomitant CAS. Case presentation A 76-year-old man with pancreatic head cancer was referred to our department. He had a history of esophagectomy with retrosternal gastric conduit reconstruction for esophageal cancer. Computed tomography showed severe CAS and a dilated collateral route between the SMA and the splenic artery (SPA). We prepared several surgical options depending on the intraoperative findings, and performed radical pancreaticoduodenectomy with concomitant resection of the distal gastric conduit. The right gastroepiploic artery (RGEA) of the remnant gastric conduit was fed from the left middle colic artery (MCA) with microvascular anastomosis. Despite CAS, when the GDA was dissected and clamped, good blood flow was confirmed, and the proper hepatic artery did not require reconstruction. The patient was discharged on postoperative day 90. Conclusions We successfully performed radical pancreaticoduodenectomy after esophagectomy with concomitant CAS, having prepared multiple surgical options depending upon the intraoperative findings.
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Affiliation(s)
- Masaaki Minagawa
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University, Graduate School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Hirofumi Ichida
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University, Graduate School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Ryuji Yoshioka
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University, Graduate School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Yu Gyoda
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University, Graduate School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Tomoya Mizuno
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University, Graduate School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Hiroshi Imamura
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University, Graduate School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Yoshihiro Mise
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University, Graduate School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Hidehiko Yoshimatsu
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yuki Fukumura
- Department of Human Pathology, Juntendo University, Graduate School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Kota Kato
- Department of Anatomy and Life Structure, Juntendo University, Graduate School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Yoshiaki Kajiyama
- Department of Esophageal and Gastroenterological Surgery, Juntendo University, Graduate School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Akio Saiura
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University, Graduate School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
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35
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Yang F, Wang X, Jin C, He H, Fu D. Pancreatectomy with Hepatic Artery Resection for Pancreatic Head Cancer. World J Surg 2020; 43:2909-2919. [PMID: 31396672 DOI: 10.1007/s00268-019-05106-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND To report our experiences and outcome of pancreatectomy with hepatic artery resection (PT-HAR) for advanced pancreatic head cancer. METHODS A retrospective study of clinical data from 14 patients with advanced pancreatic ductal adenocarcinoma undergoing PT-HAR in a tertiary academic center between March 2010 and June 2017 was performed. Furthermore, a comparison in a match-pair analysis (1:3) with patients received standard pancreatectomy during the same period was conducted to evaluate the clinical outcome. RESULTS The PT-HAR cohort included pancreaticoduodenectomy (n = 11) and total pancreatectomy (n = 3). Of them, six underwent portal/superior mesenteric vein resection and reconstruction and three underwent hepatic artery reconstruction. Four patients without arterial reconstruction developed liver perfusion failure. No perioperative mortality occurred, with a median postoperative hospital stay of 10.5 days (range 6-39). The median overall survival was 30 months (95% confidence interval 9.8-50.2 months), with the 1-, 2-, and 3-year survival rates of 81.8%, 63.6%, and 42.4%, respectively. The matched-pair data analysis showed no significant differences between PT-HAR and standard pancreatectomy, except that liver perfusion failure occurred more frequently after PT-HAR. CONCLUSIONS PT-HAR can be performed with acceptable morbidity, mortality, and survival for advanced pancreatic head cancer. Considering the potential risk of liver perfusion failure, only highly selected patients are eligible for PT-HAR without reconstruction.
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Affiliation(s)
- Feng Yang
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China.
| | - Xiaoyi Wang
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China
| | - Chen Jin
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China
| | - Hang He
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China
| | - Deliang Fu
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China.
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36
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Sanchez AM, Alfieri S, Caprino P, Tortorelli AP, Doglietto GB. Temporary Medium Arcuate Ligament Syndrome after Pancreatoduodenectomy. Am Surg 2020. [DOI: 10.1177/000313481307900203] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Alejandro M. Sanchez
- Department of Surgical Sciences Catholic University School of Medicine Rome, Italy
| | - Sergio Alfieri
- Department of Surgical Sciences Catholic University School of Medicine Rome, Italy
| | - Paola Caprino
- Department of Surgical Sciences Catholic University School of Medicine Rome, Italy
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Abstract
Pyogenic liver abscesses are classified by the bacteria that have caused the abscess because this guides treatment and can point to the underlying cause. The most common cause is biliary disease. The diagnosis is made by imaging. Treatment is a combination of antibiotics and percutaneous drainage. Amebic liver abscess is caused by extraintestinal spread of Entamoeba histolytica. E histolytica is spread by fecal-oral transmission and typically colonizes the gastrointestinal tract. It is diagnosed based on imaging and the mainstay of treatment is metronidazole. Only about 15% of cases require percutaneous drainage. The prognosis is good, with almost universal recovery.
