Modified Appleby Procedure Research Articles

Modified Appleby procedure for locally advanced distal pancreatic cancer which underwent neoadjuvant therapy

Modified Appleby procedure for locally advanced distal pancreatic cancer which underwent neoadjuvant therapy

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

Background: Distal pancreatectomy with celiac artery resection (DPCAR) is in use for borderline-resectable pancreatic cancer. It is believed that considerable reduction of the liver arterial supply after DPCAR may cause severe liver ischemia. Although the artery reconstruction is not a problem anymore the decision to reconstruct artery has to be justified To study liver collateral arterial supply after temporary CHA, right gastroepiploic and accessory/replaced left hepatic arteries (a/rLHA). Methods: Arterial anatomy, diameters of CHA, proper hepatic (PHA), gastroduodenal(GDA) and pancreatoduodenal arteries(PDA) were registered before surgery in 110 consecutive patients with pancreatic body/tail cancer(n35), gastric cancer with pancreatic involvementn30) and liver tumors(n45)by CT. For DPCAR(n20) these data were obtained after surgery as well. Diameters of peripancreatic arteries and mean systolic blood velocity in hepatic arteries before and after CHA clamping were measured intraoperatively by Doppler ultrasound. Results: Pulse disappeared in 19 (17 %) cases after clamping of CHA,RGEA and aLHA/rLPA. Collateral arterial blood flow in the liver parenchyma was revealed in all cases. DPCAR led to increase of GDA, rRHA, PDA and RGEA blood flow in 0,9-12 times Conclusion: Doppler ultrasound is a reliable modality for intraoperative assessment of liver arterial blood supply after DPCAR; Hepatic artery reconstruction may be necessary after DPCAR in case of disappearance of arterial US signal upon the liver parenchyma.

Appleby procedure – a challenging interdisciplinary treatment for extensive pancreatic body cancer

Background: Locally advanced pancreatic body cancer with invasion of the celiac axis is a severe finding that only rarely can undergo curative resection. Methods: We here present a video highlighting the crucial steps of a modified Appleby procedure. A 52-year old patient presented with a mass in pancreas body and infiltration of the celiac axis (CA) and splenic artery (SA). Results: Preoperative angiography and embolization of the common hepatic artery (CHA) is imperative to assure an adequate retrograde hepatic blood inflow via the gastroduodenal arcade. Occasionally, it is necessary an additional embolization of a hypertrophic right gastric artery to avoid flow steal phenomenon, as in this case. The patient underwent radical curative resection after neoadjuvant chemoradiation. Surgery started with mobilization of the tail of the pancreas and spleen. Dissection of hepatoduodenal ligament and identification of the junction of gastroduodenal artery (GDA) and hepatic artery is of utmost importance. For safety reasons, it is recommendable to preliminary clamp the common hepatic artery and to prove a sufficient hepatic arterial flow by Doppler ultrasound. The common hepatic artery is then divided proximal of the junction with the GDA. CA was ligated at the level of the aorta and resected en-bloc with the specimen of distal pancreas and spleen. Conclusion: The intra- and postoperative course was uneventful; the patient could be discharged on postoperative day eleven. The histopathological findings showed an R0 resection.

Modified appleby procedure in locally advanced carcinoma of the body of pancreas with inadequate circulation through the pancreaticoduodenal arcade

Modified appleby procedure in locally advanced carcinoma of the body of pancreas with inadequate circulation through the pancreaticoduodenal arcade

Discussion of “Modified Appleby procedure for locally advanced pancreatic cancer”

Discussion of “Modified Appleby procedure for locally advanced pancreatic cancer”

Modified Appleby procedure for locally advanced pancreatic cancer

Locally advanced pancreas cancer (LAPC) involving the celiac axis is typically considered unresectable and carries a poor prognosis. We present a case of a patient with LAPC who underwent a modified Appleby procedure for tumor clearance following neoadjuvant therapy. Technical aspects include diagnostic laparoscopy to exclude occult metastatic disease followed by complete mobilization of the pancreas and spleen, preservation of the left gastric artery, and resection and reconstruction of the common hepatic artery. With proper patient selection and preparation, LAPC with celiac axis involvement can be safely resected with favorable outcomes.

