Preliminary diagnoses were poorly differentiated adenocarcinoma of the duodenum and viral hepatitis B. The surgical proposal included exploratory laparotomy and pancreaticoduodenectomy (resection of the invaded vessels and revascularization). The operation was performed under general anesthesia on August 14, 2015. A 20 cm-midline incision was made in the abdomen, and cholestatic liver and swollen gallbladder was seen. One hard mass (7 cm × 6 cm × 6 cm), surrounding the portal vascular structure, could be palpable at duodenal bulb and hepatic portal; and it was not sharply demarcated form the hepatic portal. Enlarged lymph nodes could be palpable beside greater omentum and common hepatic artery. Duodenal lateral peritoneum was opened by Kocher maneuver. After the 2nd and 3rd segments of duodenum as well as the caput pancreatis were separated from behind the peritoneum, we saw that the caput pancreatis was involved by the tumor. The superior mesenteric artery and superior mesenteric vein were separated along pancreatic inferior border because they were not involved by tumor. Based on the conditions above, we decided to carry out pancreaticoduodenectomy. After the vascular structure in the hepatoduodenal ligament, celiac trunk, common hepatic artery, and splenic artery were exposed, we found that the proper hepatic artery and gastroduodenal artery were surrounded by tumor, and they could not be completely dissociated. Therefore, we decided to cut off the proper hepatic artery followed by end-to-side anastomosis between the proper hepatic artery and the portal vein. Pancreatic transection was performed through the upper and lower margins of the pancreas on the left side of superior mesenteric vein, and then the greater and lesser gastric curvatures were separated followed by gastric amputation. After the gallbladder was removed and the common hepatic duct was cut off; tumor removal, regional lymphadenectomy, and digestive tract reconstruction were performed (Figs. 3 and 4). The operation lasted for 6.5 hours, and intraoperative blood loss was about 1500 mL. Pathology conformed diffuse large B-cell lymphoma (Fig. 5).
Liver function was dynamically monitored after operation, and it returned to normal limits 1 week later (Fig. 6). One week after operation, color Doppler ultrasound showed portal vein patency, the signal of blood stream from proper hepatic artery into portal vein, 10 cm-inner diameter of the portal vein at the hepatic portal with a high flow velocity of 21 cm/s, and 12 cm-inner diameter at the midpiece of the portal vein with a high flow velocity of 94.8 cm/s (Fig. 7). One month after operation, color Doppler ultrasound reexamination showed portal vein patency, no marked signal of blood stream in the proper hepatic artery, 8.5 cm-inner diameter of the portal vein at the hepatic portal with a high flow velocity of 22.52 cm/s, and 9.9 cm-inner diameter at the midpiece of the portal vein with a high flow velocity of 50.87 cm/s (Fig. 8). Digital subtraction arteriography was performed through the celiac trunk 1 month after operation, and it showed clear shadow of splenic artery, a compensatory artery branch into the left liver, and no shadow in the proper hepatic artery. Therefore, proper hepatic artery embolization was not performed (Fig. 9). Angiography of superior mesenteric artery revealed clear shadow of mesenteric vessels and a compensatory artery branch into the right liver (Fig. 10). Angiography of abdominal aorta showed compensatory artery branches within the liver (Fig. 11).
Pancreaticoduodenectomy, mainly applied for surgical treatment of the tumors in caput pancreatis, is difficult with high risks. It has been reported that the incidence of complications is 15% to 45% and perioperative fatality rate is less than 5% after pancreaticoduodenectomy. Due to occult pathogenesy and special biological behaviors of tumors occurring in the caput pancreatic, they readily invade surrounding blood vessels and nerves, bringing difficulties to radical resection for these tumors. Blood vessel involvement is an important factor affecting radical resection. Therefore, it is critical to understand the tumor anatomy and evaluate resectability before operation. Nowadays, preoperative assessment is mainly assisted by CT and MRI imaging examinations. CT examination, characterized by its high resolution and image clarity, is capable of showing the relation between tumor and surrounding organs and vessels, thus has been widely applied in clinic.
