J Hepatobiliary Pancreat Sci (2014) 21:251–255 DOI: 10.1002/jhbp.84
TOPIC
Computer assisted surgery, preoperative planning and navigation for pancreatic cancer Yuta Abe · Osamu Itano · Minoru Kitago · Masahiro Shinoda · Hiroshi Yagi · Taizo Hibi · Kiminori Takano · Naokazu Chiba · Shigeyuki Kawachi · Motohide Shimazu · Yuko Kitagawa
Published online: 12 February 2014 © 2014 Japanese Society of Hepato-Biliary-Pancreatic Surgery
Abstract Currently, the best treatment for locally advanced pancreatic cancer is considered to be safe and effective surgery, followed by appropriate additional therapies implemented as quickly as possible. The use of diagnostic imaging to assist surgery is being researched in a range of institutions. This report introduces the results of a study into the optimized contrast conditions for computed tomography (CT)-volume rendering image generation, effective in providing image support for pancreatic surgery, and introduces actual cases in which imaging support was used in surgery. The authors demonstrated that the conventional contrast protocols used in making a diagnosis are not necessarily the optimum protocols for image creation. It is thought that the use of image-supported surgery will improve the safety and effectiveness of pancreatic surgery. Keywords Navigation surgery · Pancreatic cancer · Simulation · Volume rendering Introduction Negative opinions are expressed in regard to unnecessarily extended dissections during the surgical removal of pancreatic cancer [1–7], but this is not synonymous with perfunctory joint neuroplexus/vascular excision or lymph node Y. Abe (*) · O. Itano · M. Kitago · M. Shinoda · H. Yagi · T. Hibi · Y. Kitagawa Department of Surgery, School of Medicine, Keio University, Tokyo 160-8582, Japan e-mail: [email protected] K. Takano · N. Chiba · S. Kawachi · M. Shimazu Department of Surgery, Hachioji Medical Center, Tokyo Medical University, Tokyo, Japan
dissection required for R0. In other words, pancreatic dissection is complex, requiring the surgeon to accurately ascertain the positional relationship between anatomically diverse blood vessels and the lesion, and to plan and execute an optimized discussion line based on an understanding of the points closest to the dissection margins to achieve R0. It is important that a safe and effective permanent cure can be obtained, and image-supported surgery is considered to be effective in achieving this. This report presents the results of a study considering the optimized contrast conditions for creating computed tomography (CT)-volume rendering images (VR images) for use in image-assisted surgery, and introduces actual cases of image-assisted surgery. Superior mesenteric vein/artery system VR image creation Volume rendering images formed from CT data can be significantly modified depending on the volume of contrast agent used and the timing of the captured image, and as a result they often present a very different image to that obtained from conventional anatomy. The authors considered the optimum contrast conditions for the generation of 3D images of the superior mesenteric blood vessels [8]. The focus of the study was 15 patients scheduled for pancreaticoduoenectomy. Cases with extreme stenosis or occlusion caused by portal infiltration were excluded. The patients underwent dynamic CT scanning of the abdominal area using the following imaging conditions, subsequent to being diagnosed as having malignant lesions on the pancreatic head (510 mg I/kg iodine contrast agent that is 350 mg I/ml or 370 mg I/ml depend on the patient’s body weight, injected at 3 ml/s. Images were taken 30, 60 and 180 s after beginning introduction of the contrast agent: Condition A).
