Distal Pancreatectomy With Celiac Axis Resection Research Articles

Prognostic impact of the distance from the root of splenic artery to tumor in the patients with pancreatic body or tail cancer

BackgroundThe impact of the distance from the root of splenic artery to tumor (DST) on the prognosis and optimal surgical procedures in the patients with pancreatic body/tail cancer has been unclear. MethodsWe retrospectively analyzed 94 patients who underwent distal pancreatectomy (DP) and 17 patients who underwent DP with celiac axis resection (DP-CAR) between 2008 and 2018. ResultsThe 111 patients were assigned by DST length (in mm) as DST = 0: n = 14, 0<DST≤10: n = 18, and 10<DST: n = 79. The median overall survival (OS) and relapse-free survival (RFS) did not significantly differ in each group. A multivariate analysis showed that DST was not an independent prognostic factor for both RFS and OS. DP-CAR did not improve the prognosis in the DST = 0 and the 0<DST≤10 groups. In the DST = 0 group, neoadjuvant therapy significantly decreased distant metastasis (P = 0.025) and improve the overall survival (P = 0.046). ConclusionsDST did not affect prognosis in patients with pancreatic body/tail cancer. Neoadjuvant therapy followed by DP may be desirable for patients with a DST = 0 tumor. For those with a 0<DST≤10 tumor, DP may be suitable; DP-CAR is an alternative when ligation and dissection of the root of the splenic artery are difficult or not possible.

Distal pancreatectomy with celiac axis resection for pancreatic body cancer: a single center review of 89 consecutive cases

Objective: To investigate the clinical efficacy of distal pancreatectomy with celiac axis resection(DP-CAR). Methods: A total of 89 consecutive patients (50 males and 39 females) who were diagnosed with pancreatic body cancer and underwent DP-CAR in Pancreas Center,First Affiliated Hospital of Nanjing Medical University between September 2013 and June 2022 were retrospectively reviewed. There were 50 males and 39 females,with age(M(IQR)) of 63(12) years(range:43 to 81 years). Perioperative parameters,pathology results and follow-up data of these patients were analyzed,χ2 or Fisher's test for categorical data while the Wilcoxon test for quantitative data. Survival results were estimated by the Kaplan-Meier survival method. Results: Among 89 cases,cases combined with portal vein-superior mesenteric vein or organ resection accounted for 22.5% (20/89) and 42.7% (38/89),respectively. The operative time,blood loss and postoperative hospital stay were 270 (110) minutes,300 (300) ml and 13 (10) days,respectively. The overall morbidity rate was 67.4% (60/89) while the major morbidity was 11.2% (10/89). The increase rate in transient liver enzymes was 42.7% (38/89),3.4% (3/89) for liver failure,53.9% (48/89) for clinically relevant postoperative pancreatic fistula,1.1% (1/89) for bile leak,3.4% (3/89) for chylous leak of grade B and C,11.2% (10/89) for abdominal infection,9.0% (8/89) for postoperative hemorrhage of grade B and C,4.5% (4/89) for delayed gastric emptying,6.7% (6/89) for deep vein thrombosis,3.4% (3/89) for reoperation,4.5% (4/89)for hospital mortality,7.9% (7/89) for 90-day mortality. The pathological type was pancreatic cancer for all 89 cases and pancreatic ductal adenocarcinoma made up 92.1% (82/89). The tumor size was 4.8(2.0) cm, ranging from 1.5 to 12.0 cm. The number of lymph nodes harvested was 14 (13)(range:2 to 33),with a positive lymph node rate of 13.0% (24.0%). The resection R0 rate was 30.0% (24/80) and the R1 (<1 mm) rate was 58.8% (47/80). The median overall survival time was 21.3 months (95%CI: 15.6 to 24.3) and the median disease-free survival time was 19.1 months (95%CI: 11.7 to 25.1). The overall survival at 1-year and 2-year were 69.60% and 39.52%. The median survival time of 58 patients with adjuvant chemotherapy was 24.3 months (95%CI: 17.8 to 32.3) while that of 13 patients without any kind of adjuvant therapy was 8.4 months (95%CI: 7.3 to 22.3). Seven patients accepted neoadjuvant chemotherapy and there was no significant morbidity among them,with a resection rate of R0 of 5/7. Conclusion: DP-CAR is safe and feasible for selective cases,which could be more valuable in improving long-term survival when combined with (neo) adjuvant therapy.