Resection of Locally Advanced Pancreatic Cancer without Regression of Arterial Encasement After Modern-Era Neoadjuvant Therapy

IntroductionModern-era systemic therapy for locally advanced pancreatic adenocarcinoma (LAPC) offers improved survival relative to historical regimens but not necessarily improved radiographic downstaging to allow more patients to undergo resection. The aim of this study was to evaluate the survival, progression, and pathologic outcomes after resection of LAPC that did not regress from > 180 degrees arterial encasement after neoadjuvant therapy. MethodsSixty-one LAPC patients were brought to the operating room after neoadjuvant therapy for NCCN-defined unresectable pancreatic cancer between 2012 and 2017. Pts were explored with intent of pancreatectomy and irreversible electroporation for margin extension; 5 (8%) had metastatic lesions on exploratory laparoscopy and were excluded from analyses. Imaging was re-examined to confirm LAPC prior to surgery. Data were analyzed from a prospective pancreatic cancer database. ResultsPatients had arterial involvement of the celiac axis (37.5%) and/or superior mesenteric artery (42.9%) and/or an extended length of the common hepatic (n = 44.6%) artery. Twenty-nine males and 27 females, median 65 years of age, received neoadjuvant gemcitabine-based (58.9%) or FOLFIRINOX (35.7%) chemotherapy and stereotactic body (42.9%) or intensity-modulated (51.8%) radiation therapy. Median months from initiation of neoadjuvant therapy to surgery was 7.5. Sixty-one percent underwent Whipple, 21% distal, and 18% modified Appleby procedures; 57% patients underwent venous reconstruction. Ninety-day mortality was 2%. An R0 margin was achieved in 80%, and 53% were N0. Median overall and progression-free survival was 18.5 (95%CI 12.27–32.33) and 8.5 months (95%CI 6.0–15.0), respectively. One- and 3-year survival from surgery was 68.5% (95%CI 53.0–79.7) and 39.0% (95%CI 23.7–53.8), respectively. ConclusionWith modern-era neoadjuvant therapy, R0 resections can be achieved in a majority of non-metastatic patients with locally advanced, unresectable disease based on cross-sectional imaging.

Enhanced Vascular Collateralization Through the Pancreaticoduodenal Arcade Secondary to Median Arcuate Ligament Compression of the Celiac Axis in the Setting of Pancreatic Body Adenocarcinoma: The Ideal Scenario for the Modified Appleby Procedure

Abstract Background: A modified Appleby procedure for pancreatic body tumors relies upon collateral vessels maintaining blood flow to the proper hepatic artery (PHA) through the pancreaticoduodenal arcade (PDA) off of the superior mesenteric artery (SMA). Compression of the celiac axis by the median arcuate ligament (MAL) promotes the expansion of collateral vessels without preoperative intervention. Case Presentation: A 51-year-old male with asymptomatic compression of the celiac artery presented with new onset insulin-dependent diabetes mellitus. He underwent imaging that demonstrated a locally advanced pancreatic body tumor that encased the superior mesenteric vein and portal vein confluence and involved the common hepatic artery. He had an adequate response to neoadjuvant FOLFIRINOX chemotherapy and underwent an uncomplicated modified Appleby procedure with a margin negative resection. Hepatic blood flow was adequate through the PHA as a result of collateralization of blood flow through the PDA off th...

Distal Pancreatectomy with en Bloc Celiac Axis Resection (Modified Appleby Procedure) for Locally Advanced Pancreatic Body Cancer: A Single-Center Review of 80 Consecutive Patients.

