Second surgery after a pancreaticoduodenectomy in patients with periampullary malignancies

BACKGROUND/AIMS: Few case reports have previously documented a second surgery after pancreaticoduodenectomy due to recurrence or other reasons in patients with periampullary malignancies. The present report summarized the experience of this clinic with secondary surgery after Pancreaticoduodenectomy (PD). METHODOLOGY: During the past 7 years, 7 out of 95 patients with periampullary malignancies underwent a second surgery after pancreaticoduodenectomy at this institution. The clinical courses of these patients are presented and 2 interesting cases are shown in the present study. RESULTS: One patient with lower bile duct adenocarcinoma underwent a remnant splenopancreatectomy due to pancreatic recurrence 36 months after pancreaticoduodenectomy. The other patient with lower bile duct adenocarcinoma underwent a hepatectomy due to a solitary liver metastasis 47 months after a pancreaticoduodenectomy. These 2 patients have survived 4 and 13 months after the second surgery. In the 7 patients requiring secondary surgery, 5 underwent the procedure due to recurrent disease, and 4 of the 5 received the second surgery to remove the lesion. The mean interval between pancreaticoduodenectomy and the second operation was 32 months in the 5 patients with recurrent disease and 27 months in the all 7 patients. One of the 5 patients died of recurrent disease only 5 months after the second procedure because the surgery was a palliative bypass. However, the other 3 survived more than 1 year after the resection of the lesion at the recurrent site. CONCLUSIONS: The present study reports 2 rare cases with lower bile duct adenocarcinoma in which a recurrent tumor was removed after pancreaticoduodenectomy. In this study, 4 patients undergoing a curative re-operation survived more than 1 year after the surgery. The present study was small, but the findings are significant because of the scarcity of reports of patients undergoing secondary surgery after PD.     

Neoadjuvant therapy may lead to successful surgical resection and improved survival in patients with borderline resectable pancreatic cancer

Background:

Borderline resectable pancreatic cancers are technically amenable to surgical resection, but are associated with increased risk of locoregional recurrence. Patients with these tumours may be treated with neoadjuvant therapy in an attempt to improve margin-negative resection rates.

Methods:

The University of Cincinnati Pancreatic Cancer Database was retrospectively reviewed. Borderline resectable disease was defined by the following radiographic criteria: (i) short segment occlusion of the superior mesenteric vein (SMV), portal vein (PV) or SMV/PV confluence; (ii) short segment hepatic artery encasement, or (iii) superior mesenteric artery/coeliac artery abutment of <180 degrees. Patients with resectable disease who had questionable metastatic disease or poor performance status were also included.

Results:

Twenty-nine patients met the criteria. Of these, 26 underwent a full course of neoadjuvant therapy. Twelve (46%) underwent surgical resection and 14 had tumour progression or were deemed unresectable at laparotomy. The most common neoadjuvant therapy regimen was gemcitabine-based chemotherapy alone (58%). Of those undergoing surgery, 67% had margin-negative (R0) resections and 42% required venous resection. Median survival was 15.5 months for unresected patients and 23.3 months for resected patients.

Discussion:

Borderline resectable pancreatic tumours can be treated neoadjuvantly, resulting in margin-negative resection and survival rates similar to those in initially resectable disease.     

Isolating tape method is useful for an early judgment of curability during pancreaticoduodenectomy for pancreatic cancer

Positive surgical margin of extrapancreatic nerve plexus (ENP) is a major cause of non‐curative resection during pancreaticoduodenectomy (PD) for periampullary carcinoma (PC), which is difficult to detect at the early stage of PD. We describe a novel surgical technique using an isolating tape (iTape)‐oriented ENP‐first dissection (IOEFD) during PD. The iTape is firstly passed through the retroperitoneal space between ENP and inferior vena cava. Then, the iTape is further extracted from major vessels such as the common hepatic and superior mesenteric artery. Consequently, the iTape encircles ENP alone. By tugging both ends of the iTape and vessel tapes to various directions from the caudal and cranial side of the pancreas, ENP is individually dissected without dividing any organ or tissue. Ten patients with periampullary carcinomas, consisting of one distal bile duct carcinoma, four ampullary carcinomas and five pancreatic head carcinomas underwent IOEFD during PD. Among these, nine underwent PDs after confirming negative surgical margin of ENP by IOEFD, while in the other case, PD was abandoned and converted to digestive bypass because of positive ENP margin during IOEFD. By final pathological diagnosis, R0 resection has been established in all nine patients who underwent PD with IOEFDs. Our pilot study indicated that inappropriate non‐curative resection can be avoided by IOEFD during PD.     

