Treatment strategy for pancreatic head cancer with celiac axis stenosis in pancreaticoduodenectomy:A case report and review of literature

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 thenperformed.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.

Pancreaticoduodenectomy: Secondary stenting of the celiac trunk after inefficient median arcuate ligament release and reoperation as an alternative to simultaneous hepatic artery reconstruction

In patients undergoing pancreaticoduodenectomy(PD),unrecognized hemodynamically significant celiac axis(CA) stenosis impairs hepatic arterial flow by suppressing the collateral pathways supplying arterial flow from the superior mesenteric artery and leads to serious hepatobiliary complications due to liver and biliary ischemia, with a high rate of mortality. CA stenosis is usually due to an extrinsic compression by a previously asymptomatic median arcuate ligament(MAL). MAL is diagnosed by computerized tomography in about 10% of the candidates for PD, but only half are found to be hemodynamically significant during the gastroduodenal artery clamping test with Doppler assessment, which is mandatory before any resection. MAL release is usually efficient to restore an adequate liver blood inflow and prevent ischemic complications. In cases of failure in MAL release, postponed PD with secondary stenting of the CA and reoperation for PD should be considered as an alternative to immediate hepatic artery re-construction, which involves the risk of postoperative thrombosis of the arterial reconstruction. We recently used this two-stage strategy in a patient undergoing surgery for pancreatic adenocarcinoma.

Vascular resection and reconstruction at pancreatico-duodenectomy:technical issues

BACKGROUND:With the improvement of perioperative management over the years,pancreatico-duodenectomy has become a safe operation despite its technical complexity.The presence of concomitant visceral artery occlusion unrelated to the underlying malignancy and concomitant major venous infiltration by tumor poses additional hazards to resection which could compromise the postoperative outcome.DATA SOURCES:A MEDLINE database search was performed to identify relevant articles using the key ords 'median arcuate ligament syndrome','superior mesenteric artery','replaced right hepatic artery',and 'portal vein resection'.Additional papers and book chapters were identified by a manual search of the references from the key articles.RESULTS:Computed tomography with 3-dimensional reconstruction of the vascular anatomy provides most key information on the potential vascular problems encountered during surgery.A trial clamping of the gastroduodenal artery provides a simple intraoperative assessment for the presence of any significant visceral arterial occlusion.Depending on the timing of diagnosis,division of the median arcuate ligament,bypass or endovascular stenting should be considered.Portal and superior mesenteric vein resection had been used with increasing frequency and safety.The steps and methods taken to reconstruct the venous continuity vary with individual surgeons,and the anatomical variations encountered.With segmental loss of the portal vein,opinions differs with regard to the preservation of the splenic vein,and when divided,the necessity of restoring its continuity;source of the autologous vein graft when needed and whether the use of synthetic graft is a safe alternative.CONCLUSIONS:During a pancreatico-duodenectomy,images of computed tomography must be carefully studied to appreciate the changes and variation of vascular anatomy.Adequate preoperative preparation,acute awareness of the probable arterial and venous anatomical variation and the availability of expertise,especially micro-vascular surgery,for vascular reconstruction would help to make the complex pancreatic resection a safer procedure.

Recurrent pyogenic liver abscess after pancreatoduodenectomy caused by common hepatic artery injury:A case report

BACKGROUND Pancreaticoduodenectomy(PD)has been increasingly performed as a safe treatment option for periampullary malignant and benign disorders.However,the operation may result in significant postoperative complications.Here,we present a case that recurrent pyogenic liver abscess after PD is caused by common hepatic artery injury in atypical celiac axis anatomy.CASE SUMMARY A 56-year-old man with a 1-d history of fever and shivering was diagnosed with hepatic abscess.One year and five months ago,he underwent PD at a local hospital to treat chronic pancreatitis.After the operation,the patient had recurrent intrahepatic abscesses for 4 times,and the symptoms were relieved after percutaneous transhepatic cholangial drainage combining with anti-inflammatory therapy in the local hospital.Further examination showed that the recurrent liver abscess after PD was caused by common hepatic artery injury due to abnormal abdominal vascular anatomy.The patient underwent percutaneous drainage but continued to have recurrent episodes.His condition was eventually cured by right hepatectomy.In this case,preoperative examination of the patient’s anatomical variations with computed tomography would have played a pivotal role in avoiding arterial injuries.CONCLUSION A careful computed tomography analysis should be considered mandatory not only to define the operability(with radical intent)of PD candidates but also to identify atypical arterial patterns and plan the optimal surgical strategy.

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.

Tricks and tips in pancreatoduodenectomy

Pancreaticoduodenectomy(PD) is the standard surgical treatment for tumors of the pancreatic head,proximal bile duct,duodenum and ampulla,and represents the only hope of cure in cases of malignancy.Since its initial description in 1935 by Whipple et al,this complex surgical technique has evolved and undergone several modifications.We review three key issues in PD:(1) the initial approach to the superior mesenteric artery,known as the artery-first approach;(2) arterial complications caused by anatomic variants of the hepatic artery or celiac artery stenosis;and(3) the extent of lymphadenectomy.

Preoperative microcoil embolization of the common hepatic artery for pancreatic body cancer

AIM:To evaluate safety and feasibility of microcoil embolization of the common hepatic artery under proper or distal balloon inflation in preoperative preparation for en bloc celiac axis resection for pancreatic body cancer.METHODS:Fifteen patients(11 males,4 females;median age,67 years) with pancreatic body cancer involving the nerve plexus surrounding the celiac artery underwent microcoil embolization.To alter the total hepatic blood flow from superior mesenteric artery(SMA),microcoil embolization of the common hepatic artery(CHA) was conducted in 2 cases under balloon inflation at the proximal end of the CHA and in 13 cases under distal microballoon inflation at the distal end of the CHA.RESULTS:Of the first two cases of microcoil embolization with proximal balloon inflation,the first was successful,but there was microcoil migration to the proper hepatic artery in the second.The migrated microcoil was withdrawn to the CHA by an inflated microballoon catheter.Microcoil embolization was successful in the other 13 cases with distal microballoon inflation,with no microcoil migration.Compact microcoil embolization under distal microballoon inflation created sufficient resistance against the vascular wall to prevent migration.Distal balloon inflation achieved the requisite 1 cm patency at the CHA end for vascular clamping.All patients underwent en bloc celiac axis resection without arterial reconstruction or liver ischemia.CONCLUSION:To impede microcoil migration to the proper hepatic artery during CHA microcoil embolization,distal microballoon inflation is preferable to proximal balloon inflation.