The aim of the study was to identify the survival of patients with locally advanced pancreatic cancer (LAPC) and assess the effect of surgical resection after neoadjuvant therapy on patient outcomes.An increasing number of LAPC patients who respond favorably to neoadjuvant therapy undergo surgical resection. The impact of surgery on patient survival is largely unknown.All LAPC patients who presented to the institutional pancreatic multidisciplinary clinic (PMDC) from January 2013 to September 2017 were included in the study. Demographics and clinical data on neoadjuvant treatment and surgical resection were documented. Primary tumor resection rates after neoadjuvant therapy and overall survival (OS) were the primary study endpoints.A total of 415 LAPC patients were included in the study. Stratification of neoadjuvant therapy in FOLFIRINOX-based, gemcitabine-based, and combination of the two, and subsequent outcome comparison did not demonstrate significant differences in OS of 331 non-resected LAPC patients (P = 0.134). Eighty-four patients underwent resection of the primary tumor (20%), after a median duration of 5 months of neoadjuvant therapy. FOLFIRINOX-based therapy and stereotactic body radiation therapy correlated with increased probability of resection (P = 0.006). Resected patients had better performance status, smaller median tumor size (P = 0.029), and lower median CA19-9 values (P < 0.001) at PMDC. Patients who underwent surgical resection had significant higher median OS compared with those who did not (35.3 vs 16.3 mo, P < 0.001). The difference remained significant when non-resected patients were matched for time of neoadjuvant therapy (19.9 mo, P < 0.001).Surgical resection of LAPC after neoadjuvant therapy is feasible in a highly selected cohort of patients (20%) and is associated with significantly longer median overall survival.

This study assesses the safety and outcomes of the largest cohort of pancreatectomy with arterial resection (P-AR).A high postoperative mortality rate and uncertain oncologic benefits have limited the use of P-AR for locally advanced pancreatic adenocarcinoma.We retrospectively reviewed a prospectively maintained database of patients who underwent P-AR between January 1990 and November 2017. Univariate and multivariate Cox analyses were used to assess prognostic factors for survival.There were 118 consecutive resections (51 pancreaticoduodenectomies, 18 total pancreatectomies, and 49 distal splenopancreatectomies). Resected arterial segments included the coeliac trunk (50), hepatic artery (29), superior mesenteric artery (35), and other segments (4). The overall mortality and morbidity were 5.1% and 41.5%, respectively. There were 84 (75.4%) patients who received neoadjuvant chemotherapy, 105 (89%) simultaneous venous resections, and 101 (85.5%) arterial reconstructions. The rates of R0 resection and pathologic invasion of venous and arterial walls were 52.4%, 74.2%, and 58%, respectively. The overall survival was 59%, 13%, and 11.8% at 1, 3, and 5 years, respectively. The median overall survival after resection was 13.70 months (CI 95%:11-18.5 mo). In multivariate analysis, R0 resection (HR: 0.60; 95% CI: 0.38-0.96; P = 0.01) and venous invasion (HR: 1.67; 95% CI: 1.01-2.63; P = 0.04) were independent prognostic factors.In a specialized setting, P-AR for locally advanced pancreatic adenocarcinoma can be performed safely with limited mortality and morbidity. Negative resection margin and the absence of associated venous invasion might predict favorable long-term outcomes.