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38
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Miyazaki K, Morine Y, Saito Y, Yamada S, Tokuda K, Ikemoto T, Imura S, Shimada M. Pancreatoduodenectomy co-morbid with celiac axis compression syndrome: a report of three cases. Surg Case Rep 2020; 6:113. [PMID: 32449014 PMCID: PMC7246236 DOI: 10.1186/s40792-020-00878-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 05/17/2020] [Indexed: 02/06/2023] Open
Abstract
Background Celiac axis compression syndrome (CACS) is a relatively rare disease. Because of the nature of the blood flow in the celiac region when a pancreatoduodenectomy (PD) is performed for CACS, the celiac region can become ischemic. The aim of this study is to report on the importance of pre-operative diagnosis of CACS in terms of the outcomes for patients post-operatively. In this study, three 3 cases of PD co-morbid with CACS are reported: one intra-operative diagnosis case and two pre-operative diagnosis cases. Case presentation The one case, not diagnosed with CACS prior to the operation, had a hard post-operative course because of complication caused by ischemia of the celiac region compared with the two cases diagnosed prior to the operation, who had a good post-operative course because of pre-operative or intra-operative intervention. Conclusions Post-operative complications due to CACS are preventable by pre-operative diagnosis and appropriate interventions.
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Affiliation(s)
- Katsuki Miyazaki
- The Department of Digestive and Transplant Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 770-8503, Japan
| | - Yuji Morine
- The Department of Digestive and Transplant Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 770-8503, Japan
| | - Yu Saito
- The Department of Digestive and Transplant Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 770-8503, Japan
| | - Shinichiro Yamada
- The Department of Digestive and Transplant Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 770-8503, Japan
| | - Kazunori Tokuda
- The Department of Digestive and Transplant Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 770-8503, Japan
| | - Tetsuya Ikemoto
- The Department of Digestive and Transplant Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 770-8503, Japan
| | - Satoru Imura
- The Department of Digestive and Transplant Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 770-8503, Japan
| | - Mitsuo Shimada
- The Department of Digestive and Transplant Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 770-8503, Japan.
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39
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Elbanna KY, Jang HJ, Kim TK. Imaging diagnosis and staging of pancreatic ductal adenocarcinoma: a comprehensive review. Insights Imaging 2020; 11:58. [PMID: 32335790 PMCID: PMC7183518 DOI: 10.1186/s13244-020-00861-y] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 03/06/2020] [Indexed: 02/06/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) has continued to have a poor prognosis for the last few decades in spite of recent advances in different imaging modalities mainly due to difficulty in early diagnosis and aggressive biological behavior. Early PDAC can be missed on CT due to similar attenuation relative to the normal pancreas, small size, or hidden location in the uncinate process. Tumor resectability and its contingency on the vascular invasion most commonly assessed with multi-phasic thin-slice CT is a continuously changing concept, particularly in the era of frequent neoadjuvant therapy. Coexistent celiac artery stenosis may affect the surgical plan in patients undergoing pancreaticoduodenectomy. In this review, we discuss the challenges related to the imaging of PDAC. These include radiological and clinical subtleties of the tumor, evolving imaging criteria for tumor resectability, preoperative diagnosis of accompanying celiac artery stenosis, and post-neoadjuvant therapy imaging. For each category, the key imaging features and potential pitfalls on cross-sectional imaging will be discussed. Also, we will describe the imaging discriminators of potential mimickers of PDAC.