With the development of medical imaging technology, 3-D visualization reconstruction has widely used in recent years. The capability of 3-D visualization reconstruction, including arbitrarily rotating, zooming, combinatorially viewing, vitrification and concealing target organ model, makes it powerful in displaying the tumor's volume and shape, anatomical relationship with organs and vessels, and the invasion condition. Tumors and vessels cannot be stereoscopically shown in CT images, but the 3-D visualization reconstruction can greatly make up the limitation, and can provide more reliable preoperative assessment and more effective surgical proposal.
For the tumors occurring in caput pancreatic and involving hepatic artery, it is difficult to obtain radical resection only by classical pancreatoduodenectomy, so simultaneous removal of the hepatic artery is necessary. Because blood supply for the liver is mainly from portal vein; if liver function is normal, liver artery ligation usually will not lead to liver ischemia or necrosis. However, in extensive radical resection of tumor in porta hepatis, exposure of blood vessels in hepatoduodenal ligament often cut off the blood supply of collateral circulation for the remaining liver, so hepatic artery resection may cause severe biliary tract ischemia-related complications such as liver abscess, bilioenteric anastomotic leakage, and even hepatic failure. Based on the reduction of liver blood perfusion and increased incidence of hepatic encephalopathy after portacaval shunt for the treatment of portal hypertension, Cohn (1952) and Fisher (1954) conceived the idea of liver perfusion using arterial blood instead of portal vein blood. Portal vein arterialization could be performed by multiple ways such as complete or partial portal vein arterialization, direct or bridging anastomosis. The blood supply could be from hepatic artery, right renal artery, splenic artery and right gastric artery, etc. Portal vein arterialization could effectively improve liver function, promote hepatic cell regeneration, prevent hepatic failure, and reduce biliary tract complications.[12,13] One case had acute hepatic failure and was not suitable for liver transplantation, this patient tried to receive portal vein arterialization and finally this patient was discharged from hospital because his liver function gradually recovered after operation. Tsivian et al performed a systematic review for literatures and found that portal vein arterialization was safe and reliable in prevention and treatment for acute liver failure. Portal vein arterialization can benefit liver in a short time. However, it may also induce some adverse side effects such as increased portal vein pressure, hepatic cell apoptosis, and reduced hepatotrophic factors. To reduce the adverse side effects caused by portal vein arterialization, Bonnet et al adopted the method to limit portal vein flow, and Kondo et al carried out anastomotic embolism after portal hypertension and collateral circulation were observed by angiography. Therefore, limiting blood flow and anastomotic embolism are the main methods to reduce or avoid the adverse side effects caused by portal vein arterialization. Chen et al believe that it is reasonable to block arterialization 1 to 6 months after operation.
Because the patient in this study had a 10-year medical history of viral hepatitis B and increased total bilirubin level before operation, and exposure of blood vessels in the hepatoduodenal ligament led to loss of hepatic blood supply from hepatic artery and most collateral circulation; complications such as liver damage, bilioenteric anastomotic leakage, liver abscess, and even liver failure would readily occur. Therefore, we adopted the anastomosis between portal vein and proper hepatic artery to increase portal vein blood flow and promote liver function recovery. Six days after operation, the liver function returned to normal limits, and no biliary tract complications occurred. To avoid side effects such as portal hypertension induce by long-term portal vein arterialization, proper hepatic artery embolism was planned. Digital subtraction arteriography angiography revealed anastomotic occlusion of portal vein arterialization and formation of liver compensatory arterial branches. Anastomotic occlusion might be caused by long proximal hepatic artery, end-to-side anastomosis, and small anastomotic stoma. And the increase in portal pressure caused by artery blood perfusion decreased the pressure difference between arteries and veins, reducing blood flow rate at anastomotic stoma and finally resulting in thrombosis. Moreover, the formation of compensatory arterial branches was beneficial for liver function recovery. No biliary fistula or anastomotic leakage occurred in this case, suggesting that this surgical proposal was safe and effective.