Anatomic variations in the hepatic arteries were studied in donor livers that were used for orthotopic transplantation.Variations have occurred in 25% to 75% of cases. Donor livers represent an appropriate model for study because extrahepatic arterial anatomy must be defined precisely to ensure complete arterialization of the graft at time of transplantation.Records of 1000 patients who underwent liver harvesting for orthotopic transplantation between 1984 and 1993 were reviewed.Arterial patterns in order of frequency included the normal Type 1 anatomy (n = 757), with the common hepatic artery arising from the celiac axis to form the gastroduodenal and proper hepatic arteries and the proper hepatic dividing distally into right and left branches; Type 3 (n = 106), with a replaced or accessory right hepatic artery originating from the superior mesenteric artery; Type 2 (n = 97), with a replaced or accessory left hepatic artery arising from the left gastric artery; Type 4 (n = 23), with both right and left hepatic arteries arising from the superior mesenteric and left gastric arteries, respectively; Type 5 (n = 15), with the entire common hepatic artery arising as a branch of the superior mesenteric; and Type 6 (n = 2), with the common hepatic artery originating directly from the aorta.These data are useful for the planning and conduct of surgical and radiological procedures of the upper abdomen, including laparoscopic operations of the biliary tract.

The presence of an aberrant right hepatic artery (a-RHA) could influence the oncological and postoperative outcomes after pancreaticoduodenectomy (PD). A comparative study was conducted, including patients who underwent PD with a-RHA or with normal RHA anatomy. The primary endpoints were R1 resection in all margins (pancreatic, anterior, posterior, superior mesenteric artery, and portal groove), overall survival (OS), and disease-free survival (DFS). The secondary endpoints were morbidity, mortality, biliary leak (BL), postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), post pancreatectomy hemorrhage (PPH), length of stay (LOS), and operative time (OT). The selection bias was measured using the d-value and limited using entropy balancing analysis. Patients with arterial variants were 84 (37.5%), 39 (17.4%) of whom had a-RHA from SMA. The patients with a-RHA were more frequently symptomatic (d = 0.652), often affected by PDAC (d = 0.369), and judged borderline resectable (d = 0.588). Neoadjuvant therapy was more frequently proposed for patients with a-RHA (d = 0.465). The patients with a-RHA often had the Wirsung dilated compared to those without a-RHA (d = 0.336). After bias correction, the R1 resection rate on the superior mesenteric artery (SMA) margin was higher in the a-RHA group than in patients with normal RHA anatomy (OR 2.3; 1.1-5.2; P = 0.045). OS, DFS, morbidity, mortality, biliary leak (BL), postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), post pancreatectomy hemorrhage (PPH), length of stay (LOS), and operative time (OT) were similar in unmatched and matched population. The presence of a-RHA seems to increase the risk of R1 resection in the SMA margin.© 2025. The Author(s).

En-bloc celiac axis resection (CAR) was first proposed by Lyon H. Appleby in 1952 for gastric cancer and later modified for pancreatic resections with gastric preservation by Nimura et al. in 1976. CAR remains uncommon, performed in fewer than 0.2 cases annually. Advancements in preoperative imaging and anatomy understanding, ischemic complication management, and centralization of care have improved outcomes. This report presents a robotic distal pancreatectomy (DP) with CAR and superior mesenteric artery (SMA) divestment.A 65-year-old woman presented with back pain. Imaging revealed biopsy-proven pancreatic adenocarcinoma in the pancreatic body, encasing the celiac, splenic, and common hepatic arteries with SMA abutment. Following four cycles of neoadjuvant FOLFIRINOX, follow-up imaging demonstrated stable disease without metastasis. The need for hepatic artery reconstruction was assessed intraoperatively, with alternative strategies detailed in the accompanying video.The patient underwent a distal pancreatectomy and splenectomy with class Ia CAR. Surgery was conducted in a caudal approach, lasted 420 minutes with minimal blood loss (100 ml). Laparoscopic ultrasound (lapUS) and indocyanine green (ICG) perfusion were used to assess resectability, vascular perfusion, and targeted blood vessels. The postoperative course was uneventful, except for a Grade B chyle leak managed conservatively. No liver or gastric ischemia occurred. Adjuvant chemotherapy was initiated two months postoperatively.Enhanced visualization, improved dexterity, and adjuncts including lapUS and ICG are potential benefits that are available to surgeons with the robotic platform when performing arterial divestment and CAR via a caudal approach.© 2025. Society of Surgical Oncology.

