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

Distal Pancreatectomy With En Bloc Celiac Axis Resection (DP-CAR) for Locally Advanced Pancreatic Cancer: A Safe and Effective Procedure

OBJECTIVE

To determine perioperative and oncologic outcomes after distal pancreatectomy with en bloc resection of the celiac axis (DP-CAR).

BACKGROUND

DP-CAR can be used in a selective group of patients to resect locally advanced pancreatic cancer involving the celiac axis or common hepatic artery without arterial reconstruction by preserving retrograde blood flow via the gastroduodenal artery to the liver and stomach.

METHODS

We analyzed all consecutive patients who had undergone DP-CAR between May 2003 and April 2022 at a tertiary hospital specialized in pancreatic surgery and present one of the largest single-center studies.

RESULTS

A total of 71 patients underwent DP-CAR. Additional venous resection (VR) of the mesenterico-portal axis was performed in 31 patients (44%) and multivisceral resection (MVR) in 42 patients (59%). Margin-free (R0) resection was achieved in 40 patients (56%). The overall 90-day mortality rate was 8.4% for the entire patient cohort. After a cumulated experience of 16 cases, the 90-day mortality dropped to 3.6% in the following 55 patients. Extended procedures with (+) additional MVR with or without (+/-) VR resulted in higher major morbidity (Clavien-Dindo ≥IIIB; standard DP-CAR: 19%; DP-CAR + MVR +/- VR: 36%) and higher 90-day mortality (standard DP-CAR: 0%; DP-CAR + MVR +/- VR: 11%). Median overall survival after DP-CAR was 28 months.

CONCLUSIONS

DP-CAR is a safe and effective procedure but requires experience. Frequently, surgical resection has to be extended with MVR and VR to accomplish tumor resection, which results in promising oncologic outcomes. However, extended resections were associated with increased morbidity and mortality.

Clinical significance of variant hepatic artery in pancreatic resection: A comprehensive review

The anatomical structure of the pancreaticoduodenal region is complex and closely related to the surrounding vessels. A variant of the hepatic artery, which is not a rare finding during pancreatic surgery, is prone to intraoperative injury. Inadvertent injury to the hepatic artery may affect liver perfusion, resulting in necrosis, liver abscess, and even liver failure. The preoperative identification of hepatic artery variations, detailed planning of the surgical approach, careful intraoperative dissection, and proper management of the damaged artery are important for preventing hepatic hypoperfusion. Nevertheless, despite the potential risks, planned artery resection has become acceptable in carefully selected patients. Arterial reconstruction is sometimes essential to prevent postoperative ischemic complications and can be performed using various methods. The complexity of procedures such as pancreatectomy with en bloc celiac axis resection may be mitigated by the presence of an aberrant right hepatic artery or a common hepatic artery originating from the superior mesenteric artery. Here, we comprehensively reviewed the anatomical basis of hepatic artery variation, its incidence, and its effect on the surgical and oncological outcomes after pancreatic resection. In addition, we provide recommendations for the prevention and management of hepatic artery injury and liver hypoperfusion. Overall, the hepatic artery variant may not worsen surgical and oncological outcomes if it is accurately identified pre-operatively and appropriately managed intraoperatively.

Hemodynamic, Surgical and Oncological Outcomes of 40 Distal Pancreatectomies with Celiac and Left Gastric Arteries Resection (DP CAR) without Arterial Reconstructions and Preoperative Embolization

DPCAR’s short- and long-term outcomes are highly diverse, while the causes and prevention of ischemic complications are unclear. To assess oncological, surgical, and hemodynamic outcomes of 40 consecutive DPCARs for pancreatic (n37) and gastric tumors (n3) (2009−2021), retrospective analyses of mortality, morbidity, survival, and hemodynamic consequences after DPCAR were undertaken using case history data, IOUS, and pre- and postoperative CT measurements. In postoperative complications (42.5%), the pancreatic fistula was the most frequent event (27%), 90-day mortality was 7.5. With 27 months median follow-up, median overall (OS) and progression-free survival (PFS) for PDAC were 29 and 18 months, respectively; with 1-, 3-, and 5-years, the OS were 90, 60, and 28%, with an R0-resection rate of 92.5%. Liver and gastric ischemia developed in 0 and 5 (12.5%) cases. Comparison of clinical and vascular geometry data revealed fast adaptation of collateral circulation, insignificant changes in proper hepatic artery diameter, and high risk of ischemic gastropathy if the preoperative diameter of pancreaticoduodenal artery was <2 mm. DP CAR can be performed with acceptable morbidity and survival. OS and RFS in this super-selective cohort were compared to those for resectable cancer. The changes in the postoperative arterial geometry could explain the causes of ischemic complications and determine directions for their prevention.