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Affiliation(s)
- Khaled Y Elbanna
- Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital and Women's College Hospital, University of Toronto, Toronto, ON, Canada.
| | - Hyun-Jung Jang
- Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital and Women's College Hospital, University of Toronto, Toronto, ON, Canada
| | - Tae Kyoung Kim
- Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital and Women's College Hospital, University of Toronto, Toronto, ON, Canada
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40
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Terlouw LG, Moelker A, Abrahamsen J, Acosta S, Bakker OJ, Baumgartner I, Boyer L, Corcos O, van Dijk LJ, Duran M, Geelkerken RH, Illuminati G, Jackson RW, Kärkkäinen JM, Kolkman JJ, Lönn L, Mazzei MA, Nuzzo A, Pecoraro F, Raupach J, Verhagen HJ, Zech CJ, van Noord D, Bruno MJ. European guidelines on chronic mesenteric ischaemia - joint United European Gastroenterology, European Association for Gastroenterology, Endoscopy and Nutrition, European Society of Gastrointestinal and Abdominal Radiology, Netherlands Association of Hepatogastroenterologists, Hellenic Society of Gastroenterology, Cardiovascular and Interventional Radiological Society of Europe, and Dutch Mesenteric Ischemia Study group clinical guidelines on the diagnosis and treatment of patients with chronic mesenteric ischaemia. United European Gastroenterol J 2020; 8:371-395. [PMID: 32297566 PMCID: PMC7226699 DOI: 10.1177/2050640620916681] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Chronic mesenteric ischaemia is a severe and incapacitating disease, causing
complaints of post-prandial pain, fear of eating and weight loss. Even though
chronic mesenteric ischaemia may progress to acute mesenteric ischaemia, chronic
mesenteric ischaemia remains an underappreciated and undertreated disease
entity. Probable explanations are the lack of knowledge and awareness among
physicians and the lack of a gold standard diagnostic test. The
underappreciation of this disease results in diagnostic delays, underdiagnosis
and undertreating of patients with chronic mesenteric ischaemia, potentially
resulting in fatal acute mesenteric ischaemia. This guideline provides a
comprehensive overview and repository of the current evidence and
multidisciplinary expert agreement on pertinent issues regarding diagnosis and
treatment, and provides guidance in the multidisciplinary field of chronic
mesenteric ischaemia.
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Affiliation(s)
- Luke G Terlouw
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Adriaan Moelker
- Department of Radiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jan Abrahamsen
- Department of Clinical Physiology, Viborg Regional Hospital, Viborg, Denmark
| | - Stefan Acosta
- Department of Clinical Sciences Malmö, Lund University, Lund, Sweden.,Department of Cardio-Thoracic and Vascular Surgery, Skane University Hospital, Malmö, Sweden
| | - Olaf J Bakker
- Department of Vascular Surgery, Sint Antonius hospital, Nieuwegein, the Netherlands.,Department of Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Iris Baumgartner
- Division of Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Louis Boyer
- Department of Diagnostic and Interventional Radiology, Montpied University Hospital, Clermont-Ferrand, France
| | - Olivier Corcos
- Department of Gastroenterology, Intestinal Stroke Center, Hopital Beaujon APHP, Clichy, France
| | - Louisa Jd van Dijk
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Mansur Duran
- Department of Vascular and Endovascular Surgery, Marienhospital Gelsenkirchen, Gelsenkirchen, Germany
| | - Robert H Geelkerken
- Department of Vascular Surgery, Medisch Spectrum Twente, Enschede, the Netherlands.,Multi-modality Medical Imaging (M3I) group, Faculty of Science and Technology, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Giulio Illuminati
- Department of Surgical Sciences, University of Rome La Sapienza, Rome, Italy
| | - Ralph W Jackson
- Department of Interventional Radiology, Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - Jussi M Kärkkäinen
- Heart Center, Kuopio University Hospital, Kuopio, Finland.,Department of Vascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jeroen J Kolkman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, the Netherlands.,Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Lars Lönn
- Department of Radiology, University of Copenhagen, Copenhagen, Denmark
| | - Maria A Mazzei
- Department of Medical, Surgical and Neuro Sciences, Diagnostic Imaging, University of Siena, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Alexandre Nuzzo
- Department of Gastroenterology, Hopital Beaujon APHP, Clichy, France
| | - Felice Pecoraro
- Department of Surgical Oncological and Oral Sciences, University of Palermo, Vascular Surgery Unit, AOUP 'P. Giaccone' Palermo, Palermo, Italy
| | - Jan Raupach
- Department of Radiology, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Hence Jm Verhagen
- Department of Vascular Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Christoph J Zech
- Radiology and Nuclear Medicine, University of Basel, Basel, Switzerland
| | - Desirée van Noord
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis and Vlietland, Rotterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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41
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Intraoperative evaluation of hepatic artery blood flow during pancreatoduodenectomy (HEPARFLOW): Protocol of an exploratory study. Int J Surg Protoc 2020; 21:21-26. [PMID: 32346665 PMCID: PMC7182758 DOI: 10.1016/j.isjp.2020.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/15/2020] [Accepted: 03/17/2020] [Indexed: 12/28/2022] Open
Abstract
Assessment of flow rates of the hepatic artery during pancreatoduodenectomy. Identification of pre- and intraoperative factors influencing liver blood flow. Relevance of a celiac axis stenosis by pancreatoduodenectomy.