It is common for the liver to be supplied blood by a hepatic artery branching off the coeliac trunk. Occasionally, a replaced common hepatic artery (RCHA), emerges from the superior mesenteric artery (SMA), can supply the liver in 1.5-4.0% of cases. Computed tomography (CT) angiography is a highly accurate method for identifying arterial anomalies, which may remain undetected until the time of surgery, leading to unexpected complications.A 53-year-old male exhibiting symptoms of decreased appetite, weight loss, vomiting, and altered sclera, urine, and stool colour, underwent a contrast-enhanced CT scan revealing biliary tract dilatation and pancreatic abnormalities, leading to a pancreaticoduodenectomy. During the surgery, an uncommon arterial finding-CHA from SMA-was noted. Pancreatic cancer was confirmed. The patient was discharged a week post-surgery without issues, emphasizing perioperative care progress.The authors' study focused on the detection conditions of the same hepatic artery anomaly in eight cases reported between 2017 and 2023. In two of them the anomaly was discovered in cadaver by routine autopsy. In three cases, this variation was identified before the surgery, but in three other cases it wasn't detected until the surgical procedure. In the authors' case, due to multiple reasons, the anomaly remained undetectable until the surgery.This study underscores the importance of thorough preoperative evaluation to grasp vascular variations for better patient care. Also, a noteworthy observation in our case is that the surgeon identified an expanded hepatic vessel, prompting further investigation into this anomaly.Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.

Spleen preservation during laparoscopic distal pancreatectomy (LSPDP) should be pursued if safe and oncologically justified. The aim of the presented study was to compare surgical outcomes and identify risk factors for unplanned splenectomy during laparoscopic distal pancreatectomy and evaluate short and long-terms outcomes.The following study is a retrospective cohort study of consecutive patients who underwent laparoscopic distal pancreatectomy, with the intention of preserving the spleen, for benign tumors of the body and tail of the pancreas between August 2012 and December 2022. Follow-up for patients' survival was completed in January 2023. In all, 106 patients were in total included in this study. Median age was 58 (41 to 67) years. The study population included 29 males (27.4%) and 77 females (72.6%).Spleen preservation was possible in 67 (63.2%) patients. The tumor size was larger in the splenectomy group (respectively, 30 (16.5 to 49) vs. 15 (11 to 25); P<0.001). Overall, serious postoperative morbidity was 13.4% in the LSPDP group and 20.5% in the second group (P=0.494). There were no perioperative deaths. The postoperative pancreatic fistula rate was 18% in the splenectomy group and 14.9% in the LSPDP group, while B and C fistulas were diagnosed in 15.4% and 10.5% of patients, respectively. In the multivariate logistic regression model, tumor size >3 cm was found to independently increase odds for unplanned splenectomy (OR 8.41, 95%CI 2.89-24.46; standardized for BMI).Unplanned splenectomy during the attempt of LSPDP does not increase the risk for postoperative morbidity and postoperative pancreatic fistula. The independent risk factor for unplanned splenectomy during LSPDP is tumor size above 3 cm.Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.

\nThe incidence of delayed gastric emptying (DGE) is high in patients undergoing distal pancreatectomy with celiac axis en‐bloc resection (DP‐CAR).

