Impact of Vascular Anomalies on Pancreatoduodenectomy Procedure

Radiological classification of the Heidelberg triangle and its application in laparoscopic pancreaticoduodenectomy for malignancies

BACKGROUND

The TRIANGLE operation benefits patients with pancreatic cancer; however, the Heidelberg triangle, where the operation occurs, contains vessels that can impact safety, especially in laparoscopic pancreaticoduodenectomy (LPD) with the TRIANGLE operation. This study aimed to identify Heidelberg triangle vessel types and their implications in pancreaticoduodenectomy (PD).

METHODS

Retrospective collection of radiographic data was performed from January 2017 to April 2023. Three-dimensional (3D) CT reconstructions were performed on patients. Vascular types in the Heidelberg triangle were classified based on named vessels crossing its interior. The impact of these types on surgical outcomes and complications in PD with the TRIANGLE operation was assessed.

RESULTS

Preoperative CT reconstruction was conducted on 184 pancreatic surgery patients. The findings revealed 99 patients (53.8%) with the type I Heidelberg triangle, lacking named vessels crossing the interior. Type II (n = 85, 46.2%), with named vessels crossing the interior, was identified. Among reconstructed patients who underwent PD with the TRIANGLE operation (n = 103), they were categorized as type I (n = 57) or type II (n = 46). The results showed that LPD patients with type II had significantly higher median intraoperative blood loss (300 mL vs. 200 mL, P = 0.030) and mean examined lymph nodes (17.2 ± 7.6 vs. 13.4 ± 5.2, P = 0.019) compared to those with type I. No significant differences were found in operative time or postoperative complications.

CONCLUSION

The presence of named vessels crossing the interior of the Heidelberg triangle was associated with increased intraoperative bleeding during LPD combined with the TRIANGLE operation. Therefore, targeted preoperative planning is required before the operation, thus improving the safety of the TRIANGLE operation in minimally invasive surgery.

Right hepatic artery anomalies in pancreatoduodenectomy-a risk for arterial resection but not for postoperative outcomes

Background

Pancreatoduodenectomy (PD) is a complex surgical procedure known for its significant morbidity rates, and the presence of an aberrant hepatic artery (AHA) introduces additional challenges. The impact of AHA on post-PD outcomes has been a subject of conflicting findings in the medical literature. This study aimed to investigate how variations in hepatic arterial anatomy influence intra-operative variables and postoperative morbidity.

Methods

A retrospective analysis was conducted on 113 PD cases. Patients with variant hepatic arterial anatomy (n=38) were categorized as Group 1, while those without vascular abnormalities comprised Group 2. Perioperative and postoperative outcomes were examined.

Results

Patients in Groups 1 and 2 exhibited similar characteristics, and no notable differences in surgical complications were observed. There was, however, a noticeable trend towards a higher incidence of postpancreatectomy hemorrhage (PPH) in Group 1 (31.6% vs. 20.0%; P=0.17). Furthermore, a statistically significant increase in the rate of arterial resections was noted in patients with vascular anomalies (10.5% vs. 1.33%; P=0.02).

Conclusions

The prevalence of vascular abnormalities in the hepatic arterial circulation is more frequent than initially anticipated. These anomalies present additional complexities to the already intricate PD procedure, leading to a heightened necessity for arterial resection, albeit without any discernible impact on postoperative complications.

Strategic Approach to Aberrant Hepatic Arterial Anatomy during Laparoscopic Pancreaticoduodenectomy: Technique with Video

BACKGROUND

It is critical for every pancreatic surgeon to determine how to protect the aberrant hepatic artery intraoperatively in order to safely implement laparoscopic pancreatoduodenectomy (LPD). "Artery-first" approaches to LPD are ideal procedures in selected patients with pancreatic head tumors. Here, we described our surgical procedure and experience of aberrant hepatic arterial anatomy-LPD (AHAA-LPD) in a retrospective case series. In this study, we also sought to confirm the implications of the combined SMA-first approach on the perioperative and oncologic outcomes of AHAA-LPD.

METHODS

From January 2021 to April 2022, the authors completed a total of 106 LPDs, of which 24 patients underwent AHAA-LPD. We evaluated the courses of the hepatic artery via preoperative multi-detector computed tomography (MDCT) and classified several meaningful AHAAs. The clinical data of 106 patients who underwent AHAA-LPD and standard LPD were retrospectively analyzed. We compared the technical and oncological outcomes of the combined SMA-first approach, AHAA-LPD, and the concurrent standard LPD.

