Prosthetic Graft for Superior Mesenteric-Portal Vein Reconstruction in Pancreaticoduodenectomy: A Retrospective,Multicenter Study

Background

The use of prosthetic grafts for superior mesenteric-portal vein reconstruction (SMPVR) after pancreaticoduodenectomy (PD) with venous resection remains controversial. We evaluated the effectiveness and safety of using polytetrafluoroethylene (PTFE) interposition grafts for SMPVR after PD.

Methods

We identified 76 patients who underwent PD with segmental vein resection for pancreatic head and periampullary neoplasms at three centers between January 2007 and June 2012. The venous reconstruction technique depended on the length of venous involvement. Forty-two and 34 patients underwent SMPVR with primary anastomosis and SMPVR with PTFE interposition grafts, respectively. The postoperative morbidity, mortality, and patency were compared. For the patients with pancreatic ductal adenocarcinoma (n?=?65), survival was compared between the SMPVR with primary anastomosis (n?=?36) and SMPVR with PTFE interposition graft groups (n?=?29).

Results

Patients undergoing SMPVR with PTFE grafts had larger tumor sizes (3.4?±?0.9 cm, 2.9?±?0.9 cm, P?=?0.016), longer operative durations (492.9?±?107.5 min, 408.8?±?78.8 min, P?<?0.001), and greater blood loss (986.8?±?884.5 ml, 616.7?±?485.5 ml, P?=?0.040) compared to those undergoing SMPVR with primary anastomosis. However, 30-day postoperative morbidity and mortality did not differ (29.4 and 2.9 %, respectively, for PTFE grafts and 33.3 and 7.1 %, respectively, for primary anastomosis). There were no cases of graft infection. The estimated cumulative patency of SMPVR 6 and 12 months after surgery did not differ (87.9 and 83.5 % after PTFE grafts, respectively, and 94.4 and 86.4 % after primary anastomosis, respectively). For patients who underwent surgery for pancreatic ductal adenocarcinoma, there were no significant differences in the median survival time (11 vs. 12 months) or the 1-, 2-, and 3-year survival rates (35.7, 12.5, and 4.2 vs. 36.4, 17.3, and 8.7 %, respectively) for the PTFE and primary anastomosis groups.

Conclusions

PTFE grafts could provide a safe and effective option for venous reconstruction after PD in patients with segmental vein resection.     

Use of Cold-Stored Vein Allografts for Venous Reconstruction During Pancreaticoduodenectomy

Introduction

Venous resections and reconstructions of portal vein and/or superior mesenteric vein in course of pancreaticoduodenectomy are becoming a common practice and many surgical options have been described, from simple tangential resection and venorrhaphy to large segmental resections followed by interposition grafting. The aim of this study was to report the first experience of using fresh cadaveric vein allografts for venous reconstruction during pancreaticoduodenectomy focusing on technical feasibility and postoperative outcomes.

Methods

From January 2001 to October 2012, out of 151 patients undergoing pancreaticoduodenectomy for pancreatic head tumor, 22 (14.5 %) received a vascular resection of the mesentericoportal axis. In five of these patients, vascular reconstruction was accomplished by using cold-stored venous allografts of iliac and femoral veins from donor cadaver. Patients’ data, surgical techniques, and clinical outcomes were analyzed.

Results

Five patients undergoing pancreaticoduodenectomy were selected to receive a vascular reconstruction using a fresh venous allograft for patch closure in three cases, conduit interposition in one case and a Y-shaped graft in the last case. No graft thrombosis or stenosis occurred postoperatively and at long-term follow-up. Mortality rate was zero.

Conclusion

The use of fresh vein allografts is a feasible and effective technique for venous reconstruction during pancreaticoduodenectomy. However, prospective surveys including large cohorts of patients are necessary to confirm these results.     

