Distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic body cancer: long-term results

Abstract

Objective: To analyze the long-term results of distal pancreatectomy with en bloc celiac axis resection (DP-CAR), a newly designed extended surgical procedure for locally advanced cancer of the pancreatic body.

Summary background data: Pancreatic body cancer often involves the common hepatic artery and/or the celiac axis and is regarded as an unresectable disease. We previously reported the feasibility and safety of DP-CAR in 10 patients and 3 preliminary cases; however, the long-term results are unknown.

Methods: Between May 1998 and September 2005, 23 patients underwent DP-CAR. No reconstruction of the arterial system was required because of early development of the collateral arterial pathways via the pancreatoduodenal arcades from the superior mesenteric artery. We routinely used preoperative coil embolization of the common hepatic artery to enlarge the collateral pathways.

Results: The postoperative mortality rate was 0%, despite a high morbidity rate (48%). The chief postoperative complications were pancreatic fistula and ischemic gastropathy. Contrary to expectations, postoperative diarrhea was mild. Preoperative intractable abdominal and/or back pain in 10 patients was completely alleviated immediately after surgery. The surgical margins were histologically negative in 21 patients (91%). The estimated overall 1- and 5-year survival rates were 71% and 42%, respectively, and the median survival was 21.0 months. The sites of recurrence were the liver in 6 patients and local recurrence in 2.

Conclusions: DP-CAR offers a high R0 resectability rate and may potentially achieve complete local control in selected patients. The persisting early hepatic recurrence may indicate DP-CAR for the treatment of less advanced disease.

FIGURE 1. Late arterial phase contrast-enhanced CT showing a representative case. The common hepatic (H), splenic (S), and celiac (C) arteries are involved with a solid tumor (T) in the pancreatic body. However, the gastroduodenal artery (GDA) and superior mesenteric artery (SMA) can be preserved. An asterisk indicates the involved portal vein.

FIGURE 2. Schematic cross-sectional view showing the extent of a distal pancreatectomy with en bloc celiac axis resection. A dotted line indicates the dissection plane. adr, adrenal gland; Ao, aorta; CA, celiac axis; CHA, common hepatic artery; crus, crus of the diaphragm; Du, duodenum; g, celiac ganglion; IVC, inferior vena cava; pl, celiac plexus; PV, portal vein; SA, splenic artery; SV, splenic vein.

FIGURE 3. Operative photograph after completion of DP-CAR. Ao, aorta; CA, celiac axis; CHA, common hepatic artery; crus, crus of the diaphragm; GDA, gastroduodenal artery; graft, interposed iliac vein graft; IVC, inferior vena cava; RV, renal vein; SMA, superior mesenteric artery; SMV, superior mesenteric vein.

FIGURE 4. Schematic drawing of the collateral arterial pathways via the pancreatoduodenal arcades from the superior mesenteric artery following DP-CAR. APD, anterior pancreatoduodenal arcade; CA, celiac axis; CHA, common hepatic artery; GDA, gastroduodenal artery; GEA, right gastroepiploic artery; LGA, left gastric artery; PHA, proper hepatic artery; PPD, posterior pancreatoduodenal arcade; SA, splenic artery; SMA, superior mesenteric artery.

FIGURE 5. The serum concentrations of alanine aminotransferase (ALT) and amylase on postoperative day 1. Normal ranges: ALT, 4–45 IU/L; amylase, 40–160 IU/L.

FIGURE 6. Estimated postoperative survival for patients who underwent DP-CAR.