[Distal pancreatectomy with resection of the celiac trunk, right or left hepatic artery without arterial reconstruction (extended DP-CAR)]

OBJECTIVE

To evaluate safety and postoperative outcomes of DP-CAR with resection of one of the lobar hepatic arteries without arterial reconstruction (extended DP-CAR).

MATERIAL AND METHODS

Perioperative data and survival after 7 extended DP-CARs R0 were retrospectively analyzed. Arterial blood flow in the liver was assessed using intraoperative ultrasound and postoperative CT angiography.

RESULTS

Among 40 DP-CARs, resection of left or right hepatic artery was performed in 7 cases of aberrant anatomy including 1 case of portal vein resection. Mortality and ischemic complications were not observed. The main source of blood supply to the «devascularized» liver lobe was interlobar communicating artery or the arcade of the lesser curvature of the stomach. Incidence of pancreatic fistula was 44%, mean blood loss - 230 (100-650) ml, surgery time - 259 (195-310) min, mean hospital-stay - 14 (9-26) days. Median survival of patients with pancreatic ductal adenocarcinoma was 25 months after combined treatment. Three patients died after 26, 28 and 77 months. Other patients are alive without progression for 109, 24, 23 and 12 months after therapy onset.

CONCLUSION

Extended DP-CAR is advisable and safe procedure if reliable intraoperative control of liver and stomach blood supply is ensured.

Borderline resectable pancreatic cancer and vascular resections in the era of neoadjuvant therapy

While pancreatic cancer is still characterized by early systemic spread and poor outcomes, the treatment of this disease has changed significantly in recent years due to major advancements in systemic therapy and advanced surgical techniques. Broader use of effective neoadjuvant approaches combined with aggressive surgical operations within a multidisciplinary setting has improved outcomes. Borderline resectable pancreatic cancer is characterized by tumor vascular invasion, and is a setting where the combination of potent neoadjuvant chemotherapy and aggressive surgical methods, including vascular resections and reconstructions, shows its full potential. Hopefully, this will lead to improved local control and curative treatment in a number of patients with this aggressive malignancy.

Distal Pancreatectomy with Celiac Axis Resection (Modified Appleby Procedure) and Arterial Reconstruction for Locally Advanced Pancreatic Adenocarcinoma After FOLFIRINOX Chemotherapy and Chemoradiation Therapy

BACKGROUND

Resectability of pancreatic carcinoma (PC) is directly linked to vascular extension (Tempero MA et al. in J Natl Compr Canc Netw 15(8):1028-1061, 2017. https://doi.org/10.6004/jnccn.2017.0131 ; Isaji S et al. in Pancreatology 18(1):2-11, 2018. https://doi.org/10.1016/j.pan.2017.11.011 ). Involvement of the celiac axis (CA) is typically a contraindication to surgery. High postoperative morbidity and subsequent poor prognosis have been observed in this case, especially for contact > 180° requiring arterial resection (Tempero MA et al. 2017). Recent medical advances in PC treatment, such as FOLFIRINOX-based chemotherapy eventually followed by chemoradiation therapy, offer the potential to select tumour for surgery and to obtain a negative-margin resection even in case of unresectable PC at diagnosis (Suker M et al. in Lancet Oncol 17(6):801-10, 2016. https://doi.org/10.1016/s1470-2045(16)00172-8 ; Pietrasz D et al. in Ann Surg Oncol 26(1):109-117, 2019. https://doi.org/10.1245/s10434-018-6931-6 ). A major pathologic response has been observed in more than 20% of patients after this treatment and is associated with an improved survival (Suker M et al. 2016; Pietrasz D et al. 2019). This evolution allows aggressive surgical strategies with the possibility of long-term disease control for patients showing a good response to induction treatment.

PATIENT

This video presents the case of a 66-year-old man diagnosed with a locally advanced ductal adenocarcinoma of the pancreatic body with a 360° involvement of the CA and the hepatic artery. After eight courses of FOLFIRINOX chemotherapy and a capecitabin-based chemoradiation, a surgical exploration was planned for potential resection.

