Standardized Technique Of Distal Pancreatectomy With Celiac Axis Resection – Tricks To Achieve Zero Mortality Over 53 Cases

Abstract

Presenter: Yosuke Inoue | Cancer Institute Hospital, Japanese Foundation for Cancer Research Background: Distal pancreatectomy with celiac axis resection (DP-CAR) has been accepted as one promising option for advanced pancreatic body cancers. However, it contains difficulty in dissection of the celiac axis, risk of massive intraoperative bleeding, and potential risk of gastric ischemia due to defect of the left gastric artery, leading to high incidence of mortality. Methods: In this video, we present the standardized technique of DP-CAR, by which we achieved no mortality over 53 cases. It includes 4 technical tips. The first: Celiac first approach and clamping to minimize the blood loss during following dissection. The second: Left kidney mobilization to obtain opened view during retroperitoneal dissection. The third: Left gastric artery reconstruction to avoid ischemic gastropathy. The last: Confirmation of blood flow of left gastric artery using ICG fluorescence imaging. Results: Patients comprised 26 locally advanced, 17 borderline resectable, and 10 resectable according to NCCN guideline. UR-LA included 21 patients who underwent neoadjuvant therapy. Twenty-six patients underwent DP-CAR with high ligation of CA, and 27 underwent DP-CAR with CA ligation at distal of LGA origin (mDP-CAR). When compared between DP-CAR and mDP-CAR, operation duration (498 vs. 406 min, P=0.0018) was longer in DP-CAR and blood loss (664 vs. 520 ml, P＝0.27) was similar among groups. Blood transfusion was needed in only one patient (2%) in DP-CAR group. Postoperative complication included ischemic gastropathy in 2, pancreatic fistula (B/C) in 18/1(25%), and delayed gastric emptying in 15(28%). Complication ≥ C-D grade 3 occurred in 17 patients (32%) without mortality. R0 resection was achieved in 21(81%) vs. 24 patients (89%, P=0.47, 0mm rule). Conclusion: DP-CAR is promising procedure to achieve R0 in advanced pancreatic body cancer. CA first approach, Left kidney mobilization, and LGA preservation/reconstruction are technical tips to minimize surgical risks.