Leading article
Combined vascular resection and reconstruction during hepatobiliary and pancreatic cancer surgery M. Miyazaki Department of General Surgery, Chiba University, 1-8-1, Inohana, Chuoh-ku, Chiba, 260-0856 Japan (e-mail: [email protected])
Based on the BJS lecture at the 21st Annual Meeting of the European Surgical Association, Athens, Greece, April 2014 Published online 21 August 2014 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9618
Hepatobiliary and pancreatic malignancies frequently involve major vessels such as the inferior vena cava (IVC), hepatic vein, portal vein and foregut arteries, especially the hepatic artery. Tumours involving these structures are often considered unresectable and the patients incurable. Early efforts to include vascular resections as part of hepatectomy and pancreatectomy were associated with increased surgical morbidity and mortality, but recent studies from high-volume centres have shown that combined vascular resections can be undertaken safely with acceptable morbidity and mortality. In turn, this might lead to better outcomes in selected patients. The retrohepatic IVC may be involved by direct invasion in the context of hepatic metastases, intrahepatic cholangiocarcinoma and gallbladder carcinoma. Hepatocellular carcinoma is often associated with intracaval extension of tumour thrombus. Surgical resection of hepatic metastases involving the IVC was reported in 16 patients from Chiba University in 19991 when surgical morbidity and mortality rates were 25 and 6 per cent respectively, with a 5-year survival rate of 27 per cent. In the past few years, European series from Leeds2 and Paris3 have reported IVC resections combined with hepatectomy, with surgical mortality rates between 11 and 14 per cent, and a 5-year survival rate approaching 40 per cent. In a series of 60 patients undergoing combined IVC resections with hepatectomy, including ex vivo © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
procedures in six, Hemming and colleagues4 had a surgical mortality rate of 8 per cent with 35 per cent 5year survival. Replacement of the cava may be necessary after circumferential resection5 in patients who before surgery have poor development of a collateral circulation, when oliguria occurs or if haemodynamic stability cannot be maintained during surgery. Portal vein resection as a component of hepatectomy is sometimes necessary for patients with intrahepatic cholangiocarcinoma, hilar cholangiocarcinoma and gallbladder cancer. The Chiba series reported in 20076 showed that combined vascular resection was performed in 43 of 161 patients with hilar cholangiocarcinoma who underwent surgical resection. Surgical mortality rates were 4 and 8 per cent in the non-vascular resection and portal vein resection groups respectively, but the 5-year survival rate was 25 per cent after portal vein resection. Interestingly, if hepatic artery resection was also needed in an attempt to achieve clear margins, survival was the same as that in patients with unresectable disease. Neuhaus and co-workers7 also reported longterm survival after combined portal vein resection for hilar cholangiocarcinoma with a 5-year survival rate of 58 per cent. On the contrary, Nagino et al.8 reported that hepatectomy with simultaneous resection of the portal vein and hepatic artery for advanced perihilar cholangiocarcinoma resulted in favourable long-term outcomes with acceptable mortality. However, most publications suggest that surgical
mortality rates lie between 2 and 15 per cent, but with a beneficial effect on long-term survival in patients with hilar cholangiocarcinoma. A systematic review and meta-analysis9 of the role of vascular resection in the treatment of hilar cholangiocarcinoma demonstrated that increased morbidity and mortality was due mainly to the addition of hepatic artery resection compared with portal vein resection alone. This review also showed that routine vascular resection did not always improve negative resection margin rates and had no impact on long-term survival. From this point of view, portal vein resection should not be undertaken routinely and done only where there is suspicion of cancer invasion. Combined hepatic arterial resection results in higher morbidity and mortality with no proven survival benefit and should therefore be performed in select patients. Portal vein resection as part of pancreatectomy is now widely regarded as a safe and feasible procedure with acceptable morbidity and mortality rates. Combined portal vein resection with pancreatectomy should be considered where there is a suspicion of invasion of the portal vein to achieve clear resection margins on the basis of preoperative imaging rather than making the decision purely on operative findings. Unlike the situation with hepatic resections, combined arterial resections involving the coeliac axis, at least in the context of distal pancreatectomy, have been reported without a marked increase in surgical mortality. Distal pancreatectomy with en bloc BJS 2015; 102: 1–3
2