Laparoscopic radical antegrade modular pancreatosplenectomy (Lap-RAMPS) for left-sided pancreatic cancer remains a technically challenging procedure. How to approach the splenic artery in laparoscopic surgery has not been discussed in adequate detail, and the implications of an artery-first approach in left-sided pancreatic cancer remain unclear.Forty-five consecutive patients with left-sided resectable pancreatic cancer underwent Lap-RAMPS between July 2018 and September 2020. They were divided according to whether Lap-RAMPS was performed using an anterocranial splenic artery-first (ASF) approach (ASF group, n = 23) or via another approach (non-ASF group, n = 22). Clinical, pathological, and short-term outcomes were reviewed and compared between the groups.The ASF approach was performed safely in all patients with resectable left-sided pancreatic cancer, and none required conversion to laparotomy. The ASF group had better outcomes in terms of conspicuous bleeding from the spleen during splenic mobilization (P = 0.016) and blood pooling during posterior dissection (P = 0.035). Consequently, blood loss was significantly less and operation time was significantly shorter in the ASF group than in the non-ASF group. There was no significant between-group difference in other short-term outcomes, including mortality, length of hospital stay, or Clavien-Dindo classification.The ASF approach was safe when performed for resectable left-sided pancreatic cancer and may help to prevent congestion of the pancreas and lessen intraoperative blood loss.© 2022. Society of Surgical Oncology.

In recent years multidetector computed tomography (MDCT) has been used to investigate vascular anatomy for scientific and diagnostic purposes. These studies allow for much larger sample sizes than traditional cadaveric studies. The aim of this research was to perform a systematic review and meta‐analysis on studies investigating the variations of the celiac trunk using MDCT. Major medical databases were used to find studies investigating celiac trunk anatomy using MDCT. Extracted information included demographic details, number of normal celiac trunks, and number of each variant celiac trunk. Using a random effects meta‐analysis the pooled prevalence of each variation was calculated. A total of 36 studies from 14 countries and four continents were included in the meta‐analysis. The total number of subjects included was 17,391. The total prevalence of variant celiac trunks was 10.85%. The different types of celiac trunk variations with their prevalences were: gastrosplenic trunk (3.46%), hepatosplenic trunk (3.88%), hepatogastric trunk (0.24%), absent celiac trunk (0.28%), celiacomesenteric trunk (0.46%), hepatosplenomesenteric trunk (0.26%), gastrosplenomesenteric trunk (0.07%), and celiacomesenteric anastomosis (0.09%). A total of 61 cases (0.19%) were either not described or not described adequately to be included in our classification. Major variations of the celiac trunk are not uncommon and should be anticipated before radiological and surgical interventions. Knowledge of celiac trunk anatomy is important in hepatopancreatobiliary surgery, transplantology, and interventional radiology.

Pancreaticoduodenectomy with vascular resection/reconstruction can be safely completed following 6 standard steps plus basic principles of vascular surgery. Particular attention is paid to the location of the tumor relative to the 2 first-order vein branches, portal vein -splenic vein -superior mesenteric vein confluence, inferior mesenteric vein, and the presence of arterial perineural invasion. Successful resection following neoadjuvant therapy can result in median survival 3 times that of historical controls.Copyright © 2021 Elsevier Inc. All rights reserved.

Mesopancreas dissection with central vascular ligation and the superior mesenteric artery (SMA)-first approach represent the cornerstone of current principles for radical resection for pancreatic head cancer. The surgeon dissecting around the SMV and SMA should be aware regarding the anatomical variants in this area. The aims of this systematic review and meta-analysis are to detail the surgical anatomy of the superior mesenteric vessels and to propose a standardized terminology with impact in pancreatic cancer surgery.We conducted a systematic search to identify all published studies in PubMed/MEDLINE and Google Scholar databases from their inception up to March 2017.Seventy-eight studies, involving a total of 18,369 specimens, were included. The prevalence of the mesenteric-celiac trunk, replaced/accessory right hepatic artery (RRHA), common hepatic artery, and SMV inversion was 2.8, 13.2, 2.6, and 4.1%, respectively. The inferior pancreaticoduodenal artery has its origin into the first jejunal artery, SMA, and RRHA, in 58.7, 35.8, and 1.2% of cases, respectively. The SMV lacks a common trunk in 7.5% of cases. The first jejunal vein has a trajectory posterior to the SMA in 71.8% of cases. The left gastric vein drains into the portal vein in 58%, in splenic vein (SV) in 35.6%, and into the SV-PV confluence in 5.8% of cases.Complex pancreaticoduodenal resections require detailed knowledge of the superior mesenteric artery and vein, which is significantly different from the one presented in the classical textbooks of surgery. We are proposing the concept of the first jejunopancreatic vein which impacts the current oncological principles of pancreatic head cancer resection.

