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Innovation in surgical technique
What does preoperative three-dimensional image contribute to complex pancreatic surgery?
¿Qué aporta la imagen tridimensional preoperatoria en la cirugía pancreática compleja?
Marina Garcés-Albir
Corresponding author
garalma@hotmail.com

Corresponding author.
, Elena Muñoz-Forner, Dimitri Dorcaratto, Luis Sabater
Unidad HBP, Servicio de Cirugía General y del Aparato Digestivo, Hospital Clínico Universitario de Valencia, Instituto de Investigación Biomédica INCLIVA, Departamento de Cirugía, Universitat de Valencia, Valencia, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Three-dimensional &#40;3D&#41; technology is quickly and firmly becoming established in the world of surgery due to the many advantages that it can provide when planning operations&#44; facilitating vision in the operating room or improving teaching&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Over the last few years&#44; several programs have appeared that allow us to obtain 3D images prior to surgery&#44; especially in liver surgery&#46; However&#44; the development of 3D models for pancreatic surgery has not been as widespread&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The objective of this article is to present a new tool that can assist surgeons when planning and performing complex pancreatic surgery&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Surgical technique</span><p id="par0020" class="elsevierStylePara elsevierViewall">We present the case of a 40-year-old male patient with borderline resectable pancreatic cancer&#46; After discussion of the case in the multidisciplinary committee&#44; we decided to place a coated metallic biliary stent and administer neoadjuvant chemotherapy treatment &#40;FOLFIRINOX&#44; 12 cycles&#41;&#46; The computed tomography &#40;CT&#41; evaluation of the response to treatment revealed a neoplasm in the head of the pancreas&#44; which was in contact with the mesenteric-portal venous axis in more than 180&#176;&#46; In addition&#44; there was tumor contact with the superior mesenteric artery &#40;SMA&#41; and invasion of the right hepatic artery &#40;RHA&#41; originating at the SMA&#46; Given the complexity of the case&#44; a 3D image was created with the Cella Medical Solutions&#174; Virtual Model&#44; which confirmed the CT findings and also allowed us to obtain&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0025" class="elsevierStylePara elsevierViewall">360&#176; visualization of the tumor and related adjacent structures &#40;pancreatic and biliary anatomy&#44; stomach&#44; duodenum&#44; portal venous system&#44; vena cava and arterial vascularization&#41; with the possibility to modify and adapt the parameters and movement of the image in 3D &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0030" class="elsevierStylePara elsevierViewall">Venous study with the ability to observe a 360&#176; image of the relationship between the tumor and the superior mesenteric vein &#40;SMV&#41;&#44; splenic vein&#44; portal vein and their collateral branches&#46; In addition&#44; the program offers objective evaluation in accordance with NCCN<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> criteria &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0035" class="elsevierStylePara elsevierViewall">Arterial study with the ability to observe a 360&#176; image of the relationship between the tumor and the most important arterial structures &#40;SMA&#44; celiac trunk and its collateral branches&#44; and anatomical variants&#41;&#46; Their objective evaluation also followed NCCN<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> criteria &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0040" class="elsevierStylePara elsevierViewall">Confirmation of whether the tumor contact areas with the SMV&#44; SMA and RHA were tumor areas with invasion of vascular structures or not &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></li></ul></p><p id="par0045" class="elsevierStylePara elsevierViewall">After the findings provided by the complementary tests&#44; and in the absence of disease progression during preoperative therapy&#44; we decided to proceed with exploration in the operating room&#46; Using bilateral subcostal laparotomy&#44; we carried out a pancreaticoduodenectomy &#40;PD&#41;&#46; As an RHA originating at the SMA had been identified during the preoperative study&#44; we performed a resection using the initial SMA approach&#46; The highlights of the surgery were&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">Resection of the RHA &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41; and end-to-end anastomosis</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">SMV resection &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41; and Clavien plasty repair</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">At the area of &#8203;&#8203;contact with the SMA&#44; we were able to dissect the tumor without resecting the artery as there was no invasion&#46;</p></li></ul></p><p id="par0065" class="elsevierStylePara