Adverse Tumor Biology Associated with Mesenterico-Portal Vein Resection Influences Survival in Patients with Pancreatic Ductal Adenocarcinoma

Background

Although pancreatoduodenectomy (PD) with mesenterico-portal vein resection (VR) can be performed safely in patients with resectable pancreatic ductal adenocarcinoma (PDAC), the impact of this approach on long-term survival is controversial.

Patients and Methods

Analyses of a prospectively collected database revealed 122 consecutive patients with PDAC who underwent PD with (PD+VR) or without (PD?VR) VR between January 2004 and May 2012. Clinical data, operative results, and survival outcomes were analysed.

Results

Sixty-four (53 %) patients underwent PD+VR. The majority (84 %) of the venous reconstructions were performed with a primary end-to-end anastomosis. Demographic and postoperative outcomes were similar between the two groups. American Society of Anesthesiologists (ASA) score, duration of operation, intraoperative blood loss, and blood transfusion requirement were significantly greater in the PD+VR group compared with the PD?VR group. Furthermore, the tumor size was larger, and the rates of periuncinate neural invasion and positive resection margin were higher in the PD+VR group compared with the PD?VR group. Histological venous involvement occurred in 47 of 62 (76 %) patients in the PD+VR group. At a median follow-up of 29 months, the median overall survival (OS) was 18 months for the PD+VR group, and 31 months for the PD?VR group (p = 0.016). ASA score, lymph node metastasis, neurovascular invasion, and tumor differentiation were predictive of survival. The need for VR in itself was not prognostic of survival.

Conclusions

PD with VR has similar morbidity but worse OS compared with a PD?VR. Although VR is not predictive of survival, tumors requiring a PD+VR have more adverse biological features.     

Indication for the use of an interposed graft during portal vein and/or superior mesenteric vein reconstruction in pancreatic resection based on perioperative outcomes

Purpose

Combined portal vein and/or superior mesenteric vein (PV/SMV) resection with pancreatic resection sometimes leads to prolonged survival for patients with pancreatic cancer. In this study, we evaluated perioperative outcomes of patients with PV/SMV reconstruction and considered indications for the use of a graft during this procedure.

Methods

We performed PV/SMV resection with pancreatic resection in 128 patients, including 14 using grafts. Complications associated with PV/SMV reconstruction and harvesting venous grafts and reconstructed PV/SMV patency during follow-up were assessed.

Results

Of the 128 patients, 5 underwent total pancreatectomy, 99 pancreaticoduodenectomy, and 24 distal pancreatectomy. In the 14 patients who underwent PV/SMV reconstruction with grafts, the grafts were harvested from the external iliac vein (EIV) in 10 patients and internal jugular vein (IJV) in the other 4. Five patients (3.9 %) had an intraoperative or postoperative acute thrombus or stenosis of reconstructed PV/SMV after direct end-to-end anastomosis. However, PV/SMV patency was excellent after reconstruction using grafts. There were no significant differences in other complications between groups with and without the use of grafts. Three patients (30 %) with EIV grafts had postoperative leg edema, and one of them required analgesics until his death because of leg pain caused by compartment syndrome, whereas no patients with IJV grafts had complications associated with sacrificing veins.

Conclusions

Depending on the length and/or position of the removed PV/SMV segment, interposed graft may be required for reconstruction in some patients, and the use of graft vein, particularly using IJV, is an appropriate procedure that is not associated with any complications.     

Significance of Portal Vein Invasion and Extent of Invasion in Patients Undergoing Pancreatoduodenectomy for Pancreatic Adenocarcinoma

Introduction

Several studies have confirmed the safety of pancreatoduodenectomy with portal/mesenteric vein resection and reconstruction in select patients. The effect of vein invasion and extent of invasion on survival is less clear. The purpose of this study was to examine the association between tumor invasion of the portal/mesenteric vein and long-term survival.

