Two successful curative operations using stomach-preserving distal pancreatectomy with celiac axis resection for the treatment of locally advanced pancreatic body cancer

Large vessel invasion is a serious factor determining whether an operation for pancreatic body cancer is feasible. The Appleby operation is a radical operation for the treatment of pancreatic body cancer that has infiltrated the celiac axis. Since this procedure includes a total gastrectomy, the operation is associated with a high morbidity, mortality, and deteriorating postoperative quality of life (QOL). We experienced two cases in which radical operations consisting of a stomach-preserving distal pancreatectomy with en bloc resection of the celiac, common hepatic, and left gastric artery were performed. The use of adjuvant chemotherapy in these cases led to a good postoperative QOL.     

Portal vein resection without reconstruction during Appleby operation in a patient with pancreatic body carcinoma with cavernous transformation.

The prognosis of pancreatic body carcinoma has been poor due to cancerous invasion of major vessels. Resection of the involved vessels may improve resectability and prognosis. We report a patient who had a pancreatic body carcinoma with cavernous transformation of the portal vein, in whom the portal vein was resected without reconstruction during an Appleby operation. A 67 year-old man was admitted for evaluation of back pain. Enhanced computed tomography showed no main trunk of the portal vein but a developed collateral circulation. Celiac angiography revealed encasement of the common hepatic, splenic and celiac artery. Venous angiography revealed obstruction of the portal and splenic veins with cavernous transformation surrounding these veins. Pre-operative diagnosis was carcinoma in the pancreatic body, which invaded the portal vein, the celiac and common hepatic arteries. The Appleby operation combined with resection of the portal vein without reconstruction could be performed, by preserving collateral vessels and monitoring hepatic venous oxygen saturation (ShvO2) to prevent hepatic ischemia caused by occlusion of the portal vein. The post-operative course was uneventful.     

Successful pancreatectomy with en-bloc resection of the celiac artery and portal vein for pancreatic endocrine carcinoma

Invasion to the celiac axis and portal vein is one reason for the unresectability of pancreatic carcinoma of the body and tail. Some authors advocate a radical distal pancreatectomy with en-bloc resection of the celiac artery and portal vein. However, long-term survival is still rare. We report here on a very rare, long-term survivor of a locally-advanced endocrine carcinoma of the body of the pancreas that was treated by distal pancreatectomy with en-bloc resection of the celiac artery and portal vein. The patient recovered well postoperatively, and has survived for 55 months without evidence of recurrence. The experience gained in the present case suggests that radical pancreatectomy with en-bloc resection of the celiac artery and portal vein is a potential approach that might increase tumor resectability and improve the prognosis of patients with locally-advanced endocrine carcinomas of the pancreas.     

Total pancreatectomy with en bloc celiac axis resection for a pancreatic adenocarcinoma involving both the gastroduodenal artery and the celiac artery

A pancreatic adenocarcinoma involving both the celiac artery and the gastroduodenal artery is often considered to be unresectable because the simultaneous division of both arteries may result in an acute severe ischemia of the liver and the stomach. We report here a case of total pancreatectomy with en bloc celiac axis resection for a 61-year-old female with a pancreatic adenocarcinoma involving both the celiac artery and the gastroduodenal artery. The patient had a replaced right hepatic artery from the superior mesenteric artery and a replaced left hepatic artery from the left gastric artery, which was directly arising from the aorta. Preserving these collateral arteries, neither hepatic artery reconstruction nor total gastrectomy was needed after resection. The reported incidence of similar arterial anatomy was only 0.2% but the precise evaluation of arterial anatomy is important to offer a chance of curative resection for patients with usually unresectable locally advanced pancreatic cancer.     

Important technical remarks on distal pancreatectomy with en-bloc celiac axis resection for locally advanced pancreatic body cancer (with video)

Background

We have already reported the feasibility, safety, and excellent long-term results of distal pancreatectomy with en-bloc celiac axis resection (DP-CAR) for locally advanced pancreatic body cancer. An international standard for the surgical technique of DP-CAR has yet to be established.