252 Fig. 1 A visual scale provides numerical values indicating how clearly blood vessels can be visualized, and is scored out of a maximum score of five by evaluating the visualization/ continuity of five branches of each of the superior mesenteric artery and the superior mesenteric vein. (reproduced from [8])
J Hepatobiliary Pancreat Sci (2014) 21:251–255 Superior Mesenteric Artery
Superior Mesenteric Vein
Inferior pancreaticoduodenal artery right or middle colic artery
Gastro-colic trunk
Inferior mesenteric vein
Jejunal artery Ilial vein
Ilio-colic argery
Ileo-colic vein
Jejunal vein
Ilial artery
Immediately prior to surgery, the patients underwent a dynamic CT (700 mg I/kg, injected at 4 ml/s. First phase was 20–30 s after injection started, second phase 20 s after first phase: Condition B) in order to determine the final staging of the tumor and generate a pre-surgery VR image. The comparison method involved A: a comparison of the CT value of the superior mesenteric artery during the first phase with the CT value of the main portal vein in the second phase. Next, B: an image analysis workstation SYNAPSE VINCENT (manufactured by Fujifilm) was used to generate VR images of the abdominal arteries (first phase) and veins (second phase), and the potential for visualization of blood vessels was compared. A Visual Scale (Fig. 1) was used to evaluate the potential for visualization of blood vessels. This provides numerical values indicating how clearly blood vessels can be visualized, and is scored out of a maximum score of five by evaluating the visualization/continuity of five branches of each of the superior mesenteric artery and the superior mesenteric vein. The CT value in evaluation of the superior mesenteric artery (Table 1a) was highest under Condition B, with higher iodine volume. According to the Visual Scale, however, both conditions scored highly at over four points, demonstrating no significant difference, and indicating that there is no need to increase the volume of contrast agent used when creating VR images of the superior mesenteric artery. Next, in evaluation of the superior mesenteric vein (Table 1b), there was a significant increase in visualization potential on the Visual scale between Condition A, with an average of 3.3, and Condition B, with an average of 4.4. The difference was also clear using the images themselves (Fig. 2), in which the visualization of the vein systems was excellent under Condition B. This is caused by inconsistencies in the contrast agent within blood vessels between the superior mesenteric vein and the portal vein system. In other words, the contrast agent passes through the spleen/ stomach/small and large intestines and various other organs in order to enter the mesenteric vein, causing a time lag. As a result, it is possible to “lose” a branch of even a large blood
Table 1 Comparison of volume rendering (VR) image construction potential of superior mesenteric vein, under differing CT imaging conditions
(a)
(b)
SMA Condition A Condition B SMV Condition A Condition B
Visual scale
CT value
4.4 ± 0.7 4.8 ± 0.4
285 ± 55.4 401 ± 74.1*
3.3 ± 0.7 4.4 ± 0.5*
152 ± 19 241 ± 33*
(a) Superior mesenteric artery (SMA). (b) Superior mesenteric vein (SMV). Condition A: 510 mg I/kg iodine contrast agent, injected at 3 ml/s. Images were taken 30, 60 and 180 seconds after beginning introduction of the contrast agent. Condition B: 700 mg I/kg, injected at 4 ml/s. First phase was 20–30 s after injection started, second phase 20 s after first phase (reproduced from [8]). *P < 0.05
vessel if this attribute is not understood when creating VR images. In this way, the authors have indicated the possibility that conventional contrast protocols used in diagnosis [9] may not always be the optimum protocols for image creation. Purpose of image-assisted surgery The most important objective is the achievement of R0 with safety and effectiveness It must be remembered that creating images for imageassisted surgery is no more than one tool in achieving safe and effective R0 surgery, and that they do not replace the original images used to ensure pre-surgery diagnostic accuracy. The greatest advantage of image-assisted surgery is that it facilitates greater understanding of the complex anatomical variations of blood vessels, making it easier for surgeons and assistants to understand the selection during surgery of blood vessels that can be dissected and organs that may be excised together, and facilitating an understanding of
J Hepatobiliary Pancreat Sci (2014) 21:251–255 Fig. 2 Difference in visualization of superior mesenteric vein in volume rendering (VR) images, in the same patient, under differing computed tomography (CT) imaging conditions. Image captured by the same radiologist under the same protocols (reproduced from [8])
(a)
253 Condition A (510 mg I/kg)
Condition B (700 mg I/kg)
Visual score : 3
(b)
(c)
Visual score : 5
(d)