15-Year Experience of Distal Pancreatectomy with Celiac Axis Resection (DP-CAR) for Pancreatic Cancer-A Korean Nationwide Investigation.

As systemic treatment for pancreatic cancer advances, distal pancreatectomy with celiac axis resection (DP-CAR) has been considered a curative-intent surgical option for advanced pancreatic cancer. This study aimed to review the surgical and oncologic outcomes of patients undergoing DP-CAR based on Korean nationwide data. We collected the data of patients who underwent DP-CAR for pancreatic cancer between 2007 and 2021 at seven major hospitals in Korea. The clinicopathological characteristics, postoperative complications, and data on the survival of the patients were retrospectively reviewed. Logistic regression analysis was performed to identify risk factors for postoperative complications and survival. A total of 75 patients, consisting mainly of borderline resectable (n = 32) or locally advanced (n = 30) pancreatic cancer, were included in the analysis. Forty-two (56.0%) patients underwent neoadjuvant treatment (NAT). Twenty (26.7%) patients experienced Clavien-Dindo grade ≥ 3 complications, including four patients with ischemic gastropathy, two with hepatic ischemia, and two procedure-related mortalities. Neoadjuvant chemotherapy increased the risk of postoperative complications (p = 0.028). The median recurrence-free and overall survival were 7 and 19 months, with a 5-year survival rate of 13% and 24%, respectively. In the NAT group, a decrease in CA 19-9 and the post-NAT maximum standardized uptake value (SUVmax) in positron emission tomography were associated with survival after surgical resection. Despite the possibility of major complications, DP-CAR could be a feasible option for achieving curative resection with fair survival outcomes in patients with borderline resectable or locally advanced pancreatic cancer. Further studies investigating the safety of the procedure and identifying proper surgical candidates with potential survival gains are necessary.

Distal pancreatectomy with celiac axis resection (DP-CAR) in the era of neoadjuvant chemotherapy: What decides proper candidates for curative surgery? – A Korean nationwide investigation

So Jeong YOON, Sang-Jae PARK, Yoo-Seok YOON, Jin-Young JANG, Tae-Ho HONG, Dae Wook HWANG, Hee Joon KIM, Hongbeom KIM, Sang Hyun SHIN, Jin Seok HEO, In Woong HAN*. Ann Hepatobiliary Pancreat Surg 2023;27:S57. https://doi.org/10.14701/ahbps.2023S1.BP-BEST-OP-6

Outcomes of Distal Pancreatectomy With Celiac Axis Resection for Pancreatic Cancer.

This study aimed to show the clinical and oncologic outcomes of distal pancreatectomy with celiac axis resection (DP-CAR) from a high-volume single center and analyze them from diverse perspectives. Forty-eight patients with pancreatic body and tail cancer with celiac axis involvement who underwent DP-CAR were included in the study. The primary outcome was morbidity and 90-day mortality, and the secondary outcome was overall survival and disease-free survival. Morbidity (Clavien-Dindo classification grade ≥3) occurred in 12 patients (25.0%). Thirteen patients (27.1%) had pancreatic fistula grade B and 3 patients (6.3%) had delayed gastric emptying. The 90-day mortality was 2.1% (n = 1). The median overall survival was 25.5 months (interquartile range, 12.3-37.5 months) and median disease-free survival was 7.5 months (interquartile range, 4.0-17.0 months). During the follow-up period, 29.2% of participants survived for up to 3 years and 6.3% survived for up to 5 years. Despite its associated morbidity and mortality, DP-CAR should be considered as the only therapeutic option for pancreatic body and tail cancer with celiac axis involvement when carried out on carefully selected patients performed by a highly experienced group.