Introduction Pancreatoduodenectomy is the treatment of choice for a range of benign and malignant diseases. The pancreatic head must be separated from its supplying vessels, especially the gastroduodenal artery, during this operation. However, dissection of the gastroduodenal artery can disturb blood supply to the liver and result in liver ischemia. There is currently no well-established algorithm to evaluate and ensure sufficient blood flow in patients with altered hepatic artery blood flow. To address this important issue, this study aims to establish a basis for assessing liver blood supply during pancreatoduodenectomy. Furthermore, factors influencing arterial blood flow and related postoperative complications will be evaluated. Methods and analysis The HEPARFLOW study is a single institutional single-arm prospective exploratory observational clinical trial. All consecutive patients undergoing elective partial or total pancreatoduodenectomy will be screened for inclusion until 100 patients are enrolled. Blood flow in the proper hepatic artery, gastroduodenal artery, portal vein, and additional vessels supplying the liver will be measured during pancreatoduodenectomy using Doppler flowmetry. All patients will be followed up for 90 days after surgery. At each visit, standard clinical data, postoperative complications and mortality will be recorded. Discussion This will be the first study to prospectively assess intraoperative flow rates of the hepatic artery and portal vein to evaluate liver blood supply during pancreatoduodenectomy. The preoperative and intraoperative factors influencing blood flow in the hepatic arteries will be identified. This study may also reveal the hemodynamic and clinical relevance of a compression of the celiac axis during pancreatoduodenectomy. Ethics and dissemination This study was approved by the Ethics Committee of the University of Heidelberg (S-073/2018). The results will be published in a peer-reviewed journal and will be presented at medical meetings.
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Shindo D, Yamamoto A, Amano R, Kimura K, Yamazoe S, Shimono T, Miki Y. The findings of the contrast-enhanced CT and risk factors for hepatic infarction after pancreatoduodenectomy. Jpn J Radiol 2020; 38:547-552. [PMID: 32239373 DOI: 10.1007/s11604-020-00934-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 02/16/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Hepatic infarction is a relatively rare life-threatening complication after pancreatoduodenectomy (PD). Computed tomography (CT) findings and risk factors for hepatic infarctions after PD were investigated. METHODS One hundred-fifty three patients who underwent contrast-enhanced CT (CECT) after PD between January 2011 and August 2016 were retrospectively analyzed. Hepatic infarction was defined as the non-contrast enhanced area expanding to the liver surface without mass effect on CECT. The relationships between infarctions and preoperative laboratory data or surgical procedures using uni- and multivariate analyses were examined. RESULTS Twenty-nine patients showed 47 hepatic infarctions on CT. Infarctions most commonly appeared in segment 7 (S7) (17 lesions, 36.2%). Lesions were wedge-shaped in 12 patients and spread over multiple hepatic segments in 11 patients. Univariate analysis identified celiac artery (CA) or common hepatic artery (CHA) resection (p = 0.0029) and portal vein (PV) resection (p = 0.013) as risk factors for infarctions. CA or CHA resection (p = 0.038) remained as a significant factor after multivariate logistic analysis. CONCLUSIONS Hepatic infarctions after PD were most frequently seen in S7 and PV penetrating sign was characteristic CT findings. CA or CHA resection or PV resection were revealed as risk factors for hepatic infarctions.
