Name: laparoscopic radical antegrade modular pancreatosplenectomy via dorsal-caudal artery approach for pancreatic neck-body cancer
Uploaded: 2022-11-18T12:30:00
Description: Watch this Scientific Journal Video about Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer at JoVE.com

The present protocol follows the guidelines of the Ethics of the Second Affiliated Hospital of Guangzhou University of Chinese Medicine. Informed consent was obtained from the patient for this article and the video.
1. Patient Selection
<ol>
	<li>Ensure patients have PDAC in the pancreas neck, body, and tail as confirmed by contrast enhanced computed tomography (CT). This procedure is indicated in the following cases: resectable pancreatic cancer and borderline resectable pa...

<ol>
	<li>Kim, E. Y., Hong, T. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Initial+experience+with+laparoscopic+radical+antegrade+modular+pancreatosplenectomy+for+left-sided+pancreatic+cancer+in+a+single+institution:+technical+aspects+and+oncological+outcomes.">Initial experience with laparoscopic radical antegrade modular pancreatosplenectomy for left-sided pancreatic cancer in a single institution: technical aspects and oncological outcomes.</a> BMC Surgery. 17 (1), 2 (2017).</li><li>Strasberg, S. M., Fields, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Left-sided+pancreatic+cancer:+distal+pancreatectomy+and+its+variants:+radical+antegrade+modular+pancreatosplenectomy+and+distal+pancreatectomy+with+celiac+axis+resection.">Left-sided pancreatic cancer: distal pancreatectomy and its variants: radical antegrade modular pancreatosplenectomy and distal pancreatectomy with celiac axis resection.</a> The Cancer Journal. 18 (6), 562-570 (2012).</li><li>Strasberg, S. M., Linehan, D. C., Hawkins, W. 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A., Linehan, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Radical+antegrade+modular+pancreatosplenectomy.">Radical antegrade modular pancreatosplenectomy.</a> Surgery. 133 (5), 521-527 (2003).</li><li>Sunagawa, H., Harumatsu, T., Kinjo, S., Oshiro, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ligament+of+Treitz+approach+in+laparoscopic+modified+radical+antegrade+modular+pancreatosplenectomy:+report+of+three+cases.">Ligament of Treitz approach in laparoscopic modified radical antegrade modular pancreatosplenectomy: report of three cases.</a> Asian Journal of Endoscopic Surgery. 7 (2), 172-174 (2014).</li><li>Choi, S. H., Kang, C. M., Lee, W. J., Chi, H. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Multimedia+article.+Laparoscopic+modified+anterior+RAMPS+in+well-selected+left-sided+pancreatic+cancer:+technical+feasibility+and+interim+results.">Multimedia article. Laparoscopic modified anterior RAMPS in well-selected left-sided pancreatic cancer: technical feasibility and interim results.</a> Surgical Endoscopy. 25 (7), 2360-2361 (2011).</li><li>Weitz, J., Rahbari, N., Koch, M., B&#252;chler, M. 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P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pancreaticoduodenectomy:+superior+mesenteric+artery+first+approach.">Pancreaticoduodenectomy: superior mesenteric artery first approach.</a> Journal of Gastrointestinal Surgery. 10 (4), 607-611 (2006).</li><li>Yamamoto, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=New+laparoscopic+procedure+for+left-sided+pancreatic+cancer-artery-first+approach+laparoscopic+RAMPS+using+3D+technique.">New laparoscopic procedure for left-sided pancreatic cancer-artery-first approach laparoscopic RAMPS using 3D technique.</a> World Journal of Surgical Oncology. 15 (1), 213 (2017).</li><li>Rosso, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+radical+antegrade+modular+pancreatosplenectomy+with+venous+tangential+resection:+focus+on+periadventitial+dissection+of+the+superior+mesenteric+artery+for+obtaining+negative+margin+and+a+safe+vascular+resection.">Laparoscopic radical antegrade modular pancreatosplenectomy with venous tangential resection: focus on periadventitial dissection of the superior mesenteric artery for obtaining negative margin and a safe vascular resection.</a> Annals of Surgical Oncology. 27 (8), 2902-2903 (2020).