En-bloc Celiac Axis Resection Research Articles

Distal Pancreatectomy With En Bloc Celiac Axis Resection (DP-CAR) for Locally Advanced Pancreatic Cancer: A Safe and Effective Procedure.

To determine perioperative and oncologic outcomes after distal pancreatectomy with en bloc resection of the celiac axis (DP-CAR). DP-CAR can be used in a selective group of patients to resect locally advanced pancreatic cancer involving the celiac axis or common hepatic artery without arterial reconstruction by preserving retrograde blood flow via the gastroduodenal artery to the liver and stomach. We analyzed all consecutive patients who had undergone DP-CAR between May 2003 and April 2022 at a tertiary hospital specialized in pancreatic surgery and present one of the largest single-center studies. A total of 71 patients underwent DP-CAR. Additional venous resection (VR) of the mesenterico-portal axis was performed in 31 patients (44%) and multivisceral resection (MVR) in 42 patients (59%). Margin-free (R0) resection was achieved in 40 patients (56%). The overall 90-day mortality rate was 8.4% for the entire patient cohort. After a cumulated experience of 16 cases, the 90-day mortality dropped to 3.6% in the following 55 patients. Extended procedures with (+) additional MVR with or without (+/-) VR resulted in higher major morbidity (Clavien-Dindo ≥IIIB; standard DP-CAR: 19%; DP-CAR + MVR +/- VR: 36%) and higher 90-day mortality (standard DP-CAR: 0%; DP-CAR + MVR +/- VR: 11%). Median overall survival after DP-CAR was 28 months. DP-CAR is a safe and effective procedure but requires experience. Frequently, surgical resection has to be extended with MVR and VR to accomplish tumor resection, which results in promising oncologic outcomes. However, extended resections were associated with increased morbidity and mortality.

Laparoscopic Common Hepatic Artery Ligation before Left Pancreatectomy with Celiac Artery Resection

Introduction: The best method and the exact benefit of liver preconditioning before pancreatectomy with en-bloc celiac axis resection (CAR) remain debated. We report our experience with preoperative laparoscopic common hepatic artery ligation (HAL) compared to arterial embolization.

En Bloc Celiac Axis Resection for Pancreatic Cancer: Classification of Anatomical Variants Based on Tumor Extent

En bloc celiac axis resection (CAR) for pancreatic cancer is considered increasingly after modern neoadjuvant chemotherapy (NAC). Appleby and distal pancreatectomy with CAR are anatomically inaccurate terms, as tumors can extend beyond celiac axis proper, requiring concurrent resection of the proper hepatic artery and/or superior mesenteric artery. A 3-level classification for CAR (class 1, 2, or 3) was developed after retrospective review of an arterial resection database describing anatomical variants that dictate pancreatectomy-type, formal arterial revascularization, and gastric preservation. Perioperative and oncologic outcomes were assessed. Of 90 CARs for pancreatic cancer, 89% patients received NAC, 35% requiring chemotherapeutic switch. There were 41 class 1, 33 class 2, and 16 class 3 CARs, with arterial and venous revascularization performed 62% and 66%, respectively. Ninety-day mortality decreased to 4% in the last 50 cases (p= 0.035); major morbidity was unchanged (55%). Any hepatic or gastric ischemia occurred in 20% and 10% patients, respectively, and arterial revascularization was protective. R0 resection rate (88%) was associated with chemoradiation (p= 0.004). Median overall survival was 36.2 months, superior with NAC (8.0 vs. 43.5 months). Predictors of survival after NAC included chemotherapy duration, carbohydrate antigen 19-9 response, pathologic response, and lymph node status. Major pathologic response (p= 0.036) and extended duration NAC (p= 0.007) were independent predictors on multivariate analysis. Current terminology for CAR inadequately describes all operative variants. Our classification, based on the largest single-center series, allows complex operative planning and standardized reporting across institutions. Extent of arterial involvement determines pancreatectomy type, need for arterial revascularization, and likelihood of gastric preservation. Operative mortality has improved, morbidity remains significant, and survival favorable after extended NAC with associated pathologic responses; given these factors, CAR should only be considered in fit patients with objective NAC responses at specialized centers.

