Combined resection of the gastroduodenal artery without revascularization in distal pancreatectomy with en bloc celiac axis resection (extended DP-CAR) for pancreatic cancer: A case report

INTRODUCTION

Distal pancreatectomy with en bloc celiac axis resection (DP-CAR) is performed to remove locally advanced pancreatic cancer (LAPC) that involves the celiac axis (CA), the common hepatic artery (CHA), or the root of the splenic artery (SpA). It is not usually applied to LAPC involving both the CA and the gastroduodenal artery (GDA) because transection of the GDA cannot assure hepatic perfusion. Preserving the replaced hepatic artery might allow combined resection of the GDA without revascularization.

PRESENTATION OF CASE

A 78-year-old woman who was diagnosed with LAPC of the pancreatic head and body that invaded the GDA and proper hepatic artery, as well as the CA. The left hepatic artery (LHA) was solitarily branched from the left gastric artery (LGA), which was branched from proximal to the confluence of the CHA and the SpA. The root of the LGA was intact. We successfully performed DP-CAR with combined resection of the GDA, without revascularization, by preserving the LGA.

DISCUSSION

This is the first English literature case of extended DP-CAR with preservation of the replaced LHA (r-LHA). Aberrant right and left hepatic arteries are common variations. Checking the arterial variations is very important when deciding the treatment strategy for LAPC, especially in cases that appear unresectable.

CONCLUSION

Our case indicated that the r-LHA alone can supply the entire liver in extended DP-CAR. The resectability must be decided with close evaluations of the vessel variations and the tumor status.

[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.

Preoperative hepatic artery embolization before distal pancreatectomy plus celiac axis resection does not improve surgical results: A Spanish multicentre study

BACKGROUND

Distal pancreatectomy with celiac axis resection (DP-CAR) is a surgical procedure with high morbidity and mortality performed in patients with locally advanced pancreatic cancer. Preoperative embolization of hepatic artery (PHAE) has been postulated as a technical option to increase resection rate.

OBJECTIVE

comparison of morbidity and mortality at 90 days, operative time, hospital stay and survival between patients that performed DP-CAR with and without PHAE.

METHODS

Observational retrospective multicentre study.

INCLUSION CRITERIA

patient operated in Spanish centers with DP-CAR for pancreatic cancer from April 2004 until 23 June 2018. Preoperative (PHAE, neodjuvant treatment), intraoperative (operative time and blood loss) and postoperative data (morbidity, hospital stay, R0 and survival) were studied. Complications were measured with Clavien classification at 90 days. Specific pancreatic complications were measured using ISGPS classifications. Data were analyzed using R version 3.1.3 (http://www.r-project.org). Level of significance was set at 0.05.

RESULTS

41 patients were studied. 26 patients were not embolized (NO-PHAE group) and 15 patients received PHAE. Preoperative BMI and percentage of neoadjuvant chemotherapy were the only preoperative variables different between both groups. The operative time in the PHAE group was shorter (343 min) than in the non-PHAE group (411 min) (p < 0.06). Major morbidity (Clavien > IIIa) and mortality at 90 days were higher in the PHAE group than in the non-PHAE group (60% vs 23% and 26.6% vs 11.6% respectively) (p < 0.004). No statistical difference in overall survival was observed between both groups (p = 0.14).

CONCLUSION

In our study PHAE is not related with less postoperative morbidity. Even more, major morbidity (Clavien III-IV) and mortality was higher in PHAE group.

Distal pancreatectomy with celiac artery resection acquires satisfactory survival for locally advanced pancreatic neck-body cancer

BACKGROUND

s As a curative surgical procedure for pancreatic neck-body cancer with invasion to celiac artery (CA), the security and efficacy of distal pancreatectomy (DP) with en bloc resection of the celiac artery (DP-CAR) remain controversial. The purpose of this study was to identify the postoperative outcomes of DP-CAR.

METHODS

A retrospectively analysis between January 2010 and January2019 was performed in a single center. 21 patients who underwent DP-CAR and 71 patients who underwent traditional DP for pancreatic neck-body cancer were included. Postoperative morbidity, mortality, overall survival (OS) and disease-free survival (DFS) were evaluated.

