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.     

A nonfunctioning islet cell carcinoma with tumor thrombus in both the portal and splenic veins — a case report of successful resection

A rare case of nonfunctioning islet cell carcinoma associated with tumor thrombi in both the portal and splenic veins is reported. The patient, a 49-year-old male, had a 2-year history of occasional abdominal pain. Computed tomography (CT) disclosed a huge mass in the body of the pancreas, and celiac arteriogram showed a tumor stain in the body and tail of the pancreas. Percutaneous transhepatic portography (PTP) demonstrated an irregular filling defect, indicating intraportal tumor growth. Curative surgery, which included total pancreatectomy with combined resection (50 mm in length) and reconstruction of the portal vein, distal gastrectomy, and partial resection of the transverse colon, was performed. Histological examination of the surgical specimen led to a diagnosis of nonfunctioning islet cell carcinoma with a negative immunohistochemical stain for insulin, glucagon, somatostatin, and adrenocorticotropic hormone. The patient has been well for 38 months to date without any sign of tumor recurrence. Our experience with this case has introduced a radical resection for islet cell tumor of the pancreas, even if the tumor has extended into the portal vein.     

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.     

Distal pancreatectomy with en bloc celiac resection for locally advanced pancreas carcinoma

In locally advanced pancreatic body cancers, cancer infiltrates major vessels such as the celiac axis, common hepatic artery and superior mesenteric artery or vein, which is the borderline of resectability. Patients also suffer severe abdominal pain. Kondo and Hirano et al. developed a radical operation called "distal pancreatectomy with en bloc celiac resection (DP-CAR)" for such cases. We applied this procedure three times in two patients with pancreatic body carcinomas, in which combined vascular resection was necessary. Radical operation was eventually achieved.     

Collagen-based biological glue after Appleby operation for advanced gastric cancer

Pancreatic fistula is a common complication of distal pancreatectomy; although various surgical procedures have been proposed, no clear advantage is evident for a single technique. We herein report the case of a 38-year-old patient affected by an advanced gastric carcinoma infiltrating the pancreas body, with exten- sive nodal metastases involving the celiac trunk, who underwent total gastrectomy with lymphadenectomy, distal pancreatectomy and resection en bloc of the celiac trunk (Appleby operation). At th...     

Preoperative embolization of the common hepatic artery in preparation for radical pancreatectomy for pancreas body cancer

BACKGROUND/AIMS: To assess preliminary results of preoperative embolization of the common hepatic artery in preparation for distal pancreatectomy with en bloc resection of the celiac and common hepatic arteries for carcinoma of the body of the pancreas involving these arteries. METHODOLOGY: Four patients underwent the embolization with coils 1-7 (median: 5) days before surgery. A detachable coil was used to obtain the best position of the first coil as an anchor in 3 patients. RESULTS: Immediately after embolization, collateral pathways developed from the superior mesenteric artery via the pancreatoduodenal arcades to the proper hepatic and gastroduodenal arteries in all 4 patients; however, they were relatively poor in one patient. There were no complications after embolization. The pulsation of the proper hepatic and gastroduodenal arteries was well palpable during surgery, although it had been compromised sometimes in previous cases without embolization. There were no ischemia-related complications in the 2 patients who underwent radical surgery. CONCLUSIONS: Preoperative embolization of the common hepatic artery is a safe technique and has the potential to enlarge the collateral pathways by the time of distal pancreatectomy with en bloc resection of the celiac artery and prevent postoperative fatal ischemia-related complications.     

Middle colic artery-gastroepiploic artery bypass for compromised collateral flow in distal pancreatectomy with celiac artery resection

BACKGROUND/AIMS: Radical distal pancreatectomy with en-bloc resection of the common hepatic, celiac, and left gastric arteries for pancreatic body cancer that involves these arteries does not routinely require arterial reconstruction because the collateral pathways via the pancreatoduodenal arcades from the superior mesenteric artery are recruited immediately. However, accidental injury to the pancreatoduodenal artery compromises collateral blood flow and may lead to fatal complications. This article describes the middle colic artery-gastroepiploic artery bypass as an emergent salvage procedure for restoring collateral flow. METHODOLOGY: The inferior pancreatoduodenal artery was accidentally injured in 2 of 9 patients who underwent the radical procedure between 1997 and 2001. Microvascular anastomosis between the left branch of the middle colic artery and the gastroepiploic artery in an end-to-side fashion was employed. RESULTS: The pulsation of the gastroepiploic artery and the color of the stomach recovered immediately after completion of the middle colic artery-gastroepiploic artery bypass. No ischemia-related complication developed postoperatively. Postoperative angiography showed the middle colic artery-gastroepiploic artery bypass supplying arterial flow to the liver, stomach, duodenum, and pancreas. CONCLUSIONS: The middle colic artery-gastroepiploic artery bypass is an excellent alternative restoring compromised collateral flow via the pancreatoduodenal arcades when microsurgical technique is available.     

