Leading article

Combined vascular resection and reconstruction during

hepatobiliary and pancreatic cancer surgery
M. Miyazaki
Department of General Surgery, Chiba University, 1-8-1, Inohana, Chuoh-ku, Chiba, 260-0856 Japan (e-mail: masaru@faculty.chiba-u.jp)

Based on the BJS lecture at the 21st Annual Meeting of the European Surgical Association, Athens, Greece, April 2014
Published online 21 August 2014 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9618

Hepatobiliary and pancreatic malignancies frequently involve major

vessels such as the inferior vena
cava (IVC), hepatic vein, portal vein
and foregut arteries, especially the
hepatic artery. Tumours involving
these structures are often considered
unresectable and the patients incurable. Early efforts to include vascular
resections as part of hepatectomy
and pancreatectomy were associated
with increased surgical morbidity and
mortality, but recent studies from
high-volume centres have shown that
combined vascular resections can be
undertaken safely with acceptable
morbidity and mortality. In turn, this
might lead to better outcomes in
selected patients.
The retrohepatic IVC may be
involved by direct invasion in the context of hepatic metastases, intrahepatic
cholangiocarcinoma and gallbladder
carcinoma. Hepatocellular carcinoma
is often associated with intracaval
extension of tumour thrombus. Surgical resection of hepatic metastases
involving the IVC was reported in
16 patients from Chiba University
in 19991 when surgical morbidity
and mortality rates were 25 and 6
per cent respectively, with a 5-year
survival rate of 27 per cent. In the
past few years, European series from
Leeds2 and Paris3 have reported IVC
resections combined with hepatectomy, with surgical mortality rates
between 11 and 14 per cent, and a
5-year survival rate approaching 40
per cent. In a series of 60 patients
undergoing combined IVC resections
with hepatectomy, including ex vivo
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procedures in six, Hemming and

colleagues4 had a surgical mortality
rate of 8 per cent with 35 per cent 5year survival. Replacement of the cava
may be necessary after circumferential
resection5 in patients who before
surgery have poor development of a
collateral circulation, when oliguria
occurs or if haemodynamic stability
cannot be maintained during surgery.
Portal vein resection as a component of hepatectomy is sometimes
necessary for patients with intrahepatic cholangiocarcinoma, hilar
cholangiocarcinoma and gallbladder
cancer. The Chiba series reported in
20076 showed that combined vascular
resection was performed in 43 of 161
patients with hilar cholangiocarcinoma who underwent surgical resection. Surgical mortality rates were 4
and 8 per cent in the non-vascular
resection and portal vein resection
groups respectively, but the 5-year survival rate was 25 per cent after portal
vein resection. Interestingly, if hepatic
artery resection was also needed in an
attempt to achieve clear margins, survival was the same as that in patients
with unresectable disease. Neuhaus
and co-workers7 also reported longterm survival after combined portal
vein resection for hilar cholangiocarcinoma with a 5-year survival rate of
58 per cent. On the contrary, Nagino
et al.8 reported that hepatectomy with
simultaneous resection of the portal
vein and hepatic artery for advanced
perihilar cholangiocarcinoma resulted
in favourable long-term outcomes
with acceptable mortality. However,
most publications suggest that surgical

mortality rates lie between 2 and 15

per cent, but with a beneficial effect
on long-term survival in patients with
hilar cholangiocarcinoma. A systematic review and meta-analysis9 of the
role of vascular resection in the treatment of hilar cholangiocarcinoma
demonstrated that increased morbidity and mortality was due mainly to the
addition of hepatic artery resection
compared with portal vein resection
alone. This review also showed that
routine vascular resection did not
always improve negative resection
margin rates and had no impact on
long-term survival. From this point
of view, portal vein resection should
not be undertaken routinely and done
only where there is suspicion of cancer
invasion. Combined hepatic arterial
resection results in higher morbidity
and mortality with no proven survival benefit and should therefore be
performed in select patients.
Portal vein resection as part of pancreatectomy is now widely regarded
as a safe and feasible procedure with
acceptable morbidity and mortality
rates. Combined portal vein resection
with pancreatectomy should be considered where there is a suspicion of
invasion of the portal vein to achieve
clear resection margins on the basis
of preoperative imaging rather than
making the decision purely on operative findings. Unlike the situation with
hepatic resections, combined arterial
resections involving the coeliac axis, at
least in the context of distal pancreatectomy, have been reported without a
marked increase in surgical mortality.
Distal pancreatectomy with en bloc
BJS 2015; 102: 13

coeliac axis resection resulted in a

high rate of complete resection and
favourable prognosis (estimated overall 5-year survival rate 42 per cent) in
selected patients with locally advanced
pancreatic body cancer10,11 . Arterial
resections involving the coeliac artery
and its major branches, as well as
multivisceral ex vivo surgery for
tumours involving coeliac and superior mesenteric arteries, may be
reasonable options for locally invasive
tumours with low metastatic potential,
such as sarcomas, as reported by the
Miami group12 recently.
A variety of substitutes for venous
reconstruction have been reported.
Jugular, external iliac vein, great
saphenous vein, left renal and umbilical veins, as well as synthetic grafts
have all been used for portal vein
reconstruction. As many of these
resections may involve contaminated
bile and because postoperative infectious complications occur frequently,
synthetic grafts are probably best
avoided. The clinical usefulness of a
left renal vein graft for reconstruction
of the portal vein was first reported
from Chiba in 199513 . No obvious left
kidney dysfunction has been found
after the harvest of left renal vein
graft at this centre14 . Other groups
have also used this graft successfully. The technique has a number
of advantages over other substitutes.
The left renal vein is obtained from
the same operative field without an
additional skin incision. It is harvested
quickly and easily, usually taking
only 510 min. The calibre of the
vein is often a suitable match for the
portal vein to be reconstructed. The
patency rate in an experience of 35
patients using a left renal vein graft
for portal vein reconstruction was 100
per cent, even at long-term followup14 . Synthetic graft reconstruction
after portal vein resection in pancreaticoduodenectomy was reported
recently in a multicentre analysis15 .
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Published by John Wiley & Sons Ltd

M. Miyazaki

Among 36 procedures, the overall

graft patency rate was 76 per cent, and
portal vein thrombosis within 30 days
after surgery occurred in 91 per cent.
It would seem that a synthetic graft
should not be selected as a portal vein
substitute if an autogenous vein graft
is available. An alternative approach is
the use of a synthetic graft as an intraoperative temporary portal vein shunt,
followed by its removal after tumour
excision combined with portal vein
resection16 .
Combined vascular resection during
hepatobiliary and pancreatic cancer
resections can expand the indications
for surgery. This might lead to a
survival benefit for some patients
with locally advanced tumours and
no evidence of distant metastases.
In view of the complication rates,
these procedures should probably be
restricted to carefully selected patients
at high-volume centres.

Disclosure

The author declares no conflict of

interest.
10

References
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