TECHNIQUE

The key steps of the procedure are presented, i.e. surgical exposition, assessment of resectability with frozen sections of peri-arterial tissues, en bloc resection (Strasberg SM et al. in Surgery 133(5):521-527, 2003. https://doi.org/10.1067/msy.2003.146 ), and primary end-to-end arterial reconstruction.

CONCLUSION

A modified Appleby operation for locally advanced PC is a technically challenging but feasible procedure in experienced teams. It offers the possibility of en bloc R0 resection of a locally advanced PC with the potential of long-term disease local control. This video may help surgeons to perform this complex intervention.

Celiac axis stenosis and digestive disease: Diagnosis, consequences and management

Arterial blood flow to the organs of the upper abdomen is provided by the celiac axis (CA) and the superior mesenteric artery (SMA) that communicate between each other via the gastro-duodenal artery, the anterior and posterior pancreatico-duodenal arcades, the branches of the dorsal pancreatic artery and inconsistently, though a supplementary arcade that connects the CA and the SMA (arcade of Bühler). Celiac axis stenosis may or may not have a hemodynamic impact on the splanchnic circulation. Hemodynamically significant CA stenosis can be asymptomatic, or symptomatic with variables clinical consequences. Management depends on whether the mechanism of stenosis is extrinsic or intrinsic. When upper gastrointestinal interventional radiology or surgery is indicated, stenosis can pose technical difficulties or create severe ischemia requiring good understanding of this entity in the planning of operative steps and adapted management. Management of CA stenosis is therefore multidisciplinary and may involve interventional radiologists, gastrointestinal surgeons, vascular surgeons as well as medical physicians. Even though the prevalence of CA stenosis is relatively low (between 5 and 10%) and irrespective of its etiology, surgeons, radiologists and physicians must be aware of it because it can intervene in the management of upper gastrointestinal disease. It must be sought, and treatment must be adapted to each particular situation to avoid potentially severe complications.

Systematic review and meta-analysis of contemporary pancreas surgery with arterial resection

Objective

Advances in multimodality treatment paralleled increasing numbers of complex pancreatic procedures with major vascular resections. The aim of this meta-analysis was to evaluate the current outcomes of arterial resection (AR) in pancreatic surgery.

Methods

A systematic literature search was carried out from January 2011 until January 2020. MOOSE guidelines were followed. Predefined outcomes were morbidity, pancreatic fistula, postoperative bleeding and delayed gastric emptying, reoperation rate, mortality, hospital stay, R0 resection rate, and lymph node positivity. Duration of surgery, blood loss, and survival were also analyzed.

Results

Eight hundred and forty-one AR patients were identified in a cohort of 7111 patients. Morbidity and mortality rates in these patients were 66.8% and 5.3%, respectively. Seven studies (579 AR patients) were included in the meta-analysis. Overall morbidity (48% vs 39%, p = 0.1) and mortality (3.2% vs 1.5%, p = 0.27) were not significantly different in the groups with or without AR. R0 was less frequent in the AR group, both in patients without (69% vs 89%, p < 0.001) and with neoadjuvant treatment (50% vs 86%, p < 0.001). Weighted median survival was shorter in the AR group (18.6 vs 32 months, range 14.8–43.1 months, p = 0.037).

Conclusions

Arterial resections increase the complexity of pancreatic surgery, as demonstrated by relevant morbidity and mortality rates. Careful patient selection and multidisciplinary planning remain important.

Electronic supplementary material

The online version of this article (10.1007/s00423-020-01972-2) contains supplementary material, which is available to authorized users.

Distal pancreatectomy with en bloc celiac axis resection for pancreatic cancer: a pooled analysis of 109 cases

The aim of this study was to define the clinical outcome and prognostic determinants of distal pancreatectomy with en bloc celiac axis resection (DP-CAR) for pancreatic body/tail cancer. A pooled data analysis was performed on individual data for patients who underwent DP-CAR for pancreatic body/tail cancer as identified by systematic literature search. A total of 32 articles involving 109 patients were eligible for inclusion. Postoperative morbidity and mortality were 53% and 4%, respectively. Preoperative abdominal and/or back pain was completely relieved immediately after surgery in 98% of patients. The 1, 3 and 5 years overall survival (OS) rates were 59%, 21% and 10%, and the median OS was 14 months. Patients who received neoadjuvant treatment had a median OS of 23 months. In conclusion, DP-CAR for locally advanced pancreatic body/tail cancer can be performed safely with low mortality and provides survival benefit when combined with neoadjuvant treatment.