Preoperative Embolization in Preparation for Distal Pancreatectomy with En Bloc Celiac Axis Resection

Preoperative Embolization in Preparation for Distal Pancreatectomy with En Bloc Celiac Axis Resection

Is distal pancreatectomy with en-bloc celiac axis resection effective for patients with locally advanced pancreatic ductal adenocarcinoma? -Multicenter surgical group study

ObjectivesWe retrospectively investigated the operative outcomes of patients who underwent distal pancreatectomy (DP) for invasive pancreatic ductal adenocarcinoma (PDAC) located at the body and tail. MethodsData from 395 patients with PDAC who underwent DP with margin-negative resection (R0 or R1) were collected from seven high-volume centers in Japan from 2001 to 2012. Among them, 72 patients underwent DP with en-bloc celiac axis resection (DP-CAR). The remaining 323 patients underwent conventional DP with splenectomy (DP-S). To determine the efficacy of DP-CAR, clinicopathological data were compared between the DP-CAR and the DP-S groups. ResultsThe DP-S group consisted mainly of patients with resectable disease (93%), and conversely, all patients in the DP-CAR group had borderline resectable or unresectable disease. The overall morbidity was significantly higher in the DP-CAR group than in the DP-S group (63% vs 47%, respectively; P = 0.017). The median survival time (MST) of the DP-CAR group was significantly shorter than that of the DP-S group (17.5 vs 28.6 months, respectively; P = 0.004). However, the MST of patients in the DP-CAR group (n = 61, 85%) who received adjuvant therapy was significantly longer than that of patients in the DP-S group (n = 65, 20%) who underwent R1 resection (21.9 vs 16.7 months, respectively; P = 0.024). ConclusionDP-CAR followed by adjuvant chemotherapy provided an acceptable overall survival rate in patients with highly advanced PDAC, but should be performed with great caution because of high morbidity. Patients with a high risk of positive surgical margins with DP-S may be candidates for DP-CAR.

術前化学療法後に腹腔動脈幹合併尾側膵切除術を施行し，固有肝動脈-空腸動脈バイパスを併施した局所進行膵体尾部癌の1 例

膵体部癌は腹腔動脈や総肝動脈などの重要な血管に近接しており，その直接浸潤で手術非適応とされることが多い．腹腔動脈浸潤症例については，術前に総肝動脈を塞栓し，側副血行路の発達により肝血流を維持して腹腔動脈幹合併切除を伴った尾側膵切除術を行うことで切除可能な症例がある．症例は68 歳，男性．膵体尾部癌の診断であった．術前化学療法を施行し，総肝動脈を塞栓し，膵切除を行った．術中に肝血流障害を認め，固有肝動脈-空腸動脈バイパスにより回避し得た症例である．このような症例は，われわれは経験がなく，文献的考察を加え報告する．

Tu1618 Roux-en-Y Drainage of the Pancreatic Stump by Nonstented Duct-to-Mucosa Anastomosis Reduced the Amylase Level in the Drainage Fluid After Distal Pancreatectomy With En-bloc Celiac Axis Resection

Background: Pancreatic cancer is one of the leading causes of cancer mortality. Surgery is the only chance of cure, but is inappropriate for patients with metastasis. Aim: To evaluate the frequency of liver metastasis on MRI in patients with resectable pancreatic cancer and normal liver on contrast enhanced MDCT. Methods: Between April 2012-13, all patients with resectable pancreatic cancer based on CT staging underwent MRI liver utilising hepatocyte specific contrast agent and diffusion weight imaging. Results: Forty five consecutive patients were examined. Thirty two were male and 13 were female. Median age was 64 years (range 31-76 years). MRI was performed at a median of 2 weeks from CT. Thirteen (29%) patients with normal liver on CT had findings consistent with liver metastases while 4 (9%) had indeterminate liver lesions on MRI. Three of the 4 patients with indeterminate liver lesions demonstrated progression on follow up imaging consistent with metastases. One of the 28 patients with a normal MRI liver underwent palliative bypass on discovering a 5mm subcapsular lesion at laparotomy. At a median follow up of 12 months, 3 of the remaining 27 patients with normal MRI had evidence of liver metastasis (7, 10 and13 months post MRI) while 4 had extrahepatic disease. Survival was significantly reduced in patients with liver metastasis on MRI (p=0.01). Conclusion: MRI identified liver metastases in 36% of patients with resectable pancreatic cancer on MDCT and should be included in the routine staging of these patients.