coeliac axis resection resulted in a high rate of complete resection and favourable prognosis (estimated overall 5-year survival rate 42 per cent) in selected patients with locally advanced pancreatic body cancer10,11 . Arterial resections involving the coeliac artery and its major branches, as well as multivisceral ex vivo surgery for tumours involving coeliac and superior mesenteric arteries, may be reasonable options for locally invasive tumours with low metastatic potential, such as sarcomas, as reported by the Miami group12 recently. A variety of substitutes for venous reconstruction have been reported. Jugular, external iliac vein, great saphenous vein, left renal and umbilical veins, as well as synthetic grafts have all been used for portal vein reconstruction. As many of these resections may involve contaminated bile and because postoperative infectious complications occur frequently, synthetic grafts are probably best avoided. The clinical usefulness of a left renal vein graft for reconstruction of the portal vein was first reported from Chiba in 199513 . No obvious left kidney dysfunction has been found after the harvest of left renal vein graft at this centre14 . Other groups have also used this graft successfully. The technique has a number of advantages over other substitutes. The left renal vein is obtained from the same operative field without an additional skin incision. It is harvested quickly and easily, usually taking only 5–10 min. The calibre of the vein is often a suitable match for the portal vein to be reconstructed. The patency rate in an experience of 35 patients using a left renal vein graft for portal vein reconstruction was 100 per cent, even at long-term followup14 . Synthetic graft reconstruction after portal vein resection in pancreaticoduodenectomy was reported recently in a multicentre analysis15 . © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
M. Miyazaki
Among 36 procedures, the overall graft patency rate was 76 per cent, and portal vein thrombosis within 30 days after surgery occurred in 9⋅1 per cent. It would seem that a synthetic graft should not be selected as a portal vein substitute if an autogenous vein graft is available. An alternative approach is the use of a synthetic graft as an intraoperative temporary portal vein shunt, followed by its removal after tumour excision combined with portal vein resection16 . Combined vascular resection during hepatobiliary and pancreatic cancer resections can expand the indications for surgery. This might lead to a survival benefit for some patients with locally advanced tumours and no evidence of distant metastases. In view of the complication rates, these procedures should probably be restricted to carefully selected patients at high-volume centres.
Disclosure
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7
8
9
The author declares no conflict of interest. 10
References 1 Miyazaki M, Ito H, Nakagawa K, Ambiru S, Shimizu H, Kato A et al. Aggressive surgical resection for hepatic metastases involving the inferior vena cava. Am J Surg 1999; 177: 294–298. 2 Malde DJ, Khan AK, Prased KR, Toogood GJ, Lodge PA. Inferior vena cava resection with hepatectomy: challenging but justified. HPB (Oxford) 2011; 13: 802–810. 3 Azoulay D, Pascal G, Salloum C, Adam R, Castaing D, Tranecol N. Vascular reconstruction combined with liver resection for malignant tumours. Br J Surg 2013; 100: 1764–1775. 4 Hemming AW, Mekeel KL, Zendejas I, Kim RD, Sicklick JK, Reed AI. Resection of the liver and inferior
www.bjs.co.uk
11
12
13
vena cava for hepatic malignancy. J Am Coll Surg 2013; 217: 115–124. Yoshidome H, Takeuchi D, Ito H, Kimura F, Shimizu H, Ambiru S et al. Should the inferior vena cava be reconstructed after resection for malignant tumors? Am J Surg 2005; 189: 419–424. Miyazaki M, Kato A, Ito H, Kimura F, Shimizu H, Ohtsuka M et al. Combined vascular resection in operative resection for hilar cholangiocarcinoma: does it work or not? Surgery 2007; 141: 581–588. Neuhaus P, Thelen A, Jonas S, Puhl G, Denecke T, Veltzke-Schlieker W et al. Oncological superiority of hilar en bloc resection for the treatment of hilar cholangiocarcinoma. Ann Surg Oncol 2012; 19: 1602–1608. Nagino M, Nimura Y, Nishio H, Ebata T, Igami T, Matsushita M et al. Hepatectomy with simultaneous resection of the portal vein and hepatic artery for advanced perihilar cholangiocarcinoma: an audit of 50 consective cases. Ann Surg 2010; 252: 115–123. Abbas S, Sandroussi C. Systematic review and meta-analysis of the role of vascular resection in the treatment of hilar cholangiocarcinoma. HPB (Oxford) 2013; 15: 492–503. Hishinuma S, Ogata Y, Tomisawa M, Ozawa I. Stomach-preserving distal pancreatectomy with combined resection of the celiac artery: radical procedure for locally advanced cancer of the pancreas body. J Gastrointest Surg 2007; 11: 743–749. Hirano S, Kondo S, Ambo Y, Tanaka E, Schichinohe T, Suzuki O et al. Distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic body cancer: long-term results. Ann Surg 2007; 246: 46–51. Kato T, Lobrittlo SJ, Tzakis A, Raveh Y, Sandoval PR, Martinez M et al. Multivisceral ex vivo surgery for tumors involving celiac and superior mesenteric arteries. Am J Transplant 2012; 12: 1323–1328. Miyazaki M, Itoh H, Kaiho T, Ambiru S, Togawa A, Sasada K et al.