Methods

A retrospective review of a prospectively maintained database of patients who underwent pancreatoduodenectomy for pancreatic adenocarcinoma at a single academic medical center (2000–2014) was performed. Survival was compared using the Kaplan–Meier method and log-rank test. P?<?0.05 was considered statistically significant.

Results

After non-pancreatic periampullary adenocarcinomas and patients with non-segmental (lateral wall only) resection of portal/mesenteric vein were excluded, there were 567 eligible patients. Of these, segmental vein resection was performed in 90 (16 %) with end-to-end primary anastomosis (67) or interposition graft reconstruction (23). Patients with vein resection more likely received neoadjuvant systemic therapy (59 vs. 4 %, p?<?0.0001). Histopathology of patients undergoing vein resection revealed a distribution of T stage toward larger tumors and higher rates of perineural invasion. Portal/mesenteric vein resection, however, was not associated with differences in hospital stay, postoperative complications, or operative mortality. Patients with or without vein resection had comparable overall survival rates at 1-, 3-, and 5-years. On final surgical histopathology, only 52 of 90 (58 %) vein resections had adenocarcinoma involvement of the venous wall. Of these, depth of invasion was at the level of the adventitia (9), media/intima (34), and full thickness/intraluminal (9). Venous wall invasion (52) did not significantly influence overall survival (14 vs. 21 months, p?=?0.08) but was associated with significantly shorter median disease-free survival (11.3 vs. 15.8 months, p?=?0.03), predominantly due to local recurrence. The extent of invasion (adventitia, media/intima, full thickness/intraluminal) did not impact overall survival or disease-free survival (14.4 vs. 15.5 vs. 7.4 months, p?=?0.08 and 11.2 vs. 12.2 vs. 5 months, 0.59, respectively). Portal/mesenteric vein resection, histopathologic invasion, or the extent of invasion were not independent predictors of overall survival in Cox regression analysis.

Conclusion

Although Portal/mesenteric vein resection is associated with increased 90-day mortality, venous resection is not prognostic of overall survival. Although a subgroup analysis showed that a direct tumor invasion into the vein wall on final histopathology was associated with a higher rate of local recurrence but with no difference in overall survival (even when stratified according to extent of venous wall invasion), larger studies with an increased power will be needed to confirm these findings.

     

Positive clinical outcomes of the saphenous vein interposition technique for ruptured popliteal artery aneurysm

Purpose

Popliteal artery aneurysms (PAAs) can be treated successfully by surgical and endovascular methods; however, the best treatment strategy for a ruptured PAA has yet to be established. We assessed the clinical results of using saphenous vein interposition to treat ruptured PAAs in our hospital.

Methods

The subjects of this study were seven men (average age 59 years, range 43–71 years), who underwent emergency surgery for a ruptured PAA at our hospital between January 2007 and November 2012. The patients were assessed after 1, 6, and 12 months, postoperatively.

Results

All included patients underwent saphenous vein graft interposition via a medial approach. No complications or graft thromboses were encountered in the immediate postoperative period. The patients were discharged after an average of 4 days postoperatively (range 3–5 days). The patients were followed up for an average of 32 months (range 2–60 months). The medium-term graft patency was 100 %. No patients suffered early or medium-term limb loss and there was no mortality.

Conclusion

Based on our positive results, saphenous vein graft interposition should be considered as the first choice of surgical treatment for a ruptured PAA.     

Outcome of superior mesenteric-portal vein resection during pancreatectomy for borderline ductal adenocarcinoma: results of a prospective comparative study

Background

Approximately 20 % of patients affected by pancreatic ductal adenocarcinoma are amenable to surgical resection. Several tumours are reported as “borderline resectable” because of their proximity to the major vessels. In the effort to achieve a radical tumour removal, vein resection has been proposed, but its oncological benefits remain debated.

Methods

Our aim is to investigate morbidity, mortality and survival after pancreatectomy with vein resection.