elsevierViewall">The technique chosen for the reconstruction included an invaginating pancreatic&#8211;gastric anastomosis&#44; end-to-side hepaticojejunal anastomosis&#44; manual antecolic end-to-side gastrojejunal anastomosis&#44; and construction of a Braun omega loop&#46; Two non-suction drains were placed&#44; one in the right hypochondrium and the other adjacent to the pancreatic-gastric anastomosis&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The postoperative period was uneventful&#46; The drain tube was removed from the right side 48&#160;h after surgery&#46; Amylase was analyzed 72&#160;h after the procedure in the discharged fluid of the left drain&#44; which was withdrawn as the result was less than 3 times the amylase levels in blood&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">There were no 30-day or 90-day postoperative complications&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The pathology study reported a moderately differentiated ductal adenocarcinoma &#40;pT3N2 Mx&#41; with a medial resection margin &#40;venous&#41; at 1&#160;mm&#44; and the remaining margins were free&#46; This confirmed the tumor involvement of the SMV and the RHA and no invasion of the SMA&#46; Therefore&#44; it coincided with the preoperative diagnosis made by the 3D model &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">We have currently used this 3D reconstruction program for pancreatic surgery in 12 patients&#46; The indication used in our hospital is&#58; patients with borderline pancreatic cancer&#44; in whom resectability is uncertain&#46; In these 12 cases&#44; the 3D model has helped us to&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0090" class="elsevierStylePara elsevierViewall">determine the division points of the SMV and plan its reconstruction in advance in 10 patients&#59;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0095" class="elsevierStylePara elsevierViewall">diagnose uncommon anatomical variants that are difficult to interpret on CT scan &#40;RHA and left as independent branches of the celiac trunk and gastro-duodenal artery as terminal branch of the left hepatic artery&#41; in the context of a locally advanced tumor in the head of the pancreas&#44; and other more common ones such as RHA originating at the SMA&#59;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0100" class="elsevierStylePara elsevierViewall">confirm the diagnosis of non-resectability due to the impossibility to reconstruct the SMV in 2 cases&#59;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0105" class="elsevierStylePara elsevierViewall">open an alternative for tumor resection when it appeared unresectable on CT in one case&#59; and</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0110" class="elsevierStylePara elsevierViewall">as a teaching tool in all cases&#46;</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0115" class="elsevierStylePara elsevierViewall">The use of 3D images constructed from CT scans or magnetic resonance imaging &#40;MRI&#41; is widespread in other surgical procedures &#40;liver resections&#44; for instance&#41;&#44; but they are used less often for pancreatic pathologies&#46; These diagnostic tests are currently gaining popularity because they have been proven to be very useful in surgical planning&#44; especially for surgeons with less experience&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">The possibility of creating 3D reconstructions for a structure like the pancreas&#44; which is a significant surgical challenge&#44; opens up future expectations towards 3D visualization in the surgical field itself&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The 3D images are made by processing the information from the patient&#8217;s preoperative tests &#40;CT&#44; MRI&#44; PET&#44; etc&#41;&#46; This diagnostic tool provides&#58; more complete and simpler planning of the resection to be carried out&#59; easy identification of vascular anatomical variants &#40;in our case an RHA from the SMA&#41;&#59; the ability to discuss cases online with other surgeons who are not in the same place&#59; and&#44; more effective teaching&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Although the current indication for using the 3D program in our hospital is borderline resectable pancreatic cancer&#44; these indications could be extended&#46; We believe that the information provided is very valuable for performing resections with greater safety&#44; which could be reflected in shorter surgical times and even reduce complications or R1 resections&#46; Unresectable patients could also be more precisely identified&#44; thereby reducing the number of exploratory laparotomies or assisting with therapeutic decision-making&#46; Although the agreement between the 3D study and the surgery has exceeded our expectations&#44; the eventual advantages of this new tool should be evaluated in a study designed for this purpose&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">One of the potential drawbacks of this type of diagnostic reconstruction is its cost&#46; However&#44; we