Recently, distal pancreatectomy with en bloc celiac axis resection (DP-CAR) or modified Appleby procedure for locally advanced pancreatic body cancer is increasingly reported. However, actual long-term survival data are still unknown. This study retrospectively reviewed 80 consecutive patients with pancreatic body cancer who underwent DP-CAR at a single institution. The study included 40 men and 40 women with a median age of 65years (range, 44-85years). A pancreatic fistula was the most common complication, occurring in 47 patients (57.5%). Other complications with a high incidence were ischemic gastropathy (23 patients, 28.8%) and delayed gastric emptying (20 patients, 25%). According to the Clavien-Dindo classification, the major complications, defined as complications of grade 3 or higher, were observed in 33 patients (41.3%), and the in-hospital mortality involved four patients (5%). For all 80 patients, the 1-, 2-, and 5-year overall survivals (OSs) were respectively 81.1, 56.9, and 32.7%, and the median survival time was 30.9months. The actual 5-year survival for the 61 patients whose surgery was performed five or more years earlier was 27.9% (17 of 61). The 1-, 2-, and 5-year OSs for the patients who underwent preoperative therapy (100, 90, and 78.8%) were significantly better than for those who underwent upfront surgery (77.9, 51.5, and 26.7%; P<0.0001). The findings show DP-CAR to be a valid procedure for treating locally advanced pancreatic body cancer, which might contribute more to patients' survival when performed as part of multidisciplinary treatment.

Which type of arterial architecture needs hepatic artery reconstruction during DP-CAR? Experience of 20 modified Appleby procedures

Which type of arterial architecture needs hepatic artery reconstruction during DP-CAR? Experience of 20 modified Appleby procedures

Modified Appleby procedure for borderline resectable/locally advanced distal pancreatic adenocarcinoma: A major procedure for selected patients

In distal pancreatic ductal adenocarcinoma (PDAC), distal pancreatectomy with en bloc splenectomy and celiac axis resection (DP-CAR) can allow curative resection in case of tumor extension to celiac axis. From 2008 to 2013, of 102patients with localized distal PDAC, 7patients with celiac axis involvement were planned to undergo DP-CAR with curative intent. All patients received neoadjuvant treatment followed by preoperative coil embolization to enlarge collateral arterial pathways, except if a replaced right hepatic artery arising from superior mesenteric artery was present and sufficient for the blood supply. We herein analyzed indications, technique and outcomes of DP-CAR. After neoadjuvant treatment and arterial embolization, two patients experienced tumor progression and were not operated while five underwent DP-CAR. No patient required arterial reconstruction. Postoperative mortality was nil, but morbidity was 100%, mainly represented by pancreatic fistula. Postoperatively, there was a complete pain relief but chronic diarrhea was observed in all patients. Resections were R0 in three patients. One operated patient was alive and disease free at 60months whereas median overall survival of patients who underwent resection was 24months. DP-CAR for borderline resectable/locally advanced distal PDAC is associated with high morbidity and mixed long-term functional results. Neoadjuvant treatment may prevent from unnecessary surgery for patients with progressive disease and may facilitate resection with acceptable long-term survival.

Results of the modified Appleby procedure

To evaluate safety and efficacy of distal pancreatectomy with en bloc celiac artery resection (DP-CAR) for pancreatic malignancy. Medical reports of 17 patients who underwent DP-CAR procedure (15 of them with pancreatic malignancy) were retrospectively analyzed. Also we studied 27 publications describing more than 2 cases of DP-CAR. R0- and R1-resection was performed in 14 (82%) and 3 (18%) patients respectively. Postoperative complications ware observed in 11 (65%) cases. Nine of them were successfully treated. Full pain control was achieved in all patients. There were no any ischemic complications. 16 patients received chemotherapy. 2 (11%) patients died in early postoperative period due to aortic dissection in 10 days and fungal sepsis in 44 days after surgery. Median survival was 20 months. Literature review included 27 articles describing 311 operations. Herewith postoperative complications developed in 43% of cases and 90-day postoperative mortality was 4%. Median survival ranged from 9.3 to 26 months. DP-CAR is effective and safe procedure in certain patients with locally advanced pancreatic cancer.

