Ann Surg Treat Res.  2015 Oct;89(4):167-175. 10.4174/astr.2015.89.4.167.

Distal pancreatectomy with celiac axis resection for pancreatic body and tail cancer invading celiac axis

• Ham H
• Kim SG
• Kwon HJ
• Ha H
• Choi YY

• KMID: 2166885
• DOI: http://doi.org/10.4174/astr.2015.89.4.167

Abstract

PURPOSE
Pancreatic body/tail cancer often involves the celiac axis (CA) and it is regarded as an unresectable disease. To treat the disease, we employed distal pancreatectomy with en bloc celiac axis resection (DP-CAR) and reviewed our experiences.
METHODS
We performed DP-CAR for seven patients with pancreatic body/tail cancer involving the CA. The indications of DP-CAR initially included tumors with definite invasion of CA and were later expanded to include borderline resectable disease. To determine the efficacy of DP-CAR, the clinico-pathological data of patients who underwent DP-CAR were compared to both distal pancreatectomy (DP) group and no resection (NR) group.
RESULTS
The R0 resection rate was 71.4% and was not statistically different compared to DP group. The operative time (P = 0.018) and length of hospital stay (P = 0.022) were significantly longer in DP-CAR group but no significant difference was found in incidence of the postoperative pancreatic fistula compared to DP group. In DP-CAR group, focal hepatic infarction and transient hepatopathy occurred in 1 patient and 3 patients, respectively. No mortality occurred in DP-CAR group. The median survival time (MST) was not statistically different compared to DP group. However, the MST of DP-CAR group was significantly longer than that of NR group (P < 0.001).
CONCLUSION
In our experience, DP-CAR was safe and offered high R0 resection rate for patients with pancreatic body/tail cancer with involvement of CA. The effect on survival of DP-CAR is comparable to DP and better than that of NR. However, the benefits need to be verified by further studies in the future.

Keyword

Pancreatic neoplasm; Celiac artery; Pancreatectomy

MeSH Terms

Axis, Cervical Vertebra*
Celiac Artery
Humans
Incidence
Infarction
Length of Stay
Mortality
Operative Time
Pancreatectomy*
Pancreatic Fistula
Pancreatic Neoplasms
Tail*

Figure

• 

  Fig. 1 Arterial phase in contrast-enhanced abdominal CT of representative case who received DP-CAR. (A) The common hepatic artery, spleneic artery, and celiac artery (CA) are involved with low-density mass in body and tail of pancreas (6 cm × 4 cm), (B-D) Proper hepatic artery (PHA), gastroduodenal artery (GDA), superior mesenteric artery (SMA), superior mesentric vein, and portal vein were spared. DP-CAR, distal pancreatectomy with en bloc celiac axis resection; PHA, proper hepatic artery; CA, celiac axis.

• 

  Fig. 2 Schematic showing distal pancreatectomy with en bloc celiac axis resection. (A) White dotted line indicates dissection plane, (B) shematic drawing collateral arterial circulation via pancreaticoduodenal arcades from superior mesenteric artery (SMA) after DP-CAR. DP-CAR, distal pancreatectomy with en bloc celiac axis resection; CA, celiac axis; CHA, common hepatic artery; SA, splenic artery; LGA, left gastric artery; PHA, proper hepatic artery; RGA, right gastric artery; GDA, gastroduodenal artery; RGEA, right gastroepiploic artery; IPDA, inferior pancreaticoduodenal artery; PV, portal vein; SV, splenic vein; SMV, superior mesenteric vein; IMV, inferior mesenteric vein.

• 

  Fig. 3 Intraoperative view after completion of DP-CAR. The cut end of celiac axis is shown (white circle). (A) CHA was clearly divided with sufficient tumor free margin. The cut end of common hepatic artery is shown (Forcep). (B) The body and tail of the pancreas and spleen were dissected free from the left adrenal gland and Gerota's fasica. The left renal vein and SMA were exposed. DP-CAR, distal pancreatectomy with en bloc celiac axis resection; CHA, common hepatic artery; SMV, superior mesenteric vein; SMA, superior mesenteric artery.