Results

Forty patients underwent pancreatectomy and vein resection (group A), and 20 patients (group B) underwent bilio-enteric and/or gastro-entero bypass. In group A, cancer vein invasion was microscopically proven in 14 cases (35 %). Vein infiltration, tumour differentiation and node-positive disease were not adverse prognostic variables. No difference in survival was seen over a 1-year follow-up. After this period, group A showed significant survival benefits with a longer stabilisation of the disease (p?=?0.005). Tumour-free resection margins and adjuvant chemoradiotherapy were the most important prognostic factors (p?<?0.05).

Conclusions

Suspicion of vein infiltration should not be a contraindication to resection. Pancreatectomy can be safely performed with an acceptable morbidity and better survival trend.     

Isoperistaltic left colic graft interposition via a retrosternal approach for esophageal reconstruction in patients with a caustic stricture: mortality,morbidity, and functional results

Purpose

To report our results of treating esophageal caustic stricture with an isoperistaltic left colic graft interposed via a retrosternal route.

Methods

We reviewed 70 patients who underwent substernal left colon interposition, performed retrosternally, for an esophageal caustic stricture, between January, 1999 and December, 2011.

Results

The median operative time in this series was 3 h. A pharyngoplasty was performed in 10 patients (14.28 %), the thoracic inlet was found to be enlarged in 33 patients (47.1 %), and posterior cologastric anastomosis was performed in 58 patients (82.8 %). Two patients (2.8 %) died. Minor and major postoperative complications developed in 28 patients (40 %), including graft ischemia in 2 (2.8 %) and cervical anastomotic leakage in 14 (20 %). Five patients (7.14 %) developed a cervical anastomotic stricture. The functional results were satisfactory.

Conclusion

Retrosternal isoperistaltic left colic transplant interposition is an excellent long-term replacement for an esophageal caustic stricture. If performed by experienced surgeons, this procedure is effective for esophageal reconstruction.     

One-step reconstruction of the right inferior hepatic veins using auto-venous grafts in living donor liver transplantation

Purposes

Reconstruction of the right inferior hepatic vein (RIHV) presents a major technical challenge in living donor liver transplantation (LDLT) using right lobe grafts.

Methods

We studied 47 right lobe LDLT grafts with RIHV revascularization, comparing one-step reconstruction, performed post-May 2007 (n = 16), with direct anastomosis, performed pre-May 2007 (n = 31).

Results

In the one-step reconstruction technique, the internal jugular vein (n = 6), explanted portal vein (n = 5), inferior vena cava (n = 3), and shunt vessels (n = 2) were used as venous patch grafts for unifying the right hepatic vein, RIHVs, and middle hepatic vein tributaries. By 6 months after LDLT, there was no case of occlusion of the reconstructed RIHVs in the one-step reconstruction group, but a cumulative occlusion rate of 18.2 % in the direct anastomosis group. One-step reconstruction required a longer cold ischemic time (182 ± 40 vs. 115 ± 63, p < 0.001) and these patients had higher alanine transaminase values (142 ± 79 vs. 96 ± 46 IU/L, p = 0.024) on postoperative day POD 7. However, the 6-month short-term graft survival rates were 100 % with one-step reconstruction and 83.9 % with direct anastomosis, respectively.

Conclusion

One-step reconstruction of the RIHVs using auto-venous grafts is an easy and feasible technique promoting successful right lobe LDLT.     

Short-Term but Not Long-Term Loss of Patency of Venous Reconstruction During Pancreatic Resection Is Associated with Decreased Survival

Background

Pancreatic surgery with vascular reconstruction is increasingly performed to offer the benefits of surgical resection to patients with locally advanced disease. The short- and long-term patency rates and the clinical significance of thrombosis of such reconstructions are unknown.

Methods

We reviewed pancreatectomies requiring venous reconstruction from 1994 to 2011. We sought to identify predictors of acute (within 30 days) and late thrombosis. We compared survival of patients with thrombosis to patients with patent reconstructions.

