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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 50  |  Issue : 1  |  Page : 28-31

Distal pancreatectomy and celiac axis resection for pancreatic body carcinoma involving celiac artery


1 Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, Taoyuan, Taiwan
2 Department of Pathology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, Taoyuan, Taiwan
3 Department of Radiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, Taoyuan, Taiwan

Date of Web Publication28-Feb-2017

Correspondence Address:
Ta-Sen Yeh
Department of Surgery, Chang Gung Memorial Hospital, 5, Fu-Hsing Street, Kwei.Shan Shiang, Taoyuan
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_10_17

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  Abstract 

Pancreatic body or tail cancer with invasion to major vessels, including the common hepatic artery and the celiac artery, was previously considered to be unresectable. However, an increasing number of surgeons have aggressively adopted distal pancreatectomy, splenectomy, and celiac axis resection (DP-CAR) in this scenario to attempt curative resection, thus improving long-term survival. In this paper, we present the case of a 45-year-old man with pancreatic body cancer invading the celiac axis who underwent DP-CAR with negative margins (R0) and subsequently exhibited an uneventful postoperative course. We also reviewed literature, which unequivocally demonstrates a comparable oncological outcome between pancreatic body or tail cancer with and without celiac artery resection. To the best of our knowledge, our study is the first documented case in which DP-CAR was successfully performed in Taiwan.

Keywords: Appleby procedure, celiac artery, distal pancreatectomy, pancreatic cancer


How to cite this article:
Chang SC, Liu YY, Chen TC, Tseng CH, Yeh TS. Distal pancreatectomy and celiac axis resection for pancreatic body carcinoma involving celiac artery. Formos J Surg 2017;50:28-31

How to cite this URL:
Chang SC, Liu YY, Chen TC, Tseng CH, Yeh TS. Distal pancreatectomy and celiac axis resection for pancreatic body carcinoma involving celiac artery. Formos J Surg [serial online] 2017 [cited 2019 Oct 19];50:28-31. Available from: http://www.e-fjs.org/text.asp?2017/50/1/28/201181


  Introduction Top


Pancreatic adenocarcinoma is associated with a poor prognosis, and the 5-year survival has been estimated to be 6% worldwide in the setting of resectable pancreatic cancer.[1] Ductal adenocarcinomas of the body and tail of the pancreas account for approximately one-third of all pancreatic cancers,[2] which are usually asymptomatic until the local invasion of major vessels or the occurrence of associated neural plexuses. Previously, pancreatic body or tail cancer with invasion to major vessels including the common hepatic artery (CHA) and the celiac artery was considered unresectable. Patients with this cancer eventually develop peritoneal or distant carcinomatosis, and their median survival is poor (i.e., only 6–12 months). Distal pancreatectomy, splenectomy, and celiac axis resection (DP-CAR) were first adopted by Nimura and Fortner for treating pancreatic body and tail adenocarcinoma in 1976.[2],[3],[4],[5] Since then, an increasing number of patients previously considered unresectable have undergone this procedure, particularly Japanese patients. In this case report, we describe the case of a 45-year-old man with pancreatic body cancer invading celiac axis who underwent uneventful DP-CAR. To the best of our knowledge, this is the first documented case of successful DP-CAR in Taiwan.


