Abstract
Background. Pancreatic adenocarcinoma of the body and tail usually presents late and is typically unresectable. The modified Appleby procedure allows resection of pancreatic body carcinoma with celiac axis (CA) invasion. Given that the feasibility of this technique is based on the presence of collateral circulation, it is crucial to confirm the presence of an anatomical and functional collateral system. Methods. We here describe a novel technique used in two patients who were candidates for Appleby resection. We present their clinical scenario, imaging, operative findings, and postoperative course. Results. Both patients had a preoperative angiogram for assessment of anatomical circulation and placement of an endovascular stent to cover the CA. We hypothesize that this new technique allows enhancement of collateral circulation and helps minimize intraoperative blood loss when transecting the CA at its takeoff. Moreover, extra length on the CA margin may be gained, as the artery can be transected at its origin without the need for vascular clamp placement. Conclusion. We propose this novel technique in the preoperative management of patients who are undergoing a modified Appleby procedure. While further experience with this technique is required, we believe that it confers significant advantages to the current standard of care.
Highlights
According to the most recent report from the SEER database, an estimated 46,420 new cases of pancreatic cancer will be diagnosed in the United States in 2014, with 39,590 related deaths
Unlike tumors that arise in the head of the pancreas, which present with obstructive jaundice, those that arise in the body and tail usually present late and are typically unresectable [2,3,4]
In the 1950s, Lyon Appleby first described the feasibility of celiac axis resection for locally advanced gastric cancer, which relied on the presence of an effective superior mesenteric artery (SMA) collateral circulation to the common hepatic artery (CHA) through the gastroduodenal artery (GDA) or on the presence of aberrant anatomy [9]
Summary
Pancreatic adenocarcinoma of the body and tail usually presents late and is typically unresectable. We here describe a novel technique used in two patients who were candidates for Appleby resection. We present their clinical scenario, imaging, operative findings, and postoperative course. Both patients had a preoperative angiogram for assessment of anatomical circulation and placement of an endovascular stent to cover the CA. We hypothesize that this new technique allows enhancement of collateral circulation and helps minimize intraoperative blood loss when transecting the CA at its takeoff. We propose this novel technique in the preoperative management of patients who are undergoing a modified Appleby procedure. While further experience with this technique is required, we believe that it confers significant advantages to the current standard of care
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