Double inferior vena cava does not complicate para-aortic nodal dissection for the treatment of pancreatic carcinoma

Duplication of the inferior vena cava (IVC) involves large veins on both sides of the aorta that join anteriorly at the level of the renal arteries to become the suprarenal IVC. We report CT scan and intraoperative images of a patient with duplication of the IVC who underwent pancreaticoduodenectomy with para-aortic lymphadenectomy for carcinoma of the pancreatic head: nodal dissection along the left caval vein was not carried out. The anatomical background of the lymphatic flow to the para-aortic lymph nodes and the theoretic basis for lymph node dissection of the para-aortic area in cases of double IVC are highlighted. Lymphadenectomy along the left caval vein is not necessary in patients with double IVC who undergo pancreaticoduodenectomy with extended lymphadenectomy for carcinoma of the pancreatic head in the absence of preoperative appearance of para-aortic disease.     

Gastroduodenal artery used for arterial reconstruction during the Whipple operation

The right hepatic artery and the common hepatic artery originate from the superior mesenteric artery in approximately 10-15% of the population. Reconstruction of the hepatic artery using the gastroduodenal artery has previously been described to repair hepatic artery injury during the performance of biliary and pancreatic resections. We report the utilization of this technique in patients undergoing pancreaticoduodenectomy for a periampullary neoplasm involving a replaced right hepatic artery.     

Right hepatectomy combined with retrohepatic caval resection,using a left renal vein patch graft for advanced cholangiocarcinoma

Combined resection of the inferior vena cava for hepatobiliary malignancies remains a technical challenge. We successfully resected an intrahepatic cholangiocarcinoma involving the retrohepatic vena cava, and reconstructed the caval defect using a left renal vein patch graft. The patient was a 79-year-old man. Preoperative ultrasonography and computed tomography revealed that the tumor was located in the right lobe of the liver and was about 6?cm in diameter. Arteriogram revealed encasement of the right arterial and portal branches. Magnetic resonance imaging scan revealed that the tumor involved the retrohepatic vena cava. The patient underwent a right hepatectomy combined with resection of the retrohepatic vena cava. The resected portion of the caval wall was 3.6?cm long and 2.7?cm wide. The caval defect was reconstructed using a left renal vein patch graft of a rhomboid shape, which was made by oblique incision of the vein graft. The postoperative course was uneventful. Postoperative cavogram showed adequate patency of the reconstructed retrohepatic vena cava. The patient was disease-free 22 months after surgery. In conclusion, major liver resection combined with caval resection and reconstruction can be performed safely. Furthermore, a left renal vein graft can provide a flexible patch according to the form and size of the caval defect.     

Perioperative and long-term outcome of en-bloc arterial resection in pancreatic surgery

BackgroundPancreatic tumors are frequently diagnosed in a locally advanced stage with poor prognosis if untreated. This study assesses the safety and oncological outcomes of pancreatic surgery with arterial en-bloc resection.MethodsWe retrospectively reviewed a prospectively maintained database of patients who underwent a pancreatic resection with arterial resection between 2011 and 2020. Univariable analyses were used to assess prognostic factors for survival.ResultsForty consecutive patients (22 female; 18 male) undergoing arterial resections were included. Surgical procedures consisted of 19 pancreatoduodenectomies (PD, 48%), 16 distal splenopancreatectomy (DSP, 40%), and 5 total pancreatectomies (TP, 12%). Arterial resection included hepatic arteries (HA, N = 23), coeliac trunk (TC, N = 15) and superior mesenteric artery (SMA, N = 2). Neoadjuvant therapy was applied in 22 patients (58%). Major complications after surgery were observed in 15% of cases. 90-day mortality was 5%. Median disease-free survival and median overall survival were for the R0/CRM? group 22.8 months and 27.9 months, 9.5 and 19.8 months for the R0/CRM+ group, and 10.1 and 13.1 months for the R1 group, respectively.ConclusionIn highly selected patients, arterial en-bloc resection can be performed with acceptable mortality and morbidity rates and beneficial oncological outcome.     

