Arterial Divestment and Resection in Post-neoadjuvant Pancreatic Adenocarcinoma

Abstract

Introduction The advent of neoadjuvant therapy in the management of pancreatic adenocarcinoma has significantly improved the prognosis of the disease. Nevertheless, the only chance of long-term disease-free survival in pancreatic cancer is achieved with complete tumor resection, and artery involvement by the tumor is one of the major determinants in its resectability. We aim to evaluate the feasibility of a novel technique, namely, the periarterial divestment, which has allowed surgeons to clear the tumor tissues off the visceral arteries without the need for arterial reconstruction. Materials and methods In this single-center, retrospective, descriptive, cross-sectional study done between August 2019 and July 2021, seven consecutive patients with histologically confirmed pancreatic ductal adenocarcinoma (PDAC) who underwent neoadjuvant therapy were included. Arterial divestment was performed in six of seven patients and arterial reconstruction was performed in one of the patients. The data on perioperative and the early oncological outcome were recorded. Results Five patients underwent periarterial divestment, one underwent sub-adventitial divestment, and one underwent superior mesenteric artery reconstruction due to deeper tumor infiltration into the arterial wall. The intraoperative frozen section of periarterial tissue was positive in three cases and the final histopathological specimen after the divestment showed a positive margin in two of the cases. The clinically significant postoperative pancreatic fistula was noted in two patients, and one patient experienced grade C post-pancreaticoduodenectomy hemorrhage due to a hepatic artery pseudoaneurysm. Four patients, all of whom underwent periarterial divestment, experienced postoperative diarrhea. There were no mortality and the median postoperative hospital stay was seven days. Conclusion The need for arterial reconstruction in borderline and locally advanced pancreatic cancer can be avoided by using the periarterial divestment technique. Divestment of arteries is technically feasible and can be carried out safely without compromising the patient's oncological outcome. However, further validation of this technique must be done by well-designed studies with a greater sample size.

Strategies in the Management of Pancreatic Ductal Adenocarcinoma Involving Aberrant Right Hepatic Artery Arising From the Superior Mesenteric Artery

“…Peri-arterial divestment in pancreatic cancer surgery has brought a paradigm shift in the management of arteries involved by the tumor. Divestment of the involved artery increases the chance of complete tumor resection and avoids the morbidity related to vascular reconstruction in selected patients [ 13 - 15 ]. The same principle of peri-arterial divestment was applied in our study to manage the tumor-involved aRHA, which successfully achieved R0 resection, especially in patients with distal arterial involvement.…”