Modified Appleby Procedure Research Articles

Robotic assisted modified Appleby procedure for pancreatic cancer involving the celiac axis

Robotic assisted modified Appleby procedure for pancreatic cancer involving the celiac axis

SP2.5 Modified Appleby Procedure in the Treatment of Pancreatic Neoplasms

Abstract Aims This work aims to review the state of the art regarding the patients who may benefit from resection using the modified Appleby procedure, the pre- and post-operative procedures to increase survival, and the postoperative outcomes. Methods Research was conducted within the PubMed and Embase databases from July 2022 to January 2023, including single or multicenter articles relative to the modified Appleby procedure but comprising a multimodal approach to pancreatic neoplasms and not only the surgical technique, and papers concerning patients over the age of 18 years. Results Out of the 373 articles identified and after extracting duplicates, 267 records were accessed for a title and abstract screening. Afterward, by applying the inclusion and exclusion criteria to the remaining articles and conducting a further extensive reading of the remaining articles, 53 papers were included in this review. Secondary terms relevant to this topic were also used, allowing detection of additional research, thus totalizing the 57 publications included. Conclusion When applied to borderline resectable and locally advanced pancreatic cancer, the efficacy of the modified Appleby procedure alone is limited, but the combination with neoadjuvant chemotherapy offers the greatest chance of achieving an R0 resection. Many surgical technical options are available, with or without preoperative artery embolization, but the best results published to date were observed when employing robotic surgery with a retroperitoneal-first approach. However, the indication for performing this surgery and all its perioperative components are still a matter of debate.

Inframesocolic main pancreatic vessels-first approach for minimally invasive radical antegrade modular pancreaticosplenectomy (RAMPS): technical description and first experience.

Radical modular antegrade pancreaticosplenectomy (RAMPS) improves posterior tumor-free margins during resections of pancreatic neoplasia involving the body or tail. However, minimally invasive RAMPS is technically challenging and has been reported seldom. We present for the first time a minimally invasive RAMPS technique with an innovative approach providing early dissection and control of the main peripancreatic vessels from an inframesocolic embryonal window, suitable for laparoscopy and robotics. Minimally invasive RAMPS with inframesocolic main pancreatic vessels-first approach was performed at the Tricase Hospital (Italy) from May 2017 to April 2022 in 11 consecutive patients with neoplastic lesions of the pancreas (8 laparoscopic RAMPS and 3 robotic RAMPS). Among the laparoscopic cases, 1 included a portal vein tangential resection and 1 a celiac artery resection (modified Appleby procedure). There were no conversions, no Clavien-Dindo complications > 2, all resections' margins were tumor free, and no 90-day mortality.

Distal pancreatectomy with splenectomy and celiac artery resection (modified appleby procedure) for locally advanced pancreatic body and tail adenocarcinoma in a 71 year old female

Distal pancreatectomy with splenectomy and celiac artery resection (modified appleby procedure) for locally advanced pancreatic body and tail adenocarcinoma in a 71 year old female

Modified appleby procedure for locally advanced pancreatic body cancer

Modified appleby procedure for locally advanced pancreatic body cancer

Modified Appleby Procedure in the Treatment of Pancreatic Neoplasms

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Two Stage Robotic Modified Appleby Procedure for Locally Advanced Adenocarcinoma in the Pancreatic Body

Two Stage Robotic Modified Appleby Procedure for Locally Advanced Adenocarcinoma in the Pancreatic Body

Robotic modified Appleby: Case report, technical aspects and video

Introduction and importancePancreatic body and tail adenocarcinoma is a tumor of silent evolution, showing up as advanced disease at diagnosis in the majority cases.Case presentationA 60-year-old man, presenting a solid expansive lesion (3.1 × 2.8 cm) in the body of the pancreas, by imaging exams. There was 50% involvement of the celiac trunk at the level of the it's bifurcation and suspected peripancreatic lymph nodes. Clinical staging was cT4N1M0. After neoadjuvant chemotherapy (NQT), there was a small reduction of the tumor to 3.0 × 2.6 cm, an important decreasing of the celiac trunk involvement (25%), and also a reduction in the levels of C19–9 from 650 U/mL to 358 U/mL. Further on, the patient underwent a Robotic Modified Appleby procedure, without intra and postoperative complications.Clinical discussionLocally advanced pancreatic tumors should be referred to NQT, and those with good response might benefit to radical surgery. The modified Appleby technique - distal pancreatectomy with splenectomy and celiac trunk resection – is the procedure of choice when there is involvement of celiac trunk, but concern must be given to the liver vascularization. The use of robotic system on pancreatic surgery is emerging, but still, there is lower data regarding its safety in major pancreatic procedures.ConclusionThe use of neoadjuvant therapy is recommended to assess the in vivo response, improve oncological results and increase negative margins. Pre-operative imaging is mandatory for surgical planning. The robotic modified Appleby procedure is feasible and safe, with reduced of intraoperative blood loss and transfusion rate, corroborating the literature.

