Distal pancreatectomy with resection of the celiac trunk, right or left hepatic artery without arterial reconstruction (extended DP-CAR)

Hemodynamic, Surgical and Oncological Outcomes of 40 Distal Pancreatectomies with Celiac and Left Gastric Arteries Resection (DP CAR) without Arterial Reconstructions and Preoperative Embolization

“…Ultrasound-confirmed intraparenchymal arterial blood flow ≥20 cm/s was the main criterion of adequate collateral arterial blood flow even if pulsation on the hepatoduodenal ligament disappeared. Arterial blood flow happened to be sufficient to preserve the spleen and liver in a 50% decrease in linear blood flow velocity [ 48 ]. No postoperative liver infarctions and abscesses are important evidence of effective IOUS for monitoring of collateral hepatic blood flow adequacy.…”

“…No postoperative liver infarctions and abscesses are important evidence of effective IOUS for monitoring of collateral hepatic blood flow adequacy. Such blood flow was sufficient to ensure liver metabolism even in the disappearance of hepatoduodenal ligament pulsation and additional resection of one of the hepatic arteries [ 48 ]. Precise IOUS of hepatic blood flow and postoperative maintenance of systolic blood pressure ≥130 mm Hg within 3 days may be a possible cause of no liver ischemia and no arterial reconstructions in our study.…”

“…Nevertheless, liver and stomach ischemia is a typical adverse event for this procedure. Various methods for prevention of these complications include analysis of hepatoduodenal ligament pulsation, preoperative embolization, and ligation of the common hepatic artery [ 13 , 26 , 27 , 29 , 31 ], left gastric artery [ 13 ], celiac axis and its branches [ 13 , 51 , 52 ], aortic stenting for celiac axis blockade [ 32 ], direct measurement of pressure in common hepatic artery stump [ 8 ], intraoperative Doppler ultrasound of intraparenchymal liver arteries [ 28 ], intraoperative ICG fluorescence angiography [ 48 ] and prophylactic reconstruction of hepatic and/or left gastric artery in suspected inadequate arterial blood supply to the liver and/or stomach [ 8 , 11 , 12 , 13 , 14 , 15 ] were proposed. However, ischemic complications occur despite using these methods [ 11 , 12 , 13 , 14 , 15 , 20 , 21 , 22 , 23 , 24 , 25 ].…”

“…The adequacy of the collateral flow to the liver was assessed using pulse and IO Doppler US measurements from the arteries in the hepatoduodenal ligament and liver parenchyma. Detection of the main or collateral intraparenchymal arterial flow velocity ≥ 20 cm/sec after clamping the CHA and LGA is considered sufficient even in cases of undetectable pulse on the hepatoduodenal ligament [ 48 ]. The adequacy of the collateral flow to the stomach was assessed visually and via pulsation over the right gastroepiploic artery (RGEA) and ICG-based near-infrared fluorescence imaging (the last 11 cases).…”