Is hepatic artery coil embolization useful in distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic cancer?

Abstract

Background The exact contribution of preoperative coil embolization in distal pancreatectomy with en bloc celiac axis resection (DP-CAR) for the prevention of ischemic liver complication is not fully elucidated. Methods From January 2004 to July 2015, 31 patients underwent DP-CAR for the pancreatic body–tail cancer. Twenty-three patients received preoperative coil embolization. The characteristics and operative outcomes were analyzed retrospectively. Results The median survival time and 1- and 3-year overall survival rates were 23.7 months and 74.2% and 34.4%, respectively. No 30-day mortality occurred in any of the patients. Postoperative liver infarction developed only in 8 patients (25.8%) even though 7 of 8 patients had undergone preoperative coil embolization. Tumor contact with the gastroduodenal artery (GDA)/proper hepatic artery (PHA) on preoperative multi-detector computed tomography (MDCT), tumor size, operative time, portal vein resection, and stenosis of the GDA/PHA after DP-CAR are related to liver infarction. Among them, postoperative stenosis of the GDA/PHA on MDCT, which was observed in all 8 patients with liver infarction, was the most closely related factor to postoperative liver infarction. Tumor contact with the GDA/PHA did not worsen the R0 resection rate or overall survival rate. Conclusion Our data indicate that preoperative coil embolization of the common hepatic artery is not useful in DP-CAR as long as GDA is completely preserved during surgery.

Distal pancreatectomy with celiac axis resection (DP-CAR): Optimal perioperative outcome in a patient with locally advanced pancreas adenocarcinoma

“…However, preoperative CHA embolization is not performed in several other high-volume pancreatic centers [ 13 ]. In a recent comparative study [ 7 ], no advantage was documented in 23 patients with CHA embolization before DP-CAR over 8 without. These authors proved that liver ischemia after DP-CAR developed in patients with GDA/PHA stenosis usually after operative dissection of the tumor located too close to the GDA, which needed to be dissected off of it, but was not related to lack of preoperative CHA embolization.…”

“…4 ) and indeed, there was no liver compromise, as reflected in the normal LFTs and bilirubin postoperatively. In the literature, liver ischemic complications vary a lot: 0–62% [ 1 , 2 , 4 , 7 , 11 , 17 , 18 ], but seem to be around 20% in the larger studies [ 1 , 4 , 7 ]. Ischemic gastropathy is also not infrequent, ranging from nil [ 11 , 18 ] to 29% [ 9 ], but generally occurs in around 10% of patients [ 1 , 2 , 12 , 17 ].…”

“…Postoperative pancreatic fistula (grade B/C) is a rather frequent complication after DP-CAR ranging from 10% [ 5 ] to 55–58% [ 7 , 9 ], but most commonly around 20–30% [ [1] , [2] , [3] , [4] , 11 ]. In general, Clavien-Dindo > 3 complications are common: 25–41% [ 3 , 6 , 7 , 9 , 17 ] and certainly more frequent compared to DP alone [ 5 ].…”

“…DP-CAR is generally associated with significant mortality and morbidity, much higher than “straightforward” pancreatoduodenectomy, or DP, even in experienced hands. Mortality is reported around 10% [ 1 , 2 , 4 , 5 ] and varies between 3.5% and 18% [ 3 , [6] , [7] , [8] , [9] ], although nil mortality has also been documented [ [10] , [11] , [12] ]. Median survival after DP-CAR is generally less than 20 months [ 1 , 2 , 4 , 6 ], but this may reflect older experience before neoadjuvant chemotherapy (NAC) was the rule for locally advanced PC.…”

“…Median survival after DP-CAR is generally less than 20 months [ 1 , 2 , 4 , 6 ], but this may reflect older experience before neoadjuvant chemotherapy (NAC) was the rule for locally advanced PC. When NAC is administered, median survival may increase to 2–3 years [ 3 , 7 , 9 ]. Because DP-CAR is only sporadically performed and individual experience is limited, an orchestrated international effort by highly respected pancreatic surgeons [ 13 ] was made, so that safe and evidence-based guidelines for the indications, contraindications, management algorithms, and technicalities for this operation can be formed for wider application.…”