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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_775_Библиотеки_им_академика_М_И_Перельмана.pdf
Isolated Pancreatoduodenectomy
withPortal Vein Resection Using
theNakao Mesenteric Approach
AkimasaNakao
39
Abstract
The ideal surgical approach for pancreatic head cancer is
isolated pancreatoduodenectomy (PD); that is, en bloc
resection using non-touch isolation technique. However,
this approach is difcult because of the complex peripancreatic vascular anatomy. In 1981, we developed an antithrombogenic bypass catheter for the portal vein (PV) to
prevent portal congestion or hepatic ischemia during PV
resection and facilitate simultaneous resection of the
hepatic artery. In 1992, we developed a mesenteric
approach for PD.The mesenteric approach allows dissection from the non-cancer inltrating side and determination of cancer-free surgical margins and resectability,
followed by systematic lymphadenectomy around the
superior mesenteric artery. This approach enables early
ligation of the inferior pancreatoduodenal artery and excision of the second portion of pancreatic head nerve plexus.
Through this development of the mesenteric approach
and antithrombogenic catheter-bypass procedure of the
PV, establishment of isolated PD was completed in 1992.
This is the ideal surgery for pancreatic head cancer from
both surgical and oncological viewpoints. The precise
surgical techniques of isolated PD, using the Nakao mesenteric approach are herein introduced.
39.1 Introduction
The ideal surgical approach for cancer in the head of the pancreas is isolated pancreatoduodenectomy (PD); that is, enbloc resecstion using a non-touch isolation technique.
However, this approach is difcult because of the complex
A. Nakao (*)
Professor Emeritus, Nagoya University, Nagoya, Japan
Nagoya Central Hospital, Nagoya, Japan
Department of surgery, Nagoya Central Hospital, Nagoya, Japan
e-mail: akimasa.nakao@jr-central.co.jp
peripancreatic vascular anatomy. PD combined with portal
vein (PV) resection is sometimes necessary to complete
curative surgery for cancer in the head of the pancreas.
In 1981, we developed an antithrombogenic bypass catheter for the PV to prevent portal congestion during resection
and reconstruction [1–5]. This was accomplished by bypassing portal blood through a branch of the superior mesenteric
vein (SMV), either to the femoral vein or the intrahepatic PV
through the umbilical vein in the hepatic round ligament,
preventing both portal congestion and hepatic ischemia during simultaneous resection and reconstruction of the PV and
hepatic artery. This method circumvented the time constraints on portal occlusion during surgery. We have since
successfully resected pancreatic cancer with portal invasion
using PV catheter bypass [6–9].
Typically, the rst step in PD is Kocher’s maneuver [10].
When we rst performed PD combined with PV resection in
the 1980s, Kocher’s maneuver was routinely used as the rst
step in PD.However, pancreatic cancer with PV obstruction
and well-developed collateral veins is sometimes observed
when resecting such cancer using Kocher’s maneuver, and
massive bleeding was observed, even when PV catheter
bypass was applied. We noticed that the rst step in PD is
clearance of the mesenteric root instead of Kocher’s maneuver. Thus, we named this procedure the “mesenteric
approach” and non-touch isolation PD isolated PD [11–20].
In cancer surgery, the term “isolated” refers to en-bloc
resection using a non-touch isolation technique. In PD, all
arteries that supply the pancreatic head and all drainage veins
in this region are ligated and divided before manipulation of
cancer in the pancreatic head.
The rst step we take when performing PD is the mesenteric approach; we do not perform Kocher’s maneuver. The
mesenteric approach involves clearing the connective tissues
around the SMV and superior mesenteric artery (SMA) in
the mesenteric root, which includes systematic lymphadenectomy around the SMA [21]. Resection starts from the
non-cancerous side and cancer-free surgical margin, and
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Makuuchi et al. (eds.), The IASGO Textbook of Multi-Disciplinary Management of Hepato-Pancreato-Biliary Diseases,
https://doi.org/10.1007/978-981-19-0063-1_39
307
308
resectability can be diagnosed at the beginning of surgery.