Modified Appleby Procedure with Arterial Reconstruction for Locally Advanced Pancreatic Adenocarcinoma: A Literature Review and Report of Three Unusual Cases

BackgroundPancreatic body and tail ductal adenocarcinomas are often diagnosed with local vascular invasion of the celiac axis (CA) and its various branches. With such involvement, these tumors have traditionally been considered unresectable. The modified Appleby procedure allows for margin negative resection of some such locally advanced tumors. This procedure involves distal pancreatectomy with en bloc splenectomy and CA resection and relies on the presence of collateral arterial circulation via an intact pancreaticoduodenal arcade and the gastroduodenal artery to maintain prograde hepatic arterial perfusion. When the resultant collateral circulation is inadequate to provide sufficient hepatic and gastric arterial inflow, arterial reconstruction (AR) is necessary to “supercharge” the inflow. Herein, we review all reported cases of AR with modified Appleby procedures that we have identified in the literature, and we report our experience of three recent cases with arterial reconstruction including two cases with arterial bypasses not requiring interposition grafting. MethodsPerioperative and oncologic outcomes from our Institutional Review Board-approved database of pancreatic resections at the Thomas Jefferson University were reviewed. Additionally, PubMed search for cases of distal or total pancreatectomy with celiac axis resection and concurrent AR was performed. ResultsFrom the literature, 12 reports involving 28 patients were identified of distal and total pancreatectomy with AR after CA resection. The most common AR in the literature, performed in 12 patients, was a bypass from the aorta to the common hepatic artery (CHA) using a variety of interposition conduits. In our institutional experience, patient #1 had a primary side-to-end aorto-CHA bypass, patient #2 had a primary end-to-end bypass of the transected distal CHA to the left gastric artery in the setting a replaced left hepatic artery, and patient #3 required an aortic to proper hepatic artery bypass with saphenous vein graft and portal venous reconstruction. All patients recovered from their operations without ischemic complications, and they are currently 16, 15, and 13 months post-op, respectively. ConclusionsThe criteria for resectability in patients with locally advanced pancreatic body and tail neoplasms are expanding due to increasing experience with AR in the setting of the modified Appleby procedure. When performing AR, primary arterial re-anastomosis may be considered preferable to interposition grafting as it decreases the potential for the infectious and thrombotic complications associated with conduits and it reduces the number of vascular anastomoses from two to one. Consideration must also be given to normal variant anatomy of the hepatic circulation during operative planning as the origin of the left gastric artery is resected with the CA. The modified Appleby procedure with AR, when used in appropriately selected patients, offers the potential for safe, margin negative resection of locally advanced pancreatic body and tail tumors.

Preoperative Diagnostic Angiogram and Endovascular Aortic Stent Placement for Appleby Resection Candidates: A Novel Surgical Technique in the Management of Locally Advanced Pancreatic Cancer.

Background. Pancreatic adenocarcinoma of the body and tail usually presents late and is typically unresectable. The modified Appleby procedure allows resection of pancreatic body carcinoma with celiac axis (CA) invasion. Given that the feasibility of this technique is based on the presence of collateral circulation, it is crucial to confirm the presence of an anatomical and functional collateral system. Methods. We here describe a novel technique used in two patients who were candidates for Appleby resection. We present their clinical scenario, imaging, operative findings, and postoperative course. Results. Both patients had a preoperative angiogram for assessment of anatomical circulation and placement of an endovascular stent to cover the CA. We hypothesize that this new technique allows enhancement of collateral circulation and helps minimize intraoperative blood loss when transecting the CA at its takeoff. Moreover, extra length on the CA margin may be gained, as the artery can be transected at its origin without the need for vascular clamp placement. Conclusion. We propose this novel technique in the preoperative management of patients who are undergoing a modified Appleby procedure. While further experience with this technique is required, we believe that it confers significant advantages to the current standard of care.

