Utility of Microvascular Reconstruction in Gastrointestinal Cancer Surgery During Complex Resections and Emergency Salvage.

Major gastrointestinal surgical resections and subsequent reconstruction can occasionally need arterial or venous resection, can encounter variant anatomy, or may lead to injury to vessels. These can lead to arterial and/or venous insufficiency of viscera like the stomach, liver, colon, or spleen. Left unaddressed, these can lead to, partial or total, organ ischemia or necrosis. This can trigger a cascade of systemic clinical complications resulting in significant morbidity or even mortality. The aim of this case series is to highlight the utility of microvascular plastic surgical principles and practices in countering these vascular insufficiencies in emergency situations. Retrospective analysis of consecutive cases from March 2014 to May 2022, where intervention for emergency salvage of viscera was done. Microvascular surgical intervention for the vascular insufficient organ was performed, either by primary repair of vessels, use of interposition vein grafts, or anastomosis to a new source vessel (supercharging/super-drainage). Patients were monitored postoperatively for any signs of necrosis of viscera. Microvascular intervention was done in 21 cases: seven cases of supercharging of the gastric tube following esophagectomy, two cases of stomach salvage following pylorus-preserving pancreatoduodectomy, eight cases of hepatic artery restoration, two cases of splenic artery repair, and one each of colon salvage during coloplasty, etc. We were able to salvage the viscera of 20 cases. Arterial and venous insufficiencies can be predictably and safely reversed by precise microvascular techniques. Potentially, many greater numbers of patients can benefit from a microvascular approach to complex resections, injury, and viscera salvage.

Lesión quirúrgica de vía biliar compleja. Manejo conservador / Complex bile duct injury. Conservative management

RESUMEN La colecistectomía laparoscópica es el tratamiento de elección para la litiasis vesicular sintomática. Aunque la tasa de complicaciones es baja, las lesiones de la vía biliar representan un grave problema. La asociación con una lesión vascular (lesión compleja) genera un impacto adicional, disminuyendo la calidad de vida y la sobrevida a largo plazo. Presentamos el caso de una paciente con lesión compleja por compromiso vascular del pedículo hepático derecho que desarrolló una atrofia del parénquima correspondiente. Ante la ausencia de complicaciones sépticas, el tratamiento no operatorio pudo realizarse en forma exitosa.

ABSTRACT Laparoscopic cholecystectomy is considered the standard of care for symptomatic cholelithiasis. Although the rate of complications is low, bile duct injuries represent a serious problem. The association with vascular injury (complex injury) poses an additional impact by reducing the quality of life and long-term survival. We report the case of a female patient with complex injury due to vascular involvement of the right hepatic pedicle who developed right liver atrophy. Non-operative management was successful due to the absence of septic complications.

Risk factors of hepatic artery injury during percutaneous transhepatic biliary drainage / 中华普通外科杂志

Objective:To investigate the incidence and risk factors of hepatic artery injury during percutaneous transhepatic biliary drainage (PTBD).Methods:From Apr 2002 to Dec 2020, the clinical data of 1 446 patients undergoing PTBD were retrospectively analyzed.Results:Hepatic artery injury occurred in 7 cases, with an incidence of 0.48%. Fluoroscopy guided puncture was used in all cases. In those 7 cases (0.48%) a drainage catheter was failed to put in place after multiple attempts, hepatic artery injury occurred in 1 case; One drainage catheter was inserted in 1 314 cases (90.87%), hepatic artery injury occurred in 5 cases; One hundred and twenty-five cases (8.65%) were implanted with two drainage catheter, and 1 case had hepatic artery injury. Failure to successfully insert the drainage catheter increase the incidence of hepatic artery injury ( OR=0.06,95% CI 0.01-0.71, P=0.026) .There were 1 430 cases (98.89%) with oblique needle tip and 5 cases had hepatic artery injury; There were 16 cases (1.11%) with triangular needle tip and 2 cases had hepatic artery injury. Triangular needle tip increased the incidence of hepatic artery injury( OR=55.57, 95% CI 6.84-451.38, P<0.001). Conclusion:Hepatic artery injury is a rare complication of PTBD.The use of triangular needle and the failure of drainage were the risk factors of hepatic artery injury.