  Case Report Top


A 45-year-old man had a 2-month history of left upper quadrant abdominal pain. One and a half years ago, he had an episode of acute pancreatitis. Except for this acute pancreatitis episode, no other significant findings were detected on abdominal computed tomography at that time. Since then, he has been regularly followed up, and the level of the tumor marker cancer antigen (CA) 19-9 was found to be increasing. On arrival to our hospital, the patient had a temperature of 36°C, pulse of 71/min, blood pressure of 95/53 mmHg, respiratory rate of 15/min, and no signs of jaundice. Abdominal examination revealed no tenderness or palpable mass. The hemogram and biochemistry investigations yielded normal results, whereas a serum CA 19-9 level up to 253 IU/L was detected. Abdominal computed tomography revealed a pancreatic body tumor with celiac axis encasement, together with a replaced right hepatic artery (RHA) [Figure 1]. The patient underwent DP-CAR. During this procedure, we made a longitudinal midline incision to ensure maximum visibility. After the peritoneal and pelvic metastases were excluded, the superior mesenteric artery (SMA) was exposed to assess the resectability of the tumor. A stony hard tumor at the pancreatic body with celiac trunk invasion was detected, but the portal vein (PV), superior mesenteric vein (SMV), and SMA were free from invasion. After exposing the SMA, the CHA, gastroduodenal artery (GDA), and hepatic artery proper (HAP) were exposed. After the CHA was clamped, the pulsation of the HAP became weak, in which blood flow decreased from 0.2 to 0.05 L/min. On the basis of the preoperative computed tomography, a replaced RHA from the SMA was identified, suggesting that liver function can be safely preserved even if the CHA was sacrificed. The origin of the celiac artery was dissected, and the left gastric artery (LGA), CHA, and splenic artery were all divided. The pancreas was transected at the pancreatic neck. The splenic vein was divided, and splenectomy was simultaneously performed. The surrounding lymph nodes, nerve plexus, and the left Gerota fascia were all removed to secure the radicality [Figure 2]. Finally, the pancreatic head stump was oversewn, particularly the pancreatic duct was identified and suture-ligated. The liver and stomach appeared pinkish during and after DP-CAR. The postoperative course was uneventful, and the patient was discharged on postoperative day 10. The histopathologic findings revealed a moderately differentiated ductal adenocarcinoma of the pancreas, pT3N1cM0, Stage 2b, with metastases of peripancreatic lymph nodes (2/12) and perineural invasion [Figure 3]. In brief, R0 resection was achieved.
Figure 1: (a) Transverse view of computed tomography showing a pancreatic body cancer with celiac axis encasement (green arrow). (b) Coronary view of computed tomography showing the displaced right hepatic artery from the superior mesenteric artery (red arrow)

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Figure 2: Intraoperative photographs taken after the removal of the specimen. The origin of celiac artery was dissected, and the left gastric artery, common hepatic artery, and splenic artery were all sacrificed. The superior mesenteric artery, superior mesenteric vein, replaced right hepatic artery, and left renal vein were taped. RHA: Right hepatic artery, SMA: Superior mesenteric artery, SMV: Superior mesenteric vein, LRV: Left renal vein

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Figure 3: (a) Resected surgical specimen obtained after distal pancreatectomy, splenectomy, and celiac axis resection. (b) A histologic section showing tripods of the celiac artery, common hepatic artery, and splenic artery, and the left gastric artery was not seen in this section. Notably, perineural invasion around celiac artery was found. CA: Celiac artery, CHA: Common hepatic artery, SA: Splenic artery

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  Discussion Top


DP-CAR is also called the modified Appleby procedure and is derived from the Appleby operation.[2],[5] The Appleby procedure, which includes total gastrectomy and DP-CAR, was first performed in 1953 and achieved a more complete resection of the celiac axis lymph nodes in locally advanced gastric cancer. DP-CAR, which is modified from the original Appleby procedure, is performed to preserve the stomach.[2],[3],[4],[5] Nimura and Fortner first adopted DP-CAR for treating pancreatic body and tail adenocarcinoma in 1976. Thereafter, DP-CAR has been widely practiced and reported by Japanese surgeons, and Makary et al. were the first to perform DP-CAR in the United States in 2005.

Several indications have been presented for DP-CAR, including tumors involving the CA without invasion to the pancreatic head, proper hepatic artery (PHA), GDA, and SMA/V and clear pulsation of the PHA after temporary occlusion of the CA. Otherwise, the reconstruction of the hepatic artery is warranted. Finally, R0 resection, at least, should be achieved.[6] Before performing DP-CAR, resectability should be cautiously assessed, including exclusion of the peritoneal metastasis, inspection of the paraaortic nodes, tumor involvement of the SMV/PV, and the adequacy of collateral blood flow through the GDA.[5] Several approaches have been recommended such as right-sided approach for accessing the origin of CA and SMA or the mesenteric approach for incision of the mesenteric base and for evaluating the involvement of the PV/SMV and/or SMA. Retropancreatic, retroperitoneal eradication has also been encouraged to dissect posterior tissues of the SMV and SMA en bloc to obtain R0 resection.[3],[7],[8] Tanaka et al. reported that R0 resection was achieved in 93% patients in their case series.[3] A meta-analysis revealed considerable heterogenicity in the rate of R0 resection, ranging from 30.8% to 100%.[9]

