Distal Pancreatectomy With En Bloc Celiac Axis Resection for Locally Advanced Pancreatic Cancer

Abstract

Supplemental Digital Content is available in the text

Should We Perform Arterial Embolization Before Distal Pancreatectomy Combined with En Bloc Resection of the Celiac Axis for Locally Advanced Pancreatic Cancer?

“…In the past, the left gastric artery and/or common hepatic artery was subjected to preoperative embolization (to prevent ischemic complications, such as ischemic gastritis or ischemic hepatopathy) in most patients who underwent DP-CAR, whereas recent studies have suggested that the benefits of preoperative embolization are unclear [4,9]. This study suggested that the absence of preoperative arterial embolization before DP-CAR does not increase the risk of postoperative complications.…”

“…In addition, arterial embolization is associated with several complications. Regardless of whether preoperative embolization is performed, it is very important to confirm that the blood flow through the proper hepatic artery is sufficient using intraoperative ultrasonography and/or by palpating the patient's pulse after temporarily blocking the celiac axis [4]. We examined the cases of patients who underwent DP-CAR without preoperative embolization and investigated their postoperative courses and any associated problems.…”

“…Locally advanced cancer of the body or tail of the pancreas used to be considered to be unresectable as it often invades the celiac axis and the surrounding nerve plexus. Since extended distal pancreatectomy combined with en bloc resection of the celiac axis (DP-CAR) for locally advanced pancreatic cancer was developed [2] and reported [3], it has become one of the treatments of choice for locally advanced cancer of the body or tail of the pancreas at high volume centers for hepatobiliary/pancreatic surgery [4][5][6][7][8]. Preoperative embolization of the left gastric artery and/or common hepatic artery is often performed prior to DP-CAR to prevent ischemic complications, but its effectiveness is unclear.…”

The Role of Venous and Arterial Resection in Pancreatic Cancer Surgery

“…80 However, the results of a meta-analysis demonstrated no significant difference in mortality, morbidity, or 1-, 2-, and 3-year survival, with an average R0 resection rate of 73% for DP-CAR. 29 Three series have demonstrated a median survival time exceeding 20 months (range, 21-26 months), with R0 resection rates higher than 90%. 72,79,80 In the study by Baumgartner et al 72 all the patients were treated with neoadjuvant therapy before undergoing resection, but despite a very high rate of R0 resections (91%) and an overall median survival longer than 2 years, the median disease-free survival was only 21 weeks, with two patients who had R0 resections experiencing locoregional hepatic recurrence.…”

“…3 However, in contrast to venous resection, which currently is part of the treatment recommendations for borderline resectable tumors, arterial resection has remained controversial. The benefit of arterial resection is best demonstrated for tumors of the body and tail requiring a DP with celiac artery resection (DP-CAR), also known as the modified Appleby procedure, 29,30 and covered in more detail later.…”