Endovascular pseudoaneurysm repair after distal pancreatectomy with celiac axis resection

Erosive hemorrhage due to pseudoaneurysm is one of the most life-threatening complications after pancreatectomy.Here,we report an extremely rare case of rupture of a pseudoaneurysm of the common hepatic artery(CHA)stump that developed after distal pancreatectomy with en block celiac axis resection(DP-CAR),and was successfully treated through covered stent placement.The patient is a 66-year-old woman who underwent DP-CAR after adjuvant chemoradiotherapy for locally advanced pancreatic body cancer.She developed an intra-abdominal abscess around the remnant pancreas head 31 d after the surgery,and computed tomography(CT)showed an occluded portal vein due to the spreading inflammation around the abscess.Her general condition improved after CT-guided drainage of the abscess.However,19 d later,she presented with melena,and CT showed a pseudoaneurysm arising from the CHA stump.Because the CHA had been resected during the DP-CAR,this artery could not be used as the access route for endovascular treatment,and instead,we placed a covered stent via the inferior pancreaticoduodenal artery originating from the superior mesenteric artery.After stent placement,cessation of bleeding and anterograde hepatic artery flow were confirmed,and the patient recovered well without any further complications.CT angiography at the 6-mo follow-up indicated the patency of the covered stent with sustained hepatic artery flow.To our knowledge,this is the first reported case of endovascular repair of a pseudoaneurysm that developed after DP-CAR.     

Distal pancreatectomy: en-bloc splenectomy vs spleen-preserving pancreatectomy

Distal pancreatectomy with en-bloc splenectomy has been considered the standard technique for management of benign and malignant pancreatic disorders. However, splenic preservation has recently been advocated. The aim of this study was to review the experiences of distal pancreatectomy using the open or the laparoscopic approach and to critically discuss the need to perform splenectomy. Original articles published in the English literature of peer-reviewed medical journals were selected for detailed analysis. In patients with malignant neoplasms in the body-tail of the pancreas, splenectomy has a negative influence on long-term survival after resection. The incidence of diabetes after spleen-preserving distal pancreatectomy for chronic pancreatitis is less than after en-bloc splenectomy. Spleen salvage eliminates the risk of overwhelming infections. Laparoscopic spleen-preserving distal pancreatectomy is feasible and safe. Laparoscopic spleen-preserving distal pancreatectomy may be preferable for the advantages of a minimally invasive approach.     

Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein

Preservation of the spleen at distal pancreatectomy has recently attracted considerable attention.Since our first successful trial,spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein for tumors of the pancreas and chronic pancreatitis has been performed more frequently.The technique for spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein are outlined.The splenic vein is identified behind the pancreas and within the thin connective tissue membrane.The connective tissue membrane is cut longitudinally above the splenic vein.An important issue is to remove the splenic vein from the body of the pancreas toward the spleen,since a different approach may be very difficult.The pancreas is preferably removed from the splenic artery toward the head of the pancreas itself.This procedure is much easier than removing the pancreas from the vein side.One patient had undergone distal gastrectomy for duodenal ulcer,with reconstruction by Billroth Ⅱ tehcnique.If distal pancreatectomy with splenectomy had been performed for the lesion of the distal pancreas at the time,the residual stomach would also have to be resected.The potential damage done to the patient by reconstruction of the gastrointestinal tract in combination with distal pancreatectomy and splenectomy would have been much greater than with distal pancreatectomy only with preservation of the spleen and residual stomach.Benign lesions as well as low-grade malignancy of the body and tail of the pancreas may be a possible indication for this procedure.     

Heterotopic autotransplantation of the distal pancreas segment after total pancreatectomy for cancer of the head of the pancreas.