</li><li>Kawabata, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+versus+open+radical+antegrade+modular+pancreatosplenectomy+with+artery-first+approach+in+pancreatic+cancer.">Laparoscopic versus open radical antegrade modular pancreatosplenectomy with artery-first approach in pancreatic cancer.</a> Langenbeck's Archives of Surgery. 405 (5), 647-656 (2020).</li><li>Vissers, F. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+radical+left+pancreatectomy+for+pancreatic+cancer:+surgical+strategy+and+technique+video.">Laparoscopic radical left pancreatectomy for pancreatic cancer: surgical strategy and technique video.</a> Journal of Visualized Experiments. (160), e60332 (2020).</li><li>Ome, Y., Seyama, Y., Muto, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+distal+pancreatectomy+for+left-sided+pancreatic+cancer+using+the+&amp;#34;Caudo-Dorsal+Artery+First+Approach&amp;#34;.">Laparoscopic distal pancreatectomy for left-sided pancreatic cancer using the &amp;#34;Caudo-Dorsal Artery First Approach&amp;#34;.</a> Annals of Surgical Oncology. 26 (13), 4464-4465 (2019).</li><li>Tol, J. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Definition+of+a+standard+lymphadenectomy+in+surgery+for+pancreatic+ductal+adenocarcinoma:+a+consensus+statement+by+the+International+Study+Group+on+Pancreatic+Surgery+(ISGPS).">Definition of a standard lymphadenectomy in surgery for pancreatic ductal adenocarcinoma: a consensus statement by the International Study Group on Pancreatic Surgery (ISGPS).</a> Surgery. 156 (3), 591-600 (2014).</li><li>Asbun, H. J., Stauffer, J. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+approach+to+distal+and+subtotal+pancreatectomy:+a+clockwise+technique.">Laparoscopic approach to distal and subtotal pancreatectomy: a clockwise technique.</a> Surgical Endoscopy. 25 (8), 2643-2649 (2011).</li><li>Asbun, H. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Technique+and+audited+outcomes+of+laparoscopic+distal+pancreatectomy+combining+the+clockwise+approach,+progressive+stepwise+compression+technique,+and+staple+line+reinforcement.">Technique and audited outcomes of laparoscopic distal pancreatectomy combining the clockwise approach, progressive stepwise compression technique, and staple line reinforcement.</a> Surgical Endoscopy. 34 (1), 231-239 (2020).</li><li>Abu Hilal, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+radical+'no-touch'+left+pancreatosplenectomy+for+pancreatic+ductal+adenocarcinoma:+technique+and+results.">Laparoscopic radical 'no-touch' left pancreatosplenectomy for pancreatic ductal adenocarcinoma: technique and results.</a> Surgical Endoscopy. 30 (9), 3830-3838 (2016).</li><li>Song, K. B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Single-center+experience+of+laparoscopic+left+pancreatic+resection+in+359+consecutive+patients:+changing+the+surgical+paradigm+of+left+pancreatic+resection.">Single-center experience of laparoscopic left pancreatic resection in 359 consecutive patients: changing the surgical paradigm of left pancreatic resection.</a> Surgical Endoscopy. 25 (10), 3364-3372 (2011).</li><li>Bassi, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+2016+update+of+the+International+Study+Group+(ISGPS)+definition+and+grading+of+postoperative+pancreatic+fistula:+11+Years+After.">The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After.</a> Surgery. 161 (3), 584-591 (2017).</li><li>Mizrahi, J. D., Surana, R., Valle, J. W., Shroff, R. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pancreatic+cancer.">Pancreatic cancer.</a> Lancet. 395 (10242), 2008-2020 (2020).</li><li>Varadhachary, G. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Borderline+resectable+pancreatic+cancer:+definitions,+management,+and+role+of+preoperative+therapy.">Borderline resectable pancreatic cancer: definitions, management, and role of preoperative therapy.</a> Annals of Surgical Oncology. 13 (8), 1035-1046 (2006).</li><li>Abrams, R. 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Despite the 5 year survival rates of PDAC, this is still unsatisfactory for patients who have the chance for radical resection; surgery has been the only curative therapeutic method till now22. Resectability status is mostly assessed by the conditions of the regional critical vessels, including the SMA, CeA, CHA, and SMV24,25. Although preoperative radiography can provide adequate information about vascular conditions, surgical exploration...