Results

Of 203 pancreatectomies requiring venous reconstruction, acute thrombosis occurred in nine (4.4 %) cases and was associated with increased perioperative mortality (22.2 versus 4.6 %, p?=?0.023). Even when nonfatal, acute thrombosis was associated with decreased median survival (7.1 versus 15.9 months, p?=?0.011) and increased hazard of death (hazard ratio 8.6, confidence interval 3.7–19.9, p?<?0.001). A late loss of patency was seen in 31.2 % of cases at a median of 9.5 months. Later loss of patency was not associated with decreased median survival or increased hazard of death.

Conclusions

Acute thrombosis of the portal venous reconstructions after pancreatectomy is associated with increased perioperative mortality and, even when nonfatal, is associated with decreased survival. Late loss of patency occurs in one-third of patients but does not affect survival.     

Splenic artery use for arterial reconstruction in pancreatic surgery

Background

Extended resections in the upper GI tract, especially for pancreatic malignancies, can require resection of the hepatic or superior mesenteric artery. Besides venous or allogenous grafting, the splenic artery can be used for reconstruction in both positions.

Purpose

We hereby describe the different technical possibilities of interposition or transposition to use the splenic artery for restoration of arterial perfusion of the liver or the small bowel following resection of the hepatic or superior mesenteric artery, respectively.

Conclusion

The use of the splenic artery is a convenient and appropriate possibility to reconstruct the hepatic or superior mesenteric artery in pancreatic resection with regard to interposition and especially transposition of this vessel. It should be considered in patients suitable to undergo these procedures to extend resectability in pancreatic cancer surgery.     

Role of Major Vascular Resection in Patients with Intrahepatic Cholangiocarcinoma

Background

Historically, direct vascular extension of intrahepatic cholangiocarcinoma (ICC) has often been considered a contraindication to resection. However, recent studies have suggested safety and efficacy of hepatectomy with major vascular resection in this patient population. The aim of this study was to investigate the short and long-term clinical outcomes of patients with ICC treated with hepatectomy with or without major vascular resection.

Methods

This retrospective cohort study included all patients with ICC who underwent major liver resection between 1997 and 2011. Clinical outcomes were compared between patients treated with major hepatectomy and vascular resection (VR) and those without vascular resection (NVR). Kaplan–Meier survival estimates were used to compare overall survival (OS) between patients in VR and NVR groups.

Results

A total of 121 patients (median age 60; 42 % male) underwent major hepatectomy for ICC. Major vascular resection was performed in 14 (12 %) patients (IVC = 9, PV = 5). Age, sex, American Society of Anesthesiology (ASA) class, tumor size, lymph node status, and CA-19 9 were comparable (all p ≥ 0.184) between VR and NVR groups. Major postoperative complications (Dindo-Clavien ≥3) occurred in four (29 %) patients in the VR group and 17 (16 %) in the NVR group (p = 0.263). Postoperative death occurred in one patient in the VR group due to liver failure. Median OS did not differ between patients treated with and without vascular resection (32 vs. 49 months, respectively, p = 0.268).

Conclusions

Hepatectomy combined with IVC or PV resection can be safely performed in patients with ICC. Major vascular resection does not affect short and long-term outcomes in this patient population.     

Surgical Outcomes in Hepatocellular Carcinoma Patients with Portal Vein Tumor Thrombosis

Background

Different approaches to surgical treatment of portal vein tumor thrombosis (PVTT) have been advocated. This study investigated the outcomes of different surgical approaches in hepatocellular carcinoma (HCC) patients with PVTT.