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 adenocarcinoma of the pancreatic body: The modified appleby procedure

Distal pancreatectomy with celiac axis resection for adenocarcinoma of the pancreatic body: The modified appleby procedure

Modified appleby procedure for resection of advanced pancreatic body-tail tumors with hepatic artery or celiac axis involvement

Modified appleby procedure for resection of advanced pancreatic body-tail tumors with hepatic artery or celiac axis involvement

Mo1662 Modified Appleby Procedure With Arterial Reconstruction: A Literature Review and Report of 3 Unusual Cases

BACKGROUND Pancreatic body and tail carcinomas are often diagnosed with local vascular invasion of the celiac axis (CA) and its branches. With such involvement, these tumors have traditionally been considered unresectable. The modified Appleby procedure allows margin negative resection of such locally advanced tumors. This procedure involves distal pancreatectomy with en bloc splenectomy and CA resection and relies on the presence of collateral arterial circulation via an intact pancreaticoduodenal arcade and gastroduodenal artery (GDA). When the resultant collateral circulation is inadequate to provide sufficient hepatic and gastric arterial inflow, arterial reconstruction (AR) is necessary to supercharge the inflow. Herein, we review all reported cases of AR with modified Appleby procedures and report our experience of 3 recent cases with arterial reconstruction including 2 cases with arterial bypasses not requiring interposition grafting. METHODS A PubMed search was systematically completed of studies relating to distal pancreatectomy with CA resection and subsequent AR. RESULTS Eleven reports involving 27 patients were identified of distal and total pancreatectomy with AR after CA resection (Table 1). The most common AR, performed in 11 patients, was a bypass from the aorta to the common hepatic artery (CHA) using a variety of interposition conduits. In our experience, patient #1 had a primary side to end aorto-CHA bypass, patient #2 had a primary end to end bypass of the distal CHA to the left gastric artery (LGA) in the setting a replaced left hepatic artery (rLHA), and patient #3 required an aortic to proper hepatic artery bypass with saphenous vein graft and venous reconstruction. Patient #1 received adjuvant chemo-radiation therapy. Patient #2 received neoadjuvant chemotherapy and proton therapy with a near complete tumor response. Patient #3 received neoadjuvant chemo-radiation therapy with a near complete tumor response. All patients recovered well and they are currently 6, 5 and 2 months post-op, respectively. CONCLUSIONS Criteria for resectablilty in patients with locally advanced pancreatic body and tail neoplasms are expanding due to increasing experience with AR in the setting of the modified Appleby procedure. When performing AR, primary anastomosis may be considered preferable to interposition grafting as it decreases the potential for the infectious and thrombotic complications associated with conduits and it reduces the number of vascular anastomoses from two to one. Consideration must also be given to normal variant anatomy of the hepatic circulation (as seen in patient #2) during operative planning as the LGA is resected with the CA. The modified Appleby with AR, when used in appropriately selected patients, offers the potential for safe, margin negative resection of locally advanced tumors.

Liver blood supply after a modified Appleby procedure in classical and aberrant arterial anatomy

Reported here are two cases of a modified Appleby operation for borderline resectable ductal adenocarcinoma of the pancreatic body, in one of which a R0 distal resection was attended to by excision, not only of the celiac axis, but also of the common and left hepatic arteries in the presence of arterial anatomic variation Michels, type VIIIb. The possibility and avenues of the maintenance of the blood supply to the left hepatic lobe after surgical aggression of this kind are demonstrated employing computed tomography (CT) and 3-D CT angiography. Furthermore, both cases highlight all important worrisome aspects of pancreatic cancer resectability prediction.

Arterial liver blood supply after modified Appleby procedure with excision of the common and left hepatic arteries on the background of Michels' type III arterial anatomy

Pancreatic cancer is the fourth leading cause of cancer-related death. Early detection is challenging because symptoms are relatively nonspecific. Imaging is vital in detecting and staging pancreatic tumors, and management depends on imaging findings. Radiologists should be aware of current surgical treatments for pancreatic neoplasms, as surgeons rely on interpretation of cross-sectional imaging for presurgical planning. Understanding postsurgical anatomy is critical to assess for complications and recurrence. This review will emphasize the role of the radiologist in planning for surgery and will review postoperative changes based on surgical intervention and common complications.