Radical antegrade modular pancreatosplenectomy (RAMPS) is an exquisite procedure for malignant tumors located in the pancreatic body or tail, first described by Strasberg in 2003. This operation strategy was designed based on the blood and lymph node drainage of the pancreas, in order to achieve tumor-free dissection planes and radical resection of regional lymph nodes1. RAMPS is becoming increasingly valued by surgeons as it could be conducive to obtain tumor-free margins and relatively favorable survival results2,3,4. With advancements in minimally invasive surgical instruments and techniques, laparoscopic RAMPS (L-RAMPS) has been gradually popularized on account of several advantages, including less intraoperative blood loss, decreased requirement for blood transfusions, and fewer incision events such as pain and infection1. For well-selected patients with distal pancreatic ductal adenocarcinoma (PDAC), recent studies have demonstrated that L-RAMPS could be an effective and safe approach1,5,6.
In pancreaticoduodenectomy (PD) for a malignant tumor around the pancreatic head region, the artery-first approach is a widely accepted strategy with several advantages. The core principle of this method is to explore the superior mesenteric artery (SMA) in the early stages of surgery in order to determine the feasibility of radical resection before pancreatic transection or the ligation of major vessels7,8,9. Recent studies have demonstrated that this artery-first approach may relieve the formation of venous congestion of the distal pancreas and spleen and contribute to the effective bleeding control of the operative regions; besides, it makes lymph node dissection around the SMA more adequate7,10,11. For these reasons, the artery-first strategy is becoming an important component for PD and provides an insight into left-sided pancreatic cancer.
Until now, only some artery-first approaches for L-RAMPS procedures have been reported5,6. The core concept of these approaches is that during pancreatic cancer surgery, tumor infiltration to the SMA should be detected before the performance of irreversible surgical steps, such as transection of the pancreas parenchyma or ligation and resection of the major vessels12,13.
Here, we developed the dorsal-caudal artery approach for L-RAMPS, which might be safe and beneficial for tumors in the pancreatic neck. Our procedure further optimized the routine artery-first approaches for L-RAMPS procedures which were reported by Yamamoto and Kawabata12,14. In other words, we explored and separated the SMA first via the dorsal-caudal approach, a method that has never been reported previously. The goal and advantages of this procedure are to ensure the feasibility and safety of the operation for pancreatic neck-body cancer, which might improve the rate of R0 resection and further prognosis.
Surgeons who intend to use this procedure, however, must have substantial experience in laparoscopic pancreatic surgery. Even if they have passed the learning curve, it is critical to evaluate the patient&#39;s condition, including tumor type, vascular condition, and other parameters, because this procedure necessitates sophisticated resection techniques.
In this article, we present a case of a 50-year-old male patient with PDAC, confirmed by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) biopsy, who underwent L-RAMPS after preoperative neoadjuvant chemotherapy. Our aim is to demonstrate the clinical safety and feasibility of L-RAMPS using the dorsal-caudal artery approach, and its oncologic outcomes in patients with PDAC located in the pancreatic neck, body, or tail.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>3D Laparoscope</td>
			<td>STORZ</td>
			<td>TC200,TC302</td>
			<td></td>
		</tr>
		<tr>
			<td>Echelon Flex Powered Plus Articulating Endoscopic Linear Cutter and Endopath Echelon Endoscopic Linear Cutter Reloads with Gripping Surface Technology</td>
			<td>Ethicon Endo-Surgery</td>
			<td>ECR60G/GST60G</td>
			<td></td>
		</tr>
		<tr>
			<td>HARMONIC ACE Ultrasonic Surgical Devices</td>
			<td>Ethicon Endo-Surgery</td>
			<td>HAR36</td>
			<td></td>
		</tr>
		<tr>
			<td>Ligating Clips</td>
			<td>Teleflex Medical</td>
			<td>5,44,22,05,44,23,05,44,000</td>
			<td></td>
		</tr>
		<tr>
			<td>Ultrasonic Surgical &#38; Electrosurgical Generator</td>
			<td>Ethicon Endo-Surgery</td>
			<td>GEN11CN</td>
			<td></td>
		</tr>
	</tbody>
</table>

laparoscopic radical antegrade modular pancreatosplenectomy via dorsal-caudal artery approach for pancreatic neck-body cancer

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who have had neoadjuvant chemotherapy. Here, we present a technique to perform laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) using the dorsal-caudal artery approach by making full use of the high-definition vision and operation modes of the laparoscope.
The innovation and optimization of this operation are provided in the protocol. Priority should be given to the dorsal resection plane, including the dorsal side of the superior mesenteric artery (SMA), the dorsal side of the pancreatic head, the root of the celiac artery (CeA), the ventral side of the left renal vessels, and the renal hilum. On the condition that the operation for pancreatic neck-body cancer is feasible and safe, the second step is to perform tumor resection en bloc surrounding the SMA and CeA from the caudal to the cephalic side to increase the rate of R0 (radical zero) resection and further prognosis.

