review of literature on clinical pancreatology - The Pancreapedia

safe option as an interposition graft for portomesenteric venous reconstruction afterpancreaticoduodenectomy [481].Arterial reconstruction at pancreatic resectionThe arterial anatomy supplying the liver is highly variable. A replaced common hepatic arteryoriginating from superior mesenteric artery is a rare anomaly. It was presented the case <strong>of</strong> apatient with retropancreatic lymph nodes recurrence after laparoscopic cholecystectomy forpT2 gallbladder carcinoma, whose replaced common hepatic artery arose from the superiormesenteric artery. It was performed a Whipple operation en bloc with the replaced commonhepatic artery resection (enhanced by the tumour). The arterial reconstruction was needed(due to the severe decrease <strong>of</strong> the arterial flow after clamping the replaced common hepaticartery), using the splenic artery, without any serious complications [482].The authors report a case <strong>of</strong> operative injury <strong>of</strong> the hepatic artery during a total splenopancreasectomyprocedure for a mixed-type intraductal papillary mucinous neoplasm. Duringthe preparation <strong>of</strong> the structures <strong>of</strong> the hepatic pedicle, a "true" hepatic artery was notidentified, but only a small arterial vessel measuring about 2 mm in diameter, just in front <strong>of</strong>the portal vein, apparently emerging from the parenchyma <strong>of</strong> the pancreatic head. To obtaincomplete mobilisation <strong>of</strong> the duodeno-pancreatic block from the portal vein, it was necessaryto cut this small arterial vessel. In the postoperative period, the patient developed extensiveliver ischaemia, which was gradually resolved, but resulted in multiple stenosis <strong>of</strong> the intraandextra-hepatic biliary tree. At follow-up at three years, the patient was in fairly goodcondition, with a permanent percutaneous biliary drainage, but with no clinical or radiologicalsigns <strong>of</strong> local or distant disease. Although interruption <strong>of</strong> hepatic arterial flow is usually welltolerated, this is not always the case. It is important to predict in what circumstancescomplications are likely to occur. The main determinants that should guide the surgeon facedwith this problem are whether the portal circulation is normal, whether structures carryingcollateral blood supply have been interrupted, and whether some form <strong>of</strong> biliaryreconstruction is needed [483].Extended lymphadenectomySeveral factors argue for extended lymphadenectomy in surgery for pancreaticadenocarcinoma: 1) lymph node extension is an adverse prognostic factor; 2) some tumorrecurrences are only loco-regional suggesting that initial resection was insufficient; 3) someretrospective studies suggest that extension <strong>of</strong> lymphadenectomy improves post-resectionsurvival. Extended lymphadenectomy, including circumferential dissection <strong>of</strong> both the celiacaxis and the superior mesenteric artery and resection <strong>of</strong> para-aortic nodes, was evaluated by4 randomized trials; globally there was no survival benefit. Extended lymphadenectomyincreases, at least transiently, the risk <strong>of</strong> post-operative diarrhea. Its influence on the rate <strong>of</strong>loco-regional recurrences has not been evaluated. However, this technique should not bedefinitively and globally precluded since a more radical resection was associated with a trendtoward better long-term survival in the trial with the largest number <strong>of</strong> patients [484].CryosurgeryTo test the feasibility <strong>of</strong> cryosurgery for pancreatic carcinoma and to observe theconsequence <strong>of</strong> cryosurgery by two different techniques. Twelve healthy pigs underwentlaparotomy, during which, chop amputation <strong>of</strong> common bile duct and duodenum wereperformed, meanwhile other intra-abdominal organs with the pancreas were isolated. Twodifferent techniques <strong>of</strong> cryosurgery were performed on the pancreas. Group A (n=6)accepted the mild hypothermic cryosurgery with liquid nitrogen superficial refrigeration, andgroup B (n=6) were performed with the deep hypothermic cryosurgery at -170 o C with