Methods

We reviewed prospectively collected data for all patients who underwent hepatectomy for HCC at our hospital between December 1989 and December 2010. Patients were excluded from analysis if they had extrahepatic disease, PVTT reaching the level of the superior mesenteric vein, or hepatectomy with a positive resection margin. The remaining patients were divided into three groups for comparison: group 1, with ipsilateral PVTT resected in a hepatectomy; group 2, with PVTT extending to or beyond the portal vein bifurcation, treated by en bloc resection followed by portal vein reconstruction; group 3, with PVTT extending to or beyond the portal vein bifurcation, treated by thrombectomy.

Results

A total of 88 patients, with a median age of 54 years, were included in the analysis. Group 2 patients were younger, with a median age of 43.5 years versus 57 in group 1 and 49 in group 3 (p = 0.017). Group 1 patients had higher preoperative serum alpha-fetoprotein levels, with a median of 8,493 ng/mL versus 63.25 in group 2 and 355 in group 3 (p = 0.004), and shorter operation time, with a median of 467.5 min versus 663.5 in group 2 and 753 in group 3 (p = 0.018). No patient had thrombus in the main portal vein. Two (2.8 %) hospital deaths occurred in group 1 and one (10 %) in group 2, but none in group 3 (p = 0.440). The rates of complication in groups 1, 2, and 3 were 31.9, 50.0, and 71.4 %, respectively (p = 0.079). The median overall survival durations were 10.91, 9.4, and 8.58 months, respectively (p = 0.962), and the median disease-free survival durations were 4.21, 3.78, and 1.51 months, respectively (p = 0.363). The groups also had similar patterns of disease recurrence (intrahepatic: 33.8 vs. 28.6 vs. 40.0 %; extrahepatic: 16.9 vs. 14.3 vs. 0 %; both: 28.2 vs. 42.9 vs. 40.0 %; no recurrence: 21.1 vs. 14.3 vs. 20.0 %; p = 0.836).

Conclusions

The three approaches have similar outcomes in terms of survival, complication, and recurrence. Effective adjuvant treatments need to be developed to counteract the high incidence of recurrence.     

Feasibility of esophageal reconstruction using a pedicled jejunum with intrathoracic esophagojejunostomy in the upper mediastinum for esophageal cancer

Objective

An alternative conduit is needed when the gastric tube cannot be used as an esophageal substitute for reconstruction after esophagectomy. We adopted pedicle jejunal reconstruction with intrathoracic anastomosis in the upper mediastinum under such circumstances. The aim of this study was to evaluate the feasibility of this technique.

Methods

Two hundred and ten patients with esophageal cancer underwent esophagectomy and reconstruction from 1998 to 2013. Among them, 6 patients underwent colon interposition (colon group) and 13 underwent jejunum reconstruction (jejunum group) including 8 thoracoscopic anastomosis. The operative results of both groups were compared with those of 191 gastric tube reconstructions (stomach group).

Results

The operative times in the colon and jejunum groups were significantly longer than that in the stomach group (P = 0.001 and P = 0.018, respectively). The colon group showed more operative blood loss and more frequent anastomotic leakage and ischemic stenosis of the conduit than did the stomach group (1605 vs. 530 g, P = 0.007; 50 vs. 12.6 %, P = 0.035; 16.7 vs. 0 %, P = 0.03, respectively). There was no anastomotic leakage, conduit necrosis and mortality in the jejunum group. Ischemic stenosis of the conduit occurred more frequently in jejunum group than in the stomach group (23.1 vs. 0 %, P < 0.001). However, the stenosis could be managed safely with endoscopic treatment. Patient survival in the colon and jejunum groups was consistent with that in the stomach group.

Conclusions

Pedicle jejunal reconstruction with intrathoracic anastomosis can be performed safely under thoracotomy or thoracoscopic surgery when stomach cannot be used as an esophageal substitute after esophagectomy.     

Revisiting vascular patency after spleen-preserving laparoscopic distal pancreatectomy with conservation of splenic vessels

Background

We evaluated vascular patency and potential changes in preserved spleens after laparoscopic spleen-preserving distal pancreatectomy (SPDP) with conservation of both splenic vessels.