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Affiliation(s)
- Daisuke Shindo
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Ryosuke Amano
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kenjiro Kimura
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Sadaaki Yamazoe
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Taro Shimono
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
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Ohtsuka R, Amano H, Hashimoto M, Iwao T. Pancreaticoduodenectomy following total occlusion of the superior mesenteric artery: a case report and literature review. Surg Case Rep 2019; 5:168. [PMID: 31686292 PMCID: PMC6828884 DOI: 10.1186/s40792-019-0718-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 09/27/2019] [Indexed: 11/17/2022] Open
Abstract
Background Patients with chronic occlusion of the celiac artery and superior mesenteric artery (SMA) are often asymptomatic, and occlusion may be caused by arteriosclerosis or median arcuate ligament compression. Pancreaticoduodenectomy (PD) is occasionally performed for patients with celiac artery occlusion; however, reports on patients with SMA occlusion are rare. We report a patient with cholangiocarcinoma and total atherosclerotic occlusion of the SMA without preoperative stenting or bypass. Case presentation A 73-year-old man suspected to have lower bile duct carcinoma was admitted to our hospital for further treatment. Three-dimensional computed tomography (3DCT) showed a common bile duct tumor and total occlusion of the SMA with collateral circulation of the gastroduodenal artery (GDA) and inferior mesenteric artery (IMA). We performed a PD. During the operation, we used test clamping of the GDA, which revealed no bowel ischemia. The postoperative course was uneventful, and the patient was discharged on postoperative day (POD) 30. 3DCT on POD 98 and POD 307 showed development of collateral circulation between the IMA and SMA. Conclusion Here, we report the case of a patient with total occlusion of the SMA who subsequently underwent PD. 3DCT was instrumental in gathering vascular collateral information and thus we conclude that the assessment of collateral circulation before surgery is important.
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Affiliation(s)
- Reo Ohtsuka
- Department of Surgery, Aidu Chuo Hospital, 1-1 Tsuruga-machi, Aizuwakamatsu, 965-0011, Japan
| | - Hodaka Amano
- Department of Surgery, Aidu Chuo Hospital, 1-1 Tsuruga-machi, Aizuwakamatsu, 965-0011, Japan.
| | - Michiyo Hashimoto
- Department of Gastroenterology, Aidu Chuo Hospital, 1-1 Tsuruga-machi, Aizuwakamatsu, 965-0011, Japan.
| | - Toshiyasu Iwao
- Department of Gastroenterology, Aidu Chuo Hospital, 1-1 Tsuruga-machi, Aizuwakamatsu, 965-0011, Japan.
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Stevens CL, Reid JL, Babidge WJ, Maddern GJ. Peer review of mortality after pancreaticoduodenectomy in Australia. HPB (Oxford) 2019; 21:1470-1477. [PMID: 30956163 DOI: 10.1016/j.hpb.2019.03.356] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 02/21/2019] [Accepted: 03/04/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The data within the Australian and New Zealand Audit of Surgical Mortality (ANZASM) provides a unique opportunity to consider the contributing factors to perioperative deaths as determined by peer review. Consideration of the factors contributing to mortality after pancreaticoduodenectomy (PD) can provide greater insight into how deaths can be prevented. METHODS ANZASM data from 1 January 2010 to 30 Jun 2017 was reviewed and all deaths following PD were selected for analysis. Assessor's determination of whether management could have been improved were reviewed and classified into groups of significant clinical events using thematic analysis with a data driven approach. RESULTS The study included 87 deaths reported to ANZASM after PD. Forty-two major complications were considered significant clinical events in 29/84 (35%) of patients. The assessor determined that there was a delay in recognising a significant complication in 18/84 (21%) of patients. In 14/84 (17%) of patients, ANZASM assessment questioned the decision to operate. CONCLUSION Multi-disciplinary decision making is strongly recommended when deciding which patients to treat with PD. Late recognition, and therefore delayed action to treat complications, in almost a quarter of deaths is a significant finding that warrants consideration for clinicians involved in the postoperative care of PD patients.
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Affiliation(s)
- Claire L Stevens
- Discipline of Surgery, University of Adelaide, The Queen Elizabeth Hospital, Australia.