Fig. 3 Creating volume rendering (VR) images of the tumor and vessels. Tumor marking is carried out not only the main lesion but also progression outside of the pancreas, in particular infiltration of the retroperitoneum or nerve plexus, from 2D images. (a) 2D axial image. (b) Marking tumor lesion on 2D images. (c) VR image visualizing the tumor. (d) c with the blood vessel
the complex anatomical variations of blood vessels, as well as the configuration of the dissection line used in R0 surgery. Flow of image-assisted surgery in locally-advanced pancreatic cancer Firstly, the extent to which the cancer has locally advanced within the pancreas is evaluated using regular diagnostic imaging taken using dynamic CT scanning. Since this surgery does not involve excision, requiring the reconstruction of the superior mesenteric artery and the celiac axis, the limits of the dissecting lines are just in front of these vessels. In cases where it is suspected that the tumor is next to either the superior mesenteric artery or the abdominal cavity artery, chemotherapy should be applied before surgery [10]. When creating VR images, construct an area within the abdominal cavity showing the scope of blood vessels/ internal organs/lesions. It is therefore important to remember that the objective is to ascertain the spatial position of the lesion within the VR image, rather than to define the absolute boundaries of the lesion. It is impossible to diagnose the extent of progression of pancreatic cancer from pre-operative images, even using contemporary CT equip-
ment with excellent spatial resolution, and this is not improved by turning them into 3D images. Marking is carried out while confirming not only the main lesion but also progression outside of the pancreas, in particular infiltration of the retroperitoneum or nerve plexus, from 2D images (Fig. 3). Next, the surgery should be planned. The optimum dissecting line should be configured, using the VR image visualizing the blood vessels and lesion. Based on this dissecting line, the organs and blood vessels to be jointly excised are determined, along with their positions. Clarify the point on the dissecting line that is closest to coming into contact with the lesion, using the relationship between the cutting line and the position of the lesion. This point is the most important position in achieving R0 during surgery. At the same time, decide on the organs and blood vessels for reconstruction, and determine whether or not it is technically possible to reconstruct vessels. Prior to surgery, brief the surgeon and assistants on the procedure, using the VR image. During surgery, begin dissection according to the dissecting line established during surgical planning. Confirm the blood vessels that are indicators, to progress the surgery as according to a “map”. Arrive at the point closest to the lesion on the dissecting line as quickly as possible, submit the dissection margins of this point for frozen
254
J Hepatobiliary Pancreat Sci (2014) 21:251–255
Fig. 4 One of the closest point of proximity to the lesion on the proposed dissection line. Surface of the splenic artery
dissection line
CA SA
LGA
CA
CA
SA
CHA CHA SA
frozen section: negative
Fig. 5 Another closest point of proximity to the lesion on the proposed dissection line. Surface of the superior mesenteric artery (SMA)
Pancreas
GCT
Pancreas
GCT
dissection line
frozen section: negative SMA
SMA
pathological diagnosis, and confirm the exposure of the lesion. Once the exposure of the cancer is confirmed, if it is not considered that R0 can be achieved, excision should be abandoned. If the portal vein is also being excised, a point where the tumor has not infiltrated it should be established in advance as the cutting line, and in accordance with the 3D map showing the vein branch positional relationships, approach the cutting line carefully from the perimeter. Be careful not to go beyond the predetermined cutting line. Confirming the possibility for vein reconstruction using the surgical plan allows security in regard to safe reconstruction, and avoids unnecessarily approaching the lesion. Actual image-assisted surgery The following is an example of pancreatic cancer, accompanied by portal vein infiltration at the head of the pancreas.
Infiltration of the nerve plexus around the splenic artery and superior mesenteric artery was suspected. The patient underwent chemotherapy with radiotherapy prior to surgery, after which preoperative surgery planning was carried out. Firstly, the dissection line was established. The closest point of proximity to the lesion on the proposed dissection line was the surface of the splenic artery (Fig. 4) and superior mesenteric artery (Fig. 5). A portal vein cutting line was established in advance (Fig. 6). During surgery, the closest point of proximity to the lesion was reached swiftly, and the surface from the dissection of the splenic artery, superior mesenteric artery and nerve plexus were sent for frozen pathological diagnosis, which gave a negative result for cancer, after which a radical dissection was implemented. The predetermined portal vein cutting line was arrived at and a joint excision was possible without approaching the lesion.