BJS 2015; 102: 1–3
Combined vascular resection and reconstruction during hepatobiliary and pancreatic cancer surgery
Portal vein reconstruction at the hepatic hilus using a left renal vein graft. J Am Coll Surg 1995; 180: 497–498. 14 Suzuki T, Yoshidome H, Kimura F, Shimizu H, Ohtsuka M, Kato A et al. Renal function is well maintained after use of left renal vein graft for vascular reconstruction in
hepatobiliary-pancreatic surgery. J Am Coll Surg 2006; 202: 87–92. 15 Chu CK, Farnell MB, Nguyen JH, Stauffer JA, Kooby DA, Sclabas GM et al. Prosthetic graft reconstruction after portal vein resection in pancreaticoduodenectomy: a multicenter analysis. J Am Coll Surg 2010; 21: 316–324.
3
16 Bachellier P, Rosso E, Fuchshuber P, Addeo P, David P, Oussoultzoglou E et al. Use of a temporary intraoperative mesentericoportal shunt for pancreatic resection for locally advanced pancreatic cancer with portal vein occlusion and portal hypertension. Surgery 2014; 155: 449–456.
Snapshot quiz
Snapshot quiz 15/1 Question: What is this lesion in a small bowel resection of a 43-year-old man with a recent diagnosis of Crohn’s disease?
The answer to the above question is found on p. 15 of this issue of BJS. Kosai NR, Levin KB, Reynu R, Taher MM, Ali RAR, Palaniappan S: Minimally Invasive, Upper Gastrointestinal and Bariatric Surgery Unit, Department of Surgery, Faculty of Medicine, National University of Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Kuala Lumpur, Malaysia (e-mail: [email protected])
Snapshots in Surgery: to view submission guidelines, submit your snapshot and view the archive, please visit www.bjs.co.uk
© 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
www.bjs.co.uk
BJS 2015; 102: 1–3
Combined vascular resection and reconstruction during hepatobiliary and pancreatic cancer surgery M. Miyazaki Department of General Surgery, Chiba University, 1-8-1, Inohana, Chuoh-ku, Chiba, 260-0856 Japan (e-mail: [email protected])
Based on the BJS lecture at the 21st Annual Meeting of the European Surgical Association, Athens, Greece, April 2014 Published online 21 August 2014 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9618
Hepatobiliary and pancreatic malignancies frequently involve major vessels such as the inferior vena cava (IVC), hepatic vein, portal vein and foregut arteries, especially the hepatic artery. Tumours involving these structures are often considered unresectable and the patients incurable. Early efforts to include vascular resections as part of hepatectomy and pancreatectomy were associated with increased surgical morbidity and mortality, but recent studies from high-volume centres have shown that combined vascular resections can be undertaken safely with acceptable morbidity and mortality. In turn, this might lead to better outcomes in selected patients. The retrohepatic IVC may be involved by direct invasion in the context of hepatic metastases, intrahepatic cholangiocarcinoma and gallbladder carcinoma. Hepatocellular carcinoma is often associated with intracaval extension of tumour thrombus. Surgical resection of hepatic metastases involving the IVC was reported in 16 patients from Chiba University in 19991 when surgical morbidity and mortality rates were 25 and 6 per cent respectively, with a 5-year survival rate of 27 per cent. In the past few years, European series from Leeds2 and Paris3 have reported IVC resections combined with hepatectomy, with surgical mortality rates between 11 and 14 per cent, and a 5-year survival rate approaching 40 per cent. In a series of 60 patients undergoing combined IVC resections with hepatectomy, including ex vivo © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
procedures in six, Hemming and colleagues4 had a surgical mortality rate of 8 per cent with 35 per cent 5year survival. Replacement of the cava may be necessary after circumferential resection5 in patients who before surgery have poor development of a collateral circulation, when oliguria occurs or if haemodynamic stability cannot be maintained during surgery. Portal vein resection as a component of hepatectomy is sometimes necessary for patients with intrahepatic cholangiocarcinoma, hilar cholangiocarcinoma and gallbladder cancer. The Chiba series reported in 20076 showed that combined vascular resection was performed in 43 of 161 patients with hilar cholangiocarcinoma who underwent surgical resection. Surgical mortality rates were 4 and 8 per cent in the non-vascular resection and portal vein resection groups respectively, but the 5-year survival rate was 25 per cent after portal vein resection. Interestingly, if hepatic artery resection was also needed in an attempt to achieve clear margins, survival was the same as that in patients with unresectable disease. Neuhaus and co-workers7 also reported longterm survival after combined portal vein resection for hilar cholangiocarcinoma with a 5-year survival rate of 58 per cent. On the contrary, Nagino et al.8 reported that hepatectomy with simultaneous resection of the portal vein and hepatic artery for advanced perihilar cholangiocarcinoma resulted in favourable long-term outcomes with acceptable mortality. However, most publications suggest that surgical