Distal Pancreatectomy with Celiac Axis Resection (DP-CAR) for Distal Locally Advanced Pancreatic Ductal Adenocarcinoma (DLA-PDAC): Surgical Strategy to Reduce Morbimortality

Distal Pancreatectomy with Celiac Axis Resection (DP-CAR) for Distal Locally Advanced Pancreatic Ductal Adenocarcinoma (DLA-PDAC): Surgical Strategy to Reduce Morbimortality

Comparison of distal pancreatectomy with celiac axis resection and sub-adventitial divestment technique for locally advanced or borderline resectable pancreatic body cancer

Objective: To compare the outcomes of modified Appleby procedure and sub-adventitial divestment technique for locally advanced or borderline resectable pancreatic body cancer. Methods: A total of consecutive 58 patients(33 males and 25 females) who were diagnosed as locally advanced or borderline resectable pancreatic body cancer and underwent distal pancreatectomy at Pancreas Center, First Affiliated Hospital of Nanjing Medical University between September 2013 and May 2019 were retrospectively reviewed. The age(M(IQR)) was 62(9)years(range: 43 to 79 years). Thirty-one patients underwent distal pancreatectomy with celiac axis resection (DP-CAR) and 27 patients underwent distal pancreatectomy with sub-adventitial divestment technique(SDT). Perioperative parameters and follow-up data of these patients were analyzed. Quantitative data were compared with Wilcoxon test while categorical variables were compared with χ2 test or Fisher's exact test. Survival results were estimated by the Kaplan-Meier survival method with a Log-rank test. Results: There were no differences in age,gender,body mass index,abdominal symptoms,comorbidity or preoperative serum CA19-9 between two groups(all P>0.05). Obvious preoperative weight loss was more common in the group of SDT(48.1%(13/27) vs. 19.4%(6/31),χ²=5.431,P=0.020). Longer operative time(310(123) minutes vs. 254(137)minutes, Z=2.277,P=0.023),higher rate of combined organ resection(41.9%(13/31) vs. 14.8%(4/27),χ²=5.123,P=0.041) and longer postoperative hospital stay(15(10) days vs. 11(5)days,Z=2.292,P=0.022) were observed in the group of DP-CAR. Moreover,rate of overall morbidities was also higher (71.0%(22/31) vs. 29.6%(8/27),χ2=9.876,P=0.003),implicated by clinically relevant postoperative pancreatic fistula(61.3%(19/31) vs. 29.6%(8/27),χ2=5.814,P=0.020) in the DP-CAR group. Tumor size of the DP-CAR group was bigger(4.9(1.5)cm vs. 4.0(1.2)cm,Z=2.343,P=0.019) but no difference was seen between the DP-CAR group and SDT group in R0+R1(<1 mm) resection rate (84.0%(21/25) vs. 90.0%(18/20),P=0.678) and LNR(12.0(23.0)% vs. 9.0(18.0)%,Z=1.238,P=0.216),as well as median disease free survival(11.7 months vs. 11.4 months,Z=0.019,P=0.892) and median overall survival(16.3 months vs. 13.7 months,Z=0.172,P=0.679). Conclusions: Both DP-CAR and distal pancreatectomy with SDT are relatively safe and feasible for locally advanced or borderline resectable pancreatic body cancer. Compared with arterial resection,SDT may contribute to lower rates of postoperative complications and shorter duration of hospitalization,but no significant benefit is seen in long-term survival.

