Combined hepatic arterial resection in pancreatic resections for locally advanced pancreatic cancer

PURPOSE

Arterial involvement in advanced pancreatic cancer generally defines local unresectability. This study was aimed to evaluate the clinical outcomes of combined common hepatic arterial resection with pancreaticoduodenectomy or total pancreatectomy in patients with locally advanced pancreatic cancer involving the hepatic artery.

METHODS

Of 348 patients with pancreatic head cancers who underwent surgical resection between June 1999 and September 2015, 21 underwent combined common hepatic arterial resection with pancreaticoduodenectomy (17) or total pancreatectomy (4). Preoperative common hepatic arterial embolization was performed in 12 patients. Preoperative CT findings of hepatic arterial involvement, postoperative complications, survival rates, and prognostic factors for survival were analyzed. Twenty-one unresectable patients with locally advanced pancreatic cancer who underwent laparotomy in this study period were selected as the control group.

RESULTS

Rates of pathological arterial invasion were significantly higher in patients with level III (>180⁰) CT findings (90%,9/10) than in patients with levels I and II (<180⁰) (27%, 3/11) (p < 0.01). No surgical deaths occurred. Survival after surgical resection in all 21 patients was 47.6%, 6.6%, and 6.6% at 1, 3, and 5 years, and median survival was 11 months. The preoperative serum CA19-9 level was a significant prognostic factor for overall survival, median survivals were 21.5 and 8.3 months in the low CA19-9 and high CA19-9 groups, respectively. No significant difference in survival between the high-CA19-9 group and the unresectable group was found.

CONCLUSIONS

Combined common hepatic arterial resection in pancreaticoduodenectomy or total pancreatectomy might be feasible with an acceptable rate of surgical complications, and may have a beneficial effect on the prognosis only in patients with low preoperative serum CA19-9 levels.

Portal vein thrombosis after reconstruction in 270 consecutive patients with portal vein resections in hepatopancreatobiliary (HPB) surgery

BACKGROUNDS

This study was aimed to evaluate the occurrence of portal vein thrombosis after portal vein reconstruction.

METHODS

The portal veins were repaired with venorrhaphy, end-to-end, patch graft, and segmental graft in consecutive 270 patients undergoing hepato-pancreto-biliary (HPB) surgery.

RESULTS

Portal vein thrombosis was encountered in 20 of 163 of end-to-end, 2 of 56 of venorrhaphy, and 2 of 5 of patch graft groups, as compared with 0 of 46 of segmental graft group (p < 0.05, N.S., p < 0001, respectively). Portal vein thrombosis occurred more frequently after hepatectomy than after pancreatectomy (p < 0.0001). The restoration of portal vein blood flow was more sufficiently achieved in the early re-operation within 3 days after surgery than in the late re-operation over 5 days after surgery (p < 0.05).

CONCLUSIONS

The segmental graft might have to be more preferred in the portal vein reconstruction. The revision surgery for portal vein thrombosis should be performed within 3 days after surgery.

Vascular reconstruction using left renal vein graft in advanced hepatobiliary malignancy

BACKGROUND/AIMS

In surgical resection for advanced hepatobiliary malignancies involving the portal vein and inferior vena cava, vascular reconstruction is usually required. We utilized left renal vein grafts for vascular reconstruction in cases of these malignancies, and their clinical significance is evaluated in this study.

METHODOLOGY

Left renal vein grafts were utilized for reconstruction of the portal vein in four patients and patch repair of the inferior vena cava was performed in two patients with advanced hepatobiliary malignancies. All six patients underwent hepatic resection with vascular resection and reconstruction. Postoperative renal function and graft patency were assessed.

RESULTS

Transient slight renal disturbances appeared in some patients, but there was no severe renal dysfunction requiring specific therapy. Graft patency was maintained during the follow-up period in all patients.

CONCLUSION

The use of left renal vein grafts as autovein grafts seems appropriate in cases involving reconstruction of the portal vein and in those involving patch repair of the inferior vena cava defect in surgical resection for advanced hepatobiliary malignancies.

Idiopathic ventricular fibrillation induced with vagal activity in patients without obvious heart disease

BACKGROUND

Recently, idiopathic ventricular fibrillation (VF) has gained much attention. Although several subgroups have been described, its pathogenesis, mechanism, treatment, and prognosis remain unknown.

METHODS AND RESULTS

We studied six cases of idiopathic VF with transient late r' waves and ST elevation (late r'/ST elevation) in leads V1 through V3. Late r'/ST elevation was augmented before and after VF episodes. Signal-averaged ECGs showed late potentials even when no late r'/ST elevation occurred. During late r', a conduction delay was observed by use of body-surface maps at the anterior wall and outflow tract of the right ventricle without inhomogeneity of the repolarization phase. There was a decrease or total disappearance of late r'/ST elevation with isoproterenol, atropine, and exercise stress testing and induction or exacerbation with propranolol, edrophonium, and hyperventilation. VF was induced by programmed electrical stimulation in all cases but two, in which it was induced only after edrophonium injection. In two cases, VF was exacerbated by propranolol, and in all cases, it was uninducible with isoproterenol. Heart rate spectral analysis just before VF episodes showed a sudden rise in vagal activity in two cases. As the VF mechanism, a conduction delay exists at the anterior wall and outflow tract of the right ventricle that is possibly exacerbated by an abrupt rise in vagal activity, inducing random reentry that results in VF. Class I antiarrhythmic agents and beta-blockers were ineffective for this VF. All subjects required implantable cardioverter-defibrillators.

CONCLUSIONS

We propose this VF associated with late r'/ST elevation in the precordial leads and influenced by vagal activity as a new possible mechanism of idiopathic VF.