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.

ТЕРАТОМА ПОДЖЕЛУДОЧНОЙ ЖЕЛЕЗЫ

Pancreatic teratoma is an infrequent entity. Only a few cases have been reported in the world literature. The primary treatment for mature teratoma is radical surgery. The article presents a case of pancreatic teratoma in a 3-year-old patient. Teratoma was diagnosed preoperatively with an intravenous contrast-enhanced CT scan, which revealed that the common hepatic and splenic arteries enter the tumour walls. Intraoperative revision confirmed the CT data, and corporocaudal pancreatectomy with celiac axis resection (modified Appleby procedure) was performed to achieve R0 resection. In this case, the blood supply to the liver and stomach was derived from the superior mesenteric artery via the pancreaticoduodenal arcades and then through the gastroduodenal artery. The postoperative period was uneventful. The patient was discharged on the eighth day in satisfactory condition. Keywords: Teratoma, mature teratoma, pancreas, corporocaudal resection, celiac trunk.

3D preoperative assessment for locally advanced pancreatic cancer undergoing modified-Appleby procedure with reversed autologous arterial graft reconstruction: A case report

Advanced pancreatic ductal adenocarcinoma represents one of the most challenging oncologic diseases nowadays for many reasons: it is burdened by one of the poorest prognoses, it is often diagnosed when in an advanced stage and it demands a multimodal approach which is necessary to assign the proper patient-specific treatment. When feasible, surgical resection combined with systemic treatment is still the best curative choice and can require complex vascular resections and reconstructions to obtain R0 margins. In these cases, a detailed preoperative assessment made of blood tests, thoracoabdominal imaging and histological definition of the tumor is fundamental. Unfortunately, the current imaging techniques are not completely reliable in defining the extension of the contact between the neoplasm and the surrounding arteries and veins, especially when considering borderline and locally advanced diseases. The use of 3D reconstructions can improve the perception of crucial anatomical details for the diagnostic evaluation and the surgical procedure.

Robot-assisted Distal Pancreatectomy with En Bloc Celiac Axis Resection (Modified Appleby Procedure) after Neoadjuvant Therapy

Pancreatic carcinoma in the body and on the left side of the mesentericoportal axis is often only detected in late stages owing to unspecific or even missing clinical symptoms. In approximately 20% of the cases, there is already infiltration of the tumour into the surrounding arteries or veins. Despite locally advanced growth, 30% of patients do not have distant metastases and would potentially qualify for local resection. Arterial resections and vascular reconstruction are associated with an almost 9-fold increase in postoperative mortality compared with resections without vascular reconstruction. The Appleby procedure is a complex surgical technique originally developed for advanced gastric cancer. The technique has been further developed for patients with advanced pancreatic body and tail tumours with infiltration of the coeliac trunk (modified Appleby procedure). The advantage of the procedure is that technically, no reconstruction of the resected arteries is required. This is because a natural internal anastomosis in the pancreatic head between the A.mesenterica superior and the A.hepatica via branches of the A.gastroduodenalis is used to maintain liver perfusion and gastric blood flow. However, the surgical procedure is also associated with high morbidity and mortality, with comparably poor oncological results (R0 rates of approximately 60%). Therefore, the procedure was not recommended until a few years ago, and patients were considered inoperable. With developments in neoadjuvant therapy for pancreatic carcinoma, the Appleby procedure is being performed more frequently, with the goal of improving oncological outcomes in the context of multimodal treatment. With developments in robotics in visceral surgery, the previous limitations of minimally invasive pancreatic surgery can be overcome, and significantly more patients may benefit from the advantages of this minimally invasive surgery, such as faster convalescence. The use of robotic surgical techniques allows the extension of minimally invasive techniques into the field of complex vessel resection and reconstruction. In this video contribution, we describe a robot-assisted modified Appleby procedure using the Da Vinci Xi Surgical System in a patient with advanced pancreatic carcinoma of the pancreatic body, after neoadjuvant therapy.

Modified Appleby Procedure (Distal Pancreatectomy with Celiac Artery Resection) for Locally Advanced Pancreatic Carcinoma: Two Case Report

Modified Appleby Procedure (Distal Pancreatectomy with Celiac Artery Resection) for Locally Advanced Pancreatic Carcinoma: Two Case Report

Distal Pancreatectomy with Celiac Axis Resection—with Posterior Ramps Approach—for Locally Advanced Pancreatic Adenocarcinoma with Celiac Trunk Infiltration (Modified Appleby Procedure) (with Video)

With the advent of FOLFIRINOX and neoadjuvant radiotherapy, the surgical indications for adenocarcinoma have expanded. Locally advanced pancreatic adenocarcinomas of the body/tail with infiltration of the celiac trunk which have a good clinical, biological, and radiological response to neoadjuvant treatment may therefore be eligible for caudal pancreatectomy with resection of the celiac trunk (modified Appleby procedure). In addition to rigorous patient selection and surgical expertise, this procedure also requires experience in interventional radiology.