Surgical strategy for borderline resectable pancreatic body cancer.

271 Background: The indications for distal pancreatectomy with en-bloc celiac axis resection (DP-CAR) in pancreatic carcinoma remain controversial. Moreover, the incidence of delayed gastric emptying (DGE) is high in patients undergoing distal pancreatectomy with DP-CAR. Methods: Fifty-two consecutive patients with pancreatic cancer who underwent distal pancreatectomy, including 36 standard distal pancreatectomies (standard DP) and 16 DP-CAR were reviewed. To determine the incidence of DGE, 37 consecutive patients who underwent DP-CAR were evaluated for the incidence of DGE, including 23 patients with left gastric artery (LGA)-resecting DP-CAR (conventional DP-CAR) and compared it with 14 patients who underwent distal pancreatectomy with preservation of the LGA (modified DP-CAR). Results: The estimated overall 1- and 2-year survival rates after standard DP / DP-CAR were 81/81% and 52/53%, and the median survival times were 32/25 months, respectively, with no significant difference comparing standard DP. There were no differences in the mortality rates and the incidence of each complication between the two groups except for delayed gastric emptying. In the conventional DP-CAR group, the LGA were involved in 20 patients (87.0%). The ISGPS grades were: no DGE = 43%, grade A = 26%, B = 13% and C = 17% in the conventional DP-CAR group, and no DGE = 93%, grade A = 7%, grade B/C = 0% in the modified DP-CAR group. The R0 rate was higher in the modified DP-CAR group (79%) compared to the conventional DP-CAR group (43%) (p=0.048). On multivariate analysis, resection of the LGA was an independent risk factor for increased incidence of DGE. Conclusions: DP-CAR was a feasible and safe procedure, similar to standard DP. Modified DP-CAR significantly reduced the incidence of DGE in comparison to conventional DP-CAR.

Indication of distal pancreatectomy with en-bloc celiac axis resection in patients with pancreatic body/tail carcinoma

Indication of distal pancreatectomy with en-bloc celiac axis resection in patients with pancreatic body/tail carcinoma

Surgical strategy for patients with pancreatic body/tail carcinoma: Who should undergo distal pancreatectomy with en-bloc celiac axis resection?

Indications for distal pancreatectomy with en-bloc celiac axis resection (DP-CAR) in pancreatic carcinoma remain controversial. Fifty-two consecutive patients with pancreatic cancer who underwent distal pancreatectomy, including 36 standard distal pancreatectomies (standard DP) and 16 DP-CAR were reviewed retrospectively. After standard DP, microscopically positive margins were identified at the dissection sites around the transection margins of the splenic arteries and were detected more frequently in the patients with tumors within 10 mm from the root of the splenic artery (14%). After DP-CAR, the estimated overall survival rate in patients who were pathologically negative for portal venous and artery invasion (n = 7) was greater than that of the other patients (n = 9; P = .023, log-rank test). The estimated overall 1- and 2-year survival rates after standard DP/DP-CAR were 81/81% and 52/53%, and the median survival times were 32/25 months, respectively, with no differences noted between the groups. There were no differences in the mortality rates and the incidence of each complication between the 2 groups except for delayed gastric emptying. DP-CAR was a feasible and safe procedure, similar to standard DP. DP-CAR should be reserved for patients without tumor infiltrating either the portal venous or arterial systems.