Laparoscopic repair of transected right hepatic artery during cholecystectomy: A report of two cases.

In laparoscopic cholecystectomy (LC), the treatment of iatrogenic biliary tract injury has been given much attention. However, most accidental right hepatic artery (RHA) injuries are treated with simple clipping. The reason is that the RHA has difficulty in revascularization, and it is generally considered that RHA injury does not cause serious consequences. However, some studies suggest that some cases of RHA ligation can cause a series of pathological changes correlated to arterial ischemia, such as liver abscess, bile tumor, liver atrophy and anastomotic stenosis. Theoretically, RHA blood flow should be restored when possible, in order to avoid the complications of right hepatic ischemia. The present study involved two patients, including one male and one female patient. Both patients were admitted to the hospital with the diagnosis of chronic cholecystitis and gallbladder stone, and developed ischemia of the right half hepatic after accidental transection of the RHA. Both patients underwent continuous end-end anastomosis of the RHA with 6-0 Prolene suture. After the blood vessel anastomosis, the right half liver quickly recovered to its original bright red. No adverse complications were observed in follow-ups at three and six months after the operation. Laparoscopic repair of the RHA is technically feasible. Reconstruction of the RHA can prevent complications associated with right hepatic ischemia.

Diagnosis,treatment and etiology of hepatic infarction and abscess after pancreaticoduodenal surgery / 中国实用外科杂志

OBJECTIVE: To explore the causes and treatment of hepatic infarction and abscessafter pancreaticoduodenal surgery.METHODS: The clinical data of 11 cases of hepatic infarction or abscess after pancreaticoduodenal surgery in Peking Union Medical College Hospital between January 2012 and December 2018 were analyzed retrospectively.RESULTS: A total of 11 patients were diagnosed of hepatic infarction or abscess after PD.The overall mortality rate was27.3%(3 of 11 patients).54.5%(6/11)had biliary fistula.Of the 11 patients,7 had proper hepatic artery and right accessory hepatic artery occlusion or stenosis,1 had abdominal trunk root stenosis before operation,and 3 had PV stenosis.Enterococcus and Klebsiella were the organisms most frequently cultured,and fungi were also the common pathogens.Antibiotics and selective percutaneous drainage were the main means of treatment.CONCLUSION: Ischemia of hepatic artery and portal vein after PD is the main cause of liver infarction and liver abscess.Biliary fistula and multiple pathogenic bacteria are often associated with high mortality.

Proper hepatic artery reconstruction with gastroduodenal artery transposition during pancreaticoduodenectomy.

INTRODUCTION: Vascular injuries to hepatic arterial blood flow present a challenge in reconstruction. The location and extent of the injury dictate intraoperative decision making, with repair being performed expeditiously to preserve hepatic function. Formal arterial repair either primarily or with interposition or transposition grafts is indicated in the majority of patients. Special consideration should be made in patients with underlying liver disease and those undergoing biliary reconstructions. This latter group of patients is at high risk of complications following the injury secondary to bile duct ischemia. METHODS: A case of proper hepatic artery (PHA) transection repaired with gastroduodenal artery (GDA) transposition is presented with a relevant review of limited literature available on the subject. RESULTS: During an elective pancreaticoduodenectomy the PHA was inadvertently transected just distal to the origin of the GDA. As the GDA had not been transected at this stage of the operation, it was available for transposition. This was performed, restoring arterial blood flow to the liver and the bile duct. The patient did well postoperatively with no evidence of biliary or pancreatic leak or hepatic dysfunction at both discharge and follow-up clinic visit. CONCLUSION: Injuries to hepatic artery injury are uncommon in experienced hands. This case report is only the second instance of such injury requiring reconstruction in 434 cases of single operator experience pancreaticoduodenectomies. We present arterial transposition of GDA as a feasible method to ensure adequate arterial supply to the hepatobiliary system.