RESULTS

There were no significant differences in major complications and mortality between two groups. The patients in DP-CAR group had more T4 tumor (61.9 vs 7.0%, P < 0.001). DP-CAR group had similar R0 resection compared with DP group (71.4% vs 87.3%, P = 0.090). The patients in DP-CAR group suffered more gastric ulcer, DGE and elevated levels of postoperative hepatic enzymes. OS (27.4 vs 32.6 months) and DFS (14.9 vs 19.5 months) between DP-CAR and DP groups were comparative (P = 0.305; P = 0.065).

CONCLUSIONS

For the patients who had pancreatic neck-body cancer with invasion to CA, DP-CAR is safety and could achieve satisfactory R0 resection, OS, and DFS.

Successful intragastric suture repair using endoscopy for refractory ischemic stomach perforation: A case report

INTRODUCTION

Ischemic stomach perforation and bleeding are major complications after distal pancreatectomy with en bloc celiac axis resection (DP-CAR) for locally advanced pancreatic cancer. Although there are some treatment options for ischemic gastric events, we need to discuss the optimal treatment based on the patient's general condition and history.

CASE PRESENTATION

A 76-year-old woman with advanced pancreatic cancer underwent DP-CAR with the reconstruction of the common hepatic artery-celiac artery. She presented with a high fever and melena at 13 days and twenty-nine days after the operation, respectively. Contrast-enhanced computed tomography (CECT) demonstrated ischemic stomach perforation, which was localized. Although nonsurgical treatments, including endoscopic clipping and proton-pump inhibitor administration, were attempted, her symptoms were not relieved. Therefore, we performed intragastric suture repair using oral endoscopy (ISE) for gastric perforation. Although she presented with surgical site infection and a catheter-related blood stream infection after ISE, she was discharged 140 days after the first operation.

CLINICAL DISCUSSION

Ischemic gastric events following DP-CAR can be treated with non-surgical and surgical approaches. In this case, non-surgical management could not improve the patient's gastric complications, and she had to undergo surgery. Given the patient's condition, ISE was an indication for this complication and was, thus, performed among surgical procedures, resulting in the alleviation of the complication. Using ISE may provide safe and less invasive surgery.

CONCLUSION

This is the first case of ISE for use in refractory ischemic stomach perforation following DP-CAR. ISE can be a useful and minimally invasive surgical procedure.

Spanish multicenter study of surgical resection of pancreatic tumors infiltrating the celiac axis: does the type of pancreatectomy affect results?

BACKGROUND

Pancreatectomy plus celiac axis resection (CAR) is performed in patients with locally advanced pancreatic cancer. The morbidity rates are high, and no survival benefit has been confirmed. It is not known at present whether it is the type of pancreatectomy, or CAR itself, that is the reason for the high complication rates.

METHODS

Observational retrospective multicenter study.

INCLUSION CRITERIA

patient undergoing TP, PD or DP plus CAR for a pancreatic cancer.

RESULTS

Sixty-two patients who had undergone pancreatic cancer surgery (PD,TP or DP) plus CAR were studied. Group 1: 17 patients who underwent PD/TP-CAR (13TP/4PD); group 2: 45 patients who underwent DP-CAR. Groups were mostly homogeneous. Operating time was longer in the PD/TP group, while operative complications did not differ statistically in the two groups. The number of lymph nodes removed was higher in the PD/TP group (26.5 vs 17.3), and this group also had a higher positive node ratio (17.9% vs 7.6%). There were no statistical differences in total or disease-free survival between the two groups.

CONCLUSION

It seems that CAR, and not the type of pancreatectomy, influences morbidity and mortality in this type of surgery. International multicenter studies with larger numbers of patients are now needed to validate the data presented here.

