Stomach-Preserving Distal Pancreatectomy with Combined Resection of the Celiac Artery: Radical Procedure for Locally Advanced Cancer of the Pancreatic Body

Abstract

To enhance the resectability of cancer of the pancreatic body, a new surgical technique should be developed. Of 25 patients with cancer of the pancreatic body who underwent distal pancreatectomy with curative intent, seven with cancer invasion around the celiac artery underwent stomach-preserving distal pancreatectomy with combined resection of the celiac artery. This procedure secured arterial blood supply to the whole stomach and liver via the inferior pancreaticoduodenal artery without arterial reconstruction. There was no postoperative mortality. One patient developed transient passage disturbance in the duodenum. Another one developed a minor pancreatic fistula. No patients had serious complications related to ischemia of the stomach or liver. The quality of life of the patients after surgery was well maintained, and planned adjuvant therapy was accomplished. Local recurrence was evident in only two patients. The median survival time of patients who underwent distal pancreatectomy with (n = 7) or without (n = 18) resection of the celiac artery was 19 and 25 months, respectively. The overall survival rate was not significantly different between the two groups (P = 0.5300). The present study suggests that this surgical procedure is a rational approach to locally advanced pancreatic body cancer invading around the celiac artery. In view of the feasibility of this procedure, it can also be adopted for less advanced cancer of the pancreatic body to enhance local control and survival.

Distal Pancreatectomy for Body-Tail Pancreatic Cancer: Is There a Role for Celiac Axis Resection?

“…After the first DP-CAR for body-tail pancreatic cancer performed by Nimura et al [7] in 1976, only 90 patients emerged from a careful literature review [7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28] (table 2). Since there are no large series of DP-CAR for pancreatic cancer, we pooled our own findings with published reports in an attempt to draw some conclusions about the related surgical risk and long-term results.…”

“…Our resectability rate therefore rose from 29.2% (49/168) to 32.1% (54/168) thanks to DP-CAR. After pooling our own with data reported in the literature [9,11,12,17,19], we collected 621 patients with body-tail pancreatic cancer. One-hundred and eighty-two patients (29.3%) underwent DP, 42 (6.8%) DP-CAR and in 397 (63.9%) the cancers were unresectable.…”

“…Nimura et al [7] performed the first DP-CAR in a patient with body-tail pancreatic cancer in 1976. To date, DP-CAR for the surgical treatment of body-tail pancreatic cancer has been reported in a limited number of patients, mainly by Far Eastern authors [7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22], while experience with this operation in Western countries is limited and more recent [23,24,25,26,27,28]. The indication for DP-CAR was recently extended to patients without any direct invasion of the CA to increase the radical resection (R0) rate for advanced body-tail pancreatic cancer [18].…”

Liver blood supply after a modified Appleby procedure in classical and aberrant arterial anatomy

“…Just the same, not only does radical removal of pancreatic body carcinoma with the use of Appleby's technique improve patient life quality, it also significantly prolongs survival, which was attested to, not only in cases of arterial resection necessitating no reconstruction [5,11,[13][14][15][16][17][18][19][20][21] , but in those resorting to repair as well [16,[23][24][25] . Completeness (radicality) of resection is one of the dominant independent prognostic factors for pancreatic cancer [46][47][48][49][50][51][52][53] .…”

“…In 1976, Nimura applied Appleby's technique to treat locally advanced pancreatic body-tail carcinoma [4] and in 1991, Nagino et al [5] and Hishinuma et al [6] succeeded in preserving the stomach in the absence of its invasion from pancreatic tumor by means of sparing the gastroduodenal and right gastroepiploic arteries (GDA and RGEA), thereby modifying Appleby's operation. By the year 2003, two dozen such operative interventions had been accomplished [5,[7][8][9][10][11][12][13][14][15] , at most, but refinements in diagnosis and surgical technique have progressively promoted their growing in number [5,11,[15][16][17][18][19][20][21][22][23][24] . The modified Appleby procedure case reviews in the literature tend to say nothing about the pattern of the celiacmesenteric arterial vasculature encountered, in as much as, when dealing with variant arteries and the classical arterial architecture, this sort of surgery can be successfully performed without vascular reconstruction.…”