Autotransplantation of the distal pancreas segment with pancreaticojejunostomy was performed in four patients with cancer of the head of the pancreas to preserve endocrine pancreatic function after extended total pancreatectomy. All patients had tumor involvement of both the celiac axis and the portal vein. The pancreatic graft was determined to be cancer-free by frozen section histologic and pancreatic juice cytologic examinations. The distal pancreas segment was autotransplanted to the iliac vessels heterotopically and placed in the extraperitoneal pocket to avoid untoward effects of any local recurrence or pancreatic leakage. This procedure, in the form of reconstruction, might be called modified subtotal pancreatoduodenectomy. Postoperatively, all patients remained normoglycemic without exogenous insulin administration, and their quality of life was considered satisfactory.     

胰腺间变癌的临床病理特点——附6例报告

目的胰腺间变癌是少见的胰腺外分泌恶性肿瘤，本文探讨其临床病理学特点。方法回顾性分析6例胰腺间变癌的临床特点并结合文献讨论。结果本组6例，其中男5例，女1例，年龄4j～74岁。肿瘤位于胰头3例，胰体尾3例。行胰头十二指肠切除术3例，其中1例作肠系膜上静脉切除重建术，另1例同时行肠系膜上动、静脉切除重建术。3例胰体尾肿块，2例行胰体尾切除、脾切除术．另1例肿瘤已侵犯周围脏器，行全胃、结肠脾曲、腹腔动脉切除术。病理检查：肿瘤细胞呈多形性．可见圆形、卵圆形、多边形和梭形的肿瘤细胞，核大深染，异型明显，也可见巨核或多核的瘤巨细胞及破骨细胞样巨细胞。随访5例，术后平均生存5．5月．均死于肿瘤腹腔内和肝脏转移。结论胰腺间变癌组织学特点为肿瘤细胞的多形性，并可见巨核或多核的巨细胞或破骨细胞样巨细胞．呈侵袭性生长，易侵犯周围脏器、大血管和发生肝脏、淋巴结转移，恶性程度高，预后差。     

Distal pancreatectomy and portal vein resection without vascular reconstruction for endocrine tumors with massive intraportal growth: report of a case

Pancreatic endocrine tumors (PETs) are relatively rare. Owing to their slow growing characteristics, an aggressive surgical approach has been considered to improve patients' survival. A case of PET with portal vein (PV) thrombus, successfully treated by distal pancreatectomy with concomitant PV resection and removal of PV tumor thrombus, preserving collateral pathways, is reported.     

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.     

Total pancreatectomy for multiple neuroendocrine tumors of the pancreas in a patient with von Hippel–Lindau disease

Von Hippel–Lindau disease (VHLD) is an autosomal dominant familial syndrome associated with multiple neoplasms. Medical management of pancreatic lesions is still controversial, especially for pancreatic neuroendocrine tumors (NET). We report an experience of total pancreatectomy for multiple pancreatic neuroendocrine tumors in a VHLD patient, and discuss the indication of surgical treatment. The patient was a 33-year-old Japanese female with a medical history of VHLD-associated tumors. At 27 years of age, abdominal computed tomography revealed a number of strongly enhanced round tumors throughout the pancreas. She underwent total pancreatectomy with portal vein resection because of back pain and an increase of tumor size. Pathological examination reconfirmed the diagnosis of multiple pancreatic NET invading the portal vein. She has been well with intensive insulin therapy and has shown no recurrence of NET for more than one year. This is a rare case of total pancreatectomy with portal vein resection for treatment of pancreatic NET in a VHLD patient. Total pancreatectomy is a viable option for treatment of multi-centric or extensive pancreatic NET because of a favorable prognosis of NET after radical surgical treatment.     

Successful surgical resection of solid cystic tumor of the pancreas with multiple liver metastases and a tumor thrombus in the portal vein

We report a case of solid cystic tumor of the pancreas with widespread liver metastases and a tumor thrombus in the portal vein. The patient was a 43-year-old woman. She was referred because of an upper abdominal mass and weight loss. Computed tomography disclosed a 10-cm cystic and calcified mass in the body and tail of the pancreas and multiple masses in the liver. She underwent a distal pancreatectomy with splenectomy, extended right lobectomy, and partial resection of the liver. All the tumors were completely resected despite the presence of 20 liver metastases. Histopathological studies showed a tumor thrombus in the intrahepatic portal vein. The patient is well without any signs of recurrence 8 months after the operation. Aggressive surgical resection is considered to yield a good outcome for solid cystic tumor with liver metastases and tumor thrombus of the portal vein.     