Pancreaticoduodenectomy in the elderly over 80 years:a case report

Introduction A ge limits for radical surgery have become a matter of interest because of aging of the population. There are a large series of very elderly patients undergoing cardiothoracic and vascular procedures, but few studies have been undertaken on the outcomes of these patients following major intra-abdominal surgery.[1] Among digestive tumors, the incidences of periampullary malignant tumor and pancreatic ductal adenocarc- inoma are one of the highest. Before the early 1990s, there was…     

Inferior vena cavectomy for renal cell carcinoma with intracaval tumor thrombus

Excision of the inferior vena cava for renal cell carcinoma with intracaval tumor thrombus is infrequently performed. Herein the authors report a 60-year old woman with a right renal cell carcinoma and massive occluding tumor thrombus of the inferior vena cava. Following a negative metastatic workup, this patient underwent surgery to remove the tumor and thrombus. Thrombectomy occurred via excision of the affected portion of inferior vena cava and proximal left renal vein. Reconstruction of the vena cava was not undertaken. The patient did not suffer any morbidity during recovery in hospital. Her renal function was normal upon discharge. All resection margins were negative for tumor. This experience is compared to those reported in the literature. Postoperative morbidity may be minimized by careful patient selection. Suitable patients should have a right-sided tumor with an occlusive subhepatic vena caval tumor thrombus.     

Celiac axis occlusion of a patient undergoing pancreaticoduodenectomy after distal gastrectomy

In patients with celiac axis occlusion, performance of pancreaticoduodenectomy involves sacrifice of the gastroduodenal artery which results in a risk of hepato-pancreato-biliary and other organic ischemia. Celiac axis occlusion does not recently seem an uncommon finding in cases of pancreaticoduodenectomy but diagnosis of celiac axis occlusion may be difficult in patients with former abdominal surgery. The present case report shows a patient with pancreatic head adenocarcinoma, in whom a preoperative diagnosis of celiac axis occlusion was not proved because of displacement of the celiomesenteric arterial branches based on former distal gastrectomy with Kocher's maneuver. A 56-year-old man with malignant obstruction of the lower bile duct was referred to our hospital for undergoing pancreaticoduodenectomy. In his past history, the patient had undergone distal gastrectomy reconstructed with Billroth I method due to gastric ulcer. In preoperative abdominal angiography, the celiac axis was not detected at the normal position and was incorrectly recognized to be anomalously originated from the superior mesenteric artery. During surgery, hepatic arterial flow was markedly diminished by clamping of the gastroduodenal artery. Celiac axis occlusion was then proved and the thick and tight median arcuate ligament was detected. Hepatic arterial blood flow was recovered by a complete division of the median arcuate ligament. Postoperative course of the patient was uneventful. In cases of pancreaticoduodenectomy, careful preoperative angiographic diagnosis is needed for patients with celiac axis occlusion who have undergone former gastric surgery because the celio-mesenteric arterial branches have been displaced by Kocher's maneuver. The present report also demonstrates another patient with a typical celiac axis stenosis.     

Treatment for hepatocellular carcinoma associated with tumor embolus in the inferior vena cava

Hepatic resection and removal of the tumor embolus was performed in six patients with hepatocellular carcinoma associated with tumor embolus in the inferior vena cava, without distant metastasis. Hepatic resection was performed in five patients under total hepatic vascular exclusion (THVE) with veno-venous bypass, using a centrifugal force pump and in one patient, under simple THVE without the bypass. In one patient, partial resection of segment VIII was performed, in one, a central bi-segmentectomy, and in four, right hepatic lobectomies were performed. Surgery was safely performed in all the 5 patients under THVE using the centrifugal force pump. One patient who underwent partial hepatic resection under the simple THVE, suffered cardiac arrest during surgery, but resuscitation was successful. Three patients died of reccurence within 1 year. The other three patients survived for 10 months, 2 years and 10 months, and 3 years and 10 months, respectively, after surgery. There were recurrences in the first two, patients, in both, treated by transcatheter arterial embolization, and to date, the third patient is disease-free. Hepatic resection was safely performed in patients with hepatocellular carcinoma associated with tumor embolus in the inferior vena cava, under conditions of THVE using the centrifugal force pump. Prolonged survival can be anticipated, with favorable liver function, in those patients in whom most of the lesion is resected.     