Vascular Resection for Pancreatic Cancer: 2019 French Recommendations Based on a Literature Review From 2008 to 6-2019

Introduction: Vascular resection remains a subject of debate in the management of Pancreatic Ductal Adenocarcinoma (PDAC). These French recommendations were drafted on behalf of the French National Institute of Cancer (INCA-2019).

Material and Methods: A systematic literature search, with PubMed, Medline® (OvidSP), EMBASE, the Cochrane Library, was performed for abstracts published in English from January 2008 to June 2019, and identified systematic reviews/metaanalyses, retrospective analyses and case series dedicated to vascular resections in the setting of PDAC. All selected articles were graded for level of evidence and strength of recommendation was given according to the GRADE system.

Results: Neoadjuvant treatment should be performed rather than direct surgery in borderline and locally advanced non-metastatic PDAC with venous and/or arterial infiltration (T4 stage). Patients who respond or those with stable disease and good performance status should undergo surgical exploration to assess resectability because cross-sectional imaging often fails to identify the extent of the remaining viable tumor. Combining vascular resection with pancreatectomy in these cases increases the feasibility of curative resection which is still the only option to improve long-term survival. Venous resection (VR) is recommended if resection is possible in the presence of limited lateral or circumferential involvement but without venous occlusion and in the absence of arterial contact with the celiac axis (CA; cephalic tumors) or the superior mesenteric artery (SMA; all tumor locations) (Grade B). The patients should be in good general condition because mortality and morbidity are higher than following pancreatectomy without VR (Grade B). In case of planned VR, neoadjuvant treatment is recommended since it improves both rate of R0 resections and survival compared to upfront surgery (Grade B). Due to their complexity and specificities, arterial resection (AR; mainly the hepatic artery (HA) or the CA) must be discussed in selected patients, in multidisciplinary team meetings in tertiary referral centers, according to the tumor location and the type of arterial extension. In case of invasion of a short segment of the common HA, resection with arterial reconstruction may be proposed after neoadjuvant therapy. In case of SMA invasion, neoadjuvant therapy may be followed by laparotomy with dissection and biopsy of peri-arterial tissues. A pancreaticoduodenectomy (PD) with SMA-resection is not recommended if the frozen section examination is positive (Grade C). In case of distal PDAC with invasion of the CA, a distal pancreatectomy with CA-resection without arterial reconstruction may be proposed after neoadjuvant therapy and radiologic embolization of the CA branches (expert opinion).

Conclusion: For PDAC with vascular involvement, neoadjuvant treatment followed by pancreatectomy with venous resection or even arterial resection can be proposed as a curative option in selected patients with selected vascular involvement.

Vascular Resections for Pancreatic Ductal Adenocarcinoma: Vascular Resections for PDAC

BACKGROUND AND AIMS

It has become clear that vein resection and reconstruction for pancreatic ductal adenocarcinoma (PDAC) is the standard of care as supported by multiple guidelines. However, resection of large peri-pancreatic arteries remains debatable.

MATERIALS AND METHODS

This review examines the current state of vascular resection with curative intent for PDAC in the last 5 years. Herein, we consider venous (superior mesenteric vein, portal vein), as well as arterial (superior mesenteric artery, celiac trunk, hepatic artery) resection or both with or without reconstruction.

RESULTS

Improvement of multidrug chemotherapy has revolutionized care for PDAC that should shift traditional surgical thinking from an anatomical classification of resectability to a prognostic and biological classification.

CONCLUSION

The present review gives an overview on the results of pancreatectomy associated with vascular resection, with consideration of new perspectives offered by the availability of better systemic therapies.

[Pure laparoscopic DP-CAR procedure with portal vein resection]

OBJECTIVE

To improve short- and long-term outcomes of locally advanced pancreatic body-tail cancer followed by major vessels invasion.

MATERIAL AND METHODS

A case report of pure laparoscopic DP-CAR procedure with portal vein resection for locally advanced pancreatic body-tail cancer followed by severe abdominal pain in a 49-year-old patient is presented.