Retroperitoneal-first laparoscopic approach (Retlap)-assisted distal pancreatectomy with celiac axis resection (DP-CAR): A novel minimally invasive approach for achieving adequate dorsal surgical margin

BackgroundDistal pancreatectomy with celiac axis resection (DP-CAR) is a procedure to secure a surgical margin for a locally advanced pancreatic body cancer that invades the celiac axis. However, in patients with cancer close to the root of the celiac axis, obtaining adequate surgical margins can be difficult because the tumor obstructs the field of vision to the root of the celiac axis. Previously, we described the retroperitoneal-first laparoscopic approach (Retlap) to achieve both accurate evaluation of resectability for locally advanced pancreatic cancer requiring DP-CAR [1] and adequate surgical margin for laparoscopic distal pancreatectomy [2]. In this video, we introduce Retlap-assisted DP-CAR as a minimally invasive approach for performing an artery-first pancreatectomy [3, 4] and achieving sufficient dorsal surgical margin (Fig. 1). MethodsOur patient is a 67-year-old man with a 55 × 29-mm pancreatic body tumor after chemotherapy. Preoperative computed tomography revealed a tumor close to the root of the celiac axis. Because the area of tumor invasion on preoperative images was near the root of the celiac artery, Retlap-assisted DP-CAR was performed to determine whether the celiac axis can be secured and obtain an adequate dorsal surgical margin (Fig. 2). ResultsThe operative time and estimated blood loss was 715 min and 449 mL, respectively. In spite of the advanced tumor's location and size, R0 resection was achieved in a minimally invasive way. ConclusionRetlap-assisted DP-CAR is not only technically feasible and useful for achieving accurate evaluation of resectability but also facilitates obtaining an adequate surgical margin.

Distal Pancreatectomy with Celiac Axis Resection (DP-CAR) with Preoperative Embolization of CHA (Common Hepatic Artery). Experience from a High-Volume Center

Background: Surgery is the only potential curative treatment of PDAC (pancratic ductal adenocarcinoma). When tumor is located in the body and/or tail of the pancreas and involves the CHA and/or CA (celiac axis/trunc) tumor has until recently been considered unresectable. Distal pancreatectomy with en bloc resection of the celiac axis (DP-CAR) may be an option to achieve R0 resection. To enhance collateral arterial supply for the liver and stomach, preoperative embolization of the CHA with operation two weeks later may be indicated. Methods: Patients with locally advanced tumors in the body and/or tail of pancreas were evaluated for DP-CAR procedures with preoperative embolization of CHA and in some cases left gastric artery (LGA) if involved in tumor. Patients with tumors involving GDA (gastroduodenal artery) or central (<2cm) of the CT (celiac trunc) and patients with metastatic disease (M1) were not included. Results: From May 2013 to Juli 2021 a total of 29 patients went through DP-CAR with preoperative embolization. We did not record any adverse events related to the preoperative embolization of CHA. Patients had longer postoperative hospitalization, but no difference in major complications, including pancreatic fistulas, when compared to our standard distal pancreatectomies. Conclusion: Preoperative embolization is feasible and may in be a good option as preparation for DP-CAR. In high-volume centers DP-CAR can be performed with outcomes comparable to standard distal pancreatectomies.

Robot Assisted Distal Pancreatectomy with Celiac Axis Resection (DP-CAR) for Pancreatic Cancer: Surgical Planning and Technique.

Malignant pancreatic tumors involving the celiac artery can be resected with a distal pancreatectomy, splenectomy and celiac axis resection (DP-CAR), relying on collateral flow to the liver through the gastroduodenal artery (GDA). In the current manuscript, the technical conduct of robotic DP-CAR is outlined. The greater curve of the stomach is mobilized with care to avoid sacrificing the gastroepiploic vessels. The stomach and liver are retracted cephalad to facilitate dissection of the porta hepatis. The hepatic artery (HA) is dissected and encircled with a vessel loop. The gastroduodenal artery (GDA) is carefully preserved. The common HA is clamped and triphasic flow in the proper HA via the GDA is confirmed using intra-operative ultrasound. A retropancreatic tunnel is made over the superior mesenteric vein (SMV). The pancreas is divided with an endovascular stapler at the neck. The inferior mesenteric vein (IMV) and splenic vein are ligated. The HA is stapled proximal to the GDA. The entire specimen is retracted laterally with further dissection cephalad to expose the superior mesenteric artery (SMA). The SMA is then traced back to the aorta. The dissection continues cephalad along the aorta with the bipolar energy device used to divide the crural fibers and celiac nerve plexus. The specimen is mobilized from the patient's right to left until the origin of the celiac axis is identified and oriented towards the left. The trunk is circumferentially dissected and stapled. Additional dissection with hook cautery and the bipolar energy device fully mobilizes the pancreatic tail and spleen. The specimen is removed from the left lower quadrant extraction site and one drain is left in the resection bed. A final intra-operative ultrasound of the proper HA confirms pulsatile, triphasic flow in the artery and liver parenchyma. The stomach is inspected for evidence of ischemia. Robotic DP-CAR is safe, feasible and when used in conjunction with multi-modality therapy, offers potential for long-term survival in selected patients.