Methods

We retrospectively analyzed the patency of conserved splenic vessels in patients who underwent laparoscopic or robotic splenic vessel-conserving SPDP from January 2006 to August 2010. The patency of the conserved splenic vessels was evaluated by abdominal computed tomography and classified into three grades according to the degree of severity.

Results

Among 30 patients with splenic vessel-conserving laparoscopic SPDP, 29 patients with complete follow-up data were included in this study. During the follow-up period (median: 13.2?months), grades 1 and 2 splenic arterial obliteration were observed in one patient each. A total of five patients (17.2%) showed grade 1 or 2 obliteration in conserved splenic veins. Most patients (82.8%) had patent conserved splenic vein. Four patients (13.8%) eventually developed collateral venous vessels around gastric fundus and reserved spleen, but no spleen infarction was found, and none presented clinical relevant symptoms, such as variceal bleeding. There was no statistical difference in vascular patency between the laparoscopic and robotic groups (P?>?0.05).

Conclusions

Most patients showed intact vascular patency in conserved splenic vessels and no secondary changes in the preserved spleen after laparoscopic splenic vessel-conserving SPDP.     

Neoadjuvant Therapy and Vascular Resection During Pancreaticoduodenectomy: Shifting the Survival Curve for Patients with Locally Advanced Pancreatic Cancer

Background

Neoadjuvant therapy and vascular resection may offer patients with locally advanced pancreatic cancer potential cure.

Methods

We reviewed medical records of patients with ductal adenocarcinoma who underwent pancreaticoduodenectomy (PD) from 1992 through 2011. We identified patients who received neoadjuvant therapy (NA+) or required vascular resection (VR+) for locally advanced disease and compared outcomes to those who did not.

Results

Of the 643 patients who were initially explored, 506 (143 NA+ and 363 NA? patients) ultimately underwent PD. There were no significant differences in R0 resection or morbidity. Mortality was higher in the NA+ versus NA? group (7.0 vs 3.0 %, p = 0.04). More NA+ patients underwent PD VR+ (p < 0.001). Among VR+ patients, neoadjuvant therapy resulted in significantly lower R1 resection. Among resected patients, survival of NA+ patients was significantly longer than both NA? patients (27.3 vs 19.7 months, p < 0.05) and patients abandoned because of locally advanced disease. Age, tumor grade, lymph node ratio, and R1 resection were independent predictors of poor survival.

Conclusions

Neoadjuvant therapy and vascular resection offer patients with locally advanced pancreatic cancer the chance for cure with acceptable morbidity and mortality. These patients have improved survival over patients deemed locally inoperable by traditional criteria.     

Anastomotic leakage after low anterior resection for rectal cancer: comparison of stapled versus compression anastomosis

Purpose

Surgical technique and perioperative management in rectal cancer surgery have been substantially improved and standardized during the last decades. However, anastomotic leakage following low anterior resection still is a significant problem. Based on animal experimental data of improved healing of compression anastomosis, we hypothesized that a compression anastomotic device might improve healing rates of the highest-risk anastomoses.

Methods

All low anterior resections for rectal cancer performed or directly supervised by the senior author between January 2004 and June 2012 were analyzed. Only patients with a stapled or compression anastomosis located within 6 cm from the anal verge were included. Until December 2008, circular staplers were employed, while since January 2009, a novel compression anastomotic device was used for rectal reconstruction exclusively.

Results

Out of 197 patients operated for rectal cancer, a total of 96 (34 females, 35.4 %) fulfilled inclusion criteria. Fifty-eight (60.4 %) were reconstructed with circular staplers and 38 (39.6 %) using a compression anastomotic device. Significantly, more laparoscopic procedures were recorded in the compression anastomosis group, but distribution of gender, age, body mass index, American Society of Anaesthesiologists score, rate of preoperative radiotherapy, tumor staging, or stoma diversion rate were similar. Anastomotic leakage was observed in seven cases (7/58, 12.1 %) in the stapled and twice (2/38, 5.3 %) in the compression anastomosis group (p?=?0.26).