RESULTS

Liver or stomach ischemia was not observed. Portal wall resection wasn't associated with any complication and resulted R0-resection. Postoperative period was complicated by Grade B pancreatic fistula. Preoperative abdominal pain completely disappeared after surgery. Surgery time was 330 min, intraoperative blood loss - 300 ml. The patient is currently undergoing FOLFIRINOX adjuvant chemotherapy. CT in 90 days after surgery confirmed no progression of disease or liver/stomach blood supply congestion.

CONCLUSION

Modern technologies provide the opportunity to perform pure laparoscopic advanced surgical procedures with major vessels resection. Pure laparoscopic DP-CAR procedure with portal vein resection is effective and safe procedure that can be performed with all principles of open surgery and is associated with acceptable short- and long-term results.

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.

Radical pancreatic cancer surgery-with arterial resection

Extended surgery with arterial resection in pancreatic cancer remains a controversial topic. Although not recommended as a standard procedure, arterial resection may be feasible in selected patients and with the availability of new multimodal treatment approaches it may gain increasing impact in pancreatic cancer therapy as a complete tumor removal is still the only opportunity to achieve long-term survival for this disease. With regard to the surgical approach, one must differentiate between resection and reconstruction of the celiac axis and the hepatic artery as its most important branch, and resection/reconstruction of the superior mesenteric artery. Both procedures are technically possible and require a distinct level of surgical experience as well as interdisciplinary management for preoperative diagnosis and treatment of postoperative complications to achieve good outcomes. Besides arterial resection followed by reconstruction, there are specific situations when arteries may be resected without reconstruction, e.g., during distal pancreatectomy with celiac axis resection. In addition, in some cases arterial resections can be avoided despite a suspected tumor attachment by sharp dissection on the adventitial layer of the respective artery, especially after neoadjuvant therapy which is increasingly performed for borderline resectable and locally advanced tumor findings. This review summarizes definitions, diagnostics, technical aspects and outcomes of arterial resection in pancreatic cancer surgery in the context of the current literature and evidence.

Distal Pancreatectomy with Celiac Axis Resection (DP-CAR) for Pancreatic Cancer. How I do It

Approximately 30% of all pancreatic cancer patients have locally advanced (AJCC stage 3) disease. A sub-group of these patients-where the cancer only involves the celiac axis-may benefit from distal pancreatectomy with celiac axis resection (DP-CAR). Previous studies have shown that DP-CAR offers a survival benefit to a selected group of patients with otherwise unresectable pancreatic cancer, when performed by experienced pancreatic cancer treatment teams at high-volume centers. This article proposes a standardized approach to DP-CAR, including routine neoadjuvant (FOLFIRINOX) chemotherapy. This approach to selecting patients and performing DP-CAR has the potential to improve short-term outcomes and overall survival in selected patients, but it should be reserved for high-volume centers.

Outcomes After Distal Pancreatectomy with Celiac Axis Resection for Pancreatic Cancer: A Pan-European Retrospective Cohort Study

BACKGROUND

Western multicenter studies on distal pancreatectomy with celiac axis resection (DP-CAR), also known as the Appleby procedure, for locally advanced pancreatic cancer are lacking. We aimed to study overall survival, morbidity, mortality and the impact of preoperative hepatic artery embolization (PHAE).

METHODS

Retrospective cohort study within the European-African Hepato-Pancreato-Biliary-Association, on DP-CAR between 1-1-2000 and 6-1-2016. Primary endpoint was overall survival. Secondary endpoints were radicality (R0-resection), 90-day mortality, major morbidity, and pancreatic fistulae (grade B/C).

RESULTS

We included 68 patients from 20 hospitals in 12 countries. Postoperatively, 53% of patients had R0-resection, 25% major morbidity, 21% an ISGPS grade B/C pancreatic fistula, and 16% mortality. In total, 82% received (neo-)adjuvant chemotherapy and median overall survival in 62 patients with pancreatic ductal adenocarcinoma patients was 18 months (CI 10-37). We observed no impact of PHAE on ischemic complications.

CONCLUSIONS

DP-CAR combined with chemotherapy for locally advanced pancreatic cancer is associated with acceptable overall survival. The 90-day mortality is too high and should be reduced. Future studies should investigate to what extent increasing surgical volume or better patient selection can improve outcomes.