J Hepatobiliary Pancreat Sci (2014) 21:251–255
255
PV reconstruction
SMV
dissection line of SMA plexus
dissection line of SMA plexus
SMV Fig. 6 A portal vein dissection line was established in advance and actual surgery
Conclusions The authors introduced a case of image-supported surgery to treat pancreatic cancer, which improves both safety and effectiveness. The implementation of neither more nor less dissection than required and adjuvant chemotherapy [11, 12] as soon as possible may improve the results of treatment of pancreatic cancer patients. Ideally, this type of imageassisted surgery will be further used to offer optimized surgical treatment. Conflict of interest
5.
6.
7.
None declared. 8.
References 1. Pedrazzoli S, DiCarlo V, Dionigi R, Mosca F, Pederzoli P, Pasquali C, et al. Standard versus extended lymphadenectomy associated with pancreatoduodenectomy in the surgical treatment of adenocarcinoma of the head of the pancreas. Ann Surg. 1998;228:508–17. 2. Yeo CJ, Cameron JL, Sohn TA, Coleman J, Sauter PK, Hruban RH, et al. Pancreaticoduodenectomy with or without extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma. comparison of morbidity and mortality and short-term outcome. Ann Surg. 1999;229:613–24. 3. Yeo CJ, Cameron JL, Lillemoe KD, Sohn TA, Campbell KA, Sauter PK, et al. Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma, part 2. Ann Surg. 2002;236:355– 68. 4. Riall TS, Cameron JL, Lillemoe KD, Campbell KA, Sauter PK, Coleman J, et al. Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for
9.
10.
11.
12.
periampullary adenocarcinoma, part 3: update on 5-year survival. J Gastrointest Surg. 2005;9:1191–206. Kennedy EP, Yeo CJ. Pancreaticoduodenectomy with extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma. Surg Oncol Clin N Am. 2007;16:157–76. Farnell MB, Pearson RK, Sarr MG, DiMagno EP, Burgart LJ, Dahl TR, et al. A prospective randomized trial comparing standard pancreatoduodenectomy with pancreatoduodenectomy with extended lymphadenectomy in resectable pancreatic head adenocarcinoma. Surgery. 2005;138:618–28. Nimura Y, Nagino M, Takao S, Takada T, Miyazaki K, Kawarada Y, et al. Standard versus extended lymphadenectomy in radical pancreatoduodenectomy for ductal adenocarcinoma of the head of the pancreas: long-term results of a Japanese multicenter randomized controlled trial. J Hepatobiliary Pancreat Sci. 2012;19:230– 41. Abe Y, Takano K, Tanabe M, Itano O, Shinoda M, Kitago M, et al. Surgical approach in borderline resectable pancreatic cancer with preoperative 3D-CT computer assisted surgery planning. Tan to Sui. 2013;34:87–95 (Japanese). Bipat S, Phoa SS, van Delden OM, Bossuyt PM, Gouma DJ, Lamris JS, et al. Ultrasonography, computed tomography and magnetic resonance imaging for diagnosis and determining resectability of pancreatic adenocarcinoma: a meta-analysis. J Comput Assist Tomogr. 2005;29:438–45. Gillen S, Schuster T, Meyer Zum Büschenfelde C, Friess H, Kleeff J. Preoperative/neoadjuvant therapy in pancreatic cancer: a systematic review and meta-analysis of response and resection percentages. PLoS Med. 2010;7:e1000267. Oettle H, Post S, Neuhaus P, Gellert K, Langrehr J, Ridwelski K, et al. Adjuvant chemotherapy with gemcitabine vs observation in patients undergoing curative-intent resection of pancreatic cancer: a randomized controlled trial. JAMA. 2007;297:267–77. Ueno H, Kosuge T, Matsuyama Y, Yamamoto J, Nakao A, Egawa S, et al. A randomised phase trial comparing gemcitabine with surgery-only in patients with resected pancreatic cancer: Japanese Study Group of Adjuvant Therapy for Pancreatic Cancer. Br J Cancer. 2009;101:908–15.