Robot Assisted Distal Pancreatectomy with Celiac Axis Resection (DP-CAR) for Pancreatic Cancer: Surgical Planning and Technique

Robot Assisted Distal Pancreatectomy with Celiac Axis Resection (DP-CAR) for Pancreatic Cancer: Surgical Planning and Technique

Details and Outcomes of Distal Pancreatectomy with Celiac Axis Resection Preserving the Left Gastric Arterial Flow.

To describe the technical details and efficacy of distal pancreatectomy with celiac axis resection (DP-CAR) and left gastric artery (LGA) flow preservation for pancreatic ductal adenocarcinoma (PDAC). This single-center, retrospective analysis investigated short- and long-term outcomes of DP-CAR performed on 55 patients with PDAC from 2011 to 2019. Our method included LGA reconstruction after total resection of the CA (rDP-CAR group; 24 patients) or LGA preservation if the tumor invasion was away from its root (pDP-CAR group; 31 patients), a CA-first approach to reduce blood loss during dissection, and conservative drain management with or without jejunal serosal patching at the pancreatic stump. Among the study patients, 23 had locally advanced PDAC and 22 had borderline resectable PDAC. Median operation duration was 443min (248-810), estimated blood loss was 600mL (150-2280), and incidence of transfusion was 2%. Ischemic complications occurred exclusively in the rDP-CAR group, including two patients with ischemic gastropathy (8%) and three patients with findings of liver ischemia on computed tomography (13%). One patient underwent relaparotomy for stomach perforations, and 19 patients (35%) had pancreatic fistula, including 8 patients who underwent conservative drain placement for more than 3 weeks without specific symptoms. There were no Clavien-Dindo grade 4 or higher postoperative complications. Preoperative therapy showed improved 3-year overall survival rates than without (54% vs. 37%, p=0.027). Using the standardized technique, DP-CAR was safely performed with no mortality and acceptable long-term survival.

Distal Pancreatectomy with Celiac Axis Resection: Systematic Review and Meta-Analysis.

Simple SummaryThe literature is conflicting regarding the feasibility and survival outcomes of distal pancreatectomy with celiac axis resection (DP-CAR), although this procedure, in selected cases, represents the only therapeutical option for patients with locally advanced pancreatic cancer. The available studies often include small surgical populations, and there are important variations in the inclusion criteria and pre- and post-operative treatment. The purpose of this study was to provide an overview of the literature of the last 15 years, to evaluate the efficacy and the clinical safety of this procedure. This could help physicians in the choice of a multidisciplinary targeted therapeutical plan for patients. The combination of neoadjuvant chemo/radiochemotherapy and demolitive surgeries such as DP-CAR could have a role in changing the survival outcomes of patients with locally advanced pancreatic adenocarcinoma.Background: Major vascular invasion represents one of the most frequent reasons to consider pancreatic adenocarcinomas unresectable, although in the last decades, demolitive surgeries such as distal pancreatectomy with celiac axis resection (DP-CAR) have become a therapeutical option. Methods: A meta-analysis of studies comparing DP-CAR and standard DP in patients with pancreatic adenocarcinoma was conducted. Moreover, a systematic review of studies analyzing oncological, postoperative and survival outcomes of DP-CAR was conducted. Results: Twenty-four articles were selected for the systematic review, whereas eleven were selected for the meta-analysis, for a total of 1077 patients. Survival outcomes between the two groups were similar in terms of 1 year overall survival (OS) (odds ratio (OR) 0.67, 95% confidence interval (CI) 0.34 to 1.31, p = 0.24). Patients who received DP-CAR were more likely to have T4 tumors (OR 28.45, 95% CI 10.46 to 77.37, p < 0.00001) and positive margins (R+) (OR 2.28, 95% CI 1.24 to 4.17, p = 0.008). Overall complications (OR, 1.72, 95% CI, 1.15 to 2.58, p = 0.008) were more frequent in the DP-CAR group, whereas rates of pancreatic fistula (OR 1.16, 95% CI 0.81 to 1.65, p = 0.41) were similar. Conclusions: DP-CAR was not associated with higher mortality compared to standard DP; however, overall morbidity was higher. Celiac axis involvement should no longer be considered a strict contraindication to surgery in patients with locally advanced pancreatic adenocarcinoma. Considering the different baseline tumor characteristics, DP-CAR may need to be compared with palliative therapies instead of standard DP.