The inferior pancreatoduodenal artery (IPDA), which arises
from the SMA, is rst ligated and divided; thus, it is an
artery-rst operation. This approach makes it possible to perform total excision of the mesopancreas [22]; in other words,
the second portion of the pancreatic head nerve plexus (PLph
II) is completely excised, which is the so-called SMA margin
[23]. This is the most important technique with which to
obtain a cancer-free surgical margin in PD for cancer in the
pancreatic head. The mesenteric approach also makes it easy
to reconstruct the PV using an end-to-end anastomosis after
PV resection.
The development of PV catheter bypass and the mesenteric approach have made it possible to easily and safely perform isolated PD with PV resection.
39.2 Surgical Techniques Used
intheNakao Mesenteric Approach
39.2.1 Laparotomy
Laparotomy is performed with an upper midline skin incision. The abdominal cavity is examined by washing cytology
and ultrasound.
39.2.2 Supramesocolic Approach
A. Nakao
Fig. 39.1 Mesenteric incision from the Treitz ligament to the lower
border of the second portion of the duodenum
39.3 Mesenteric Incision
The rst step in isolated PD is the mesenteric approach, and
the rst step of the mesenteric approach is incision of the
mesentery from the ligament of Treitz to the lower border of
the second portion of the duodenum using electrocautery
(Fig.39.1). The surface of the mesentery is incised until the
anterior walls of the SMV and SMA are exposed. With this
approach, Kocher’s maneuver is not performed.
The supramesocolic approach is usually indicated for cancer
of the distal bile duct or the duodenal papilla of Vater. After
laparotomy via an upper midline skin incision, the gastrocolic ligament is divided and the lesser peritoneal cavity is
opened. The middle colic artery (MCA) and middle colic
vein (MCV) are visible on the anterior surface of the mesocolon. The SMV and SMA are exposed along the roots of the
MCV and MCA.The SMV and SMA are then taped. The
connective tissues, including the lymph nodes along the
SMA, are dissected. The rst jejunal artery (JA1) and the
IPDA are exposed in this procedure. Preoperative multidetector computed tomography is very important to detect the
location of the IPDA.Total mesopancreas excision is usually
unnecessary for cancer of the distal bile duct or papilla of
Vater. The supramesocolic mesenteric approach makes it
easy to perform systematic lymph node dissection around
the SMA and to achieve early ligation of the IPDA.
39.2.3 Inframesocolic Approach
The inframesocolic approach is usually indicated for ductal
adenocarcinoma of the pancreatic head. This is the typical
Nakao mesenteric approach.
39.4 Connective Tissue Clearance around
theSMV andSMA
All of the connective tissues, including the lymph nodes
around the SMV and SMA (No. 14d lymph nodes) [23], are
dissected to the lower border of the pancreatic head (Fig.39.2).
If no cancer invasion of the PLph II is observed, the nerve
plexus around the SMA (PLsma) is completely preserved to
avoid severe postoperative diarrhea (Fig. 39.2). If cancer
invasion into the PLph II or the PLsma is detected, the PLsma
is resected together with the PLph II to obtain a cancer-free
surgical margin. If it is difcult or impossible to obtain cancer-free surgical margins, radical resection is terminated.
Radical resection is also terminated when reconstruction of
the SMV is determined impossible because of severe cancer
invasion into the peripheral branches of the SMV.
39.5 Division oftheMCA andMCV
The MCA and MCV are exposed on the anterior side of the
SMA and SMV.They are generally ligated and divided at the
root. This makes it easier to perform connective tissue clear-
39 Isolated Pancreatoduodenectomy withPortal Vein Resection Using theNakao Mesenteric Approach
The term “mesopancreas” was rst used in 2007 by
Gockel etal. [22] However, there is no precise anatomical
denition for the mesopancreas. In the Japanese classication of pancreatic cancer [23, 24], extrapancreatic nerve
plexus anatomy is precisely described. I propose that “mesopancreas” refers to the PLph II.During radical PD for cancer
of the pancreatic head, the rst portion of the pancreatic head
nerve plexus (PLph I) and the PLph II are completely excised
using the mesenteric approach.