Distal Pancreatectomy with En Bloc Celiac Axis Resection for the Treatment of Locally Advanced Pancreatic Body and Tail Cancer

Pancreatic body and tail carcinoma (PBTC) is an aggressive disease with a low resectability rate. Celiac axis infiltration usually contraindicates resection. Extended distal pancreatectomy with combined en bloc celiac axis resection (DP-CAR, also named Appleby operation) was described as a new concept for the curative treatment of these tumors. The aim of this study was to analyze the results of DP-CAR in PBTC. Analyze by summarizing the 24 cases of PBTC during October 2005 to August 2010 in the pancreatic surgery of our hospital and analyzing the clinical manifestations, surgical processing, pathological effects and survival rate of the patients. The postoperative mortality rate was 0%, despite a high morbidity rate (54%). Preoperative intractable abdominal and/or back pain in all the patients was completely alleviated immediately after surgery. During the follow-up survey among all the patients of 2 to 37 months (with an average follow-up survey of 12.67 months), no patient was still alive, with the median survival of 9.25 months. Estimated overall 1- and 3-year survival rates were 46% and 4%, respectively. DP-CAR offers a high resectability rate without increasing the mortality rate given skilled surgical technique.

局所進行膵体部癌に対する腹腔動脈合併切除を伴う尾側膵切除（DP-CAR）の成績とQOL

局所進行膵体部癌に対する腹腔動脈合併切除を伴う尾側膵切除（DP-CAR）の成績とQOL

Total Pancreatectomy with En Bloc Celiac Axis Resection for a Pancreatic Adenocarcinoma Involving both the Gastroduodenal Artery and the Celiac Artery

A pancreatic adenocarcinoma involving both the celiac artery and the gastroduodenal artery is often considered to be unresectable because the simultaneous division of both arteries may result in an acute severe ischemia of the liver and the stomach. We report here a case of total pancreatectomy with en bloc celiac axis resection for a 61-year-old female with a pancreatic adenocarcinoma involving both the celiac artery and the gastroduodenal artery. The patient had a replaced right hepatic artery from the superior mesenteric artery and a replaced left hepatic artery from the left gastric artery, which was directly arising from the aorta. Preserving these collateral arteries, neither hepatic artery reconstruction nor total gastrectomy was needed after resection. The reported incidence of similar arterial anatomy was only 0.2% but the precise evaluation of arterial anatomy is important to offer a chance of curative resection for patients with usually unresectable locally advanced pancreatic cancer.

Distal Pancreatectomy with En bloc Celiac Axis Resection Performed while Monitoring Hepatic Arterial Flow by using a Transonic Flowmeter during Operation

Pancreatic body cancer often involves the common hepatic artery and/or the celiac axis, and is regarded as an unresectable disease. Hepatic blood flow must be monitored while performing distal pancreatectomy with en bloc celiac axis resection (DP-CAR) for managing the progression of pancreatic body cancer. We first confirmed a safe level of blood flow by monitoring hepatic venous oxygen saturation (ShvO2) to prevent hepatic ischemia caused by occlusion of the common hepatic artery. However, this method is technically difficult and a long period of time is required to insert the catheter. Thus, we monitored hepatic arterial flow by using a transonic flowmeter in the hepatic artery during operation. Between April 1992 and January 2011, 14 patients underwent DP-CAR. In 6 of these 14 patients we measured ShvO2. In 2 of the 14 patients, a transonic flowmeter was used for determining the hepatic arterial flow during operation. There were no complications during this operation. Operation time when the blood flow was monitored using a transonic flowmeter was less than that when ShvO2 was measured. Monitoring the transonic flowmeter hepatic artery is a useful and quick method for real-time evaluation of hepatic circulation during operation.

Is celiac axis resection justified for T4 pancreatic body cancer?

The clinical impact of the distal pancreatectomy with en-bloc celiac axis resection for locally advanced pancreatic body cancer remains unclear. We reviewed the records of 13 patients who underwent distal pancreatectomy-celiac axis resection between 1991 and 2009, 58 patients who underwent distal pancreatectomy for pancreatic body cancer involving major vessels, the extrapancreatic neural plexus or other organs (T4 according to the Japanese stage classification) between 1991 and 2009, and 24 patients with unresectable locally advanced pancreatic cancer without distant metastases (unresectable group) between 2001 and 2009. The clinicopathologic factors and overall survival among the 3 groups were compared. The distal pancreatectomy-celiac axis resection group was associated with a significantly higher incidence of morbidity (92% vs 60%, P = .03) and positive surgical margins (69% vs 26%, P = .003) than the distal pancreatectomy group; however, no survival difference was found between the 2 groups. No survivor has lived more than 3 years after operation in the distal pancreatectomy-celiac axis resection group. The distal pancreatectomy-celiac axis resection group had a significantly better prognosis than the unresectable group (median survival time, 20.8 vs 9.8 months; P = .01). Aggressive resection for T4 pancreatic body cancer by distal pancreatectomy-celiac axis resection can be justified for otherwise unresectable tumors. The surgical indication should be evaluated carefully because of the higher incidence of morbidity and lower incidence of curability compared with distal pancreatectomy, as well as because there have been no long-term survivors so far.