can find 3D reconstructions with a price no higher than that of other consumable materials commonly used in this type of surgery&#46; Therefore&#44; using this tool does not seem to be a disadvantage when we consider that this cost is largely outweighed by the advantages described above &#40;avoiding exploratory laparotomies in unresectable patients&#44; reducing complications&#44; etc&#41;&#46; Another problem we face with these programs is usability&#46; However&#44; the increasingly precise development of these tools goes hand in hand with the simplification of their use to make them agile and intuitive&#46; In this case&#44; the program used is designed to provide the information that surgeons would like to obtain before facing a case of these characteristics in a simple manner&#44; with no need for prior training in it use&#46; In addition&#44; the images can be consulted from different devices &#40;computer&#44; mobile phone&#44; operating room monitors&#44; etc&#41;&#44; which facilitates their access&#46; There is also the possibility of printing a 3-dimensional model when appropriate&#46; In our case&#44; we have only considered it once&#44; for educational purposes&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Several studies have been published about the use of 3D images in surgery&#46; Despite this&#44; their development in pancreatic surgery has not been as extensive&#46; Three-dimensional images have been used statically to study volumes&#44; locate structures&#44;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> or to plan specific surgeries&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Until now&#44; no other dynamic program with the possibility of 360&#176; visualization had been developed that is so easy for the surgeon to use&#44; providing a view of the relationship between the different structures and precise identification of the tumor&#44; thereby simplifying appropriate planning of the surgical technique for each patient&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflict of interests</span><p id="par0140" class="elsevierStylePara elsevierViewall">The INCLIVA Biomedical Research Institute has collaborated in the development of the 3D modelling program for pancreatic surgery &#40;Cella Medical Solutions&#174;&#41;&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The possibility of modelling diagnostic images in three dimensions &#40;3D&#41; in pancreatic surgery is a novelty that provides us multiple advantages&#46; A better visualization of the structures allows us a more accurate planning of the surgical technique and makes it easier the surgery in complex cases&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">We present the case study of a <span class="elsevierStyleItalic">borderline</span> pancreatic head adenocarcinoma patient to illustrate the advantages of 3D modelling in complex pancreatic surgery&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">The help of 3D technology allowed us to optimally plan the intervention and facilitate surgical resection&#46; The use of this tool could translate into&#58; shorter operative time&#44; fewer intraoperative complications or an increase in R0 resections&#46; The usability of the program used in our case&#44; agile and intuitive&#44; was an added advantage&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La posibilidad de modelizaci&#243;n de im&#225;genes diagn&#243;sticas en tres dimensiones &#40;3D&#41; en cirug&#237;a pancre&#225;tica es una novedad que nos aporta m&#250;ltiples ventajas&#46; Una mejor visualizaci&#243;n de las estructuras nos permite una planificaci&#243;n de la t&#233;cnica quir&#250;rgica m&#225;s precisa y nos facilita la realizaci&#243;n de la cirug&#237;a en casos complejos&#46;</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Presentamos el caso de un paciente diagnosticado de un adenocarcinoma de cabeza de p&#225;ncreas <span class="elsevierStyleItalic">borderline</span> para ilustrar las ventajas de la modelizaci&#243;n 3D en cirug&#237;a pancre&#225;tica compleja&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">La ayuda de la tecnolog&#237;a 3D nos permiti&#243; planificar de manera &#243;ptima la intervenci&#243;n facilitando la resecci&#243;n quir&#250;rgica&#46; El uso de esta herramienta podr&#237;a tRHAucirse en&#58; menor tiempo operatorio&#44; menores complicaciones intraoperatorias o un aumento de las resecciones R0&#46; La usabilidad del programa utilizado en nuestro caso&#44; &#225;gil e intuitivo&#44; fue una ventaja a&#241;adida&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Garc&#233;s-Albir M&#44; Mu&#241;oz-Forner E&#44; Dorcaratto D&#44; Sabater L&#46; &#191;Qu&#233; aporta la imagen tridimensional preoperatoria en la cirug&#237;a pancre&#225;tica compleja&#63; Cir Esp&#46; 2021&#59;99&#58;602&#8211;607&#46;</p>"
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      "seccion" => array:1 [
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Article information
ISSN: 21735077
Original language: English
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