Methods

DP-CAR was carefully performed in 42 patients in Hokkaido University Hospital from 1998 to July 2007. Arterial blood flow alteration and collateral flow development toward the liver and stomach was obtained following preoperative routine transcatheter arterial embolization of the common hepatic artery. The right-sided approach to the superior mesenteric artery and celiac artery, and the preservation of the inferior pancreatoduodenal artery during the dissection of the plexus around the pancreatic head, are the key techniques in DP-CAR.

Results

The operative morbidity and mortality were 43 and 4.8%, respectively. R0 resection could be done in 39 (93%) patients. Median operation time and intraoperative blood loss were 478?min and 1030?ml, respectively. Ischemic gastropathy was complicated in 5 (12%) patients, but liver abscess was found in only one patient and no liver failure was encountered.

Conclusions

We emphasize again the feasibility and safety of DP-CAR; it should be a treatment of choice for locally advanced pancreatic body cancer.     

Tips and tricks of the surgical technique for borderline resectable pancreatic cancer: mesenteric approach and modified distal pancreatectomy with en‐bloc celiac axis resection

Borderline resectable (BR) pancreatic cancer involves the portal vein and/or superior mesenteric vein (PV/SMV), major arteries including the superior mesenteric artery (SMA) or common hepatic artery (CHA), and sometimes includes the involvement of the celiac axis. We herein describe tips and tricks for a surgical technique with video assistance, which may increase the R0 rates and decrease the mortality and morbidity for BR pancreatic cancer patients. First, we describe the techniques used for the “artery‐first” approach for BR pancreatic cancer with involvement of the PV/SMV and/or SMA. Next, we describe the techniques used for distal pancreatectomy with en‐bloc celiac axis resection (DP‐CAR) and tips for decreasing the delayed gastric emptying (DGE) rates for advanced pancreatic body cancer. The mesenteric approach, followed by the dissection of posterior tissues of the SMV and SMA, is a feasible procedure to obtain R0 rates and decrease the mortality and morbidity, and the combination of this aggressive procedure and adjuvant chemo(radiation) therapy may improve the survival of BR pancreatic cancer patients. The DP‐CAR procedure may increase the R0 rates for pancreatic cancer patients with involvement within 10 mm from the root of the splenic artery, as well as the CHA or celiac axis, and preserving the left gastric artery may lead to a decrease in the DGE rates in cases where there is more than 10 mm between the tumor edge and the root of the left gastric artery. The development of safer surgical procedures is necessary to improve the survival of BR pancreatic cancer patients.     

A new test to avoid arterial complications during pancreaticoduodenectomy

Celiac trunk or superior mesenteric artery stenosis are usually innocuous conditions. In such patients, arterial blood supply to the stomach, spleen, liver and bowel is sustained through extraordinarily well-developed pathways through the pancreas. If division of these collateral vessels is necessary during a surgical procedure such as pancreaticoduodenectomy, life-threatening celiac organ or bowel ischemia may occur. The authors describe a new test, using pancreatic inflow occlusion, to reliably identify celiac trunk or superior mesentery artery stenosis. The authors describe two cases of celiac axis occlusion and one case of superior mesenteric artery stenosis. In all three presented cases the gastroduodenal artery clamping test was negative and ischemia was only noticed after pancreatic section, suggesting that in severe occlusions this test may fail in diagnosing the vascular abnormality. All patients were successfully treated by revascularization with no operative mortality. If the diagnosis is unsuspected and in cases where appropriate angiographic studies have not been obtained before pancreatic resection, a test occlusion of the gastroduodenal artery should always precede its ligation. However, this test may not be effective in all cases and in instances where high suspicion of celiac axis or mesenteric stenosis is present, other maneuvers, such as pancreatic inflow test, could be helpful for the diagnosis of these rare and morbid situations.     