RESULTS

All the operations were successful. The combined SMA-first approaches were used by the authors to manage 24 resectable AHAA-LPD patients. The mean age of the patients was 58.1 ± 12.1 years; the mean operation time was 362 ± 60.43 min (325-510 min); blood loss was 256 ± 55.72 mL (210-350 mL); the postoperation ALT and AST were 235 ± 25.65 IU/L (184-276 IU/L) and 180 ± 34.43 IU/L (133-245 IU/L); the median postoperative length of stay was 17 days (13.0-26.0 days); the R0 resection rate was 100%. There were no cases of open conversion. The pathology showed free surgical margins. The mean number of dissected lymph nodes was 18 ± 3.5 (14-25); the number of tumor-free margins was 3.43 ± 0.78 mm (2.7-4.3 mm). There were no Clavien-Dindo III-IV classifications or C-grade pancreatic fistulas. The number of lymph node resections was greater in the AHAA-LPD group (18 vs. 15, p < 0.001). Surgical variables (OT) or postoperative complications (POPF, DGE, BL, and PH) showed no significant statistical differences in both groups.

CONCLUSIONS

In performing AHAA-LPD, the combined SMA-first approach for the periadventitial dissection of the distinct aberrant hepatic artery to avoid hepatic artery injury is feasible and safe when performed by a team experienced in minimally invasive pancreatic surgery. The safety and efficacy of this technique need to be confirmed in large-scale-sized, multicenter, prospective randomized controlled studies in the future.

Evaluation of the Educational Quality of the Top 30 Most Viewed Laparoscopic Distal Pancreatectomy Videos on YouTube

Background: Online surgical videos serve as useful adjuncts for surgical training. YouTube is a social media platform increasingly used for education. However, the educational qualities of these videos have not been proven. This study aims to review the topmost 30 viewed videos on laparoscopic distal pancreatectomy (LDP) on YouTube. Methods: A YouTube search was performed on August 1, 2020, using the term "laparoscopic distal pancreatectomy." Inclusion criteria were LDP with or without splenectomy. Exclusion criteria were open or robotic distal pancreatectomy and radical antegrade modular pancreatosplenectomy. To grade the videos, we used a modified version of the LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS) 24 of the original 37 consensus statements were used in our study. Results: Twenty-nine of the top 30 most viewed videos were included (1 video was a duplicate). The overall mean view count and number of likes were 7195 (range 2322-39,927) and 17 (range 0-108), respectively. Thirteen videos (44.8%) were on LDP with splenic preservation. The mean conformity to the modified LAP-VEGaS was 9.3 (range 4-16) with a mean of 38.8% (range 16.7%-66.7%) of the criteria met. There was weak correlation between the number of views and the number of criteria met (ρ = 0.189, P < .05). Twelve videos (41.4%) described about staple line management, nine videos (31%) about tips and tricks to reduce postoperative pancreatic fistula, including drainage tube management, and three videos (10.3%) identified the common hepatic artery. Videos with no commentary had the lowest mean percentage of criteria met (24.6%). Conclusion: The topmost viewed LDP surgical videos have gaps in meeting the educational needs of a trainee. Video uploaders should be cognizant of the learning needs of surgical trainees.

Clinical significance of variant hepatic artery in pancreatic resection: A comprehensive review

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.

Pancreaticoduodenectomy preserving aberrant gastroduodenal artery utilized in a previous coronary artery bypass grafting: A case report and review of literature

RATIONALE

Pancreaticoduodenectomy (PD) is a technically demanding procedure with high rates of morbidity and mortality. Therefore, preoperative evaluation of anatomy is indispensable. Multi-detector row computed tomography (CT) enables us to precisely understand arterial anatomy. It is a well-known fact that anatomical variants are often present in the hepatic artery (HA) but rarely in the gastroduodenal artery (GDA). We present the case of a patient with ampullary cancer with a rare anatomical anomaly, "replaced GDA (rGDA) " arising from the superior mesenteric artery, along with a history of coronary artery bypass grafting (CABG) using right gastroepiploic artery (RGEA).

PATIENT CONCERNS

A 69-year-old male patient was referred to our department for further investigation of elevated hepatobiliary enzymes. He presented with no symptoms besides intermittent fever of 38°C. He had an operative history of CABG using the RGEA.

DIAGNOSIS

Abdominal CT and esophagogastroduodenoscopy showed an ampullary tumor and biopsy specimen from the lesion revealed adenocarcinoma. CT angiography revealed the rGDA instead of a normal common HA.

INTERVENTION

We performed a safe PD, preserving the rGDA and the RGEA to maintain hepatic and cardiac perfusion.

OUTCOMES

Owing to the presence of a refractory pancreatic fistula, the length-of-hospital stay was extended, and he was discharged on postoperative day 72 without vascular complications. At present, the patient is in good physical condition and does not present with cardiovascular complications as well as tumor recurrence at 6 months after surgery.

LESSONS

This is possibly the first case of a patient who underwent PD and has a proper HA following a GDA arising from a superior mesenteric artery (rGDA) and has a previous operative history of CABG using the gastroepiploic artery. The coexistence of the history of cardiovascular surgery made PD for this patient considerably more challenging.In the case of a rare anatomical anomaly, a coronary artery bypass via the RGEA should not be considered as an obstacle when R0 resection is achievable.