The most crucial point during surgery is the preservation of the arteries of the collateral pathways, particularly the inferior pancreatic duodenal artery (IPDA) and GDA, to avoid hepatic and gastric ischemia,[2],[5] which represent the most common complications associated with DP-CAR. Hepatic ischemia results from insufficient HPA after ligation of the CHA or the left hepatic artery replaced from LGA. By contrast, gastric ischemia results from poor collateral flow in the setting of disruption of the left gastric and left gastroepiploic arteries. To avoid hepatic ischemia, it is crucial to detect the presence of collateral arterial circulation from SMA through an intact IPDA and the GDA to maintain hepatic arterial perfusion in a retrograde manner.[2],[4] Insufficient flow can be detected by palpation, Doppler ultrasonography, hepatic vein oxygen saturation, fluorescein staining, or pre- and post-clamping CHA stumps pressure; a mean arterial pressure that decreased by >25% suggests the necessity of vascular reconstruction of the CHA.[2],[8],[10] In addition, preoperative embolization of the CHA has been adopted to promote collateralization before performing DP-CAR.[2],[10] Other complications such as delayed gastric emptying and pancreatic fistula have been frequently encountered.

Increasing evidence has shown that DP-CAR can be safely performed for locally advanced adenocarcinomas of the pancreatic neck and body with celiac artery invasion. Relatively large surgical series (<12 cases) of DP-CAR are summarized in [Table 1].[3], 9, [11],[12],[13],[14],[15],[16],[17],[18] The number of DP-CAR cases ranged from 12 to 42. The associated mortality rates were as low as 0%–6.7%, whereas the morbidity rates were considerably high, ranging from 35% to 92%. Moreover, ischemia, pancreatic fistula, and delayed gastric emptying were found to be the three common complications contributing to postoperative morbidity in DP-CAR. Gastric, gallbladder, and hepatic ischemia were also common complications.[12] Gastric ischemia was reported in 8.3%–19.42% of patients. By contrast, liver ischemic problems, including liver dysfunction or infarction or liver abscess, were rare and demonstrated acceptable rates. Although pancreatic fistula was a common complication in DP-CAR, its incidence was not significantly different from that in DP. Yamamoto et al.[14] reported that the rate of delayed gastric emptying was as high as 30.7% in the DP-CAR group, which was significantly different from that in the DP group (8.6%, P = 0.03). Intraoperative factors such as operating time and intraoperative blood loss were found to be associated with morbidity. Some series compared blood loss and found that blood loss was significantly higher in the DP-CAR group than in the DP group, which resulted from the more complicated operative procedure, including occasional vascular (arterial or venous) reconstruction.[12] In addition, resection of other organs, such as gallbladder resection, gastrectomy, and colon resection, during DP-CAR might be necessary occasionally. The complexity of the procedure was related to the prolonged operative time.
Table 1: Literature review of distal pancreatectomy with celiac artery resection for pancreatic cancer

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The long-term outcome is the most crucial concern for DP-CAR. The median overall survival ranged from 9.7 to 25 months in patients who underwent DP-CAR, and the estimated overall 1- and 3-year survival rates in patients who underwent DP and DP-CAR were 42.6%–81% and 4%–52%, respectively,[9],[11],[16] both which are not very promising. However, in a case-controlled study, Wu et al. demonstrated that although the overall survival of patients undergoing DP-CAR was comparable to that of patients undergoing conventional distal pancreatectomy (14 vs. 15 months, P = 0.197), patients who underwent DP-CAR had a significantly prolonged median survival time compared with those did not undergo surgery (14 vs. 5 months, P = 0.013). More recently, a meta-analysis [9] concluded that DP-CAR is acceptable because this procedure broadens surgical indications, minimizes surgical mortality rate, and has obvious survival benefit and effective pain control. Nevertheless, this complicated and technically demanding surgical procedure with extraordinary surgical morbidities should only be performed by experienced surgeons in high-volume centers.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Siegel RL, Miller KD, Jemal A. Cancer statistics, 2015. CA Cancer J Clin 2015;65:5-29.  Back to cited text no. 1
    