Cancer of the pancreas. Pylorus-preserving resection of the pancreas

Pylorus-preserving pancreaticoduodenectomy represents an important advance in the history of pancreatic surgery. The operation can be performed with a low operative mortality and morbidity, is technically easier than the standard Whipple resection, and it minimizes the long-term physiological disturbance to the patient. Clinical and experimental evidence has substantiated the view that preservation of the pylorus reduces the incidence of marginal anastomotic ulceration following pancreatectomy. Although gastric emptying may be prolonged transiently in the immediate postoperative period, this complication is easily managed, and is hardly a frequent long-term problem. PPPD is associated with a lower incidence of enterogastric reflux, dumping and diarrhoea than the classical Whipple operation, and patients who have had PPPD are more likely to regain their preoperative and preillness weight. Initial concerns about the use of PPPD in malignant disease have not been borne out, and should now be considered for curative or palliative resections of lesions in the periampullary region including the head of the pancreas. Present data suggest that PPPD does not compromise the long-term survival in patients with periampullary cancers. There is little doubt that the excellent results reported with this procedure as with other forms of major pancreatic surgery, are not simply related to improvements in surgical technique but to establishment of specialist pancreatic surgery.     

Right-to-left shunting with normal pulmonary pressure complicating atrial septal defect surgery

We report on a patient in whom a right-to-left shunt with normal pulmonary arterial pressures occurred after surgery of an inferior vena caval sinus venosus-type atrial septal defect. In addition to the inferior vena cava to left atrium anatomic defect, the exceptional occurrence of a post-operative right atrial inflow stenosis contributed to the right-to-left shunting.     

Combined resection of the inferior vena cava for hepato-biliary and pancreatic malignancies

Seven cases of hepato-biliary and pancreatic malignancies that underwent partial resection of the inferior vena cava) were reviewed. Histological findings of inferior venca cava involvement were direct invasion in 5 cases, tumor thrombus in 1 case, and adhesion in 1 case. Correct preoperative diagnosis of inferior vena cava involvement was made in only 2 cases. A retrospective study on enhanced CT revealed that irregular deformity of the inferior vena cava had suggested inferior vena cava involvement. Total occlusion of the inferior vena cava was employed temporarily for inferior vena cava resection in 3 cases. A saphenous vein graft was used for reconstruction in 2 cases. Complications due to inferior vena cava resection are, as yet, unknown. One patient is alive, without recurrence, 24 months after the operation. One case underwent re-resection of liver metastasis, and is alive 17 months after the operation. Although advanced hepato-biliary and pancreatic malignancies involving inferior vena cava have been regarded as having a poor prognosis, an aggressive surgical approach may be applicable in some cases.     

Delayed massive arterial hemorrhage after pancreaticoduodenectomy for cancer. Management of a life-threatening complication

BACKGROUND/AIMS: Delayed massive arterial hemorrhage from the operating field occurs in 1-4% of cases after pancreaticoduodenectomy, with a mortality rate up to 50%. The purpose of this study was to define diagnostic and treatment methodologies to maximize survival. METHODOLOGY: Between 1990 and 1999, 84 pancreaticoduodenectomies were performed for periampullary and pancreatic head cancer. After surgery, massive bleeding occurred in two patients (2.3%), 30 and 8 days after resection, respectively. RESULTS: Pancreatic leak and disruption of the pancreaticojejunostomy were reported in both cases. Bleeding was controlled by suture ligation of the stump of the gastroduodenal artery. Completion pancreatectomy and a new pancreaticojejunostomy were respectively performed. Hemorrhage recurred in both cases from a ruptured pseudoaneurysm of the hepatic artery, requiring re-exploration and surgical ligation. The first patient died of re-bleeding despite completion pancreatectomy, the other survived after oversewing the residual pancreatic stump at re-exploration. CONCLUSIONS: Early diagnosis and management of pancreatic leak represents the only means to prevent a delayed massive arterial hemorrhage. Transarterial embolization or surgical ligation of the hepatic artery proximal to the celiac axis represents the procedure of choice to control the bleeding. Taking down the pancreatic anastomosis and oversewing the pancreatic stump is safe and effective. Extensive drainage of the operating field should always be associated to prevent multisystem organ failure.     