39.8 Exposure oftheJejunal Arteries
andtheIPDA andTotal Mesopancreas
Excision
Fig. 39.2 Connective tissue clearance around the SMV and SMA.The
PLph II between the uncinate process and the SMA is exposed. SMA
superior mesenteric artery, SMV superior mesenteric vein, PLph II second portion of the pancreatic head nerve plexus
ance around the root of the SMA (No. 14 lymph nodes) compared with preservation of the MCA and MCV.
39.6 Division oftheGastrocolic Ligament
andIncision oftheMesocolon
The gastrocolic ligament is incised near the transverse colon
and the lesser abdominal cavity is opened. The mesocolon
can therefore be examined from both the anterior and posterior sides, and the anterior surface of the pancreas can be
visualized.
The root of the mesocolon is horizontally incised and
resected, preserving the arcade of the MCA.Generally, no
ischemic changes occur in the transverse colon when the
arcade of the MCA is preserved. This makes it easier and
safer to perform connective tissue clearance around the root
of the SMA through the large opening in the mesocolon.
The rst and second branches of the jejunal artery generally
reside behind the SMA.The IPDA is usually a branch of the
JA1 and lies within the region of the PLph II.There are many
anatomical variations of the IPDA.Ligation and division of
the IPDA (Fig. 39.3) and total excision of the PLph II
(Fig. 39.4) from the attachment of the SMA complete the
mesenteric approach; in other words, total excision of the
mesopancreas is accomplished. Early ligation of the dorsal
pancreatic artery from the SMA also reduces intraoperative
bleeding [25]. In patients with locally advanced cancer, excision of the JA1, the second branches of the jejunal artery, and
total excision of PLsma may be necessary. If it is difcult to
expose the IPDA or JA1 using the mesenteric approach,
these vessels can be exposed by dividing the pancreas along
309
39.7 Connective Tissue Clearance Around
theRoot oftheSMA andExposure
oftheMesopancreas (PLph II)
Connective tissue clearance around the SMV and SMA proceeds to the roots of the SMV and SMA.All connective tissues of the mesenteric root are dissected, including the
lymph nodes (No. 14d, p lymph nodes). The PLsma is preserved if cancer invasion to the PLph II or PLsma is not
observed. The mesopancreas is exposed between the uncinate process of the pancreatic head and the SMA (Fig.39.2).
Fig. 39.3 Exposure of the IPDA in the PLph II. SMA superior mesen-
teric artery, SMV superior mesenteric vein, PLph II second portion of
the pancreatic head nerve plexus, JA1 rst jejunal artery, IPDA inferior
pancreatoduodenal artery
310
Fig. 39.4 Excision of the PLph II and completion of the mesenteric
approach. PLph II second portion of the pancreatic head nerve plexus,
SMA superior mesenteric artery, SMV superior mesenteric vein
A. Nakao
39.10 Typical Procedures After
theMesenteric Approach toPerform
Isolated PD
After completion of the mesenteric approach, the operative
eld moves to the hepatic hilum. The gallbladder is resected
along with the common hepatic duct. Clearance of the hepatoduodenal ligament and lymph nodes (No. 12a, b, p) is performed, and the gastroduodenal artery is ligated and divided.
The stomach is divided at the pre-pylorus, and lymph node
dissection around the common hepatic artery (CHA; No. 8a,
p) and celiac artery (No. 9) is performed. The dorsal pancreatic artery from the CHA, celiac artery, or splenic artery is
ligated and divided by these lymph node dissection procedures [24]. The PLph I is also dissected.