Outcomes after distal pancreatectomy with celiac axis resection for pancreatic cancer: a single center retrospective study

Introduction: As distal pancreatectomy with celiac axis resection (DP-CAR) is the only possible cure for pancreatic body and tail cancer with celiac axis involvement, we performed this study to show the post-operative outcomes of DP-CAR. Method: 48 patients with pancreatic body and tail cancer with celiac axis involvement who underwent DP-CAR in Asan medical center between January 2008 and December 2018 were included in the study. We retrospectively reviewed the patient's preoperative, operative and postoperative data. Primary outcome was major morbidity and 90-day mortality, and secondary outcome was overall survival. Results: Major morbidity occurred in 9 patients (18.8%). 13 patients (27.1%) had pancreatic fistula grade B or C according to ISGPS guideline. There was 1 case (2.1%) of 90-day mortality after operation. Kaplan-Meier estimated median overall survival was 25.0 months. Conclusions: DP-CAR is a good treatment option for cure in pancreatic body and tail cancer with celiac axis involvement without significant morbidity and mortality.

Successful conversion surgery of distal pancreatectomy with celiac axis resection (DP-CAR) with double arterial reconstruction using saphenous vein grafting for locally advanced pancreatic cancer: a case report

BackgroundPancreatic cancer is a disease with a poor prognosis, requiring multidisciplinary treatment combining chemotherapy and surgery for effective management. Distal pancreatectomy with celiac axis resection (DP-CAR) is a surgical intervention performed for locally advanced pancreatic cancer, but the benefit of arterial reconstruction in DP-CAR is unclear.Case presentationA 49-year-old man with pancreatic cancer was referred to our hospital. Imaging revealed a 54-mm tumor mainly in the pancreatic body, but with arterial infiltration including into the celiac, common hepatic, left gastric, splenic and gastroduodenal arteries. Distant metastases were not detected. The patient was diagnosed with unresectable locally advanced pancreatic cancer and chemoradiotherapy was planned. Three cycles of gemcitabine (1000 mg/m2) plus nab-paclitaxel (125 mg/m2) every 4 weeks were followed by irradiation (2 Gy/day, total 50 Gy over 25 days) together with S-1 administration (80 mg/m2/day). A partial response (PR) according to Response Evaluation Criteria in Solid Tumors (RECIST) was achieved, so surgical intervention was considered. Because the tumor had invaded the root of the gastroduodenal artery, we performed DP-CAR with resection of the gastroduodenal artery, followed by arterial reconstruction of the proper hepatic and left gastric arteries, anastomosed with the abdominal aorta using a great saphenous vein graft in the shape of a “Y”. Histopathology showed that 60% of tumor cells were destroyed by the chemoradiotherapy, defined as grade IIb in the Evans classification. No malignancy was detected at the surgical margin, including the celiac artery, gastroduodenal artery or pancreatic stump; thus R0 surgery was successful. S-1 (80 mg/day) was administered as adjuvant chemotherapy for 6 months. The patient is now doing well without recurrence for > 2 years after the initial treatment (more than 16 months after surgery).ConclusionFor locally advanced pancreatic cancer, multidisciplinary treatment combining gemcitabine/nab-paclitaxel-based chemoradiotherapy and then DP-CAR surgery with gastroduodenal artery resection and arterial reconstruction using saphenous vein grafting enabled R0 resection in this patient and led to a favorable long-term prognosis.