TOPIC
Computer assisted surgery, preoperative planning and navigation for pancreatic cancer Yuta Abe · Osamu Itano · Minoru Kitago · Masahiro Shinoda · Hiroshi Yagi · Taizo Hibi · Kiminori Takano · Naokazu Chiba · Shigeyuki Kawachi · Motohide Shimazu · Yuko Kitagawa
Published online: 12 February 2014 © 2014 Japanese Society of Hepato-Biliary-Pancreatic Surgery
Abstract Currently, the best treatment for locally advanced pancreatic cancer is considered to be safe and effective surgery, followed by appropriate additional therapies implemented as quickly as possible. The use of diagnostic imaging to assist surgery is being researched in a range of institutions. This report introduces the results of a study into the optimized contrast conditions for computed tomography (CT)-volume rendering image generation, effective in providing image support for pancreatic surgery, and introduces actual cases in which imaging support was used in surgery. The authors demonstrated that the conventional contrast protocols used in making a diagnosis are not necessarily the optimum protocols for image creation. It is thought that the use of image-supported surgery will improve the safety and effectiveness of pancreatic surgery. Keywords Navigation surgery · Pancreatic cancer · Simulation · Volume rendering Introduction Negative opinions are expressed in regard to unnecessarily extended dissections during the surgical removal of pancreatic cancer [1–7], but this is not synonymous with perfunctory joint neuroplexus/vascular excision or lymph node Y. Abe (*) · O. Itano · M. Kitago · M. Shinoda · H. Yagi · T. Hibi · Y. Kitagawa Department of Surgery, School of Medicine, Keio University, Tokyo 160-8582, Japan e-mail: [email protected] K. Takano · N. Chiba · S. Kawachi · M. Shimazu Department of Surgery, Hachioji Medical Center, Tokyo Medical University, Tokyo, Japan
dissection required for R0. In other words, pancreatic dissection is complex, requiring the surgeon to accurately ascertain the positional relationship between anatomically diverse blood vessels and the lesion, and to plan and execute an optimized discussion line based on an understanding of the points closest to the dissection margins to achieve R0. It is important that a safe and effective permanent cure can be obtained, and image-supported surgery is considered to be effective in achieving this. This report presents the results of a study considering the optimized contrast conditions for creating computed tomography (CT)-volume rendering images (VR images) for use in image-assisted surgery, and introduces actual cases of image-assisted surgery. Superior mesenteric vein/artery system VR image creation Volume rendering images formed from CT data can be significantly modified depending on the volume of contrast agent used and the timing of the captured image, and as a result they often present a very different image to that obtained from conventional anatomy. The authors considered the optimum contrast conditions for the generation of 3D images of the superior mesenteric blood vessels [8]. The focus of the study was 15 patients scheduled for pancreaticoduoenectomy. Cases with extreme stenosis or occlusion caused by portal infiltration were excluded. The patients underwent dynamic CT scanning of the abdominal area using the following imaging conditions, subsequent to being diagnosed as having malignant lesions on the pancreatic head (510 mg I/kg iodine contrast agent that is 350 mg I/ml or 370 mg I/ml depend on the patient’s body weight, injected at 3 ml/s. Images were taken 30, 60 and 180 s after beginning introduction of the contrast agent: Condition A).
