Vascular Involvements in Cholangiocarcinoma: Tips and Tricks

Cholangiocarcinoma (CCA) is an aggressive malignancy of the biliary tract. To date, surgical treatment remains the only hope for definitive cure of CCA patients. Involvement of major vascular structures was traditionally considered a contraindication for resection. Nowadays, selected cases of CCA with vascular involvement can be successfully approached. Intrahepatic CCA often involves the major hepatic veins or the inferior vena cava and might necessitate complete vascular exclusion, in situ hypothermic perfusion, ex situ surgery and reconstruction with autologous, heterologous or synthetic grafts. Hilar CCA more frequently involves the portal vein and hepatic artery. Resection and reconstruction of the portal vein is now considered a relatively safe and beneficial technique, and it is accepted as a standard option either with direct anastomosis or jump grafts. However, hepatic artery resection remains controversial; despite accumulating positive reports, the procedure remains technically challenging with increased rates of morbidity. When arterial reconstruction is not possible, arterio-portal shunting may offer salvage, while sometimes an efficient collateral system could bypass the need for arterial reconstructions. Keys to achieve success are represented by accurate selection of patients in high-volume referral centres, adequate technical skills and eclectic knowledge of the various possibilities for vascular reconstruction.

Eight-Year Survival Following Left Hepatic Trisectionectomy With Combined Hepatic Artery And Portal Vein Resection For Advanced Perihilar Cholangiocarcinoma

We report the case of a patient with exceptional survival over 8 years after left trisectionectomy combined with portal vein and hepatic artery resection and reconstruction for advanced perihilar cholangiocarcinoma. Such extended hepatectomy with vascular resection is the only way to obtain free tumor margin. It can be performed with acceptable morbidity and mortality and it is the only hope to prolong survival.

Greater Saphenous Vein Graft Revascularization of the Left Hepatic Artery after Resection of Intrahepatic Cholangiocarcinoma with Common Hepatic Artery Resection

Resection of biliary tract malignancies may require resection of the hepatic vasculature. While immediate revascularization of the liver is necessary, reconstruction is difficult when the original vessels are unavailable. We document a case in which a segment of the common hepatic artery was excised during tumor resection and the remaining proximal vessel displayed intima dissection. A greater saphenous vein was placed as a bridge between the remaining left hepatic artery and gastroduodenal artery for successful revascularization.

Vascular Resections for Pancreatic Ductal Adenocarcinoma: Vascular Resections for PDAC

Background and Aims: It has become clear that vein resection and reconstruction for pancreatic ductal adenocarcinoma (PDAC) is the standard of care as supported by multiple guidelines. However, resection of large peri-pancreatic arteries remains debatable. Materials and Methods: This review examines the current state of vascular resection with curative intent for PDAC in the last 5 years. Herein, we consider venous (superior mesenteric vein, portal vein), as well as arterial (superior mesenteric artery, celiac trunk, hepatic artery) resection or both with or without reconstruction. Results: Improvement of multidrug chemotherapy has revolutionized care for PDAC that should shift traditional surgical thinking from an anatomical classification of resectability to a prognostic and biological classification. Conclusion: The present review gives an overview on the results of pancreatectomy associated with vascular resection, with consideration of new perspectives offered by the availability of better systemic therapies.