| | - Jessica L Reid
- Discipline of Surgery, University of Adelaide, The Queen Elizabeth Hospital, Australia
| | - Wendy J Babidge
- Discipline of Surgery, University of Adelaide, Australian and New Zealand Audit of Surgical Mortality, Royal Australasian College of Surgeons, Australia
| | - Guy J Maddern
- Discipline of Surgery, University of Adelaide, The Queen Elizabeth Hospital, Australia
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Patel A, Sokolich J, Buggs J, Rogers E, Bowers V. Alternative Surgical Treatment for Hepatic Artery Stenosis or Occlusion with Pancreatic Surgery. Am Surg 2019. [DOI: 10.1177/000313481908500807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Achintya Patel
- Morsani College of Medicine University of South Florida Tampa, Florida
| | - Julio Sokolich
- Transplant Surgery Tampa General Medical Group Tampa, Florida
| | - Jacentha Buggs
- Transplant Surgery Tampa General Medical Group Tampa, Florida
| | - Ebonie Rogers
- Transplant Research Tampa General Hospital Tampa, Florida
| | - Victor Bowers
- Transplant Surgery Tampa General Medical Group Tampa, Florida
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Ueda A, Sakai N, Yoshitomi H, Furukawa K, Takayashiki T, Kuboki S, Takano S, Suzuki D, Kagawa S, Mishima T, Nakadai E, Miyazaki M, Ohtsuka M. Is hepatic artery coil embolization useful in distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic cancer? World J Surg Oncol 2019; 17:124. [PMID: 31315628 PMCID: PMC6637588 DOI: 10.1186/s12957-019-1667-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 07/10/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The exact contribution of preoperative coil embolization in distal pancreatectomy with en bloc celiac axis resection (DP-CAR) for the prevention of ischemic liver complication is not fully elucidated. METHODS From January 2004 to July 2015, 31 patients underwent DP-CAR for the pancreatic body-tail cancer. Twenty-three patients received preoperative coil embolization. The characteristics and operative outcomes were analyzed retrospectively. RESULTS The median survival time and 1- and 3-year overall survival rates were 23.7 months and 74.2% and 34.4%, respectively. No 30-day mortality occurred in any of the patients. Postoperative liver infarction developed only in 8 patients (25.8%) even though 7 of 8 patients had undergone preoperative coil embolization. Tumor contact with the gastroduodenal artery (GDA)/proper hepatic artery (PHA) on preoperative multi-detector computed tomography (MDCT), tumor size, operative time, portal vein resection, and stenosis of the GDA/PHA after DP-CAR are related to liver infarction. Among them, postoperative stenosis of the GDA/PHA on MDCT, which was observed in all 8 patients with liver infarction, was the most closely related factor to postoperative liver infarction. Tumor contact with the GDA/PHA did not worsen the R0 resection rate or overall survival rate. CONCLUSION Our data indicate that preoperative coil embolization of the common hepatic artery is not useful in DP-CAR as long as GDA is completely preserved during surgery.
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Affiliation(s)
- Atsuhiko Ueda
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Nozomu Sakai
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan.
| | - Hideyuki Yoshitomi
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Katsunori Furukawa
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Tsukasa Takayashiki
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Satoshi Kuboki
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Shigetsugu Takano
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Daisuke Suzuki
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Shingo Kagawa
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Takashi Mishima
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Eri Nakadai
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Masaru Miyazaki
- Surgery and Digestive Disease Center, International University of Health and Welfare, Mita Hospital, Tokyo, Japan
| | - Masayuki Ohtsuka
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
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Brinkmann S, Chang DH, Kuhr K, Hoelscher AH, Spiro J, Bruns CJ, Schroeder W. Stenosis of the celiac trunk is associated with anastomotic leak after Ivor-Lewis esophagectomy. Dis Esophagus 2019; 32:5367736. [PMID: 30820543 DOI: 10.1093/dote/doy107] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Transthoracic esophagectomy with gastric tube formation is the surgical treatment of choice for esophageal cancer. The surgical reconstruction induces changes of gastric microcirculation, which are recognized as potential risk factors of anastomotic leak. This prospective observational study investigates the association of celiac trunk (TC) stenosis with postoperative anastomotic leak. One hundred fifty-four consecutive patients with esophageal cancer scheduled for Ivor-Lewis esophagectomy were included. Preoperative staging computed tomography (CT) was used to identify TC stenosis. Any narrowing of the lumen due to atherosclerotic changes was classified as stenosis. Percentage of stenotic changes was calculated using the North American Symptomatic Carotid Endarterectomy Trial formula. Multivariable analysis was used to identify possible risk factors for leak. The overall incidence of TC stenosis was 40.9%. Anastomotic leak was identified in 15 patients (9.7%). Incidence of anastomotic leak in patients with stenosis was 19.4% compared to 2.3% in patients without stenosis. Incidence of stenosis in patients with leak was 86.7% (13 of 15 patients) and significantly higher than 38.8% (54 of 139 patients) in patients without leak (P < 0.001). There was a significant difference in median degree of TC stenosis (50.0% vs 39.4%; P = 0.032) in patients with and without leak. In the multivariable model, TC stenosis was an independent risk factor for anastomotic leak (odds ratio: 5.98, 95% CI: 1.58-22.61). TC stenosis is associated with postoperative anastomotic leak after Ivor-Lewis esophagectomy. Routine assessment of TC for possible stenosis is recommended to identify patients at risk.