A 50-year-old man with upper abdomen discomfort and chronic malnutrition had a 3.2 cm x 2.5 cm tumor in the pancreatic neck identified. He had previously been healthy and had a normal BMI (19.9 kg/m2).
No distant metastasis, major vessels (besides the splenic artery and vein), or lymph node infiltration were detected on the preoperative imaging evaluation. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was performed to confirm the pathological diagnosis of PDAC. The p...

Watch this Scientific Journal Video about Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer at JoVE.com

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

With advancements in laparoscopic techniques, laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) has been widely recognized. However, owing to several technical difficulties in this procedure, the artery-first approach in L-RAMPS still remains uncommon. Here, we developed the dorsal-caudal artery approach for L-RAMPS, which might be safe and beneficial for pancreatic neck tumors.

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who ...

Clinical case. Number one, history. No major comorbidity.Number two, chief complaint. Confirmed pancreatic cancer for more than two months. Number three, C-A-1-9-9 value is 4666.38 unit per milliliter.CEA value is normal. Number four, CT scan. The range of pancreatic neck-body cancer is 3.2 times 2.5 centimeters with the splenic artery and vein were invaded.Number five, pathology. Fine-needle aspiration was done to confirm the diagnosis of adenocarcinoma. After four cycles of neoadjuvant chemotherapy.Number one, past CT.The tumor maximum diameter was reduced from 3.2 centimeter to 2.5 centimeter. Clinical improvement in performance status, pain, early satiety, weight, nutritional status. Number three, C-A-1-9-9 reduced from 4, 666 to 1, 350 unit per millimeter, more than 50%decrease.Surgical technique. Place anesthetized patient on the operation table in a supine position. Ensure legs are spreading apart.Make sure the first surgeon is on the right side of the patient. The first assistant is on the left side and the second assistant with the laparoscope is between the patient's legs. This procedure employs a five-port technique as shown in figure one.Perform routine diagnostic laparoscope from the start, to exams liver and the peritoneal surfaces for extra pancreatic metastasis. Open the lesser sac using an ultrasound knife by dividing gastrocolic ligament approximately two centimeters distal from the gastroepiploic artery and vein. Dissect and resect the short gastric vessels for facilitating splenectomy.Suspend the stomach above from the surface of the pancreas. Divide and pass through the gap between the posterior surface of pancreatic neck and the junction part of SMV, PV, and splenic vein. Then carefully clear this area in preparation for pancreatic transaction.Elevate the transverse colon and its mesentery Perform the Kocher Maneuver to expose the interior surface of the left renal vein. The surgeon adds a gap between IVC and pancreatic head. Explore the lymph node station number 16.Place the entire small bowel on the right side to provide access to the dorsal side of SMA. Identify the SMA above the left renal vein. Then, dissect it along its peri-adipose tissue plane on the interior left margin and separate it from the pancreas.Perform the resection range to the left and the posterior plane behind the adrenal gland and onto to the surface to the left kidney. Expose left renal vein. Expose left renal artery.Ligate it and cutoff left at renal vein. Return to the upper colon region. Isolate and excise splenocolic and perisplenic ligaments.Anatomize the common hepatic artery and gastroduodenal artery. Dissect the gastroduodenal lymph nodes, and then identify the correct hepatic artery. Move the GDA to the right side using a rubber band for the exposure of interior surface of portal vein.Divide and pass through the tunnel between the posterior surface of pancreatic neck. Transect the pancreas peritoneum using a mechanical stapler device. Have passed to frozen pathology during the operation.Ligate and cut off splenic vein. To skeletonize the common hepatic artery, left gastric artery, splenic artery and the celiac axis, dissect at a clear en bloc superior pancreatic lymph nodes. Resect fat and a fibrous tissues from the caudal to the cephalic site of SMA and the celiac axis.Remove the lymph nodes from the Heidelberg Triangle, which is bounded by the portal vein, celiac axis and SMA. During this procedure, isolate and divide a range of splenic artery. Our account of the larger dorsal and caudal spaces create it.Ligate and cut off splenic artery exposed and ligate left gastric artery. Expose the left renal vein to determine the dorsal dissection plane. Expose left phrenic artery.Finally, using an antegrade method, dissect the distal pancreas and spleen, as well as the surrounding soft tissues. Pack the specimen. Representative results.The total time for the procedure was 240 minutes with a blood loss of 15 millimeter. The postoperative pancreatic fistula was grade A.No peritoneal fluid was found on postoperative CT examination on P-O-D 7. The drains were removed on day number eight, after operation.The patient's recovery was uncomplicated, and he was discharged on the 13 day after the surgery.Pathology. Moderately poorly differentiated at adenocarcinoma of the pancreatic ductal adenocarcinoma Margins negative. 15 lymph nodes without malignancy.The tumor was staged as T2, N0 and M0.Conclusion. Laparoscopic radical antegrade modular pancreatosplenectomy via dorsal-caudal artery approach is a technically challenging, but safe and a reproducible procedure for pancreatic neck-body cancer. It must be performed only at high volume centers by surgeons with extensive experience.