Successful conversion surgery of distal pancreatectomy with celiac axis resection (DP-CAR) with double arterial reconstruction using saphenous vein grafting for locally advanced pancreatic cancer: a case report

Background

Pancreatic cancer is a disease with a poor prognosis, requiring multidisciplinary treatment combining chemotherapy and surgery for effective management. Distal pancreatectomy with celiac axis resection (DP-CAR) is a surgical intervention performed for locally advanced pancreatic cancer, but the benefit of arterial reconstruction in DP-CAR is unclear.

Case presentation

A 49-year-old man with pancreatic cancer was referred to our hospital. Imaging revealed a 54-mm tumor mainly in the pancreatic body, but with arterial infiltration including into the celiac, common hepatic, left gastric, splenic and gastroduodenal arteries. Distant metastases were not detected. The patient was diagnosed with unresectable locally advanced pancreatic cancer and chemoradiotherapy was planned. Three cycles of gemcitabine (1000 mg/m²) plus nab-paclitaxel (125 mg/m²) every 4 weeks were followed by irradiation (2 Gy/day, total 50 Gy over 25 days) together with S-1 administration (80 mg/m²/day). A partial response (PR) according to Response Evaluation Criteria in Solid Tumors (RECIST) was achieved, so surgical intervention was considered. Because the tumor had invaded the root of the gastroduodenal artery, we performed DP-CAR with resection of the gastroduodenal artery, followed by arterial reconstruction of the proper hepatic and left gastric arteries, anastomosed with the abdominal aorta using a great saphenous vein graft in the shape of a “Y”. Histopathology showed that 60% of tumor cells were destroyed by the chemoradiotherapy, defined as grade IIb in the Evans classification. No malignancy was detected at the surgical margin, including the celiac artery, gastroduodenal artery or pancreatic stump; thus R0 surgery was successful. S-1 (80 mg/day) was administered as adjuvant chemotherapy for 6 months. The patient is now doing well without recurrence for > 2 years after the initial treatment (more than 16 months after surgery).

Conclusion

For locally advanced pancreatic cancer, multidisciplinary treatment combining gemcitabine/nab-paclitaxel-based chemoradiotherapy and then DP-CAR surgery with gastroduodenal artery resection and arterial reconstruction using saphenous vein grafting enabled R0 resection in this patient and led to a favorable long-term prognosis.

Distal pancreatectomy with celiac axis resection (DP-CAR): Optimal perioperative outcome in a patient with locally advanced pancreas adenocarcinoma

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DP-CAR: A rare, technically demanding operation with significant morbidity & mortality.

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DP-CAR may provide curative (R0) resection of an otherwise unresectable cancer.

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Our patient had optimal perioperative outcome and excellent histology result.

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To the best of our knowledge this is the first DP-CAR case in Greece.

Introduction

Distal pancreatectomy with en bloc celiac axis resection (DP-CAR) is an operation technically demanding, uncommonly performed, even in high-volume pancreatic centers, which may offer a curative resection in patients with locally advanced cancer of the body of the pancreas, otherwise considered unresectable.

Presentation of case

We present, in clinical and technical detail, a patient with DP-CAR with a very good intraoperative and postoperative course, no complications, short hospital stay, and histology consistent with a curative resection.

Discussion

Because of the scarcity of DP-CAR, even high-volume individual centers have been able to gather relatively limited experience, and only in a time frame of more than a decade each.

Conclusion

DP-CAR can be curative for a minority of patients with pancreatic adenocarcinoma and is performed only in centers with a long, dedicated interest in advanced pancreatic surgery with a well-known track record in resection of borderline and locally advanced pancreatic cancer involving major peripancreatic veins.

Extended right surgical margin in distal pancreatectomy with celiac axis resection for pancreatic body cancer under the presence of replaced right hepatic artery; A case report

BACKGROUND

While distal pancreatectomy with celiac axis resection (DP-CAR) contributes to R0 resection for pancreatic body cancer, arterial blood flow to the liver from gastroduodenal artery is essential. However, in the presence of replaced right hepatic artery (r-RHA), extended DP-CAR (Ex-DP-CAR) in which the right edge of pancreatic resection includes the confluence of gastroduodenal artery (GDA) and proper hepatic artery (PHA) may be feasible. Herein, we report a patient with r-RHA and perform Ex-DP-CAR without reconstruction of PHA.