An Aggressive Approach to Locally Confined Pancreatic Cancer: Defining Surgical and Oncologic Outcomes Unique to Pancreatectomy with Celiac Axis Resection (DP-CAR).

Background:Modern chemotherapeutics have led to improved systemic disease control for patients with locally advanced pancreatic cancer (LAPC). Surgical strategies such as distal pancreatectomy with celiac axis resection (DP-CAR) are increasingly entertained. Herein we review procedure specific outcomes and assess biologic rationale for DP-CAR.Methods:A prospectively maintained single-institution database of all pancreatectomies was queried for patients undergoing DP-CAR. We excluded all patients for whom complete data were not available and those who were not treated with contemporary multi-agent therapy. Data was supplemented with dedicated chart review and outreach for long-term oncologic outcomes.Results:Fifty-four patients underwent DP-CAR between 2008–2018. The median age was 62.7 years. 98% received induction chemotherapy. Arterial reconstruction was performed in 17% and concomitant visceral resection in 30%. R0 resection rate was 87%. Postoperative complications were common (43%) with chyle leak being the most frequent (17%). Length of stay was 8 days, readmission occurred in one-third, and ninety-day mortality was 2%. Disease recurrence occurred in 74% during a median follow up of 17.4 months. Median recurrence-free (RFS) and overall survival (OS) were 9 and 25 months, respectively.Conclusions:Following modern induction paradigms, DP-CAR can be performed with low mortality, manageable morbidity, and excellent rates of margin-negative resection in high volume settings. The profile of complications of DP-CAR is distinct from pancreaticoduodenectomy and simple distal pancreatectomy. OS and RFS are similar to those undergoing resection of borderline resectable and resectable disease. Improved systemic disease control will likely lead to increasing utilization of aggressive surgical approaches to LAPC.

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

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.

Impact of the distance from the root of the splenic artery to the tumor in patents with the pancreatic body/tail cancer.

221 Background: The impact of the distance from the root of the splenic artery to the tumor (DST) on prognosis and selection of operative procedures in patients with pancreatic body/tail cancer remains to be unclear. Methods: Between 2008 and 2018, 98 and 17 patients who underwent distal pancreatectomy (DP) and DP with celiac axis resection (DP-CAR) for conventional pancreatic ductal carcinoma were retrospectively analyzed. DST (mm) was measured by preoperative CT scan images. The indications for DP-CAR are the following: tumor involvement of the common hepatic artery and/or the celiac artery or difficulty in keeping surgical margin at the stump of the splenic artery. Results: Patients with DST = 0 had longer operation time ( p = 0.005), greater amount of blood loss ( p= 0.002), and higher morbidity rate ( p= 0.010) than those with DST &gt; 0. The rate of introducing adjuvant chemotherapy in the DST = 0 group was significantly lower than that in the DST &gt; 0 group (50% vs. 82%, p= 0.012). The median survival time (MST) of the DST = 0 group was significantly worse than that of the DST &gt; 0 group (20 vs. 56 months, p&lt; 0.001). In contrast, there was no significant difference of MST between the groups of 0 &lt; DST≤10 and DST &gt; 10 ( p= 0.499). Multivariate analyses revealed that DST = 0 (HR 4.51, p= 0.001), preoperative CA19-9 ≥40 U/mL (HR 2.91, p= 0.032) and preoperative neutrophil-to-lymphocyte ratio ≥2.3 (HR 2.49, p= 0.001) were independent prognostic factors. Regarding to the operative procedures, DP-CAR was performed 12 out of 14 patients with DST = 0, and 5 out of 16 patients with 0 &lt; DST≤10. In the DST = 0 group, DP-CAR presented greater amount of dissected lymph nodes, higher rate of R0 resection, and lower rate of recurrence despite they were not identified statistically significant. In the 0 &lt; DST≤10 group, DP-CAR tended to need longer operative time and higher rate of blood transfusion compared to DP, while there was no difference of prognosis. Conclusions: Multidisciplinary treatment including DP-CAR should be warranted for patients with DST = 0, which was a prognostic indicator. If surgical margin at the root of the splenic artery is secured in patients with DST &gt; 0, DP should be an acceptable procedure.