252 Fig. 1 A visual scale provides numerical values indicating how clearly blood vessels can be visualized, and is scored out of a maximum score of five by evaluating the visualization/ continuity of five branches of each of the superior mesenteric artery and the superior mesenteric vein. (reproduced from [8])
J Hepatobiliary Pancreat Sci (2014) 21:251–255 Superior Mesenteric Artery
Superior Mesenteric Vein
Inferior pancreaticoduodenal artery right or middle colic artery
Gastro-colic trunk
Inferior mesenteric vein
Jejunal artery Ilial vein
Ilio-colic argery
Ileo-colic vein
Jejunal vein
Ilial artery
Immediately prior to surgery, the patients underwent a dynamic CT (700 mg I/kg, injected at 4 ml/s. First phase was 20–30 s after injection started, second phase 20 s after first phase: Condition B) in order to determine the final staging of the tumor and generate a pre-surgery VR image. The comparison method involved A: a comparison of the CT value of the superior mesenteric artery during the first phase with the CT value of the main portal vein in the second phase. Next, B: an image analysis workstation SYNAPSE VINCENT (manufactured by Fujifilm) was used to generate VR images of the abdominal arteries (first phase) and veins (second phase), and the potential for visualization of blood vessels was compared. A Visual Scale (Fig. 1) was used to evaluate the potential for visualization of blood vessels. This provides numerical values indicating how clearly blood vessels can be visualized, and is scored out of a maximum score of five by evaluating the visualization/continuity of five branches of each of the superior mesenteric artery and the superior mesenteric vein. The CT value in evaluation of the superior mesenteric artery (Table 1a) was highest under Condition B, with higher iodine volume. According to the Visual Scale, however, both conditions scored highly at over four points, demonstrating no significant difference, and indicating that there is no need to increase the volume of contrast agent used when creating VR images of the superior mesenteric artery. Next, in evaluation of the superior mesenteric vein (Table 1b), there was a significant increase in visualization potential on the Visual scale between Condition A, with an average of 3.3, and Condition B, with an average of 4.4. The difference was also clear using the images themselves (Fig. 2), in which the visualization of the vein systems was excellent under Condition B. This is caused by inconsistencies in the contrast agent within blood vessels between the superior mesenteric vein and the portal vein system. In other words, the contrast agent passes through the spleen/ stomach/small and large intestines and various other organs in order to enter the mesenteric vein, causing a time lag. As a result, it is possible to “lose” a branch of even a large blood
Table 1 Comparison of volume rendering (VR) image construction potential of superior mesenteric vein, under differing CT imaging conditions
(a)
(b)
SMA Condition A Condition B SMV Condition A Condition B
Visual scale
CT value
4.4 ± 0.7 4.8 ± 0.4
285 ± 55.4 401 ± 74.1*
3.3 ± 0.7 4.4 ± 0.5*
152 ± 19 241 ± 33*
(a) Superior mesenteric artery (SMA). (b) Superior mesenteric vein (SMV). Condition A: 510 mg I/kg iodine contrast agent, injected at 3 ml/s. Images were taken 30, 60 and 180 seconds after beginning introduction of the contrast agent. Condition B: 700 mg I/kg, injected at 4 ml/s. First phase was 20–30 s after injection started, second phase 20 s after first phase (reproduced from [8]). *P < 0.05
vessel if this attribute is not understood when creating VR images. In this way, the authors have indicated the possibility that conventional contrast protocols used in diagnosis [9] may not always be the optimum protocols for image creation. Purpose of image-assisted surgery The most important objective is the achievement of R0 with safety and effectiveness It must be remembered that creating images for imageassisted surgery is no more than one tool in achieving safe and effective R0 surgery, and that they do not replace the original images used to ensure pre-surgery diagnostic accuracy. The greatest advantage of image-assisted surgery is that it facilitates greater understanding of the complex anatomical variations of blood vessels, making it easier for surgeons and assistants to understand the selection during surgery of blood vessels that can be dissected and organs that may be excised together, and facilitating an understanding of
J Hepatobiliary Pancreat Sci (2014) 21:251–255 Fig. 2 Difference in visualization of superior mesenteric vein in volume rendering (VR) images, in the same patient, under differing computed tomography (CT) imaging conditions. Image captured by the same radiologist under the same protocols (reproduced from [8])
(a)
253 Condition A (510 mg I/kg)
Condition B (700 mg I/kg)
Visual score : 3
(b)
(c)
Visual score : 5
(d)