39.11 Portal Vein Resection
andReconstruction
If cancer invasion into the PV or SMV is observed, the PV or
SMV can be resected and reconstructed. End-to-end anastomosis in portal reconstruction is easily performed by the
mesenteric approach without tension. During resection of the
SMV–PV conuence, splenic vein reconstruction is generally unnecessary and left gastric vein preservation is very
important to reduce left-sided portal hypertension [26, 27]
(Fig.39.6). Simultaneous resection of the PV and CHA can
be performed safely using PV catheter bypass. When we use
antithrombogenic PV catheter bypass, the catheter is
Fig. 39.5 Portal vein catheter bypass between a branch of the superior
mesenteric vein and the femoral vein
the line of the SMA because the root of the SMA can be
visualized easily. The mesenteric approach is completed
using these procedures (Fig.39.4).
39.9 Antithrombogenic PV Catheter Bypass
When resection and reconstruction of the PV and SMV are
possible even if the PV and SMV are severely stenosed or
obstructed due to cancer invasion, the antithrombogenic PV
catheter bypass procedure can be applied to reduce PV congestion and operative bleeding (Fig.39.5). When it will be
time-consuming to resect and reconstruct the PV and the
SMV during surgery. The catheter bypass procedure is a
good indication.
Fig. 39.6 Resection of the SMV–PV conuence and end-to-end anas-
tomosis between the PV and SMV.The SV was not reconstructed. The
LGV was preserved in this case to reduce left-sided portal hypertension. LGV left gastric vein, PV portal vein, SMV superior mesenteric
vein, SV splenic vein, CHA common hepatic artery, SA splenic artery,
Panc pancreas
39 Isolated Pancreatoduodenectomy withPortal Vein Resection Using theNakao Mesenteric Approach
311
extracted after vascular reconstruction. These procedures
conclude isolated PD with the mesenteric approach.
39.12 Reconstruction oftheAlimentary
Canal
After completion of isolated PD, alimentary tract reconstruction is performed.
39.13 Discussion
Previously, Kocher’s maneuver was the rst step in PD.Based
on our extensive experience with vascular resection using
antithrombogenic PV catheter bypass in PD [1–5], we developed a mesenteric approach [11, 12]. In our opinion, isolated
PD using this mesenteric approach and antithrombogenic PV
catheter bypass is the ideal surgery to treat cancer of the pancreatic head from both surgical and oncological viewpoints.
No randomized controlled trials have compared the surgical and oncological merits of the Nakao mesenteric approach
with Kocher’s conventional approach to PD. However, in
patients with resectable cancer of the pancreatic head, isolated PD using the Nakao mesenteric approach is suspected to
result in higher survival compared with conventional PD
using Kocher’s maneuver [28]. Therefore, a randomized controlled trial is being undertaken in Japan to compare the surgical and oncological benets of these two procedures [29].
The mesenteric approach allows dissection from the noncancer- inltrated side and initial determination of cancerfree margins and resectability, followed by systematic
lymphadenectomy around the SMA [21]. This approach also
enables early ligation of the IPDA, which reduces venous
congestion in the pancreatic head along with ligation of the
gastroduodenal artery and total mesopancreas excision,
which makes it an artery-rst operation.
The term “mesopancreas” has no precise anatomical denition [22]. We propose that the mesopancreas can be dened
as the PLph II according to the classication of pancreatic
carcinoma described by the Japan Pancreas Society [23, 24].
Additionally, it is better to use the PLph I or PLph II instead
of the mesopancreas.
Compared with the recent developments in chemotherapy
and chemoradiotherapy for pancreatic cancer, conversion
surgery for unresectable locally advanced pancreatic cancer
has been indicated for some time. The mesenteric approach
and PV catheter bypass are essential techniques in conversion surgery. The Nakao mesenteric approach has been gradually adapted throughout Japan. By mastering this mesenteric
approach and PV catheter bypass, surgeons can successfully
perform isolated PD.