mortality rates lie between 2 and 15 per cent, but with a beneficial effect on long-term survival in patients with hilar cholangiocarcinoma. A systematic review and meta-analysis9 of the role of vascular resection in the treatment of hilar cholangiocarcinoma demonstrated that increased morbidity and mortality was due mainly to the addition of hepatic artery resection compared with portal vein resection alone. This review also showed that routine vascular resection did not always improve negative resection margin rates and had no impact on long-term survival. From this point of view, portal vein resection should not be undertaken routinely and done only where there is suspicion of cancer invasion. Combined hepatic arterial resection results in higher morbidity and mortality with no proven survival benefit and should therefore be performed in select patients. Portal vein resection as part of pancreatectomy is now widely regarded as a safe and feasible procedure with acceptable morbidity and mortality rates. Combined portal vein resection with pancreatectomy should be considered where there is a suspicion of invasion of the portal vein to achieve clear resection margins on the basis of preoperative imaging rather than making the decision purely on operative findings. Unlike the situation with hepatic resections, combined arterial resections involving the coeliac axis, at least in the context of distal pancreatectomy, have been reported without a marked increase in surgical mortality. Distal pancreatectomy with en bloc BJS 2015; 102: 1–3
2
coeliac axis resection resulted in a high rate of complete resection and favourable prognosis (estimated overall 5-year survival rate 42 per cent) in selected patients with locally advanced pancreatic body cancer10,11 . Arterial resections involving the coeliac artery and its major branches, as well as multivisceral ex vivo surgery for tumours involving coeliac and superior mesenteric arteries, may be reasonable options for locally invasive tumours with low metastatic potential, such as sarcomas, as reported by the Miami group12 recently. A variety of substitutes for venous reconstruction have been reported. Jugular, external iliac vein, great saphenous vein, left renal and umbilical veins, as well as synthetic grafts have all been used for portal vein reconstruction. As many of these resections may involve contaminated bile and because postoperative infectious complications occur frequently, synthetic grafts are probably best avoided. The clinical usefulness of a left renal vein graft for reconstruction of the portal vein was first reported from Chiba in 199513 . No obvious left kidney dysfunction has been found after the harvest of left renal vein graft at this centre14 . Other groups have also used this graft successfully. The technique has a number of advantages over other substitutes. The left renal vein is obtained from the same operative field without an additional skin incision. It is harvested quickly and easily, usually taking only 5–10 min. The calibre of the vein is often a suitable match for the portal vein to be reconstructed. The patency rate in an experience of 35 patients using a left renal vein graft for portal vein reconstruction was 100 per cent, even at long-term followup14 . Synthetic graft reconstruction after portal vein resection in pancreaticoduodenectomy was reported recently in a multicentre analysis15 . © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
M. Miyazaki
Among 36 procedures, the overall graft patency rate was 76 per cent, and portal vein thrombosis within 30 days after surgery occurred in 9⋅1 per cent. It would seem that a synthetic graft should not be selected as a portal vein substitute if an autogenous vein graft is available. An alternative approach is the use of a synthetic graft as an intraoperative temporary portal vein shunt, followed by its removal after tumour excision combined with portal vein resection16 . Combined vascular resection during hepatobiliary and pancreatic cancer resections can expand the indications for surgery. This might lead to a survival benefit for some patients with locally advanced tumours and no evidence of distant metastases. In view of the complication rates, these procedures should probably be restricted to carefully selected patients at high-volume centres.