Perioperative CT angiography assessment of locally advanced distal pancreatic carcinoma to evaluate feasibility of the modified Appleby procedure

PurposeTo study the perioperative CT angiography (CTA) findings of modified Appleby procedure candidates for the surgical feasibility in patients with locally advanced distal pancreatic cancer (LAPC) and to assess CTA performance. Materials and methodsThis retrospective study evaluated CTA of patients with distal LAPC who underwent modified Appleby procedure between March 2004 and October 2017. Preoperative CT scans performed within up to three months prior to the surgery and postoperative scans, at least one of which was within one month of surgery, were reviewed. Data was collected reporting tumor size, relation to vessels, changes from neoadjuvant chemoradiation, modifications to the surgery and complications. The CTA findings were correlated with operative notes and surgical pathology. Statistical analysis was performed using binary classification method to evaluate CTA performance. ResultsConsecutive 20 patients underwent modified Appleby procedure in the study period. In 18/20 patients who received neoadjuvant chemoradiation, mean pancreatic mass size significantly reduced from 4.58 + 1.17 cm to 3.55 + 0.84 cm (p = 0.002). The celiac axis (CA) was encased in all, whereas none of the patients had encasement of the superior mesenteric artery (SMA) or involvement of gastroduodenal artery (GDA). The CTA had 88.89% sensitivity, 100% specificity, and 90% accuracy for evaluating the arterial involvement. ConclusionDistal LAPC patients, in particular those who have significant size reduction after neoadjuvant chemoradiation, with encasement of CA and without encasement of SMA and GDA can undergo a technically successful modified Appleby procedure. CTA offers accurate and valuable perioperative assessment of the surgical candidates.

Combining Appleby with RAMPS – Laparoscopic Radical Antegrade Modular Pancreatosplenectomy with Celiac Trunk Resection

BackgroundRadical Antegrade Modular Pancreatosplenectomy (RAMPS) minimizes the risk of a positive retroperitoneal margin and maximizes lymph node harvest in distal pancreatic cancers.1-7 In those with celiac trunk involvement, resection of the celiac trunk (modified Appleby procedure) is a surgical option in which postoperative liver perfusion relies on blood flow via superior mesenteric artery (SMA) and gastroduodenal artery (GDA).8, 9 PatientA 66-year-old male was diagnosed with a 3.8 × 2.5 cm pancreatic body adenocarcinoma abutting the celiac trunk. Neoadjuvant FOLFIRINOX was initiated with a uniquely good response. TechniquePrior to surgery, a novel preoperative 3D simulation technique accounting for organ displacement during pneumoperitoneum with the goal of optimizing port placement and surgical decision making was employed. At surgery, a RAMPS procedure was performed with the renal vessels and adrenal gland being dissected first (reversed from typical open approach). Following dissection along the SMA towards the celiac axis, desmoplastic reaction enveloping the celiac trunk necessitated its resection. Arterial liver perfusion was confirmed with intraoperative ultrasound. ConclusionL-RAMPS and modified Appleby procedure is a curative option for patients with distal pancreatic cancers that invade the celiac trunk and in whom the tumor biology is well controlled. A preplanned approach with 3D reconstruction accounting for organ displacement due to pneumoperitoneum optimizes surgical decision making and port placement for visual alignment caudally along the SMA.

Модифицированная операция Appleby в условиях регионального онкологического диспансера

Модифицированная операция Appleby в условиях регионального онкологического диспансера

Modified Appleby procedure in a regional oncology dispensary

Modified Appleby procedure in a regional oncology dispensary

Appleby Procedure (Distal Pancreatectomy With Celiac Artery Resection) for Locally Advanced Pancreatic Carcinoma: Indications, Outcomes, and Imaging.

OBJECTIVE. We describe the indications, surgical technique, outcome, and imaging findings in patients with pancreatic ductal adenocarcinoma (PDAC) treated with distal pancreatectomy and celiac artery resection (modified Appleby procedure). CONCLUSION. Distal pancreatectomy and celiac artery resection is a feasible surgery in selected patients with locally advanced PDAC. Knowledge of surgical technique and imaging features may aid radiologists in identifying patients with locally invasive PDAC who might benefit from resection and identifying characteristic distal pancreatectomy and celiac artery resection complications.

Why we don’t need hepatic artery reconstruction during DP-CAR? Experience of 20 modified Appleby procedures

Why we don’t need hepatic artery reconstruction during DP-CAR? Experience of 20 modified Appleby procedures