References
1. Nakao A, Horisawa M, Suenaga M, etal. Temporal portosystemic
bypass with the use of the heparinized hydrophilic catheter. Jpn J
Artif Organs. 1982;11:962–5. (In Japanese with English abstract)
2. Nakao A, Hirosawa M, Kondo T, et al. Total pancreatectomy
accompanied by portal vein resection using catheter–bypass of the
portal vein. Shujutsu (Operation). 1983;37:1–6. (In Japanese)
3. Nakao A, Kondo T.New technique of radical pancreatectomy with
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English abstract)
4. Nakao A, Kano T, Nonami T, etal. Application of an antithrombogenic Anthron bypass tube to experimental orthotopic liver transplantation. Studies on blood coagulation and brinolysis. ASAIO
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6. Nakao A, Harada A, Nonami T, Takagi H.Clinical experience of
107 cases with portal vein resection using catheter bypass of the
portal vein. Artif Organs Today. 1993;3:107–12.
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H.Clinical signicance of portal invasion by pancreatic head carcinoma. Surgery. 1995;117:50–5.
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9. Nakao A, Kanzaki A, Fujii T, et al. Correlation between radiographic classication and pathological grade of portal vein wall
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10. Kocher T.Mobilisierung des duodenum und gastroduodenostomie.
Zentralbl Chir. 1903;2:33–40. (In German)
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12. Nakao A, Takagi H. Isolated pancreatectomy for pancreatic head
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15. Nakao A.Isolated pancreatoduodenectomy combined with portal
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16. Nakao A.Extended resection for pancreatic cancer: risks and benets. In: Beger HG, Nakao A, Neoptolemos JP, Peng SY, Sarr MG,
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18. Nakao A. Mesenteric approach in pancreatoduodenectomy. J
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20. Nakao A.Nakao mesenteric approach in pancreatotduodenectomy
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22. Gockel I, Domeyer M, Wolloscheck T, Konerding MA, Junginger
T.Resection of the mesopancreas (RMP): a new surgical classication of a known anatomical space. World J Surg Oncol. 2007;5:44.
23. Japan Pancreas Society. Classication of pancreatic carcinoma. 3rd
English ed. Tokyo: Kanehara; 2011.
24. Yoshioka H, Wakabayashi T. Therapeutic neurotomy on head of
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UMIN000029615.
Pancreaticoduodenectomy withHepatic
Artery Resection
AtsushiOba, TomotakaKato, MarcoDel Chiaro,
Y.H.AndrewWu, YosukeInoue, andYuTakahashi
40
Abstract
With the development of novel and effective multidrug
chemotherapy, several pancreatic centers have reported
that the combination of preoperative chemotherapy and
arterial resection can provide a favorable long-term
prognosis for T4-stage (i.e., major artery inltration)
pancreatic cancer (PC) patients. A recent nomogram
formulated to predict the post-resection prognosis of
PC found that neoadjuvant treatment was an independent prognostic factor, whereas T4 stage was not a factor of poor prognosis. This implies that systemic
control is the most important factor for improving the
prognosis of PC and local progression has less impact
on the prognosis in the era of useful multidrug regimens. However, even if favorable control of PC is
achieved with neoadjuvant chemotherapy, pancreatectomy with hepatic artery (HA) resection is technically
challenging. This approach requires a high expertise
that is characterized with detailed preoperative image
preparation, planning several options of HA reconstruction, meticulous intraoperative resection, and
appropriate postoperative management. This chapter
A. Oba (*)
Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute
Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
Division of Surgical Oncology, Department of Surgery, University
of Colorado, Anschutz Medical Campus, Denver, CO, USA
e-mail: atsushi.oba@jfcr.or.jp
T. Kato · Y. Inoue · Y. Takahashi
Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute
Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
M. Del Chiaro · Y. H. A. Wu
Division of Surgical Oncology, Department of Surgery, University
of Colorado, Anschutz Medical Campus, Denver, CO, USA
examines the innovative surgical approach and management in the pancreaticoduodenectomy with HA
resection and reconstruction.