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Research

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Medicine

Bioluminescent Orthotopic Model of Pancreatic Cancer Progression

Pancreatic cancer has an extremely poor five-year survival rate of 4-6%. New therapeutic options are critically needed and depend on improved understanding of pancreatic cancer biology. To better understand the interaction of cancer cells with the pancreatic microenvironment, we demonstrate an orthotopic model of pancreatic cancer that permits non-invasive monitoring of cancer progression. Luciferase-tagged pancreatic cancer cells are resuspended in Matrigel and delivered into the pancreatic tail during laparotomy. Matrigel solidifies at body temperature to prevent leakage of cancer cells during injection. Primary tumor growth and metastasis to distant organs are monitored following injection of the luciferase substrate luciferin, using in vivo imaging of bioluminescence emission from the cancer cells. In vivo imaging also may be used to track primary tumor recurrence after resection. This orthotopic model is suited to both syngeneic and xenograft models and may be used in pre-clinical trials to investigate the impact of novel anti-cancer therapeutics on the growth of the primary pancreatic tumor and metastasis.

Improved understanding of pancreatic cancer biology is critically needed to enable the development of better therapeutic options to treat pancreatic cancer. To address this need, we demonstrate an orthotopic model of pancreatic cancer that permits non-invasive monitoring of cancer progression using in vivo bioluminescence imaging.

Pancreatic cancer has an extremely poor five-year survival rate of 4-6%.  New therapeutic options are critically needed and depend on improved ...

Studying Pancreatic Cancer Stem Cell Characteristics for Developing New Treatment Strategies

Pancreatic ductal adenocarcinoma (PDAC) contains a subset of exclusively tumorigenic cancer stem cells (CSCs) which have been shown to drive tumor initiation, metastasis and resistance to radio- and chemotherapy. Here we describe a specific methodology for culturing primary human pancreatic CSCs as tumor spheres in anchorage-independent conditions. Cells are grown in serum-free, non-adherent conditions in order to enrich for CSCs while their more differentiated progenies do not survive and proliferate during the initial phase following seeding of single cells. This assay can be used to estimate the percentage of CSCs present in a population of tumor cells. Both size (which can range from 35 to 250 micrometers) and number of tumor spheres formed represents CSC activity harbored in either bulk populations of cultured cancer cells or freshly harvested and digested tumors 1,2. Using this assay, we recently found that metformin selectively ablates pancreatic CSCs; a finding that was subsequently further corroborated by demonstrating diminished expression of pluripotency-associated genes/surface markers and reduced in vivo tumorigenicity of metformin-treated cells. As the final step for preclinical development we treated mice bearing established tumors with metformin and found significantly prolonged survival. Clinical studies testing the use of metformin in patients with PDAC are currently underway (e.g., NCT01210911, NCT01167738, and NCT01488552). Mechanistically, we found that metformin induces a fatal energy crisis in CSCs by enhancing reactive oxygen species (ROS) production and reducing mitochondrial transmembrane potential. In contrast, non-CSCs were not eliminated by metformin treatment, but rather underwent reversible cell cycle arrest. Therefore, our study serves as a successful example for the potential of in vitro sphere formation as a screening tool to identify compounds that potentially target CSCs, but this technique will require further in vitro and in vivo validation to eliminate false discoveries.

Pancreatic cancer stem cells (CSCs) can be expanded in vitro using the anchorage-independent sphere culture technique, which represents a powerful tool to study CSC biology and can serve as the first step to develop novel CSC-targeting therapies. Here the methodology for expanding, analyzing and targeting of pancreatic CSCs is provided.

Pancreatic ductal adenocarcinoma (PDAC) contains a subset of exclusively tumorigenic cancer stem cells (CSCs) which have been shown to drive tumor ...