Distal pancreatectomy with resection of the celiac axis and reconstruction of the hepatic artery for carcinoma of the body and tail of the pancreas

Distal pancreatectomy with resection of the celiac axis can increase resectability of carcinoma of the body and tail of the pancreas. We performed reconstruction of the hepatic artery to avoid complications caused by a decrease in hepatic arterial flow. We carried out distal pancreatectomy with resection of the celiac axis for carcinoma of the body and tail of the pancreas in four patients. When pulsation in the proper hepatic artery was weak after occlusion of the celiac axis, we performed reconstruction of the hepatic artery, using the splenic artery, which had been taken beforehand from the resected specimen. In two patients, we performed reconstruction of the hepatic artery. These two patients underwent reconstruction of the portal vein combined with prolonged clamping of the portal vein. Levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were elevated just after the operation, but recovered to normal levels within 10 days. No complications related to hepatic ischemia were observed. These results suggested that reconstruction of the hepatic artery allowed us to safely perform distal pancreatectomy with resection of the celiac axis for carcinoma of the body and tail of the pancreas.     

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.     

The significance of intraoperative Doppler ultrasonography in evaluating hepatic arterial flow when assessing the indications for the Appleby procedure for pancreatic body cancer

Background/purpose

The Appleby procedure has been used in the surgical treatment of advanced gastric cancer. This procedure consists of a combined resection of the whole of the stomach, the body and tail of the pancreas, and the spleen, as well as resection of the celiac artery. This procedure can also be used for operative resection of cancer of the body of the pancreas. The hepatic arterial flow is supplied from the arcade of the supramesenteric artery. In the past, the extent of hepatic arterial flow after the celiac artery had been clamped was evaluated by finger palpation. However, this is not an objective method.

Methods

Here, we describe two patients with pancreatic body cancer, in one of whom the Appleby procedure was followed. However, in the other, this operation could not be performed because the residual blood supply to the liver would have been inadequate. The hepatic arterial flow was assessed using intraoperative Doppler ultrasonography (US) of the intrahepatic artery (arterial flow of segment 3).

Results

In case 1 (a 45-year-old man), the hepatic arterial flow prior to clamping of the celiac artery was 68.4?cm/s, and this flow was reduced to 22.1?cm/s after the clamping. The color and consistency of the liver surface remained good. Because there was adequate hepatic arterial flow after the celiac artery was clamped, the Appleby procedure was performed. However, in case 2 (a 65-year-old man), the hepatic arterial flow after the celiac artery had been clamped was reduced from 47.9?cm/s to 14.3?cm/s. The liver surface became dark and the liver shrank. In addition, there were various preoperative medical conditions in this patient. We decided not to proceed with the Appleby procedure.

Conclusions

Intraoperative Doppler US measurement of the hepatic arterial flow is a useful technique, particularly in combination with the assessment of the color and tension of the liver, the age of the patient, and the extent of preoperative comorbidity, in determining whether an Appleby procedure is feasible.     

Monitoring hepatic venous hemoglobin oxygen saturation during Appleby operation for pancreatic cancer

BACKGROUND/AIMS: When an Appleby operation is performed for pancreatic body and tail carcinoma, it is necessary for prevention of hepatic ischemia to estimate accurately the hepatic circulation after resection of the celiac artery, the common hepatic artery and the portal vein. We studied the hepatic circulation by monitoring the ShvO2 (hepatic venous hemoglobin oxygen saturation) during an Appleby operation. METHODOLOGY: We performed an Appleby operation on 8 patients with pancreatic cancer. In 6 of 8 patients, a 7-Fr fiberoptic flow direct catheter was inserted in the right hepatic vein. The ShvO2 values were monitored continuously during surgery. RESULTS: The ShvO2 value was 76 +/- 3.5% just after laparotomy, and reduced to 61 +/- 13.2% after clamping the common hepatic artery. The values of the ShvO2 returned to 70.8 +/- 10.9% one hour after clamping. But, one patient underwent reconstruction of the common hepatic artery, because the ShvO2 value still stood at 50%. Combined resection of the portal vein was performed in 5 out of 8 patients. Two patients underwent resection of the portal vein without reconstruction due to the development of the collateral vein, one patients; resection of the portal vein with reconstruction, and two patients; wedge resection. In all 5 patients, the ShvO2 was stable during resection of the portal vein. CONCLUSIONS: Monitoring the ShvO2 is a useful method to evaluate at real time the hepatic circulation during the Appleby operation, and to decide if reconstruction of the common hepatic artery or the portal vein is needed or not.     