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Affiliation(s)
- S Brinkmann
- Department of General, Visceral and Cancer Surgery, University of Cologne, Germany
| | - D H Chang
- Department of Radiology, University of Cologne, Germany
| | - K Kuhr
- Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Germany
| | - A H Hoelscher
- Department of Surgery, AGAPLESION Markus Krankenhaus, Frankfurt, Germany
| | - J Spiro
- Department of Radiology, University of Cologne, Germany
| | - C J Bruns
- Department of General, Visceral and Cancer Surgery, University of Cologne, Germany
| | - W Schroeder
- Department of General, Visceral and Cancer Surgery, University of Cologne, Germany
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Yuhn C, Hoshina K, Miyahara K, Oshima M. Computational simulation of flow-induced arterial remodeling of the pancreaticoduodenal arcade associated with celiac artery stenosis. J Biomech 2019; 92:146-154. [PMID: 31202524 DOI: 10.1016/j.jbiomech.2019.05.043] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 04/26/2019] [Accepted: 05/29/2019] [Indexed: 02/07/2023]
Abstract
Arterial remodeling of the pancreaticoduodenal arcade, which enables collateral flow to the liver, spleen, and stomach, is a well-recognized clinical sign of celiac artery (CA) stenosis. However, the hemodynamic changes due to remodeling are poorly understood, despite their importance in surgical procedures such as pancreaticoduodenectomy. In this study, a framework to simulate remodeling of the arterial network following pathological flow alterations was developed and applied to investigate the hemodynamic characteristics of patients with CA stenosis. A one-dimensional-zero-dimensional cardiovascular model was used for blood flow simulation. After introducing CA stenosis into the normal network, arterial remodeling was simulated by iteratively changing the diameter of each artery until time-averaged wall shear stress reached its value under normal conditions. A representative case was simulated to validate the present framework, followed by simulation cases to investigate the impact of stenosis severity on remodeling outcome. A markedly dilated arcade was observed whose diameter agreed well with the corresponding values measured in subjects with CA stenosis, confirming the ability of the framework to predict arterial remodeling. A series of simulations clarified how the geometry and hemodynamics after remodeling change with stenosis severity. In particular, the arterial remodeling and resulting blood flow redistribution were found to maintain adequate organ blood supply regardless of stenosis severity. Furthermore, it was suggested that flow conditions in patients with CA stenosis could be estimated from geometric factors, namely, stenosis severity and arcade diameter, which can be preoperatively and non-invasively measured using diagnostic medical images.
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Affiliation(s)
- Changyoung Yuhn
- Department of Mechanical Engineering, The University of Tokyo, Tokyo, Japan.
| | - Katsuyuki Hoshina
- Department of Vascular Surgery, The University of Tokyo, Tokyo, Japan
| | - Kazuhiro Miyahara
- Department of Vascular Surgery, The University of Tokyo, Tokyo, Japan
| | - Marie Oshima
- Interfaculty Initiative in Information Studies, The University of Tokyo, Tokyo, Japan
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Feasibility and Safety of Spleno-Aortic Bypass in Patients with Atheromatous Celiac Trunk Stenosis in Pancreaticoduodenectomy. J Gastrointest Surg 2019; 23:882-884. [PMID: 30761469 DOI: 10.1007/s11605-019-04142-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 01/23/2019] [Indexed: 01/31/2023]
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Abstract
Pancreatic ductal adenocarcinoma (PDAC) remains a dismal prognosis and surgery is the only chance for cure. However, only few of the patients have localized tumor eligible for curative complete resection. Preoperative management and well-staging of the disease are the cornerstone for appropriate surgery and major issues to define the best therapeutic strategy. This review focuses on the surgical and optimal perioperative management of PDAC and summarizes updates data on the subject.
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