Important technical remarks on distal pancreatectomy with en‐bloc celiac axis resection for locally advanced pancreatic body cancer (with video)

We have already reported the feasibility, safety, and excellent long-term results of distal pancreatectomy with en-bloc celiac axis resection (DP-CAR) for locally advanced pancreatic body cancer. An international standard for the surgical technique of DP-CAR has yet to be established. DP-CAR was carefully performed in 42 patients in Hokkaido University Hospital from 1998 to July 2007. Arterial blood flow alteration and collateral flow development toward the liver and stomach was obtained following preoperative routine transcatheter arterial embolization of the common hepatic artery. The right-sided approach to the superior mesenteric artery and celiac artery, and the preservation of the inferior pancreatoduodenal artery during the dissection of the plexus around the pancreatic head, are the key techniques in DP-CAR. The operative morbidity and mortality were 43 and 4.8%, respectively. R0 resection could be done in 39 (93%) patients. Median operation time and intraoperative blood loss were 478 min and 1030 ml, respectively. Ischemic gastropathy was complicated in 5 (12%) patients, but liver abscess was found in only one patient and no liver failure was encountered. We emphasize again the feasibility and safety of DP-CAR; it should be a treatment of choice for locally advanced pancreatic body cancer.

Postoperative Bowel Function and Nutritional Status following Distal Pancreatectomy with En-Bloc Celiac Axis Resection

Background/Aims: Distal pancreatectomy with en-bloc celiac axis resection (DP-CAR) is routinely accompanied by complete resection of the bilateral celiac ganglions and the circumferential plexus of the superior mesenteric artery. The postoperative condition including bowel movement, nutritional status, and tolerance to adjuvant chemotherapy has never been studied. Methods: 40 patients who underwent DP-CAR were enrolled in this study. Postoperative bowel function was estimated by the requirement of anti-diarrheal agents. Changes of nutritional parameters including body weight and laboratory data for 1 year after surgery were evaluated. Results: 15 (38%) patients needed no anti-diarrheal agent after a median follow-up period of 39 months. The other patients were well controlled for their bowel movement with anti-diarrheal drugs. 13 patients who received adjuvant chemotherapy tolerated it well despite hematologic toxicity in 7 patients who received gemcitabine. Postoperative body weight was significantly decreased and reached a plateau value at postoperative month 3. The values of laboratory data indicating nutritional status were significantly lower at 1 month after surgery and recovered between 3 and 12 months. Conclusion: The patients who underwent DP-CAR scarcely suffered from intractable diarrhea and could achieve a feasible nutritional status after surgery to be able to receive adjuvant chemotherapy.

Extended pancreatectomy with resection of the celiac axis: the modified Appleby operation

Background Celiac axis invasion by central and distal pancreatic cancers has been considered a contraindication to resection. Appleby first described en-bloc celiac axis resection with total gastrectomy for locally advanced gastric cancer. We present our experience with a modification of this procedure in central pancreatic cancers involving the celiac trunk. Methods Three patients with central pancreatic cancers invading the celiac axis are reviewed. All patients underwent extended pancreatectomy with en-bloc resection of the celiac axis. Results Margins were grossly clear of tumor in all patients. The mean length of stay was 8.3 ± 1.1 days. There was no evidence of clinically significant gastric or hepatic ischemia. All 3 patients remain disease free at 34, 14, and 14 months from surgery, respectively. Comments Extended pancreatectomy with celiac axis resection can result in prolonged survival and should be considered in central and distal pancreatic cancers invading the celiac trunk.