Fig. 3 Creating volume rendering (VR) images of the tumor and vessels. Tumor marking is carried out not only the main lesion but also progression outside of the pancreas, in particular infiltration of the retroperitoneum or nerve plexus, from 2D images. (a) 2D axial image. (b) Marking tumor lesion on 2D images. (c) VR image visualizing the tumor. (d) c with the blood vessel
the complex anatomical variations of blood vessels, as well as the configuration of the dissection line used in R0 surgery. Flow of image-assisted surgery in locally-advanced pancreatic cancer Firstly, the extent to which the cancer has locally advanced within the pancreas is evaluated using regular diagnostic imaging taken using dynamic CT scanning. Since this surgery does not involve excision, requiring the reconstruction of the superior mesenteric artery and the celiac axis, the limits of the dissecting lines are just in front of these vessels. In cases where it is suspected that the tumor is next to either the superior mesenteric artery or the abdominal cavity artery, chemotherapy should be applied before surgery [10]. When creating VR images, construct an area within the abdominal cavity showing the scope of blood vessels/ internal organs/lesions. It is therefore important to remember that the objective is to ascertain the spatial position of the lesion within the VR image, rather than to define the absolute boundaries of the lesion. It is impossible to diagnose the extent of progression of pancreatic cancer from pre-operative images, even using contemporary CT equip-
ment with excellent spatial resolution, and this is not improved by turning them into 3D images. Marking is carried out while confirming not only the main lesion but also progression outside of the pancreas, in particular infiltration of the retroperitoneum or nerve plexus, from 2D images (Fig. 3). Next, the surgery should be planned. The optimum dissecting line should be configured, using the VR image visualizing the blood vessels and lesion. Based on this dissecting line, the organs and blood vessels to be jointly excised are determined, along with their positions. Clarify the point on the dissecting line that is closest to coming into contact with the lesion, using the relationship between the cutting line and the position of the lesion. This point is the most important position in achieving R0 during surgery. At the same time, decide on the organs and blood vessels for reconstruction, and determine whether or not it is technically possible to reconstruct vessels. Prior to surgery, brief the surgeon and assistants on the procedure, using the VR image. During surgery, begin dissection according to the dissecting line established during surgical planning. Confirm the blood vessels that are indicators, to progress the surgery as according to a “map”. Arrive at the point closest to the lesion on the dissecting line as quickly as possible, submit the dissection margins of this point for frozen
254
J Hepatobiliary Pancreat Sci (2014) 21:251–255
Fig. 4 One of the closest point of proximity to the lesion on the proposed dissection line. Surface of the splenic artery
dissection line
CA SA
LGA
CA
CA
SA
CHA CHA SA
frozen section: negative
Fig. 5 Another closest point of proximity to the lesion on the proposed dissection line. Surface of the superior mesenteric artery (SMA)
Pancreas
GCT
Pancreas
GCT
dissection line
frozen section: negative SMA
SMA
pathological diagnosis, and confirm the exposure of the lesion. Once the exposure of the cancer is confirmed, if it is not considered that R0 can be achieved, excision should be abandoned. If the portal vein is also being excised, a point where the tumor has not infiltrated it should be established in advance as the cutting line, and in accordance with the 3D map showing the vein branch positional relationships, approach the cutting line carefully from the perimeter. Be careful not to go beyond the predetermined cutting line. Confirming the possibility for vein reconstruction using the surgical plan allows security in regard to safe reconstruction, and avoids unnecessarily approaching the lesion. Actual image-assisted surgery The following is an example of pancreatic cancer, accompanied by portal vein infiltration at the head of the pancreas.
Infiltration of the nerve plexus around the splenic artery and superior mesenteric artery was suspected. The patient underwent chemotherapy with radiotherapy prior to surgery, after which preoperative surgery planning was carried out. Firstly, the dissection line was established. The closest point of proximity to the lesion on the proposed dissection line was the surface of the splenic artery (Fig. 4) and superior mesenteric artery (Fig. 5). A portal vein cutting line was established in advance (Fig. 6). During surgery, the closest point of proximity to the lesion was reached swiftly, and the surface from the dissection of the splenic artery, superior mesenteric artery and nerve plexus were sent for frozen pathological diagnosis, which gave a negative result for cancer, after which a radical dissection was implemented. The predetermined portal vein cutting line was arrived at and a joint excision was possible without approaching the lesion.