CASE PRESENTATION

A 39-year-old man with pancreatic cancer, cT4N0M0 (UICC 8th), underwent DP-CAR after neoadjuvant chemotherapy (NAC). After laparotomy, unlike the evaluation in preoperative imaging, the tumor was found to invade the confluence of GDA and PHA. After confirmation of arterial blood flow to the liver, GDA and PHA was ligated and Ex-DP-CAR was completed with R0 margin status. The postoperative course was uneventful, with no recurrence 18 months after the surgery.

CONCLUSION

We performed Ex-DP-CAR with resection of the confluence of GDA and PHA in the presence of r-RHA, which has a potential role in expanding the surgical indications for R0 resection by reducing the risk of ischemic complications without reconstruction of arterial blood supply to the liver.

Distal pancreas-coeliac axis resection with preoperative selective embolization of the coeliac axis: a single high-volume centre experience

BACKGROUND

Patients with ductal adenocarcinoma in the body and/or tail of the pancreas with involvement of the common hepatic artery and/or celiac axis have until recently been considered unresectable. In selected cases, distal pancreatectomy (DP) with en bloc celiac axis resection (DP-CAR) may be an option to achieve R0 resection.

METHODS

Patients with tumours in the body and/or tail of the pancreas locally advanced with involvement of the common hepatic artery and/or celiac axis, with no distant metastases, were evaluated for DP-CAR procedures. Preoperative embolization was performed 10-14 days prior to surgery to enhance collateral arterial supply for the liver and stomach.

RESULTS

A total of 21 patients went through DP-CAR of whom 15 were preoperatively embolized. R0 resection vas achieved in 76% of the patients comparable to our standard distal pancreatectomies. The DP-CAR patients had a significant longer postoperative hospital stay, but no difference in major complications, including pancreatic fistulas compared with our standard distal pancreatectomies. No 30 nor 90 days postoperative mortality were recorded. Median survival in patients who underwent DP and DP-CAR procedures was 24.0 and 23.5 months, respectively (P > 0.5).

CONCLUSION

Outcomes after DP-CAR are comparable to standard distal pancreatectomies. DP-CAR after preoperative embolization is feasible and may in selected patients be a good option for treating patients with tumours in the body and/or tail of the pancreas with central arterial involvement.

Efficacy of Neoadjuvant Chemotherapy in Distal Pancreatectomy with En Bloc Celiac Axis Resection (DP-CAR) for Locally Advanced Pancreatic Cancer

BACKGROUNDS

Distal pancreatectomy with en bloc celiac axis resection (DP-CAR) is an extended surgical procedure for patients with locally advanced cancer of the pancreatic body and tail. Recently, the usability of neoadjuvant chemotherapy (NAC) in pancreatic cancer was reported. The purpose of this study was to clarify the impact of NAC on surgical outcomes and prognosis in DP-CAR patients.

METHODS

This study retrospectively reviewed 20 consecutive patients who underwent DP-CAR at a single institution.

RESULTS

Eleven of 20 patients (55.0%) received NAC. Their first regimens were gemcitabine (GEM) plus nab-PTX (n = 7, 63.6%), GEM plus S-1 (n = 3, 27.3%), and GEM (n = 1, 9.1%). Although two patients converted to a second regimen, none abandoned NAC due to adverse effects or could not undergo a planned procedure for disease progression. There were no significant differences in intraoperative variables, morbidity, including pancreatic fistula and delayed gastric emptying, and mortality between patients with and without NAC; however, patients with NAC had a significantly lower proportion of arterial invasion (p = 0.025), lymphatic invasion (p < 0.0001), and vascular invasion (p = 0.035). There were no significant differences in the induction rate of adjuvant chemotherapy (p = 0.201). The recurrence-free survival and overall survival rates in patients with NAC were significantly higher than in patients without NAC (p = 0.041 and p = 0.018, respectively).

CONCLUSION

DP-CAR following NAC was associated with a preferable prognosis and had no negative effect on surgical outcomes. Therefore, NAC in DP-CAR patients might be a beneficial and safe therapeutic strategy.