In summary, 3-D visualization reconstruction can provide reliable basis and assistance for the accurate assessment and surgical design before pancreatoduodenectomy, and also is conducive to full preparation for extensive pancreatoduodenectomy and vessel reconstruction. Meanwhile, from the case of this study, we can see that it is certainly worth adopting portal vein arterialization when retention of hepatic artery is impossible or conventional arterial anastomosis is required during pancreatoduodenectomy. Although portal vein arterialization is used in clinic as an important remedial measure, its application still needs to be standardized.
The authors thank National Natural Science Foundation of China (No. 81272246, 81101502, 61271336, 61327001) for the support.
1. Su Z-j, Duan P, Liu C-h. Application of 3-D visualization in the treatment for cholangiocarcinoma in porta hepatic. Chin J Digeste Surg
2. Zhao Y, Wang H-q, Liu Y, et al Basis and clinic about portal vein arterialization
. Med Recapitulate
3. Zhou X-h, He Y, Gong J-p. Prevention and treatment for four main complications after pabcreaticoduodenectomy. Chin J Curr Adv Gen Surg
4. Chua TC, Saxena A. Extended pancreaticoduodenectomy
with vascular resection for pancreatic caxlcer: a systematic review. J Gastrointest Surg
5. Gong Y, Zhang L-d, Ding J. Clinical significance of vascular resection and reconstruction during pancreaticoduodenectomy
for treatment of pancreatic cancer. Chin J Digest Surg
6. Fang C-h, Xiang N. Application of digital mini-invasive technique in the surgery for liver, gallbladder and pancreas. Chin J Min Invasive Surg
7. Su Z-j, Li W-g, Chen F-z, et al Application of three dimensional visualization technique in preoperative evaluation of retroperitoneal tumor. Chin J Pract Surg
8. Guan X-q, Ghen Y, Gu S-c, et al Feasibility study on extended pancreaticoduodenectomy
combined with resection of hepatic artery, proper hepatic artery and internal iliac vein. Chin J Bases Clin Gen Surg
9. Iseki J, Noie T, Touyama K. Mesenteric arterioportal shunt after hepatic artery interruption. Surgery
10. Li W-g, Huang Z-q. Application of portal vein arterialization
in liver transplantation. Digest Surg
11. Zhao Y, Wang H-q. Basis and clinic about portal vein arterialization
. Med Recapitulate
12. Zhang J-j, Meng X-k. Current situation and prospect about application of portal vein arterialization
in genneral surgery. Chin J Hepatobil Surg
13. Chen Y-l, Huang Z-q, Zhou N-x. Application of portal vein arterialization
of in the radical resection for hepatic portal cholangiocarcinima. Chin J Gen Surg
14. Nardo B, Puviani L. Technical aspects of portal wein arterialization for acute liver failure: from rat lab to man. Transplant Ptoc
15. Tsivian M, Neri F, Prezzi D. Portal vein arterialization
in hepatobiliary surgery and liver transplantation. Transplant Proc
16. Li W-g, Li B, Gao L-j. Long-term effects of flow-limited portal vein arterialization
on hepatic function and structure in rats. Chin J Gen Surg
17. Bonnet S, Sauvanet A, Bruno O. Long-term survival after portal vein arterialization
for portal vein thrombosis in orthotopic liver transplantation. Gastroenterol Clin Biol
18. Kondo S, Hirano S, Ambo Y. Artefioportal shunting alternative to microvaacular reconstruction after hepatic artery resection. Br J Surg
Keywords:Copyright © 2016 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.
pancreaticoduodenectomy; portal vein arterialization; 3-dimensional visualization reconstruction