F. M. Ponzini2, D. Moskal2, L. Kowal2, G. Sun2, B. Im2, S. Cannaday1, A. Nevler1, A. P. Shah3, W. R. Maley3, H. Lavu1, W. B. Bowne1, C. J. Yeo1 1Thomas Jefferson University, Department Of Surgery, Jefferson Pancreas, Biliary And Related Cancer Center, Philadelphia, PA, USA 2Thomas Jefferson University, Sidney Kimmel Medical College, PHILADELPHIA, PA, USA 3Thomas Jefferson University, Division Of Transplantation, Department Of Surgery, Philadelphia, PA, USA
Introduction: Locally advanced pancreas cancer (LAPC) involving the celiac axis, historically considered unresectable, portends a poor prognosis. Distal pancreatectomy (DP) and splenectomy with en bloc celiac axis resection (CAR), or modified Appleby procedure, is rarely performed but is feasible in appropriately selected patients. Herein, we report our institutional experience from 2014-2020 to assess perioperative and oncologic outcomes.
Methods: The authors conducted a retrospective review of 16 consecutive patients, identified by our Institutional Review Board-approved database, who underwent en bloc DP-CAR for biopsy-confirmed LAPC. Demographics, perioperative factors, tumor / treatment related variables, and survival were recorded and analyzed. Survival analysis was performed by Kaplan-Meier actuarial method.
Results: Our study group consists of 9 male and 7 female evaluable patients with a median age of 66 years (range, 56-75 years). Median postoperative follow-up was 19.2 months. Prior to en-bloc DP-CAR for LAPC, 15 patients (94%) received modern long course combinatorial neo-adjuvant therapy, which consisted frequently of FOLFIRINOX (63%) and radiotherapy (50%). Determinants for neoadjuvant therapy response included established radiographic RECIST response and serum pre- and post-treatment confirmed CA19-9 levels (Pretreatment: median 283 U/mL; range 1-10,334 U/mL / Post-treatment: median 64 U/mL; range- 1-306 U/mL; P < 0.001). R0 resection was achieved in 14 patients (87.5%). In fourteen patients, adequate arterial collaterals necessitated only resection and ligation of the distal common hepatic artery (CHA). Two patients required aorto-CHA and distal CHA to left gastric artery bypasses, respectively, to ensure adequate hepatic perfusion. The median operative time and EBL were 390 min (range, 368- 456 min) and 425 mL (range, 263- 900 ml), respectively. Postoperatively, the median length of stay was 5 days (range, 4-9 days) per our accelerated pancreatectomy recovery pathway. Overall, nine patients (56%) developed complications during the 30-day postoperative period which included no occurrences of liver ischemia and no surgery associated mortalities. The median survival after resection was 34.9 months. (Figure 1). The 1- and 3-year survival rates were 75% and 19%, respectively. Remarkably, amongst this study group, survivorship included 5 and 7-year patient survivors.
Conclusion: Our modern institutional experience demonstrates that en bloc DP-CAR, although rarely performed, can be a safe and potentially effective treatment option for appropriately selected patients with LAPC.