40.1 Introduction
T4-stage pancreatic cancer (PC) implies a tumor that involves
the hepatic artery (HA), superior mesenteric artery (SMA),
or the celiac axis and is classied as “unresectable” or
“locally advanced” PC (LAPC) according to the National
Comprehensive Cancer Network guidelines [1, 2]. Despite
the challenges of some excellent surgeons including Dr.
Fortner, the outcomes after resection were poor when surgery was initially performed on these tumors [3, 4]. However,
in recent years, with the advent of novel and effective multidrug chemotherapy, several high-volume centers have
reported that the combination of preoperative chemotherapy
and arterial resection can provide a favorable long-term
prognosis for the T4-stage PC patients [5–9]. In addition, a
recently reported National-Cancer-Database-based study
that predict the post-resection prognosis of PC found that
neoadjuvant treatment was an independent prognostic factor,
whereas T4 stage was not a factor of poor prognosis [10].
The results of this study, which was limited by a relatively
new cohort starting in 2010, suggest that in the era of useful
multidrug regimens, systemic control is of paramount importance for improving the prognosis of PC after resection and
that local progression has less impact on prognosis [10].
Even if favorable control of PC is achieved with preoperative chemotherapy, pancreatectomy with arterial resection is
technically challenging [11]. In particular, HA and SMA
reconstructions are critical and can be life-threatening. These
procedures require careful perioperative management and
needs to be performed at an institution with adequate experience. In this chapter, we will introduce our innovative surgical approach and management in the pancreaticoduodenectomy
(PD) with HA resection and reconstruction.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Makuuchi et al. (eds.), The IASGO Textbook of Multi-Disciplinary Management of Hepato-Pancreato-Biliary Diseases,
https://doi.org/10.1007/978-981-19-0063-1_40
313
314
A. Oba et al.
40.2 Indication andPreparation
Tumors located at the head or neck of the pancreas that contact or invade the HA at 180 degrees or more are eligible for
the preparation for PD with HA resection. After giving
enough neoadjuvant treatment for a borderline resectable PC
or LAPC based on the institutional strategy [12, 13], multidetector Computed Tomography (MDCT), magnetic resonance imaging, positron emission tomography-CT,
preoperative blood testing, including tumor markers, (and, if
necessary for high-risk PC, staging laparoscopy) need to be
performed to evaluate the current status and biology of the
tumor [14, 15]. Due to invasive surgery, conditional factors
including neutrophil-to-lymphocyte ratio, modied Glasgow
prognostic score (a combination of C-reactive protein and
albumin levels), or Charlson-Dayo-Comorbidity-index could
also be utilized to evaluate the indication of resection [10,
16]. A detailed understanding of the anatomy of abdomen on
MDCT is of utmost importance. Preoperative sketching of
the anatomy is highly recommended to check arterial and
venous branching anatomy and vascular anomalies. If transposition of artery (i.e., middle colic artery [MCA], gastroduodenal artery [GDA], splenic artery [SpA], or left gastric
artery, etc.) or autologous vein graft (i.e., internal jugular
vein, saphenous vein, left renal vein or external iliac vein,
etc.) is considered as an option for HA reconstruction, the
anatomy and vessel diameters of these vessels must be recognized preoperatively [17–19].
40.3 The Dissection or Resection ofHA
Resection for PC that involves major vessels is challenging.
The procedure is often complicated with increased intraoperative blood loss and longer operative time due to the tumor
invasion of organs such as the mesentery, colon, vena cava,
the development of cavernous transformation or left-side
collaterals [20, 21]. Minimal blood loss can be achieved with
precise dissection. Several high-volume centers have recently
reported good short-term results with the artery rst approach
[22–24]. The HA and super mesenteric vein (SMV)/portal
vein (PV) are vital for the liver’s blood supply and are only
cut and reconstructed at the end of the resection. The key to
safely complete PD with arterial reconstruction is dissecting
out the tissue around the SMA or pancreas and completing
the resection promptly with minimal blood loss.