Ischemic gastropathy after distal pancreatectomy with en bloc celiac axis resection versus distal pancreatectomy for pancreatic body/tail cancer

Background

Ischemic gastropathy (IG) is a major complication after distal pancreatectomy with en bloc celiac axis resection (DP-CAR) for locally advanced body/tail pancreatic ductal adenocarcinoma (PDAC), and its incidence is still unknown.

Methods

To evaluate the occurrence of IG, 77 and 18 consecutive patients with body/tail PDAC were analyzed in a retrospective and a prospective study, respectively. We utilized perioperative gastroendoscopy, Gastrointestinal Quality of Life Index (GIQLI) score, and quantitative assessment for gastric arterial blood flow using the HyperEye Medical System (HEMS) with indocyanine green (ICG) fluorescence imaging in the prospective arm.

Results

In the retrospective arm, no significant difference was noted in the occurrence rate of IG between the DP-CAR (8.7%) and DP groups (5.5%). In the prospective arm, the postoperative endoscopic scores were significantly higher in the DP-CAR group (45%) than in the DP group (11%) (p < .0007) despite no difference in the GIQLI score. The ICG-HEMS imaging system demonstrated more delayed arterial flow velocity in the IG (+) group (p < .028), but showed no significant difference in arterial flow volume compared to the IG (−) group.

Conclusion

This is the first demonstration assessing IG incidence after DP-CAR using multiple methods. Despite the high IG rate, gastric arterial flow volume was almost equally maintained in DP-CAR patients with or without IG compared with the DP group. We should note the fact that many of the IG patients do not present with typical symptoms, and proper treatment is required for those “silent” IG patients.

Distal pancreatectomy with en-bloc celiac axis resection (DP-CAR) through retroperitoneal-first laparoscopic approach (Retlap): A novel strategy for achieving accurate evaluation of resectability and minimal invasiveness

BACKGROUND

Distal pancreatectomy with en-bloc celiac axis resection (DP-CAR) for borderline resectable pancreatic body cancer is increasingly being performed [1,2]. For survival benefits, obtaining margin-free resection (R0 resection) is crucial [3]. However, in patients with cancer abutting the root of the celiac axis and/or SMA, accurate resectability using preoperative imaging is difficult to judge [4]. Recently, we developed a novel strategy named "Retlap: Retroperitoneal-first laparoscopic approach" to achieve accurate evaluation of resectability and minimal invasiveness for difficult hepatopancreatobiliary malignancies and retroperitoneal tumors. Retlap enables direct evaluation of invasion of the roots of the celiac axis and SMA through the retroperitoneal approach.

METHODS

This video demonstrates the case of a 50-year-old man with a 47 × 36-mm pancreatic body tumor after chemoradiotherapy. Preoperative computed tomography revealed tumor abutting on the roots of the celiac axis and SMA. Changes in the surrounding tissues due to chemoradiotherapy prevented accurate determination of the tumor invasion extent via preoperative imaging; thus, Retlap was applied. Retlap enabled us to identify and secure the roots of the celiac axis and SMA easily despite the advanced tumor. After confirming resectability, DP-CAR was performed.

RESULTS

The operative time and estimated blood loss were 841 min and 572 mL. A negative surgical margin using Retlap was confirmed in frozen sections and R0 resection was achieved with uneventful postoperative course.

CONCLUSION

Retlap was technically feasible and useful for achieving accurate evaluation of resectability and minimal invasiveness for DP-CAR. Retlap can help provide optimal outcomes in locally advanced pancreatic cancer cases.

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.

Is distal pancreatectomy with en-bloc celiac axis resection effective for patients with locally advanced pancreatic ductal adenocarcinoma? -Multicenter surgical group study

OBJECTIVES

We retrospectively investigated the operative outcomes of patients who underwent distal pancreatectomy (DP) for invasive pancreatic ductal adenocarcinoma (PDAC) located at the body and tail.