• 

  Fig. 4 Comparision of the survival curves according to different surgical type. There was no significant difference in the survival rate between DP-CAR and DP groups (p=0.681). DP-CAR, distal pancreatectomy with en bloc celiac axis resection; DP, distal pancratectomy; NR, no resection.

Reference

1. Varadhachary GR, Tamm EP, Abbruzzese JL, Xiong HQ, Crane CH, Wang H, et al. Borderline resectable pancreatic cancer: definitions, management, and role of preoperative therapy. Ann Surg Oncol. 2006; 13:1035–1046.

2. Ravikumar R, Sabin C, Abu Hilal M, Bramhall S, White S, Wigmore S, et al. Portal vein resection in borderline resectable pancreatic cancer: a United Kingdom multicenter study. J Am Coll Surg. 2014; 218:401–411.

3. Sperti C, Berselli M, Pedrazzoli S. Distal pancreatectomy for body-tail pancreatic cancer: is there a role for celiac axis resection? Pancreatology. 2010; 10:491–498.

4. Bockhorn M, Uzunoglu FG, Adham M, Imrie C, Milicevic M, Sandberg AA, et al. Borderline resectable pancreatic cancer: a consensus statement by the International Study Group of Pancreatic Surgery (ISGPS). Surgery. 2014; 155:977–988.

5. Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery. 2005; 138:8–13.

6. Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, et al. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery. 2007; 142:761–768.

7. Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, et al. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery. 2007; 142:20–25.

8. Takahashi Y, Kaneoka Y, Maeda A, Isogai M. Distal pancreatectomy with celiac axis resection for carcinoma of the body and tail of the pancreas. World J Surg. 2011; 35:2535–2542.

9. Okada K, Kawai M, Tani M, Hirono S, Miyazawa M, Shimizu A, et al. Surgical strategy for patients with pancreatic body/tail carcinoma: who should undergo distal pancreatectomy with en-bloc celiac axis resection? Surgery. 2013; 153:365–372.

10. Nimura Y, hattori T, Miura K, Nakashima N, Hibi M. Resection of advanced pancreatic body-tail carcinoma by Appleby's operation. Shujutu. 1976; 30:885–889.

11. Hirano S, Kondo S, Hara T, Ambo Y, Tanaka E, Shichinohe T, et al. Distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic body cancer: long-term results. Ann Surg. 2007; 246:46–51.

12. Yamamoto Y, Sakamoto Y, Ban D, Shimada K, Esaki M, Nara S, et al. Is celiac axis resection justified for T4 pancreatic body cancer? Surgery. 2012; 151:61–69.

13. Tanaka E, Hirano S, Tsuchikawa T, Kato K, Matsumoto J, Shichinohe T. Important technical remarks on distal pancreatectomy with en-bloc celiac axis resection for locally advanced pancreatic body cancer (with video). J Hepatobiliary Pancreat Sci. 2012; 19:141–147.

14. Wu X, Tao R, Lei R, Han B, Cheng D, Shen B, et al. Distal pancreatectomy combined with celiac axis resection in treatment of carcinoma of the body/tail of the pancreas: a single-center experience. Ann Surg Oncol. 2010; 17:1359–1366.

15. Hishinuma S, Ogata Y, Tomikawa M, Ozawa I. Stomach-preserving distal pancreatectomy with combined resection of the celiac artery: radical procedure for locally advanced cancer of the pancreatic body. J Gastrointest Surg. 2007; 11:743–749.

16. Shimada K, Sakamoto Y, Sano T, Kosuge T. Prognostic factors after distal pancreatectomy with extended lymphadenectomy for invasive pancreatic adenocarcinoma of the body and tail. Surgery. 2006; 139:288–295.

17. Gagandeep S, Artinyan A, Jabbour N, Mateo R, Matsuoka L, Sher L, et al. Extended pancreatectomy with resection of the celiac axis: the modified Appleby operation. Am J Surg. 2006; 192:330–335.

18. Kondo S, Katoh H, Hirano S, Ambo Y, Tanaka E, Okushiba S, et al. Results of radical distal pancreatectomy with en bloc resection of the celiac artery for locally advanced cancer of the pancreatic body. Langenbecks Arch Surg. 2003; 388:101–106.