Distal Pancreatectomy With Celiac Axis Resection Research Articles

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.

Outcomes and risk score for distal pancreatectomy with celiac axis resection (DP-CAR score): An international multicenter analysis

Background: Distal pancreatectomy with celiac axis resection (DP-CAR) is performed in selected patients with pancreatic cancer involving the celiac axis. A recent multicenter European study reported a 16% 90-day mortality, highlighting the importance of patient selection. We constructed a risk score to predict 90-day mortality and assessed oncological outcomes. Methods: Retrospective, multicenter study in patients undergoing DP-CAR at 20 European centers (model design; 2000-2016) and three very-high volume international centers in the USA and Japan (model validation; 2004-2017). We used the area-under-receiver-operator-curve (AUC) and calibration plots for validation of the 90-day mortality risk model. Secondary outcomes assessed included oncological outcomes such as resection margin status, (neo)adjuvant therapy use and survival. Results: Among 191 DP-CAR patients, 90-day mortality was 5.5% (95CI: 2.2-11%) in 5 high-volume (≥1 DP-CAR/year) and 18% (95CI: 9-30%) in 18 low-volume DP-CAR centers (P=0.020). A risk score with age, sex, BMI, ASA, multivisceral resection, open versus minimally invasive surgery, and low versus high-volume center performed well in both, the design and validation cohort (AUC 0.79 versus 0.74, P value = 0.642) and calibration was adequate after adjustment. In 174 patients with pancreatic ductal adenocarcinoma, the R0 resection rate was 60%, neoadjuvant and adjuvant therapy was used in 69% and 67% of patients, and median overall survival was 19 (95CI 15-25) months. Conclusions: In selected patients operated in high-volume centers, DP-CAR is associated with acceptable 90-day mortality and overall survival. We proposed a 90-day mortality risk score to improve patient selection and outcomes, with DP-CAR volume as dominant predictor.

The clinical impact of left gastric artery reconstruction/preservation during distal pancreatectomy with celiac axis resection for pancreatic body cancer

Background: For locally advanced pancreatic body cancer with contact to or close to the celiac axis, distal pancreatectomy with celiac axis resection (DP-CAR) is necessary to achieve R0 resection, and also postoperative adjuvant chemotherapy is important. To avoid ischemic complication and delayed administration of adjuvant chemotherapy, we have introduced the left gastric artery (LGA) reconstructing/preserving DP-CAR. Methods: This study reviewed 42 consecutive patients with pancreatic body cancer who underwent LGA reconstructing/preserving DP-CAR at our institution. If the distance between the tumor and the LGA was less than 1 cm, the LGA was cut and reconstructed. Results: Among 42 patients (24 men and 18 women with a median age of 68 years), the LGA was reconstructed in 20 patients and preserved in 22 patients, median blood loss was 590 ml and median surgical time was 446 min. 16 patients (38%) had neoadjuvant chemotherapy, R0 resection rate was 85%, and the perioperative blood transfusion rate was 0%. Ischemic gastropathy occurred in two patients (4.8%), no ischemic liver dysfunction or mortality occurred. Postoperative adjuvant chemotherapy was given 87% patients with median starting time of 67 postoperative days and the treatment continuation rate for half a year was 88%. For all 42 patients, the 1-, 3-, and 5-year overall survival rates were respectively 89.4, 44.5, and 22.9 %, and the median survival time was 28.3 months. Conclusion: LGA reconstructing/preserving DP-CAR is good approach for locally advanced pancreatic body cancer with high surgical radicality and preservation of organ function leading to smooth introduction of adjuvant therapy.

Outcomes After Distal Pancreatectomy with Celiac Axis Resection for Pancreatic Cancer: A Pan-European Retrospective Cohort Study