A new method of jejunal reconstruction after pancreaticoduodenectomy

Although advances in pancreatic surgery have reduced mortality rates, post-operative morbidity remains a frequent problem in patients undergoing pancreaticoduodenectomy. The single most significant cause of morbidity in these patients is the development of pancreatic fistula. In this study, we assessed the occurrence of pancreatic fistula after isolated Roux loop pancreaticojejunostomy with the use of a haemostatic collagen-fibrin patch (TachoSil) to prevent pancreatic leakage. A total of 27 patients (15 men and 12 women, mean age 59 years, range 19-74 years) underwent proximal Whipple-type resection. Ten patients underwent a classical pancreaticoduodenectomy while a pylorus-preserving pancreaticoduodenectomy was performed in the other 17 patients. Reconstruction was done using three-jejunal anastomosis, with TachoSil applied at the end of the pancreatic jejunal anastomosis, along the entire anastomotic circumference. None of the 27 patients who underwent pancreaticoduodenectomy developed pancreatic fistula. One patient had bleeding from the gastro-jejunal anastomoses, five patients had infections of surgical sites, and three patients developed bacterial pneumonia. There were no significant differences in duration of surgery or intra-operative blood loss between patients with soft or hard pancreatic tissue. The reconstruction technique described here with three independent jejunal loops appears to offer good protection against pancreatic leakage.     

Technical tailoring of pancreaticoduodenectomy in patients with hepatic artery anatomic variants

BACKGROUND:Pancreaticoduodenectomy is the treatment of choice for periampullary and pancreatic head tumors.In case of hepatic artery abnormalities,early pancreatic transection during pancreaticoduodenectomy may prove inappropriate Early retroportal lamina dissection improves exposure of the superior mesenteric vessels and anatomic variants of the hepatic artery,where safeguarding is mandatory.METHOD:We describe our early retroportal lamina approach in patients with anatomic variants of the hepatic artery be...     

Surgical techniques for improving outcomes in pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma is a devastating disease with extremely poor survival despite patients undergoing potentially curative resections and improvements in chemotherapeutic agents. Surgery for operable cancer in the head of the pancreas typically involves an open pancreaticoduodenectomy with a post-operative median survival of 21 months. Newer surgical techniques, however, aim to improve patient outcomes in terms of both their hospital experience and better oncological results. This article focuses on the evidence to date for some of these surgical techniques including laparoscopic and robotic surgery, the no-touch technique, venous and arterial resection, intra-operative radiofrequency ablation and intra-operative irreversible electroporation. With the increased use of these techniques we hope to see better quality of life and survival for these patients.     

Carcinoma of the head of the pancreas

BACKGROUND/AIMS: Extended radical surgery might provide a survival advantage for patients with carcinoma of the head of the pancreas. METHODOLOGY: Between January 1980 and December 1999, 144 patients with carcinoma of the head of the pancreas were treated in a community hospital setting, of whom 69 patients who underwent radical surgery were retrospectively reviewed. Surgical procedures included standard pancreaticoduodenectomy (27 patients), pylorus-preserving pancreaticoduodenectomy (27 patients), and total pancreatectomy (15 patients). Portal vein resection was performed for 15 patients. Retroperitoneal lymphadenectomy was performed for 35 patients. No patients received adjuvant chemotherapy or radiotherapy. RESULTS: The surgical resection rate was 47.9% with a surgical mortality rate of 4.3% during this period. The overall 5-year survival rate after radical surgery was 16.1% with a median survival of 12 months. Seven patients survived five years, making 16.3% of the patients available for a more than 5-year follow-up. Long-term survivors had less than two positive lymph nodes in the posterior pancreatic head. Fourteen of 15 patients undergoing portal vein resection died within 21 months. One patient having no portal vein invasion microscopically survived 27 months without recurrence. CONCLUSIONS: Extended radical surgery did not prolong survival for patients with carcinoma of the head of the pancreas.     

Autogenous vein graft from iliac artery to splenic artery for celiac occlusion in pancreaticoduodenectomy

This is a report of two patients with bile duct cancer and periampullary cancer with celiac axis occlusion who underwent pylorus-preserving pancreaticoduodenectomy and pancreaticoduodenectomy, respectively. Preoperative arteriography demonstrated complete obstruction of the celiac axis. The arterial blood flow to the liver, spleen, and stomach was sustained through the pancreaticoduodenal arcades and collaterals from the superior mesenteric artery. Therefore, reconstruction of the celiac axis circulation was required before division of the gastroduodenal artery. An autograft of the saphenous vein was placed between the iliac artery and the splenic artery, and subsequently pancreaticoduodenectomy was performed. The patients' postoperative courses were uneventful. Postoperative arteriography demonstrated patency of the grafts. When occlusion of the celiac axis exists, a bypass from the iliac artery to the splenic artery using a saphenous vein graft, may be safely and easily performed at the time of pancreaticoduodenal resection.