Conclusions

In this series, rectal reconstruction following low anterior resection using a novel compression anastomotic device was safe and (at least) equally effective compared to traditional circular staplers concerning leak rate.     

Portal Vein Thrombosis After Hepatectomy

Background

Although various complications after hepatectomy have been reported, there have been no large studies on postoperative portal vein thrombosis (PVT) as a complication. This study evaluated the incidence, risk factors, and clinical outcomes of PVT after hepatectomy.

Methods

The preoperative and postoperative clinical characteristics of patients who underwent hepatectomy were retrospectively analyzed.

Results

A total of 208 patients were reviewed. The incidence of PVT after hepatectomy was 9.1 % (n = 19), including main portal vein (MPV) thrombosis (n = 7) and peripheral portal vein (PPV) thrombosis (n = 12). Patients with MPV thrombosis had a significantly higher incidence of right hepatectomy (p < 0.001), larger resection volume (p = 0.003), and longer operation time (p = 0.021) than patients without PVT (n = 189). Multivariate analysis identified right hepatectomy as a significant independent risk factor for MPV thrombosis (odds ratio 108.9; p < 0.001). Patients with PPV thrombosis had a significantly longer duration of Pringle maneuver than patients without PVT (p = 0.002). Among patients who underwent right hepatectomy, those with PVT (n = 6) had a significantly lower early liver regeneration rate than those without PVT (n = 13; p = 0.040), and those with PVT had deterioration of liver function on postoperative day 7. In all patients with MPV thrombosis who received anticoagulation therapy, PVT subsequently resolved.

Conclusions

Postoperative PVT after hepatectomy is not rare. It is closely related to delayed recovery of liver function and delayed liver regeneration.     

One-Stage Hepatectomy Following Portal Vein Embolization for Colorectal Liver Metastasis

Background

Although portal vein embolization (PVE) has been applied for surgical resection of colorectal liver metastases (CLM), the clinical usefulness of liver surgery following PVE for CLM remains unknown.

Methods

A total of 115 patients were evaluated retrospectively. Among them, 49 underwent one-stage hepatectomy following PVE (PVE group). The remaining 66 patients underwent at least hemihepatectomy without PVE (non-PVE group). This analysis compared the short- and long-term outcomes between the PVE and non-PVE groups.

Results

There were no deaths in either group. Using the Clavien–Dindo classification, the rates of postoperative morbidity ≥ grade 1 were 34.7 % in the PVE group and 25.0 % in the non-PVE group (p = 0.26). The 3-year overall survival rates were 54.6 and 64.5 % in the PVE and non-PVE groups, respectively (p = 0.89). The multivariate analysis the variable performance/nonperformance of PVE was not detected as an independent predictor of poor survival.

Conclusions

Our one-stage hepatectomy policy of using PVE provides acceptable morbidity and favorable long-term outcomes.     

Unilateral inline replacement of infected aortofemoral graft limb with femoral vein

Objective

Aortic graft infection remains a formidable challenge for the vascular surgeon. Traditionally, reconstruction with a neoaortoiliac system (NAIS) involves removal of the entire synthetic graft with in situ reconstruction using femoral vein. Whereas the NAIS procedure is durable with excellent graft patency and a low reinfection rate, it can take up to 10 hours and result in a high perioperative complication rate with significant mortality. Not infrequently, the infection is limited to a single limb. In addition, the patient may be too frail to tolerate aortic clamping for a complete graft excision. Under such circumstances, complete excision of the aortofemoral bypass graft (AFBG) may not be indicated. It is hypothesized that local control of infection and limited reconstruction using femoral vein may be acceptable. The objective of this study was to examine the outcomes of all patients who underwent partial AFBG resection and in situ reconstruction with femoral vein.