Pancreatic cancer is associated with a poor prognosis, and surgical resection remains the only chance for curative therapy. In the absence of metastatic disease, which would preclude resection, assessment of vascular invasion is an important parameter for determining resectability of pancreatic cancer. A frequent error is to misdiagnose an involved major vessel. Obviously, surgical exploration with pathological examination remains the "gold standard" in terms of evaluation of resectability, especially from the point of view of vascular involvement. However, current imaging modalities have improved and allow detection of vascular invasion with more accuracy. A venous resection in pancreatic cancer is a feasible technique and relatively reliable. Nevertheless, a survival benefit is not achieved by curative resection in patients with pancreatic cancer and vascular invasion. Although the discovery of an arterial invasion during the operation might require an aggressive management, discovery before the operation should be considered as a contraindication. Detection of vascular invasion remains one of the most important challenges in pancreatic surgery. The aim of this article is to provide a complete review of the different imaging modalities in the detection of vascular invasion in pancreatic cancer.

Vascular invasion in pancreatic cancer: Imaging modalities, preoperative diagnosis and surgical management.

An Innovative Option for Venous Reconstruction After Pancreaticoduodenectomy: the Left Renal Vein

Advanced abdominal malignancies are occasionally invasive for the major blood vessels, such as the portal vein (PV), inferior vena cava (IVC), and major hepatic veins (HVs), and complete removal of the tumors is required for patients undergoing vascular resection and reconstruction. We used left renal vein (LRV) grafts for vascular reconstruction in patients with these malignancies and evaluated their clinical relevance. A total of 113 patients underwent vascular resection including the PV (42 patients), IVC (68 patients), and HV (3 patients) for hepatobiliary-pancreatic or abdominal tumor resection. Of these, 11 patients underwent vascular reconstruction with a LRV graft of the PV, superior mesenteric vein (SMV), and HVs in 3 patients each, and the IVC in 2 patients. The HVs were resected with segmentectomy involving Couinaud’s segments VII, VIII, and IV; VII, VIII, and II; or III, IV, VIII in each patient. The PV and SMV were resected in 5 patients undergoing pancreaticoduodenectomy for pancreatic carcinoma, and in 1 patient being treated with extended right hepatectomy and pancreaticoduodenectomy for hepatic hilar carcinoma. The IVC was partially resected in 1 patient with advanced colon cancer and 1 with malignant schwannoma. The mean graft length of LRV obtained was 3.6 (3.5–4.0) cm. The graft was used as a tube in 9 patients, and as a patch in 2 patients. The mean duration of clamping time was 41.9 (35–60) min. Portal vein thrombosis was encountered in 2 patients, and anastomotic stenosis in 1 patient. Other morbidity was not related to vascular reconstruction. One patient who underwent extended right hepatectomy and pancreaticoduodenectomy died of liver failure in the hospital. The serum creatinine level after surgery did not deteriorate except in the one patient who died in the hospital. Graft patency was maintained during the follow-up period in all patients. A LRV graft may enhance the possibility of vascular reconstruction without deteriorating serum creatinine level, and it provides sound graft patency.

Left renal vein graft for vascular reconstruction in abdominal malignancy.

Although injury of the hepatic artery is not common during the performance of biliary and pancreatic resections, the hepatic artery if involved by tumor extension can be injured during its dissection.Several methods for reconstruction of the hepatic artery have been described and although each technique is applicable in a specific situation, autologous tissue conduits are preferable in contaminated operative fields. We report here another transposition technique to reconstruct the proper hepatic artery using the gastroduodenal artery, which may provide a local autologous artery for repair of hepatic artery damage during pancreaticoduodenectomy.

Reconstruction of the hepatic artery using the gastroduodenal artery.