Outcomes and Risk Score for Distal Pancreatectomy with Celiac Axis Resection (DP-CAR): An International Multicenter Analysis

BackgroundDistal pancreatectomy with celiac axis resection (DP-CAR) is a treatment option for selected patients with pancreatic cancer involving the celiac axis. A recent multicenter European study reported a 90-day mortality rate of 16%, highlighting the importance of patient selection. The authors constructed a risk score to predict 90-day mortality and assessed oncologic outcomes.MethodsThis multicenter retrospective cohort study investigated patients undergoing DP-CAR at 20 European centers from 12 countries (model design 2000–2016) and three very-high-volume international centers in the United States and Japan (model validation 2004–2017). The area under receiver operator curve (AUC) and calibration plots were used for validation of the 90-day mortality risk model. Secondary outcomes included resection margin status, adjuvant therapy, and survival.ResultsFor 191 DP-CAR patients, the 90-day mortality rate was 5.5% (95 confidence interval [CI], 2.2–11%) at 5 high-volume (≥ 1 DP-CAR/year) and 18% (95 CI, 9–30%) at 18 low-volume DP-CAR centers (P = 0.015). A risk score with age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) score, multivisceral resection, open versus minimally invasive surgery, and low- versus high-volume center performed well in both the design and validation cohorts (AUC, 0.79 vs 0.74; P = 0.642). For 174 patients with pancreatic ductal adenocarcinoma, the R0 resection rate was 60%, neoadjuvant and adjuvant therapies were applied for respectively 69% and 67% of the patients, and the median overall survival period was 19 months (95 CI, 15–25 months).ConclusionsWhen performed for selected patients at high-volume centers, DP-CAR is associated with acceptable 90-day mortality and overall survival. The authors propose a 90-day mortality risk score to improve patient selection and outcomes, with DP-CAR volume as the dominant predictor.

Impact of indocyanine green-fluorescence imaging on distal pancreatectomy with celiac axis resection combined with reconstruction of the left gastric artery

BackgroundWe previously reported the usefulness of distal pancreatectomy with celiac axis resection (DP-CAR) with left gastric artery (LGA) reconstruction to prevent ischemic gastropathy. To evaluate the reconstruction quality, we performed intraoperative angiography with indocyanine green (ICG)-fluorescence imaging. Methods21 consecutive patients planned for DP-CAR with LGA reconstruction were enrolled in this prospective, exploratory single-arm study from 2014 to 2017. After LGA reconstruction, intraoperative angiography revealed continuous arterial flow passing through the anastomotic sites and gradually increasing tissue perfusion in the stomach. ResultsThree patients were excluded. Among the remaining 18 patients, we obtained good flow in 11 patients and poor flow in 7 patients after initial LGA reconstruction. Among the seven patients with poor flow, five underwent LGA re-anastomosis, three recovered good flow. The incidence of grade B/C DGE was 14% (2/14) in the finally good flow group and 75% (3/4) in the poor flow group (p = 0.019). Ischemic gastropathy occurred in two patients (50%) in the poor flow group (p = 0.039), including one with a gastric perforation. DiscussionOur data show that intraoperative angiography with ICG-fluorescence imaging can evaluate the reconstruction quality, thus contributing to improvements in the short-term outcome of DP-CAR with LGA reconstruction.