A Novel Technique for Reconstruction of Right and Left Hepatic Arteries in Pancreaticoduodenectomy

Open pancreaticoduodenectomy was performed. During the procedure gross tumour involvement of the proper hepatic artery and its bifurcation was seen. Vascular surgery was involved and resection and reconstruction performed. For resection of the diseased segment the proper hepatic artery was clamped proximally, as were the left and right hepatic arteries. A Fogarty catheter was introduced retrograde and anterograde to remove thrombus and heparinised saline was injected. The diseased section was removed, the remnant proper hepatic artery anastomosed to the remnant common hepatic artery, and the left gastric artery to the remnant left hepatic artery. Both were end-to-end direct anastomoses with 6-0 prolene suture. Doppler ultrasound confirmed patency of all anastomoses prior to closure.

Malignancy involving the proper hepatic artery including its bifurcation.

As for pancreaticoduodenectomy in general.

OmniTract was used for retraction. 6-0 prolene sutures were used for the vascular anastomoses.

Supine

A 55yo lady presenting with gastric outlet obstruction was found to have an obstructing duodenal mass. Her background includes BRCA1 +ve, previous breast cancer requiring bilateral mastectomy and prophylactic oophorectomy. Biopsy demonstrated poorly differentiated duodenal adenocarcinoma. CT demonstrated a 5cm mass with irregular borders at the gastroduodenal junction (as seen in the coronal CT slice included in the video), however there was no evidence of vascular involvement. PET/CT confirmed FDG avid duodenal disease (SUVmax 9.0) with mild porta hepatis lymph node avidity (SUVmax 3.9) and no distant metastases.

As for pancreaticoduodenectomy in general.

On top of the usual risks of pancreaticoduodenectomy there may be additional risk of hepatic artery thrombosis or hepatic infarction due to vascular reconstruction. In this case doppler ultrasound showed good flow through all involved vessels including hepatic arteries prior to completion of the operation. Synthetic function of the liver and bilirubin recovered to appropriate levels postoperatively, suggesting good patency of the reconstructed arteries.

Vascular involvement does however portend a poorer prognosis. Histopathology demonstrated 55mmx35mm poorly differentiated carcinoma at the gastro-duodenal junction, pT4b, pN1 (cM0). Tissue from the common hepatic artery flexure was confirmed as metastatic carcinoma while tissue from the right hepatic artery showed no evidence of malignancy. She was discharged home and planned for adjuvant chemotherapy.

Nil

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