Radiologic evaluation of patients undergoing the modified Appleby procedure for locally advanced pancreatic neoplasms: a case series

PURPOSE

Despite advances in medical and surgical care, pancreatic ductal adenocarcinoma remains one of the most locally aggressive neoplastic processes in the abdomen. Unfortunately, most pancreatic adenocarcinomas present late and are unresectable at time of diagnosis. The modified Appleby procedure is a surgical option in patients with locally advanced pancreatic neoplasms of the body and tail with vascular invasion of the celiac trunk. To our knowledge, no radiologic journal has previously reported on the pre-operative evaluation or postoperative imaging findings of such patients.

METHODS

We report herein three patients who underwent the modified Appleby procedure, each with a unique complication, in an attempt to illustrate common pitfalls of interpretation in these advanced cases.

RESULTS

Our case series emphasizes the importance of pre-operative radiologic assessment of variant arterial anatomy, knowledge of pre- and intraoperative procedures and appearances, and familiarity with potential postoperative complications.

CONCLUSIONS

Thorough understanding of the important aspects of the pre-surgical anatomy, as well as possible post-surgical complications, is the key to the radiologist being a useful participant in the clinical care of these patients.

Surgical Indications of Distal Pancreatectomy with Celiac Axis Resection for Pancreatic Body/Tail Cancer

BACKGROUND

The survival impact of distal pancreatectomy (DP) with celiac axis resection for locally advanced pancreatic body/tail cancer remains unclear.

METHODS

A total of 16 patients underwent DP with celiac axis resection, while 76 underwent standard DP for pancreatic body/tail cancer. The indications for DP with celiac axis resection included: (a) tumor invasion of either the celiac axis or common hepatic artery or both [CA/CHA (+)] and (b) tumor invasion of the root of the splenic artery, which is difficult to dissect without securing an adequate surgical margin [CA/CHA (-)].

RESULTS

DP with celiac axis resection presented longer operative time and greater amount of blood loss than DP. The median survival time was 17.5 months in the DP with celiac axis resection group and 43.1 months in the DP group (p = 0.040). Among the patients who underwent DP with celiac axis resection, the median survival time was 35.1 months in the CA/CHA (-) group and 13.2 months in the CA/CHA (+) group (p = 0.001). Comparing the patients undergoing standard DP and DP with celiac axis resection with a CA/CHA (-) status, there were no significant differences in either disease-free or overall survival times. The CA19-9 value, CA/CHA (+) status, and microscopic venous infiltration were revealed independent significant prognostic factors.

CONCLUSIONS

DP with celiac axis resection should therefore be indicated in patients with a CA/CHA (-) status. However, it is difficult to justify the use of DP with celiac axis resection in patients with CA/CHA (+) status due to the poor survival.

Systematic review of outcomes after distal pancreatectomy with coeliac axis resection for locally advanced pancreatic cancer

BACKGROUND

Pancreatic cancer involving the coeliac axis is considered unresectable by most guidelines, with a median survival of 6-11 months. A subgroup of these patients can undergo distal pancreatectomy with coeliac axis resection, but consensus on the value of this procedure is lacking. The evidence for this procedure, including the impact of preoperative hepatic artery embolization and (neo)adjuvant therapy, was evaluated.

METHODS

A systematic review was performed according to the PRISMA guidelines until 27 May 2015. The primary endpoint was overall survival; secondary endpoints included morbidity and radical resection rates.

RESULTS

A total of 19 retrospective studies, involving 240 patients, were included. The methodological quality of the studies ranged from poor to moderate. A radical resection was reported in 74·5 per cent (152 of 204), major morbidity in 27 per cent (26 of 96), ischaemic morbidity in 9·0 per cent (21 of 223) and 90-day mortality in 3·5 per cent (4 of 113). Overall, 35·5 per cent of patients (55 of 155) underwent preoperative hepatic artery embolization without an apparent beneficial impact on ischaemic morbidity. Overall, 15·7 per cent (29 of 185) had neoadjuvant and 51·0 per cent (75 of 147) had adjuvant therapy. There was a difference in survival between patient series where less than half of patients had (neo)adjuvant chemotherapy and series where more than half were receiving this treatment: case-weighted median overall survival was 16 (range 9-48) versus 18 (10-26) months respectively (P = 0·002). Overall median survival for the whole study population was 14·4 (range 9-48) months.

CONCLUSION

Distal pancreatectomy with coeliac axis resection seems a valuable option for selected patients with pancreatic cancer involving the coeliac axis with acceptable morbidity and mortality, and a median survival of 18 months when combined with (neo)adjuvant therapy.