METHODS

Data from 395 patients with PDAC who underwent DP with margin-negative resection (R0 or R1) were collected from seven high-volume centers in Japan from 2001 to 2012. Among them, 72 patients underwent DP with en-bloc celiac axis resection (DP-CAR). The remaining 323 patients underwent conventional DP with splenectomy (DP-S). To determine the efficacy of DP-CAR, clinicopathological data were compared between the DP-CAR and the DP-S groups.

RESULTS

The DP-S group consisted mainly of patients with resectable disease (93%), and conversely, all patients in the DP-CAR group had borderline resectable or unresectable disease. The overall morbidity was significantly higher in the DP-CAR group than in the DP-S group (63% vs 47%, respectively; P = 0.017). The median survival time (MST) of the DP-CAR group was significantly shorter than that of the DP-S group (17.5 vs 28.6 months, respectively; P = 0.004). However, the MST of patients in the DP-CAR group (n = 61, 85%) who received adjuvant therapy was significantly longer than that of patients in the DP-S group (n = 65, 20%) who underwent R1 resection (21.9 vs 16.7 months, respectively; P = 0.024).

CONCLUSION

DP-CAR followed by adjuvant chemotherapy provided an acceptable overall survival rate in patients with highly advanced PDAC, but should be performed with great caution because of high morbidity. Patients with a high risk of positive surgical margins with DP-S may be candidates for DP-CAR.

Locally advanced pancreatic cancer successfully treated by distal pancreatectomy with celiac axis resection (DP-CAR) after S-1 with radiation therapy followed by gemcitabine/nab-paclitaxel therapy: a case report

Background

The prognosis for pancreatic cancer remains dismal because many patients are diagnosed with unresectable cancer at the initial diagnosis. Recently, conversion surgery was reported as an effective treatment for initially unresectable pancreatic cancer with a favorable response to non-surgical treatment lasting over 240 days. Here, we describe a case of locally advanced pancreatic cancer (LAPC) successfully resected after treatment with S-1 and radiation followed by gemcitabine/nab-paclitaxel therapy.

Case presentation

A 73-year-old man with LAPC was referred to our hospital. Computed tomography findings revealed a 2.5-cm mass in the pancreatic body that had invaded the celiac artery, common hepatic artery, and splenic artery. Superior mesenteric artery (SMA) encasement was not observed, but tumor abutment over 180° with the main tumor was detected. Staging laparoscopy showed no findings of distant metastasis, and washing cytology revealed no malignancy. He was diagnosed with unresectable pancreatic cancer. Treatment with S-1 with radiation therapy followed by gemcitabine with nab-paclitaxel was performed. Six months after the initial treatment, the tumor size had decreased to 1.2 cm, and encasement of the main artery was diminished. Though abutment to the main artery, including the SMA, was still detected, distal pancreatectomy with celiac artery resection was performed. The histopathological findings around the celiac artery revealed fibrous changes with an Evans classification of grade IIb. There was no residual cancer at the periphery; thus, R0 resection was achieved. The patient has been healthy and without recurrence for more than 12 months since the initial treatment.

Conclusions

Gemcitabine/nab-paclitaxel therapy revealed high response rate for metastasic pancreatic cancer (PC), but the effect for LAPC proposing conversion surgery was not well discussed. In this case, we achieve R0 resection combined with chemoradiation therapy and gemcitabine/nab-paclitaxel therapy. This regimen was also effective for LAPC and may be used to increase the population of conversion surgery by its high response rate.

Concomitant major vessel resection in pancreatic adenocarcinoma

Increasing evidence has contraindicated extended radical dissection of pancreatic adenocarcinoma (PC). With the recent improvement of perioperative management techniques and multimodal treatment strategy for PC, concomitant major vessel resection and reconstruction has thus been aggressively attempted in association with comparatively better pathologically negative surgical margins and postoperative survival. We have discussed the clinical relevance of concomitant major vessel resection mainly focusing on indications for such resection with borderline resectable tumor associated with chemoradiotherapy, distal pancreatectomy with en bloc celiac axis resection for pancreatic body and tail cancer, and adjuvant surgery for initially unresectable pancreatic cancer.