Spleen-preserving distal pancreatectomy with preservation of the splenic artery and vein for intraductal papillary-mucinous tumor (IPMT): three interesting cases

Preservation of the spleen at distal pancreatectomy has recently attracted considerable attention. Since our first trial and success with spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein for tumors of the pancreas and chronic pancreatitis, this procedure has been performed more frequently. Three patients with intraductal papillary-mucinous tumor underwent spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein. In this procedure, the splenic vein is identified behind the pancreas and the connective tissue membrane is cut longitudinally above the splenic vein. An important point is to remove the splenic vein from the pancreas from the body of the pancreas toward the spleen. In one patient with intraductal papillary-mucinous tumor in the body of the pancreas who had undergone distal gastrectomy for duodenal ulcer 32 years previously, residual proximal gastrectomy could be avoided with this procedure. In this case, the histological diagnosis was a pseudocyst, and epithelial dysplasia was found in other pancreatic ductuli. In another case, epithelia were borderline between hyperplasia and adenoma. In both of these cases, the histological diagnosis was different from the preoperative diagnosis. Even with advances in imaging techniques, diagnosis of a cystic lesion of the pancreas is still very difficult. Ordinary distal pancreatectomy with splenectomy would have been oversurgery in these two cases, which could be avoided using our procedure. Severe complications were not found in any of the three cases and the postoperative course was uneventful. The patients have been followed as outpatients without any recurrence. Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein is easy and safe, and should be performed for some patients with intraductal papillary mucinous tumor of the pancreas.     

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.     

Distal pancreatectomy without splenectomy and with preservation of splenic vessels

BACKGROUND/AIMS: Conventional distal pancreatic resection routinely involves splenectomy. The awareness that spleen removal may lead to postoperative septic and hematological complications motivated the development of spleen-preserving procedures. Successful distal pancreatectomy with splenic conservation has been reported for treatment of benign pancreatic diseases of the distal pancreas. This report presents the results of spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein. METHODOLOGY: Ten patients underwent distal pancreatectomy with splenic vessel preservation. In all cases, both splenic vessels were separated from the pancreas towards the spleen after transecting the body of the pancreas. RESULTS: The indications for the procedure were: neuroendocrine pancreatic tumors (n = 4), cystic neoplasm of the pancreas (n = 4) and cystic-papillary pancreatic tumors (n = 2). Four patients developed pancreatic fistulas with spontaneous healing and there was no mortality. CONCLUSIONS: Spleen-preserving distal pancreatectomy with splenic vessel conservation can be safely performed and should be indicated in the surgical management of benign pancreatic diseases of the distal pancreas.     

Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein: techniques and its significance

Background

Preservation of the spleen in distal pancreatectomy has recently attracted considerable attention. Since our first trial and success with spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein for tumors of the pancreas and chronic pancreatitis, this procedure (Kimura’s procedure) has been performed very frequently.

Methods

The techniques for spleen-preserving distal pancreatectomy (SpDP) with conservation of the splenic artery and vein are clarified. The splenic vein is identified behind the pancreas and within the thin connective tissue membrane (fusion fascia of Toldt). The connective tissue membrane is cut longitudinally above the splenic vein. It is important to remove the splenic vein from the pancreas by working from the body of the pancreas toward the spleen (median approach), because it is very difficult to remove it in the other direction. The pancreas is removed from the splenic artery by proceeding from the spleen toward the head of the pancreas.

Results

Preservation of the spleen offers various advantages. The maximum platelet levels in blood serum are significantly lower in postoperative patients with splenic preservation than in those with splenectomy. The platelet count was maximal on postoperative day 10 in the 16 patients with SpDP and the count was maximal on postoperative day 13 in the 16 patients with distal pancreatectomy with splenectomy (DPS), and there was a smaller increase in the patients with SpDP than in the patients with DPS. Postoperative bleeding from an ablated splenic artery and vein in SpDP has not been encountered. Either DPS or spleen preservation without preservation of the splenic artery and vein may reduce the blood supply to the residual proximal stomach after distal gastrectomy, which is different from the findings in the Kimura procedure.

Conclusion

In SpDP, a very slight elevation of the platelet count in serum may help to prevent infarction of the lungs and brain compared to DPS. Another advantage of SpDP performed according to our procedure is that the blood supply to the proximal stomach is conserved in patients with SpDP who undergo distal gastrectomy with resection of the left gastric artery. Benign lesions, as well as low-grade malignancy of the body and tail of the pancreas, may be indications for this procedure. Surgeons should know the techniques and significance of SpDP with conservation of the splenic artery and vein, which is a very safe and reliable method.