Disclosure
5
6
7
8
9
The author declares no conflict of interest. 10
References 1 Miyazaki M, Ito H, Nakagawa K, Ambiru S, Shimizu H, Kato A et al. Aggressive surgical resection for hepatic metastases involving the inferior vena cava. Am J Surg 1999; 177: 294–298. 2 Malde DJ, Khan AK, Prased KR, Toogood GJ, Lodge PA. Inferior vena cava resection with hepatectomy: challenging but justified. HPB (Oxford) 2011; 13: 802–810. 3 Azoulay D, Pascal G, Salloum C, Adam R, Castaing D, Tranecol N. Vascular reconstruction combined with liver resection for malignant tumours. Br J Surg 2013; 100: 1764–1775. 4 Hemming AW, Mekeel KL, Zendejas I, Kim RD, Sicklick JK, Reed AI. Resection of the liver and inferior
www.bjs.co.uk
11
12
13
vena cava for hepatic malignancy. J Am Coll Surg 2013; 217: 115–124. Yoshidome H, Takeuchi D, Ito H, Kimura F, Shimizu H, Ambiru S et al. Should the inferior vena cava be reconstructed after resection for malignant tumors? Am J Surg 2005; 189: 419–424. Miyazaki M, Kato A, Ito H, Kimura F, Shimizu H, Ohtsuka M et al. Combined vascular resection in operative resection for hilar cholangiocarcinoma: does it work or not? Surgery 2007; 141: 581–588. Neuhaus P, Thelen A, Jonas S, Puhl G, Denecke T, Veltzke-Schlieker W et al. Oncological superiority of hilar en bloc resection for the treatment of hilar cholangiocarcinoma. Ann Surg Oncol 2012; 19: 1602–1608. Nagino M, Nimura Y, Nishio H, Ebata T, Igami T, Matsushita M et al. Hepatectomy with simultaneous resection of the portal vein and hepatic artery for advanced perihilar cholangiocarcinoma: an audit of 50 consective cases. Ann Surg 2010; 252: 115–123. Abbas S, Sandroussi C. Systematic review and meta-analysis of the role of vascular resection in the treatment of hilar cholangiocarcinoma. HPB (Oxford) 2013; 15: 492–503. Hishinuma S, Ogata Y, Tomisawa M, Ozawa I. Stomach-preserving distal pancreatectomy with combined resection of the celiac artery: radical procedure for locally advanced cancer of the pancreas body. J Gastrointest Surg 2007; 11: 743–749. Hirano S, Kondo S, Ambo Y, Tanaka E, Schichinohe T, Suzuki O et al. Distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic body cancer: long-term results. Ann Surg 2007; 246: 46–51. Kato T, Lobrittlo SJ, Tzakis A, Raveh Y, Sandoval PR, Martinez M et al. Multivisceral ex vivo surgery for tumors involving celiac and superior mesenteric arteries. Am J Transplant 2012; 12: 1323–1328. Miyazaki M, Itoh H, Kaiho T, Ambiru S, Togawa A, Sasada K et al.
BJS 2015; 102: 1–3
Combined vascular resection and reconstruction during hepatobiliary and pancreatic cancer surgery
Portal vein reconstruction at the hepatic hilus using a left renal vein graft. J Am Coll Surg 1995; 180: 497–498. 14 Suzuki T, Yoshidome H, Kimura F, Shimizu H, Ohtsuka M, Kato A et al. Renal function is well maintained after use of left renal vein graft for vascular reconstruction in
hepatobiliary-pancreatic surgery. J Am Coll Surg 2006; 202: 87–92. 15 Chu CK, Farnell MB, Nguyen JH, Stauffer JA, Kooby DA, Sclabas GM et al. Prosthetic graft reconstruction after portal vein resection in pancreaticoduodenectomy: a multicenter analysis. J Am Coll Surg 2010; 21: 316–324.
3
16 Bachellier P, Rosso E, Fuchshuber P, Addeo P, David P, Oussoultzoglou E et al. Use of a temporary intraoperative mesentericoportal shunt for pancreatic resection for locally advanced pancreatic cancer with portal vein occlusion and portal hypertension. Surgery 2014; 155: 449–456.
Snapshot quiz
Snapshot quiz 15/1 Question: What is this lesion in a small bowel resection of a 43-year-old man with a recent diagnosis of Crohn’s disease?
The answer to the above question is found on p. 15 of this issue of BJS. Kosai NR, Levin KB, Reynu R, Taher MM, Ali RAR, Palaniappan S: Minimally Invasive, Upper Gastrointestinal and Bariatric Surgery Unit, Department of Surgery, Faculty of Medicine, National University of Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Kuala Lumpur, Malaysia (e-mail: [email protected])
Snapshots in Surgery: to view submission guidelines, submit your snapshot and view the archive, please visit www.bjs.co.uk
© 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
www.bjs.co.uk
BJS 2015; 102: 1–3