Surgical Approach for Middle Cerebral Artery Occlusion and Reperfusion Induced Stroke in Mice

Stroke is a leading cause of death worldwide and continues to be one of the major causes of long-term adult disabilities. About 87% of strokes are ischemic in origin and occur in the territory of the middle cerebral artery (MCA). Currently the only Food and Drug Administration (FDA) approved drug for the treatment of this devastating disease is tissue plasminogen activator (tPA). However, tPA has a small therapeutic window for administration (3 - 6 hr), and is only effective in 4% of the patients who actually receive it. Current research focuses on understanding the pathophysiology of stroke in order to find potential therapeutic targets. Thus, reliable models are crucial, and the MCA occlusion (MCAo) model (also termed the intraluminal filament or suture model) is deemed to be the most clinically relevant surgical model of ischemic stroke, and is fairly non-invasive and easily reproducible. Typically the MCAo model is used with rodents, especially with mice due to all the genetic variations available for this species. Here we describe (and present in the video) how to successfully perform the MCAo model (with reperfusion) in mice to generate reliable and reproducible data.

In order to understand the pathophysiology of stroke, it is important to use reliable models. This paper will describe one of the most frequently used stroke models in mice, termed the middle cerebral artery occlusion (MCAo) model (also termed the intraluminal filament or suture model) with reperfusion.

Stroke is a leading cause of death worldwide and continues to be one of the major causes of long-term adult disabilities. About 87% of strokes are ...

Middle Cerebral Artery Occlusion Allowing Reperfusion via Common Carotid Artery Repair in Mice

The ischemic stroke is a major cause of adult long-term disability and death worldwide. The current treatments available are limited, with only tissue plasminogen activator (tPA) as an approved drug treatment to target ischemic strokes. Current research in the field of ischemic stroke focuses on better understanding the pathophysiology of stroke, to develop and investigate novel pharmaceutical targets. Reliable experimental stroke models are crucial for the progression of potential treatments. The middle cerebral artery occlusion (MCAO) model is clinically relevant and the most frequently used surgical model of ischemic stroke in rodents. However, the outcomes of this model, such as lesion volume, are associated with high levels of variability, particularly in mice. The alternative MCAO model described here allows the reperfusion of the common carotid artery (CCA) and the increased perfusion of the middle cerebral artery (MCA) territory, using a tissue pad with fibrinogen-based sealant to repair the vessel, and the improved welfare of the mice by avoiding external carotid artery (ECA) ligation. This reduces the reliance on the Circle of Willis, which is known to be highly anatomically variable in mice. Representative data show that using this alternative surgical approach decreases the variability in lesion volumes between the traditional MCAO approach and the alternative approach described here.

Intraluminal filament occlusion of the middle cerebral artery is the most frequently used in vivo model of experimental stroke in rodents. An alternative surgical approach to allow common carotid artery repair is performed here, which allows the reperfusion of the common carotid artery and a full reperfusion to the middle cerebral artery territory.

The ischemic stroke is a major cause of adult long-term disability and death worldwide. The current treatments available are limited, with only tissue ...

Laparoscopic Radical Left Pancreatectomy for Pancreatic Cancer: Surgical Strategy and Technique Video

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological resection of left-sided pancreatic cancer. Several surgical techniques have been described in recent years, but few were specifically designed for minimally invasive approaches. This study describes and demonstrates a standardized and reproducible technique for an adequate oncological resection of pancreatic cancer: laparoscopic radical left pancreatectomy (LRLP).
A 61-year-old woman presented with an incidental finding of a 3 cm mass in the left pancreas suspect for malignancy. Imaging did not reveal distant metastases, central vascular involvement, or morbid obesity, hence the patient was suitable for LRLP. This study describes the main steps of LRLP for pancreatic cancer. First, the lesser sac is opened by transecting the gastrocolic ligament. The splenic flexure of the colon is mobilized and the inferior border of the pancreas including Gerota&#39;s fascia is dissected down to the inferior border of the spleen. The pancreas is tunneled and hung, including Gerota&#8217;s fascia with a vessel loop. At the pancreatic neck, a tunnel is created between the pancreas and the portal vein, likewise a vessel loop is passed. The pancreas is then transected using the graded compression technique with an endostapler. Both the splenic vein and artery are transected before completing the resection. The entire specimen is extracted in a retrieval bag via a small Pfannenstiel incision.
Duration of the surgery was 210 min with 250 mL blood loss. Pathology revealed a R0-resection (&#62;1 mm) of a well-to-moderately differentiated adenocarcinoma originating from an intraductal papillary mucinous neoplasm. A total of 15 tumor-negative lymph nodes were resected. This is a detailed description of LRLP for left-sided pancreatic cancer as is currently being used within the international, multicenter randomized DIPLOMA (Distal Pancreatectomy Minimally Invasive or Open for PDAC) trial.