The arc of Buhler (AOB) is a direct anastomosis of the celiac axis and superior mesenteric artery. This paper reviews the literature on the AOB and provides accurate and up-to-date data on its prevalence, anatomy, and clinical significance. The main scholarly online databases were carefully searched for relevant studies related to the AOB. Information was gathered and formed the basis of the analysis of this study. In total, 11 studies were used in this meta-study, consisting of 3685 total patients tested and 50 cases of the AOB presented. The pooled prevalence estimate of the AOB was determined to be 1.7% (95% CI 0.9, 2.9). By imaging type, the prevalence of the AOB was 1.8% for radiological studies (n = 3485; 95% CI 0.9, 3.0), 1.4% for computed tomography (CT) studies (n = 1417; 95% CI 0.4, 3.0), and 1.9% for angiography studies (n = 2068; 95% CI 0.5, 4.0). The AOB is sufficiently significant and should be considered when planning surgeries or radiological procedures involving the abdomen.© 2023. The Author(s).

To investigate the diameter changes of Riolan's arch in patients with isolated superior mesenteric artery dissection (ISMAD) and to evaluate the implication for treatment selection.Ninety-five patients with CT angiography (CTA) confirmed ISMAD were retrospectively included, and another 95 cases with no positive findings on abdominal CTA were included as controls. According to the treatment methods, the patients were subsequently divided into conservative treatment (n = 68) or invasive treatment (n = 27) subgroups. According to the initial CTA images, the prevalence of Riolan's arch as well as its diameter (D) were determined in each subject, and compared between ISMAD and control cases, as well as between patients with different treatments. In patients with ISMAD, dissections were classified according to the Li classification.Riolan's arch prevalence and D were significantly elevated in the ISMAD group compared with the control group (83.16% vs. 35.79%, P < 0.001; 2.63 ± 0.56 mm vs. 2.12 ± 0.39 mm, P < 0.001). Patients with invasive treatment had significantly higher baseline D (2.93 ± 0.57 mm vs. 1.89 ± 1.14 mm, P < 0.001), and higher proportion of high-risk dissection (P < 0.001) than those administered conservative treatment. Binary logistic regression revealed D (OR = 2.771, 95% CI 1.157-6.638, P = 0.022) and Li classification (OR = 0.107, 95% CI 0.019-0.586, P = 0.010) were independent risk factors for treatment selection. With cutoff of 2.635 mm, the area under the curve, sensitivity, and specificity were 0.805, 0.778 and 0.794, respectively.Dilation of Riolan's arch is common in patients with ISMAD, and Riolan's arch diameter could be a convenient indicator of disease severity and inform subsequent treatment.© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.

Median arcuate ligament syndrome (MALS) is an uncommon condition characterized by the compression of the celiac trunk by the median arcuate ligament. Due to the anatomical proximity to the foregut, MALS has significant implications in hepato-pancreato-biliary (HPB) surgery. It can pose complications in pancreatoduodenectomy and orthotopic liver transplantation, where the collateral arterial supply from the superior mesenteric artery is often disrupted. The estimated prevalence of MALS in HPB surgery is approximately 10%. Overall, there is consensus for a cautious approach to MALS when embarking on complex foregut surgery, with a low threshold for intraoperative median arcuate ligament release or hepatic artery reconstruction. The role of endovascular intervention in the management of MALS prior to HPB surgery continues to evolve, but more evidence is required to establish its efficacy. Recognizing the existing literature gap concerning optimal management in this population, we describe our tertiary center experience as a clinical algorithm to facilitate decision-making. Research question: What is the significance and management of median arcuate ligament syndrome in patients undergoing hepato-pancreato-biliary surgery?