Concepts and techniques for revascularization of replaced hepatic arteries in pancreatic head resections

A Floortje van Oosten; Mohammad Al Efishat; Joseph R Habib; Benedict Kinny-Köster; Ammar A Javed; Jin He; Elliot K Fishman; I Quintus Molenaar; Christopher L Wolfgang

doi:10.1016/j.hpb.2023.06.002

Concepts and techniques for revascularization of replaced hepatic arteries in pancreatic head resections

HPB (Oxford). 2023 Nov;25(11):1279-1287. doi: 10.1016/j.hpb.2023.06.002. Epub 2023 Jun 3.

Authors

A Floortje van Oosten¹, Mohammad Al Efishat², Joseph R Habib², Benedict Kinny-Köster³, Ammar A Javed⁴, Jin He², Elliot K Fishman⁵, I Quintus Molenaar⁶, Christopher L Wolfgang⁷

Affiliations

¹ Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, the Netherlands; Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
² Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
³ Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁴ Department of Surgery, New York University Langone Hospital, New York City, New York, USA.
⁵ Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁶ Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, the Netherlands.
⁷ Department of Surgery, New York University Langone Hospital, New York City, New York, USA. Electronic address: Christopher.Wolfgang@NYULangone.org.

PMID: 37419779
DOI: 10.1016/j.hpb.2023.06.002

Abstract

Background: The relationship of pancreatic ductal adenocarcinoma (PDAC) to important peripancreatic vasculature dictates resectability. As per the current guidelines, tumors with extensive, unreconstructible venous or arterial involvement are staged as unresectable locally advanced pancreatic cancer (LAPC). The introduction of effective multiagent chemotherapy and development of surgical techniques, have renewed interest in local control of PDAC. High-volume centers have demonstrated safe resection of short-segment encasement of the common hepatic artery. Knowledge of the unique anatomy of the patient's vasculature is important in surgical planning of these complex resections. Hepatic artery anomalies are common and insufficient knowledge can result in iatrogenic vascular injury during surgery.

Methods and results: Here, we discuss different strategies to resect and reconstruct replaced hepatic arteries during pancreatectomy for PDAC to ensure restoration of adequate blood flow to the liver. Strategies include various arterial transpositions, in-situ interposition grafts and the use of extra-anatomic jump grafts.

Conclusion: These surgical techniques allow more patients to undergo the only available curative treatment currently available for PDAC. Moreover, these improvements in surgical techniques highlight the shortcoming of current resectability criteria, which rely mainly on local tumor involvement and technical resectability, and disregards tumor biology.

Publication types

Review