Oncologically safe left pancreatectomy requires radical resection (R0), Gerota&#8217;s (perirenal) fascia resection, and adequate lymph node dissection. This study describes the technical details of laparoscopic radical left pancreatectomy (LRLP), used in the first international multicenter randomized trial comparing minimally invasive with open left pancreatectomy for pancreatic cancer, the DIPLOMA trial.

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological ...

Robot-Assisted Radical Antegrade Modular Pancreatosplenectomy Including Resection and Reconstruction of the Spleno-Mesenteric Junction

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the spleno-mesenteric junction, for cancer of the body-tail of the pancreas. The patient is placed supine with the legs parted and a pneumoperitoneum is established and maintained at 10 mmHg. To use the surgical system, four 8 mm ports and one 12 mm port are required. The optic port is placed at the umbilicus. The other ports are placed, on either side, along the pararectal line and the anterior axillary line at the level of the umbilical line. The assistant port (12 mm) is placed along the right pararectal line. Dissection begins by detaching the gastrocolic ligament, thus opening the lesser sac, and by a wide mobilization of the splenic flexure of the colon. The superior mesenteric vein is identified along the inferior border of the pancreas. Lymph node number 8a is removed to permit clear visualization of the common hepatic artery. A tunnel is then created behind the neck of the pancreas. To permit safe resection and reconstruction of the spleno-mesenteric junction, further preemptive dissection is required before dividing the pancreatic neck to bring in clear view all relevant vascular pedicles. Next, the splenic artery is ligated and divided, and the pancreatic neck is divided, with selective ligature of the pancreatic duct. After vein resection and reconstruction, dissection proceeds to complete the clearance of peripancreatic arteries that are peeled off from all lympho-neural tissues. Both celiac ganglia are removed en-bloc with the specimen. The Gerota fascia covering the upper pole of the left kidney is also removed en-bloc with the specimen. Division of short gastric vessels and splenectomy complete the procedure. A drain is left near the pancreatic stump. The round ligament of the liver is mobilized to protect the vessels.

The robotic technique shown herein aims at faithfully reproducing the open procedure for radical treatment of cancer of the body-tail of the pancreas. The protocol also demonstrates the ability to master involvement of major peripancreatic vessels without conversion to open surgery.

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the ...

Direct Drug Delivery to Kidney via the Renal Artery

There is a need for directed injections to enable increased and specific renal exposure for efficient evaluation of drug targets in the renal research field. Accumulation of drugs in certain organs may give rise to adverse and unwanted effects, depending on the nature of injectate. To minimize spillover and/or accumulation in other tissues, the herein described method directs the formulation into the renal artery bloodstream by inserting a catheter in the infra renal aorta, just below where it branches into the renal artery, resulting in the kidney as first reached organ and distributing of formulation throughout the kidney.
This manuscript provides a detailed description of the method, as well as its challenges and difficulties. It guides the experimenter to become skillful with this type of microsurgery that requires accuracy under sterile conditions. Speed is crucial for minimizing the ischemia and practicing the procedure will increase the chance of successful injections without adverse effects. By modulating the time between injection and reperfusion as well as the injected volume, the risk of spillover to other organs is mitigated. 
Note that this technique is suitable for single dosing strategies.

This manuscript describes a method for targeted delivery to a single kidney via a catheter placed in the infrarenal abdominal aorta in the mouse.

There is a need for directed injections to enable increased and specific renal exposure for efficient evaluation of drug targets in the renal research ...

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic resection and reconstruction techniques, it is difficult to perform LPD for patients with locally advanced pancreatic head cancer after neoadjuvant therapy. Our team initiates LPD using the in-situ No-Touch isolation technique. The innovation and optimization of this modified No-Touch isolation technique emphasize exploring the distal section of superior mesenteric vein&#160;(SMV) and the left side of the superior mesenteric artery (SMA) prior to evaluating the resectability by subcolonic mesenteric approach, which is an ideal exploring approach. After that, we use the median-anterior, and left-posterior of SMA approaches to cut off the blood flow of the pancreatic head to make the tumor isolated intact, then move and dissect the tumor. It is a process fitting the surgical principle of tumor-free. This article aims to demonstrate the feasibility and safety of performing LPD using the in-situ No-Touch isolation technique, which might elevate the R0 resection rate. It is an oncological ideal operation process.

Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

No-Touch isolation procedures might prevent the dissemination of cancer cells from the primary tumor. However, these techniques are not widely accepted in laparoscopic pancreatoduodenectomy (LPD) by now. We herein present in-situ No-Touch isolation LPD with partial resection and reconstruction of the superior mesenteric vein (SMV) for pancreatic cancer after neoadjuvant therapy.

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic ...

Fluorescent Laparoscopic Central Hepatectomy for Liver Cancer Using Indocyanine Green Negative Staining

Laparoscopic hepatectomy is an important treatment method for liver cancer. In the past, the resection boundary was usually determined by intraoperative ultrasound, important vascular structures, and surgeon experience. With the development of anatomical hepatectomy, visual surgery technology has gradually been applied to this type of surgery, particularly indocyanine green (ICG)-guided anatomical hepatectomy. As ICG can be specifically ingested by hepatocytes and used for fluorescence tracing, negative staining techniques have been applied according to different tumor positions. Under ICG fluorescent guidance, the surface boundary and deep resection plane can be more accurately displayed during liver resection. Thus, the tumor-bearing liver segment can be anatomically removed, which helps to avoid damage to important vessels and reduce ischemia or congestion of the remaining liver tissue. Finally, the incidence of postoperative biliary fistula and liver dysfunction is reduced; therefore, a better prognosis is obtained after the resection of liver cancer. Centrally located liver cancer is usually defined as a tumor located at segments 4, 5, or 8 that requires resection of the middle section of the liver. These are among the most difficult hepatectomies to perform because of the large surgical wounds and multiple vessel transections. Based on the specific tumor location, we formulated the required resection ranges by designing personalized fluorescent staining strategies. By completing anatomical resection based on the portal territory, this work aims to achieve the best therapeutic effect.

The present protocol describes fluorescent negative staining in laparoscopic central hepatectomy. This technique can make hepatectomy more accurate and precise.

Laparoscopic hepatectomy is an important treatment method for liver cancer. In the past, the resection boundary was usually determined by intraoperative ...

Application of Laparoscopic Hepatectomy Combined with Intraoperative Microwave Ablation in Colorectal Cancer Liver Metastasis

Laparoscopic hepatectomy is a common treatment for colorectal cancer liver metastasis. Previously, a sufficient number of functional liver masses had to be maintained during laparoscopic hepatectomy, with a residual liver volume of &gt;40% in cirrhotic patients and &gt;30% in non-cirrhotic patients. The high incidence of complications such as bleeding, bile leakage, or liver failure due to the exposure and difficulty of the resection of specific liver segments such as S2 and S7 reduces the success rate of liver resection. At present, microwave ablation is mainly applied in the treatment of liver metastasis using a percutaneous approach, which makes it difficult to identify hidden parts or small lesions. For some liver segments, the percutaneous puncture of liver segment 7 (S7) is likely to pass through the thoracic cavity, and the percutaneous puncture of liver segment 2 (S2) adjacent to the diaphragm is likely to injure the diaphragm and heart; these issues restrict the application of percutaneous ablation in colorectal cancer liver metastasis. Considering multiple lesions, laparoscopic microwave ablation combined with hepatectomy was performed in this study. The location of the lesions was determined by contrast-enhanced ultrasound under laparoscopy, and small lesions that were difficult to detect before the operation were identified. For the scattered lesions, which had diameters less than 3 cm and were difficult to resect, ablation was adopted to substitute hepatectomy. This technique helped to more explicitly locate the tumors, simplified the operation procedures, reduced the risk of complications such as bleeding and bile leakage, shortened the operation time, accelerated the postoperative recovery, significantly improved the success rate of operation, and enhanced the clinical prognosis of colorectal cancer liver metastasis by surgical resection.

This protocol describes the laparoscopic resection of colorectal cancer liver metastases combined with ultrasound-guided microwave ablation. This technique can safely, effectively, and accurately treat refractory liver metastases &lt;3 cm, reduce postoperative complications, and accelerate the postoperative rehabilitation of patients.

Laparoscopic hepatectomy is a common treatment for colorectal cancer liver metastasis. Previously, a sufficient number of functional liver masses had to ...