Distal Pancreatectomy With En Bloc Resection of the Celiac Trunk for Extended Pancreatic Tumor Disease: An Interdisciplinary Approach

Abstract

In this small series, ischemic complications after celiacopancreatectomy occurred only in those patients who did not receive preoperative celiac trunk embolization.

Radiologic Resectability Assessment in Pancreatic Cancer

“…The Achilles heel of this procedure is the interruption of the direct arterial blood supply to the liver, bile ducts, and stomach. Despite collateral pathways via the SMA, pancreaticoduodenal arcades, and the GDA, arterial perfusion of critical organs can be compromised after this procedure, causing severe complications such as liver failure, biliary duct necrosis, perforation of the stomach, and ischemic ulcer [52,53]. In order to avoid these complications, an interdisciplinary approach was introduced.…”

“…In order to avoid these complications, an interdisciplinary approach was introduced. Preoperative digital subtraction angiography with two catheters intubating the celiac trunk and the SMA provides important information about the status of the relevant vessels [53]. In the case of preexisting celiac trunk stenosis, spontaneous collateral flow can be seen from the SMA over pancreaticoduodenal arcades to the GDA supplying the hepatic artery.…”

“…If no stenosis is present, a test occlusion of the celiac trunk with a balloon catheter can be employed to provoke collateral flow and to confirm thereby the existence of sufficient collateral arteries ( • " Fig. 4) [53]. To enhance the collateral flow already before the operation, which follows typically one week later, embo-lization of the celiac trunk is recommended in most reports on this approach as this "training" of collateralization reliably prevents ischemic complications [53,54].…”

“…4) [53]. To enhance the collateral flow already before the operation, which follows typically one week later, embo-lization of the celiac trunk is recommended in most reports on this approach as this "training" of collateralization reliably prevents ischemic complications [53,54].…”

Perioperative treatment options in resectable pancreatic cancer - how to improve long-term survival

“…The reliability of a preoperative radiological statement is diminished and can only be compensated for by thorough surgical exploration. This again -knowing of the "point of no return" of the resection of a pancreatic head carcinoma, beyond which R0-resection may still be found to be impossible in some cases -can be a drawback of the preoperative concept, potentially resulting in R2- This requires very precise planning based on radiologic imaging and a preoperative radiological intervention in order to train collateralization (see "surgical procedures" below) [22,23] . In conclusion, with the advent of new management options in preoperative therapy of pancreatic cancer, radiological imaging -for planning of biopsy and surgery as well as pre-surgical reassessment and preconditioning -has moved to the frontline of treatment decision making and become the basis of measures to achieve the treatment goal: Prolonged survival of the patients.…”