d h c r s urgical resection for hilar cholangiocarcinoma (HCCA) emains a challenge for surgeons aiming to maximize paients’ chances for longterm survival. Since 1984, it has een accepted that standard bile duct resection should be ombined with an additional major hepatic resection to btain improved oncological clearance and increase quanity and quality of survival. This aggressive approach was nitially criticized, but today a consensus exists that perorming such extended resections is the treatment of choice or HCCA.There is strong evidence of better survival when 0 resection is performed. The extended resections that nable a better oncological clearance have become achievble as a result of the major advances in surgical techniques nd preoperative and postoperative care, which have reuced morbidity and mortality after major liver resection. Recent studies suggest that portal vein resection with econstruction can increase the chance for cure in some atients with advanced HCCA who were previously hought to have inoperable disease. Because perineual invasion correlates with poorer outcomes, theoretically, esection of the hepatic artery with its nerve sheath will uarantee an even better oncological result. Arterial resecion and reconstruction can be technically problematic and ometimes unachievable, with very few cases reported in he literature. To overcome this, a recent study rom Japan by Kondo and colleagues has reported 10 cases f portal vein arterialization (PVA) after hepatic artery reection for biliary cancers, with some accompanied by mall hepatic resections. We report a case where PVA was used with good result as salvage technique during left hepatic trisectionectomy nd a second case where the same technique was used to

https://www.journalacs.org/article/S1072-7515(08)01206-4/pdf

Portal vein arterialization as a salvage procedure during left hepatic trisectionectomy for hilar cholangiocarcinoma.

BACKGROUND/AIMS Resection of hepatic arteries is often obligatory on resecting pancreatic, gastric and hepatobiliary malignancies. Hepatic artery reconstruction is required to preserve liver function and blood flow to the bile duct. We applied the gonadal vein to hepatic artery reconstruction. METHODOLOGY Hepatic artery reconstruction using a gonadal vein graft was performed in two patients: one with gallbladder cancer and the other with recurrent gastric cancer. RESULTS The right ovarian vein, 2 mm in diameter and 4 cm in length, was grafted for reconstruction between the proper hepatic and the posterior hepatic artery in one patient who underwent modified central hepatic bisegmetectomy and common bile duct resection. The left spermatic vein, 3 mm in diameter and 6 cm in length, was grafted for reconstruction between the celiac artery and the right hepatic artery in the other, who underwent upper abdominal exenteration. The former graft was occluded due to tumor invasion at 4 months after surgery, the latter one was patent at 8 weeks after surgery. CONCLUSIONS The gonadal vein had an ideal diameter and sufficient length to accomplish hepatic arterial reconstruction. The gonadal vein graft will be a new and preferable addition to the selection of an optimal graft for hepatic arterial reconstruction.

Gonadal vein graft for hepatic artery reconstruction.

Background/aims To preserve remnant liver function, extended left hepatectomy combined with middle hepatic vein reconstruction using a left renal vein graft was performed in resection of liver metastasis from sigmoid colon cancer, involving the confluence of the middle and left hepatic veins. Methodology The tumor, 5 cm in size, occupied the superior part of segment 4, and involved the confluence of the middle and the left hepatic veins. An extended left hepatectomy, including the left lobe, left caudate lobe and part of segment 8, together with the middle hepatic vein trunk, was performed. The left renal vein was resected as a graft from the confluence of the inferior vena cava just distal to the branches of the gonadal vein, renal-azygos, splenorenal communications and vertebral veins. The middle hepatic vein was reconstructed using the left renal vein 3 cm in length. Results Impaired values of liver function tests were normalized by the third postoperative day. Renal function was good throughout the postoperative period. The patient was discharged two weeks after the surgery. The reconstructed middle hepatic vein was patent, which was evaluated by a color Doppler ultrasonography, computed tomography and magnetic resonance imaging 60 days after the surgery. The patient remained well in the eight months thereafter. Conclusions Hepatic vein reconstruction using a left renal vein graft is a new and preferable addition for the selection of an optimal graft.

Hepatic vein reconstruction at inferior vena cava confluence using left renal vein graft.

Renal cell carcinoma (RCC) is often associated with an extension of tumor thrombi into the inferior vena cava (IVC) and occasionally up to the right atrium. RCC with IVC involvement has a relatively favorable prognosis when it is completely resected. We present a successfully resected case of RCC with tumor thrombi extending into the right atrium. We performed radical right nephrectomy with lymph node dissection and removed the tumor thrombi en bloc under total hepatic vascular exclusion with the veno-venous bypass between the IVC and the right atrium using an active centrifugal force pump. The patient has been in good condition for 3 years since surgery with no evidence of recurrence.

Successful resection of renal cell carcinoma with tumor thrombi extending into the right atrium: a case report.

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Papers

Gonadal vein graft for hepatic artery reconstruction.

Hepatic vein reconstruction at inferior vena cava confluence using left renal vein graft.

Successful resection of renal cell carcinoma with tumor thrombi extending into the right atrium: a case report.