J Hepatobiliary Pancreat Sci (2014) 21:251–255
255
PV reconstruction
SMV
dissection line of SMA plexus
dissection line of SMA plexus
SMV Fig. 6 A portal vein dissection line was established in advance and actual surgery
Conclusions The authors introduced a case of image-supported surgery to treat pancreatic cancer, which improves both safety and effectiveness. The implementation of neither more nor less dissection than required and adjuvant chemotherapy [11, 12] as soon as possible may improve the results of treatment of pancreatic cancer patients. Ideally, this type of imageassisted surgery will be further used to offer optimized surgical treatment. Conflict of interest
5.
6.
7.
None declared. 8.
References 1. Pedrazzoli S, DiCarlo V, Dionigi R, Mosca F, Pederzoli P, Pasquali C, et al. Standard versus extended lymphadenectomy associated with pancreatoduodenectomy in the surgical treatment of adenocarcinoma of the head of the pancreas. Ann Surg. 1998;228:508–17. 2. Yeo CJ, Cameron JL, Sohn TA, Coleman J, Sauter PK, Hruban RH, et al. Pancreaticoduodenectomy with or without extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma. comparison of morbidity and mortality and short-term outcome. Ann Surg. 1999;229:613–24. 3. Yeo CJ, Cameron JL, Lillemoe KD, Sohn TA, Campbell KA, Sauter PK, et al. Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma, part 2. Ann Surg. 2002;236:355– 68. 4. Riall TS, Cameron JL, Lillemoe KD, Campbell KA, Sauter PK, Coleman J, et al. Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for
9.
10.
11.
12.
periampullary adenocarcinoma, part 3: update on 5-year survival. J Gastrointest Surg. 2005;9:1191–206. Kennedy EP, Yeo CJ. Pancreaticoduodenectomy with extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma. Surg Oncol Clin N Am. 2007;16:157–76. Farnell MB, Pearson RK, Sarr MG, DiMagno EP, Burgart LJ, Dahl TR, et al. A prospective randomized trial comparing standard pancreatoduodenectomy with pancreatoduodenectomy with extended lymphadenectomy in resectable pancreatic head adenocarcinoma. Surgery. 2005;138:618–28. Nimura Y, Nagino M, Takao S, Takada T, Miyazaki K, Kawarada Y, et al. Standard versus extended lymphadenectomy in radical pancreatoduodenectomy for ductal adenocarcinoma of the head of the pancreas: long-term results of a Japanese multicenter randomized controlled trial. J Hepatobiliary Pancreat Sci. 2012;19:230– 41. Abe Y, Takano K, Tanabe M, Itano O, Shinoda M, Kitago M, et al. Surgical approach in borderline resectable pancreatic cancer with preoperative 3D-CT computer assisted surgery planning. Tan to Sui. 2013;34:87–95 (Japanese). Bipat S, Phoa SS, van Delden OM, Bossuyt PM, Gouma DJ, Lamris JS, et al. Ultrasonography, computed tomography and magnetic resonance imaging for diagnosis and determining resectability of pancreatic adenocarcinoma: a meta-analysis. J Comput Assist Tomogr. 2005;29:438–45. Gillen S, Schuster T, Meyer Zum Büschenfelde C, Friess H, Kleeff J. Preoperative/neoadjuvant therapy in pancreatic cancer: a systematic review and meta-analysis of response and resection percentages. PLoS Med. 2010;7:e1000267. Oettle H, Post S, Neuhaus P, Gellert K, Langrehr J, Ridwelski K, et al. Adjuvant chemotherapy with gemcitabine vs observation in patients undergoing curative-intent resection of pancreatic cancer: a randomized controlled trial. JAMA. 2007;297:267–77. Ueno H, Kosuge T, Matsuyama Y, Yamamoto J, Nakao A, Egawa S, et al. A randomised phase trial comparing gemcitabine with surgery-only in patients with resected pancreatic cancer: Japanese Study Group of Adjuvant Therapy for Pancreatic Cancer. Br J Cancer. 2009;101:908–15.