Endovascular repair using parallel grafts to treat a suprarenal pancreatitis-related abdominal aortic pseudoaneurysm

Arterial pseudoaneurysms represent an uncommon complication of acute pancreatic inflammation or chronic pancreatitis. We describe a contained rupture of a suprarenal abdominal aortic pseudoaneurysm. An aorto-uni-iliac stent-graft was adopted as the aortic main body and was combined with two chimneys and two periscope stents for celiac/superior mesenteric artery and renal arteries, respectively. The procedure was complicated by the entrapment of the celiac sheath into the barbs of the aortic stent-graft and the attempts to remove the sheath resulted in an upward migration of the stent-grafts. A bail-out endovascular procedure was used to reline the stent-grafts and the pseudoaneurysmal sac was embolized with coils.     

Surgical treatment of celiac-splenic aneurysms without arterial reconstruction

We report a case of multiple sequential celiacsplenic aneurysms which we removed completely without arterial reconstruction. The patient was a 67-year-old man. During work-up for hypertension and diabetes, a splenic artery aneurysm was identified on abdominal ultrasonography. Follow-up examination 1 year and 3 months later showed enlargement of the aneurysm. The patient was referred to our Radiology Department for treatment. Abdominal computed tomography and angiography of the celiac trunk showed that the celiac artery was narrowed and then dilated to form a fusiform aneurysm. Splenic artery aneurysms were identified immediately distal to the bifurcation with the common hepatic artery, measuring about 5 cm and 3 cm. These findings ruled out treatment by interventional radiology, and surgery was performed. At laparotomy, a white, 5-cm aneurysm was densely adherent to the pancreas, and separation was impossible. We performed en bloc resection of the pancreatic body and tail, spleen, celiac artery, and common hepatic artery. Since pulsation in the replaced right hepatic artery and the color of the stomach were good, we did not perform an arterial reconstruction. Although the surgical treatment of aneurysms generally consists of resection and arterial reconstruction, we resected the lesion safely and completely without arterial reconstruction.     

Bifid Tail of the Pancreas: A Case Presenting as a Gastric Submucosal Tumor

A 49-yr-old male was admitted to our hospital because of epigastric discomfort and a suspected tumor of the stomach on barium meal examination at the Center for Automated Multiphasic Health Test and Services. The tumor shadow of the stomach was initially considered as the "type II" gastric carcinoma according to the Borrmann's classification. Multiple endoscopical and electrocautery cutting biopsies revealed that the tumor occurred in the submucosal layer and was composed of normal pancreatic tissue. A computed tomogram showed a large mass on the pancreatic body which was adjacent to gastric wall. Selective angiography of the celiac trunk revealed that the gastric submucosal lesion was supplied by the transverse pancreatic artery. Endoscopic retrograde pancreatography showed that Wirsung's duct bad a divergence in the body of the pancreas and one of the branched ducts beaded for the posterior wall of the gastric body. On the basis of these results, a diagnosis was made of the rare pancreatic anomaly, "bifid tail of the pancreas." One of the tails formed the gastric sub, mucosal tumor. This report emphasizes the artificial diagnostic value of combined study of endoscopic retrograde pancreatography and computed tomography in determining the presence of pancreatic anomaly.     

Modified extended distal pancreatectomy for carcinoma of body and tail of pancreas

The prognosis of carcinoma in the body and tail of the pancreas is disappointing due to the low rate of resectability, since it is usually presented at an advanced stage with local invasion of adjacent major vessels. However, the postoperative survival, if resectable, is similar to carcinoma of the pancreatic head. Aggressive approach, by applying extended distal pancreatectomy with the resection of the celiac axis, may increase the resectability but promote the potential risk of hepatic dysfunction and biliary necrosis after the sudden interruption of the common hepatic artery. We modified the procedure by reanastomosis between the stump of the celiac axis and common hepatic artery without vascular graft to manage a 50-year-old woman with locally advanced carcinoma of the body and tail of pancreas. She had 2 years of disease-free survival. This modified extended pancreatectomy may be a feasible and safer procedure.     

