Clinical significance of liver ischaemia after pancreatic resection

Sir,

The aim of our study 'Clinical Significance of Liver Ischemia after Pancreatic Resection' was to characterize liver ischemia as a complication of “standard” pancreas resections. We found an incidence of 2.2% as a general risk in patients without any additional risk factors such as tumor infiltration of the hepatic artery, which underlines the importance of this possible complication.

In their letter referring to our article, Takaori et al. suggest a two-stage procedure with ligation of the hepatic artery before resection of tumors located in the body or tail of the pancreas as a prophylactic approach to prevent later liver perfusion disturbances when an extended distal pancreatectomy including resection of the celiac axis is performed [1]. This approach has been described in combination with radiological embolisation of the hepatic artery in 2000 by Kondo et al. [2]. The same group has published their experience in a 19-patient collective in 2007 [3]. However, the method described by Raut et al. [1] does not really comment our study and is dealing with a different topic.

Additionally, the authors have published their idea as a case report on one patient only. This seems to be not sufficient to draw any conclusion or give detailed recommendations for clinical management. A larger case series would be more appropriate to evaluate the feasibility and outcome. Nevertheless, the algorithm advocated by Raut et al. might be an option for selected patients “at risk” for liver ischemia due to preoperatively recognized tumor infiltration of the hepatic artery. However, larger published series dealing with this topic demonstrated that it is rarely necessary to perform any preconditioning of the liver and that hepatic artery resection can be safely performed in distal pancreatectomy without consecutive liver ischemia if the pancreatico-duodenal vessels are preserved [4, 5]. 

1) Raut V, Takaori K, Kawaguchi Y, Mizumoto M, Kawaguchi M, Koizumi M, Kodama S, Kida A, Uemoto S. Laparoscopic common hepatic artery ligation and staging followed by distal pancreatectomy with en bloc resection of celiac artery for advanced pancreatic cancer. Asian Journal of Endoscopic Surgery 2011;4(4): 199-202.

2) Kondo S, Katoh H, Shimizu T, Omi M, Hirano S, Ambo Y, Okushiba S, Morikawa T. Preoperative embolization of the common hepatic artery in preparation for radical pancreatectomy for pancreas body cancer.  Hepatogastroenterology 2000; 47(35): 1447-9.

3) Hirano S, Kondo S, Hara T, Ambo Y, Tanaka E, Shichinohe T, Suzuki O, Hazama K. Distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic body cancer: long-term results. Ann Surg. 2007; 246(1): 46-51.

4) Takahashi Y, Kaneoka Y, Maeda A, Isogai M. Distal pancreatectomy with celiac axis resection for carcinoma of the body and tail of the pancreas. World J Surg 2011; 35(11): 2535-42.

5) Wu X, Tao R, Lei R, Han B, Cheng D, Shen B, Peng C. Distal pancreatectomy combined with celiac axis resection in treatment of carcinoma of the body/tail of the pancreas: a single-center experience. Ann Surg Oncol 2010; 17(5): 1359-66.

• Commentor: MW Buchler - Department of Surgery, University of Heidelberg, Heidelberg
• Date: Feb 28, 2012

Sir,

Hackert et al. reported their experience of the postoperative liver perfusion failure in 762 consecutive patients undergoing pancreatic resection. Authors reported 2•2% incidence of postoperative live ischemia with 29% mortality rate (1). For prevention of postoperative liver ischemia, hereby we suggest our technique, particularly for the patients of pancreatic body cancers with major hepatic vessel involvement (2). We performed a two-stage procedure: Stage-1: laparoscopic staging and clamping of hepatic artery proper. Stage-2: Monitor liver functions for two weeks followed by open distal pancreatectomy with arterial resection for advanced carcinoma of the body of the pancreas.

Laparoscopic clamping of the common hepatic artery improves the collateral circulation to the liver through superior mesenteric artery via inferior pancreatico-duodenal and gastro-duodenal arteries, which we confirm by preoperative CT-angiography. With this technique, we have performed the extended pancreatic body resection, including resection of the coeliac axis without risk of postoperative liver ischemia. This method improves the chance of R0 pancreatic resection and potentially survival of a patient. Some authors advocate preoperative coil embolization of common hepatic artery for prevention of postoperative liver ischemia (3). However, preoperative coil embolization is expensive and may be useless, if peritoneal dissemination were found at the time of subsequent laparotomy. The patients with advanced cancer of pancreatic body and tail have a high risk of peritoneal dissemination (4). Thus, preoperative laparoscopy is useful to diagnosis occult metastasis missed by per-operative CT scan (5). Our technique not just helpful for prevention of postoperative liver ischemia but also identify the peritoneal metastasis missed by preoperative imaging.

Kyoichi Takaori, Vikram Raut, Shinji Uemoto
Department of Surgery, Kyoto University Hospital
drvikramraut@gmail.com

References:

1. Hackert T, Stampfl U, Schulz H, Strobel O, Buchler MW, Werner J. Clinical significance of liver ischaemia after pancreatic resection. Br J Surg 2011;98(12): 1760-1765.

2. Raut V, Takaori K, Kawaguchi Y, Mizumoto M, Kawaguchi M, Koizumi M, Kodama S, Kida A, Uemoto S. Laparoscopic common hepatic artery ligation and staging followed by distal pancreatectomy with en bloc resection of celiac artery for advanced pancreatic cancer. Asian Journal of Endoscopic Surgery 2011;4(4): 199-202.

3. Kondo S, Katoh H, Shimizu T, Omi M, Hirano S, Ambo Y, Okushiba S, Morikawa T. Preoperative embolization of the common hepatic artery in preparation for radical pancreatectomy for pancreas body cancer. Hepatogastroenterology 2000;47(35): 1447-1449.

4. Merchant NB, Conlon KC, Saigo P, Dougherty E, Brennan MF. Positive peritoneal cytology predicts unresectability of pancreatic adenocarcinoma. Journal of the American College of Surgeons 1999;188(4): 421-426.

5. Liu RC, Traverso LW. Diagnostic laparoscopy improves staging of pancreatic cancer deemed locally unresectable by computed tomography. Surg Endosc 2005;19(5): 638-642

• Commentor: Kyoichi Takaori, Vikram Raut, Shinji Uemoto - Department of Surgery, Kyoto University Hospital
• Date: Dec 27, 2011