BackgroundWestern multicenter studies on distal pancreatectomy with celiac axis resection (DP-CAR), also known as the Appleby procedure, for locally advanced pancreatic cancer are lacking. We aimed to study overall survival, morbidity, mortality and the impact of preoperative hepatic artery embolization (PHAE).MethodsRetrospective cohort study within the European-African Hepato-Pancreato-Biliary-Association, on DP-CAR between 1-1-2000 and 6-1-2016. Primary endpoint was overall survival. Secondary endpoints were radicality (R0-resection), 90-day mortality, major morbidity, and pancreatic fistulae (grade B/C).ResultsWe included 68 patients from 20 hospitals in 12 countries. Postoperatively, 53% of patients had R0-resection, 25% major morbidity, 21% an ISGPS grade B/C pancreatic fistula, and 16% mortality. In total, 82% received (neo-)adjuvant chemotherapy and median overall survival in 62 patients with pancreatic ductal adenocarcinoma patients was 18 months (CI 10–37). We observed no impact of PHAE on ischemic complications.ConclusionsDP-CAR combined with chemotherapy for locally advanced pancreatic cancer is associated with acceptable overall survival. The 90-day mortality is too high and should be reduced. Future studies should investigate to what extent increasing surgical volume or better patient selection can improve outcomes.

Robotic distal pancreatectomy combined with celiac axis resection.

A subset of pancreatic body and tail cancers present with locally advanced disease due to involvement of the celiac axis. Previously considered unresectable, these T4 tumors may be extirpated with a distal pancreatectomy and en bloc resection of the celiac trunk in carefully selected patients. In the setting of multimodality treatment, these resections can yield survival similar to resectable and borderline resectable lesions. Robotic surgery has been shown to be safe and feasible in complex pancreatic resections. This article summarizes our patient selection criteria and operative approach to robotic distal pancreatectomy with celiac axis resection (DP-CAR) for locally advanced body and tail tumors of the pancreas.

Locally advanced pancreatic cancer successfully treated by distal pancreatectomy with celiac axis resection (DP-CAR) after S-1 with radiation therapy followed by gemcitabine/nab-paclitaxel therapy: a case report

BackgroundThe prognosis for pancreatic cancer remains dismal because many patients are diagnosed with unresectable cancer at the initial diagnosis. Recently, conversion surgery was reported as an effective treatment for initially unresectable pancreatic cancer with a favorable response to non-surgical treatment lasting over 240 days. Here, we describe a case of locally advanced pancreatic cancer (LAPC) successfully resected after treatment with S-1 and radiation followed by gemcitabine/nab-paclitaxel therapy.Case presentationA 73-year-old man with LAPC was referred to our hospital. Computed tomography findings revealed a 2.5-cm mass in the pancreatic body that had invaded the celiac artery, common hepatic artery, and splenic artery. Superior mesenteric artery (SMA) encasement was not observed, but tumor abutment over 180° with the main tumor was detected. Staging laparoscopy showed no findings of distant metastasis, and washing cytology revealed no malignancy. He was diagnosed with unresectable pancreatic cancer. Treatment with S-1 with radiation therapy followed by gemcitabine with nab-paclitaxel was performed. Six months after the initial treatment, the tumor size had decreased to 1.2 cm, and encasement of the main artery was diminished. Though abutment to the main artery, including the SMA, was still detected, distal pancreatectomy with celiac artery resection was performed. The histopathological findings around the celiac artery revealed fibrous changes with an Evans classification of grade IIb. There was no residual cancer at the periphery; thus, R0 resection was achieved. The patient has been healthy and without recurrence for more than 12 months since the initial treatment.ConclusionsGemcitabine/nab-paclitaxel therapy revealed high response rate for metastasic pancreatic cancer (PC), but the effect for LAPC proposing conversion surgery was not well discussed. In this case, we achieve R0 resection combined with chemoradiation therapy and gemcitabine/nab-paclitaxel therapy. This regimen was also effective for LAPC and may be used to increase the population of conversion surgery by its high response rate.

Distal pancreatectomy with celiac axis resection (DP-CAR) for pancreatic adenocarcinoma: A systematic review

Distal pancreatectomy with celiac axis resection (DP-CAR) for pancreatic adenocarcinoma: A systematic review

Distal pancreatectomy with celiac axis resection: what are the added risks?