2.
Latona JA, Lamb KM, Pucci MJ, Maley WR, Yeo CJ. Modified appleby procedure with arterial reconstruction for locally advanced pancreatic adenocarcinoma: A literature review and report of three unusual cases. J Gastrointest Surg 2016;20:300-6.  Back to cited text no. 2
    
3.
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;19:141-7.  Back to cited text no. 3
    
4.
Mittal A, de Reuver PR, Shanbhag S, Staerkle RF, Neale M, Thoo C, et al. Distal pancreatectomy, splenectomy, and celiac axis resection (DPS-CAR): Common hepatic arterial stump pressure should determine the need for arterial reconstruction. Surgery 2015;157:811-7.  Back to cited text no. 4
    
5.
Smoot RL, Donohue JH. Modified Appleby procedure for resection of tumors of the pancreatic body and tail with celiac axis involvement. J Gastrointest Surg 2012;16:2167-9.  Back to cited text no. 5
    
6.
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;17:1359-66.  Back to cited text no. 6
    
7.
Hirono S, Yamaue H. Tips and tricks of the surgical technique for borderline resectable pancreatic cancer: Mesenteric approach and modified distal pancreatectomy with en-bloc celiac axis resection. J Hepatobiliary Pancreat Sci 2015;22:E4-7.  Back to cited text no. 7
    
8.
Casadei R, Di Marco M, Ricci C, Santini D, Serra C, Calculli L, et al. Neoadjuvant chemoradiotherapy and surgery versus surgery alone in resectable pancreatic cancer: A single-center prospective, randomized, controlled trial which failed to achieve accrual targets. J Gastrointest Surg 2015;19:1802-12.  Back to cited text no. 8
    
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;153:365-72.  Back to cited text no. 9
    
10.
Alizai PH, Mahnken AH, Klink CD, Neumann UP, Junge K. Extended distal pancreatectomy with en bloc resection of the celiac axis for locally advanced pancreatic cancer: A case report and review of the literature. Case Rep Med 2012;2012:543167.  Back to cited text no. 10
    
11.
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;35:2535-42.  Back to cited text no. 11
    
12.
Gong H, Ma R, Gong J, Cai C, Song Z, Xu B. Distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic cancer: A systematic review and meta-analysis. Medicine (Baltimore) 2016;95:e3061.  Back to cited text no. 12
    
13.
Hirano S, Kondo S, Tanaka E, Shichinohe T, Tsuchikawa T, Kato K, et al. Postoperative bowel function and nutritional status following distal pancreatectomy with en-bloc celiac axis resection. Dig Surg 2010;27:212-6.  Back to cited text no. 13
    
14.
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;151:61-9.  Back to cited text no. 14
    
15.
Shimura M, Ito M, Horiguchi A, Miyakawa S. Distal pancreatectomy with en bloc celiac axis resection performed while monitoring hepatic arterial flow by using a transonic flowmeter during operation. Hepatogastroenterology 2012;59:1498-500.  Back to cited text no. 15
    
16.
Jing W, Zhu G, Hu X, Jing G, Shao C, Zhou Y, et al. Distal pancreatectomy with en bloc celiac axis resection for the treatment of locally advanced pancreatic body and tail cancer. Hepatogastroenterology 2013;60:187-90.  Back to cited text no. 16
    
17.
Dong Y, Jing JB, Peng CH. Clinical effect of modified Appleby operation in the treatment of carcinoma of body and tail of the pancreas. J Surg Concepts Pract 2013;18:142-6.  Back to cited text no. 17
    
18.
Zhou YM, Zhang XF, Li XD, Liu XB, Wu LP, Li B. Distal pancreatectomy with en bloc celiac axis resection for pancreatic body-tail cancer: Is it justified? Med Sci Monit 2014;20:1-5.  Back to cited text no. 18
    


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