title: The significance of intraoperative Doppler ultrasonography in evaluating hepatic arterial flow when assessing the indications for the Appleby procedure for pancreatic body cancer.
abstract: OBJECTIVE
  The Appleby procedure has been used in the surgical treatment of advanced gastric cancer. This procedure consists of a combined resection of the whole of the stomach, the body and tail of the pancreas, and the spleen, as well as resection of the celiac artery. This procedure can also be used for operative resection of cancer of the body of the pancreas. The hepatic arterial flow is supplied from the arcade of the supramesenteric artery. In the past, the extent of hepatic arterial flow after the celiac artery had been clamped was evaluated by finger palpation. However, this is not an objective method.
  
  
  METHODS
  Here, we describe two patients with pancreatic body cancer, in one of whom the Appleby procedure was followed. However, in the other, this operation could not be performed because the residual blood supply to the liver would have been inadequate. The hepatic arterial flow was assessed using intraoperative Doppler ultrasonography (US) of the intrahepatic artery (arterial flow of segment 3).
  
  
  RESULTS
  In case 1 (a 45-year-old man), the hepatic arterial flow prior to clamping of the celiac artery was 68.4 cm/s, and this flow was reduced to 22.1 cm/s after the clamping. The color and consistency of the liver surface remained good. Because there was adequate hepatic arterial flow after the celiac artery was clamped, the Appleby procedure was performed. However, in case 2 (a 65-year-old man), the hepatic arterial flow after the celiac artery had been clamped was reduced from 47.9 cm/s to 14.3 cm/s. The liver surface became dark and the liver shrank. In addition, there were various preoperative medical conditions in this patient. We decided not to proceed with the Appleby procedure.
  
  
  CONCLUSIONS
  Intraoperative Doppler US measurement of the hepatic arterial flow is a useful technique, particularly in combination with the assessment of the color and tension of the liver, the age of the patient, and the extent of preoperative comorbidity, in determining whether an Appleby procedure is feasible.
authors.affiliation: First Department of Surgery, Graduate School of Medicine, University of Yamagata, 2-2-2 Iida-Nishi, Yamagata 990-9585, Japan.
authors.forename: Ichiro
authors.initials: I
authors.lastname: Hirai
authors.forename: Wataru
authors.initials: W
authors.lastname: Kimura
authors.forename: Masahiro
authors.initials: M
authors.lastname: Kamiga
authors.forename: Masaomi
authors.initials: M
authors.lastname: Mizutani
authors.forename: Akiko
authors.initials: A
authors.lastname: Takeshita
authors.forename: Toshihiro
authors.initials: T
authors.lastname: Watanabe
authors.forename: Akira
authors.initials: A
authors.lastname: Fuse
mesh_terms: D000368:Aged; D001783:Blood Flow Velocity; D002445:Celiac Artery / Q000000981:diagnostic imaging / Q000601:surgery; D006499:Hepatic Artery / Q000000981:diagnostic imaging / Q000601:surgery; D006801:Humans; D008102:Liver Circulation; D008297:Male; D008875:Middle Aged; D010180:Pancreatectomy / Q000379:methods*; D010190:Pancreatic Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D013154:Spleen / Q000473:pathology / Q000601:surgery; D013270:Stomach / Q000473:pathology / Q000601:surgery; D018608:Ultrasonography, Doppler