Inoue etal. recently classied the extent of HA dissection
during PD into three levels: Level 1 (lymph node and plexus
dissection is not required for the case such as benign disease
or low-grade malignancy); Level 2 (en bloc lymph nodes dissection preserving the nerve plexus around HA for the malignancy case without the involvement around HA); and Level
3 (en bloc dissection of lymph nodes and the nerve plexus
close to tumor invasion). Level 3 dissection is planned for
PCs that contact or invade HA [25]. The adventitia of the
common HA root and that of the peripheral branches (the
right or left HA, or proper HA) needs to be exposed and
taped. The nerve plexus is peeled off circumferentially from
both proximal and peripheral sides toward the common HA
close to the tumor. When a solid invasion of the artery is
encountered, dissection needs to be terminated immediately,
and the dissected nerve plexus closest to the tumor needs to
be taken for intraoperative frozen section to conrm negative
for cancer. After completing other PD procedures, HA resection and reconstruction can be performed where it is conrmed to be negative for cancer.
Many experienced institutions that actively perform arterial reconstruction often question whether periadventitial
dissection (PAD) or pancreatectomy with arterial resection
(PAR) is a better procedure for approaching the border
between the tumor inltration and the adventitia of the artery
[5, 26]. Loos et al. from Heidelberg group evaluated 190
patients with PAD and 195 patients with PAR (including 102
patients with HA resection; 52.3%) for LAPC.Although the
patients with PAR had more advanced PC that is characterized with higher rate of lymph node positivity and lower rate
of neoadjuvant chemotherapy induction, PAD was associated with lower morbidity and mortality after resection and
more favorable long-term prognosis [5]. Based on these
results, they concluded PAD may be the rst choice for
LAPC patients with arterial involvement after neoadjuvant
chemotherapy and if PAD was not technically feasible, PAR
can be performed in experienced centers. Although it is difcult to conclude whether PAD or PAR is better due to the
possible selection bias in this retrospective study in which
PAD was performed whenever possible, it must be recognized that arterial reconstruction is a hurdle in surgery.
40.4 HA Reconstruction
40.4.1 Simple Reconstruction Case
If a curative resection cannot be performed by sharp dissection along HA’s periadventitial layer, HA reconstruction can
be performed. In most cases, the tumor may inltrate the root
of the GDA.The most optimal approach in these situations is
to resect a short segment of HA around the root of the GDA
and perform a direct end-to-end anastomosis of the common
HA with the proper HA (Fig.40.1). With the dissection of
PD and that of HA, the central and peripheral sides of HA is
clamped by the small vascular clip, respectively, and cut with
sharp scissors, and the specimen is extracted. End-to-end
microvascular anastomosis of the common HA and the
ab
40 Pancreaticoduodenectomy withHepatic Artery Resection
c d
315
Fig. 40.1 Simple reconstruction case. (a and b) A tumor inltrating
the common hepatic artery (CHA) and the proper hepatic artery (PHA)
around the root of the gastric duodenal artery (GDA). The adventitia of
the CHA and the PHA were exposed and taped. The nerve plexus was
peeled off circumferentially toward the HA close to the tumor. When a
solid invasion of the artery was encountered, dissection was terminated.
The dissected nerve plexus closest to the tumor was taken for intraop-
proper HA is performed with interrupted 9-0 (or 8-0)
Polypropylene sutures. After reconstruction, HA blood ow
is checked with Doppler ultrasonography and palpation.
erative frozen section to conrm negative for cancer. (c and d) The
CHA and the PHA were clamped by the small vascular clip, respectively, and cut with sharp scissors, and the specimen was extracted.
End-to-end microvascular anastomosis of the CHA and the PHA was
performed with interrupted sutures. CA celiac axis, SpA splenic artery,
PV portal vein, SMV superior mesenteric vein
reconstruction, but the risk of anastomotic bleeding, infection, and obstruction due to exposure to postoperative pancreatic stula (POPF) should be well recognized [7, 17–19].
