Background The superior mesenteric artery-first approach has been proved superior in pancreatoduodenectomy compared with the standard procedure. It is unclear whether similar benefits could be obtained in distal pancreatectomy with celiac axis resection. Methods Perioperative and survival outcomes of patients who underwent distal pancreatectomy with celiac axis resection with the modified artery-first approach or traditional approach between January 2012 and September 2021 were compared. Results The entire cohort comprised 106 patients (modified artery-first approach, n = 35; traditional approach, n = 71). The most common complication was postoperative pancreatic fistula (n = 18, 17.0 per cent), followed by ischaemic complications (n = 17, 16.0 per cent) and surgical site infection (n = 15, 14.0 per cent). Intraoperative blood loss (400 versus 600 ml, P = 0.017) and intraoperative transfusion rate (8.6 versus 29.6 per cent, P = 0.015) were lower in the modified artery-first approach group compared with the traditional approach group. A higher number of harvested lymph nodes (18 versus 13, P = 0.030) and R0 resection rate (88.6 versus 70.4 per cent, P = 0.038) and a lower incidence of ischaemic complications (5.7 versus 21.1 per cent, P = 0.042) was observed in the modified artery-first approach group compared with the traditional approach group. In multivariable analysis, the modified artery-first approach (OR 0.006, 95 per cent c.i., 0 to 0.447; P = 0.020) was protective against ischaemic complications. Conclusions Compared with the traditional approach, the modified artery-first approach was associated with lower blood loss and fewer ischaemic complications, and a higher number of harvested lymph nodes and R0 resection rate. Thus, it might improve the safety, staging and prognosis of distal pancreatectomy with celiac axis resection for pancreatic cancer.

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Objective: To evaluate the survival outcomes of patients who underwent conversion surgery for metastatic pancreatic ductal adenocarcinoma (mPDAC) after neoadjuvant therapy (NAT) and to identify potential candidates that may benefit from this treatment strategy. Background: The role and eligibility population of conversion surgery for mPDAC remains controversial in the era of NAT. Methods: A consecutive cohort of patients diagnosed with mPDAC and treated with NAT followed by conversion surgery between 2019 and 2021 were confirmed from a prospective database maintained by the Department of Pancreatic Hepatobiliary Surgery of Changhai Hospital. In accordance with residual metastases and technical resectability after NAT, patients were classified as the complete pathological response of metastases (ypM0) resection group, residual metastases (ypM1) resection group, and exploration group. Median overall survival (mOS) was calculated using the Kaplan-Meier method, uni- and multivariable cox regression was performed to identify clinicopathological predictors of OS. Results: A total of 244 patients with mPDAC were identified from the prospective database, with 19 (7.8%) patients who underwent ypM0 resection, 22 (9.0%) underwent ypM1 resection, and 23 (9.4%) underwent explorative laparotomy. The mOS was 32.6 months for ypM0 resected patients, 15.1 months for ypM1 resected patients, and 13.4 months for those who underwent explorative laparotomy (P < .001). Univariable and multivariable Cox regression analyses confirmed that ypM0 resection, normalization of preoperative CA19-9 levels, and continued adjuvant therapy were independent prognostic factors of conversion surgery for mPDAC after NAT. Subgroup analyses revealed that oligometastases and continued adjuvant therapy were associated with improved prognosis in the ypM1 resection group. Conclusion: In patients with mPDAC who underwent NAT followed by conversion surgery, the complete pathological response of metastases, normalization of preoperative CA19-9 levels, and continued adjuvant therapy were independent risk factors for prognosis. Patients with residual oligometastases after treatment were expected to prolong survival through resection. These patients may benefit from conversion surgery and should be potential candidates for this treatment strategy.

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