BackgroundReported series of a distal pancreatectomy with celiac axis resection (DP‐CAR) are either small or not adequately controlled. The aim of this analysis was to report a multicentre series of modified Appleby procedures with a comparison group to determine the relative operative risk. MethodsData were gathered through the American College of Surgeons‐National Surgical Quality Improvement Program (ACS‐NSQIP) Pancreatectomy Demonstration Project. Over 14 months, 822 patients underwent a distal pancreatectomy at 43 institutions. Twenty of these patients (2.4%) also underwent a celiac axis resection. DP‐CAR patients were matched by age, gender, BMI, serum albumin, ASA class, gland texture, duct size and pathology to 172 patients undergoing DP alone. ResultsThe majority of DP and DP‐CAR patients had adenocarcinomas (61% and 60%). The median operative time for a DP alone was shorter than for a DP‐CAR (207 versus 276 min, P < 0.01). Post‐operative acute kidney injury (1% versus 10%, P < 0.03) and 30‐day mortality were higher after a DP‐CAR (1% versus 10%, P < 0.03). ConclusionA distal pancreatectomy with celiac axis resection is associated with increased operative time, post‐operative acute kidney injury and a 10% operative mortality. The decision to offer a modified Appleby procedure for a body of pancreas tumour should be made with full disclosure of the increased risks.

Distal Pancreatectomy with Celiac Axis Resection for Carcinoma of the Body and Tail of the Pancreas

We retrospectively investigated our experiences with distal pancreatectomy with celiac axis resection (DP-CAR) for locally advanced pancreatic cancer and compared the operative outcome and long-term survival between DP-CAR and standard distal pancreatectomy (DP). Although several authors reported that DP-CAR increases resectability rates, the long-term results of this operation are not clear, and there are few reports presenting a comparison of the short- and long-term results between DP-CAR and DP. From 1993 to 2010, 43 patients with invasive ductal carcinoma of the body or tail of the pancreas underwent a macroscopically curative resection (R0/1). Sixteen patients underwent DP-CAR and 27 patients underwent DP. No DP-CAR patients underwent any preoperative coil embolization of the common hepatic artery (CHA) to stimulate the development of collateral pathways from the superior mesenteric artery. The perioperative and histopathologic parameters and survival data were analyzed to compare the two operations. There was no difference in mean operative time, mean blood loss, postoperative mortality, and morbidity between DP-CAR and DP. The rates of morbidity and in-hospital mortality of DP-CAR were 56 and 6%, respectively. In DP-CAR, 15 patients did not require reconstruction of the hepatic artery and no hepatic infarctions were clinically encountered after surgery. The estimated overall 1- and 3-year survival rates in patients who underwent DP-CAR were 42.6 and 25.6%, respectively, and their survival time was significantly less than that of patients who underwent DP (median survival time: 9.7 vs. 30.9months, P=0.033). The R1 resection rates of these groups were 44% in DP-CAR and 22% in DP, respectively. DP-CAR is a safe and rational procedure for locally advanced pancreatic cancer without preoperative embolization of the CHA. Although the short-term results were equivalent to that for DP, DP-CAR did not improve the long-term survival because of the high rate of R1 resection at present.

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

Background/Aims: Body-tail pancreatic cancer is an aggressive disease with a low resectability rate and a poor prognosis. Celiac axis invasion usually contraindicates resection. The aim of this study was to analyze the feasibility of distal pancreatectomy (DP) with celiac axis resection (DP-CAR) for locally advanced body-tail pancreatic cancer. Methods: All DPs performed between January 1989 and December 2007 were considered. DP and DP-CAR were reviewed for pre-, intra-and postoperative data. An extensive, detailed literature review on DP and DP-CAR was also performed. Results: DP was performed in 49 of our patients, and 745 cases were retrieved from the literature. The overall morbidity and mortality rates were 32.0 and 3.0%, respectively. We performed DP-CAR in 5 patients with no mortality but 80% morbidity. A further 90 patients were retrieved from the literature. Arterial reconstruction was needed in 1/5 of our patients and in 13/90 of patients in the literature. Collaterals from superior mesenteric artery maintained adequate hepatic artery blood flow in the remaining 81 patients. The overall morbidity and mortality rates were 40.6 and 2.1%, respectively. The median survival ranged between 4.5 and 25 months after DP and was 13 months after DP-CAR. Conclusions: DP-CAR improves resectability without increasing the mortality rate. The complication rate after DP-CAR was higherthan after DP, but still within the range of extended DP. DP-CAR should be considered for the inclusion among the ‘extended’ procedures for the treatment of body-tail pancreatic cancers invading the celiac axis.