Del Chiaro etal. actively adopt total pancreatectomy in such
cases to avoid the risk of POPF and arterial anastomotic
40.4.2 Complicated Reconstruction Case
problems after resection. In this sense, the use of SpA for HA
reconstruction and total pancreatectomy is highly applicable
Although the above method to perform direct end-to-end
anastomosis for HA could achieve unanimous agreement
according to current literature [5, 9, 18], in a case wherein it
is not feasible due to longer defect or resected root of HA, we
have to consider other ways to reconstruct the
HA.Transposition of artery (MCA, GDA, SpA, etc), autologous artery/vein graft, articial graft (polytetrauoroethylene or polyethylene terephthalate), or cryopreserved
homologous vessels are considered as an option for HA
[19, 27, 28]. However, for the institutions where total pancre-
atectomy is avoided whenever possible in consideration of
the risk of decreased quality of life and postoperative insulin
dependence, the usage of SpA is not a priority due to preservation of the distal pancreas and the spleen [28].
In contrast, transposition of other arteries is highly promoted due to its high patency rate and simplicity of procedure [18]. As we have introduced the new procedure of distal
pancreatectomy with celiac axis resection and left gastric
316
ab
cd
A. Oba et al.
artery reconstruction, we are also actively using MCA for
HA reconstruction [8, 29]. Figure40.2 shows the representative case of HA and MCA reconstruction. Exposure of the
proper HA was not feasible as the tumor has extended to the
right HA and left HA.In response, right HA-MCA reconstruction was planned, and the MCA was exposed before HA
resection. The root of the MCA and the bifurcation of the
right and left branches within the transverse mesocolon
should be thoroughly identied. The MCA needed to be dissected carefully to avoid injury to the marginal arterial arcade
of transvers colon. In most of the time, the right branch of
MCA is suitable for reconstruction for its vessel diameter
and ability to achieve tension-free anastomosis. The right
branch of MCA was clamped temporarily, and the arterial
blood ow of the arcade was checked by palpation (indocyanine green-uorescence imaging can be done in unsure situations) [29]. After prompt extraction of the specimen and the
direct end-to-end anastomosis of PV and SMV, the MCA
was cut and reconstructed to the right HA by end-to-end
A4
A2+3
PV
RHA
CA
Sp
A
microvascular anastomosis with interrupted 9-0
Polypropylene sutures. Although some surgeons demonstrated that the left HA can be sacriced if the right HA
blood ow and intrahepatic blood ow between both right
and left lobes were sufcient [18], we prefer reconstructing
the left HA whenever possible to avoid postoperative liver
abscess complications. In this case, the right inferior phrenic
artery was exposed and reconstructed to the left HA (segment 2 and 3 artery). Doppler ultrasonography showed a better arterial pulse on the left-side intrahepatic artery after the
reconstruction of the left HA.Concomitant left lateral sectionectomy can also be performed as an alternative option.
40.4.3 Concomitant Vein Resection
Since PC is more likely to invade the PV/SMV, many cases
of HA reconstruction require concomitant vein resection and
reconstruction. To minimize the total liver ischemic period,
A4
RHA
A2+3
SpA
CHA
Sp
A
CHA
SMV
Anastomosis
A2+3
RHA
PV
Fig. 40.2 Complicated reconstruction case. (a and b) Exposure of the
PHA was not feasible as a tumor inltrating the right HA (RHA) and
the left HA (LHA). (c and d) The right branch of the middle colic artery
(rMCA) was dissected and RHA—rMCA reconstruction was performed. We prefer reconstructing the LHA whenever possible to avoid
SMV
rMCA
rIPA
RHA
CHA
SMA
postoperative liver abscess complications. In this case, the right inferior
phrenic artery (rIPA) was exposed and reconstructed to the LHA (segment 2 and 3 artery [A2+3]). Doppler ultrasonography showed a better
arterial pulse on the left-side intrahepatic artery after the LHA reconstruction. A4 segment 4 artery, SMA superior mesenteric artery
A4
A2+3
rIPA
CHA
SMA
rMCA