Isolated dissection of the celiac artery--a case report

Isolated arterial dissection, which occurs with the absence of aortic dissection, has been reported in carotid and renal arteries but rarely in visceral arteries. A case of isolated celiac artery dissection is reported here. A healthy 58-year-old man experienced sudden upper abdominal pain, which continued for several days. A body computed tomogram (CT) showed a multiple low-density wedge-shaped area in the spleen, which was diagnosed as splenic infarction, and an aneurysm with thrombus in the celiac artery. A selective angiogram showed dilatation of the celiac artery with wall irregularity, and proximal occlusion of the hepatic artery. The distal hepatic artery was fed by collateral arteries from the superior mesenteric artery. Splenic infarction was probably due to the embolism from the thrombus in the dissected celiac artery. The absence of other vascular lesions and causes or risks for the arterial dissection would suggest the occurrence of spontaneous dissection. The dissection of visceral arteries should be considered in diagnosing acute abdominal pain.     

Transcatheter embolization of a giant pancreatic pseudoaneurysm: A tale of two bleeds and one thrombus!

Erosion of a peripancreatic artery into the pseudocyst as a result of enzymatic digestion of vessel wall gives rise to a pancreatic pseudoaneurysm (PSA), which is a rare complication seen in patients with chronic pancreatitis.¹ Angiographic embolization as a treatment method for acute hemorrhage from pancreatic PSA has become increasingly popular. Here we report a unique case with bleeding from a giant pancreatic PSA where the single PSA had blood supply originating from the branches of both the celiac artery and superior mesenteric artery.     

Transpancreatic catheterization of the right hepatic artery for chemoembolization using a new infusion system

The right hepatic artery was catheterized for chemoembolization in a patient with liver-dominant metastatic breast carcinoma and occlusion of the celiac artery by tumor compression. This was accomplished by use of a new coaxial infusion catheter-steerable guidewire system passed through the superior mesenteric artery and posterior pancreatic arcade.     

Ultrasonic interventional analgesia in pancreatic carcinoma with chemical destruction of celiac ganglion

AIM: To detect the therapeutic effects of chemical destruction of celiac ganglion in patients with pancreatic carcinoma with intractable pain. METHODS: Ninety-seven cases with advanced pancreatic carcinoma received chemical destruction of celiac ganglion-5 mL pure alcohol injection around celiac artery under ultrasonic guidance. The changes of visual analogue scale (VAS), serum substance P (Sub P),β-endopeptide (β-EP) and T-lymphocyte subtypes level were compared between pre- and post-therapy. RESULTS: Successful rate of puncture was 98.7%, with one failure. No serious complications such as traumatic pancreatitis, pancreatic fistula, abdominal cavity hemorrhage or peritoneal infection occurred. VAS, serum Sub P andβ-EP level significantly changed after treatment (8.0±2.3 vs 4.6±2.1, 254.1±96.7 vs 182.4±77.6, 3.2±0.8 vs 8.8±2.1, P < 0.01, P < 0.05, P < 0.01) with complete relief rate 54.2%, partial relief rate 21.9%, ineffective rate 12.5% and recurrent rate 10.7%. The T-lymphocyte subtypes level remarkably increased when compared with that of pre-therapy (46.7±3.7 vs 62.5±5.5, P< 0.01). CONCLUSION: Our study suggests that chemical destruction of celiac ganglion under ultrasonic guidance is highly safe, and can evidently relieve cancer pain and improve the cellular immunity in patients with advanced pancreatic carcinoma.     

Venous bypass grafting for celiac occlusion in radical pancreaticoduodenectomy.

Radical pancreaticoduodenectomy was performed for cancer of the head of the pancreas in a 65-year-old male patient with congenital celiac occlusion. Preoperative angiography revealed that the arterial flow to the liver, spleen, and stomach was supplied via the pancreaticoduodenal arcade and that the dorsal pancreatic artery arose from the superior mesenteric artery. In order to perform radical pancreatectomy with sufficient clearance of lymph nodes and soft tissues around the pancreas, the celiac arterial circulation was reconstructed. The restoration of flow was effected via a saphenous vein graft between the common hepatic artery and the aorta. Postoperative angiography demonstrated patency of the graft. The patient's postoperative course was uneventful.