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

Abstract

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.

15-Year Experience of Distal Pancreatectomy with Celiac Axis Resection (DP-CAR) for Pancreatic Cancer—A Korean Nationwide Investigation

“…Gastric perforation occurs due to hemodynamic changes after resection of the celiac axis and left gastric artery. The reported incidence ranges from 3.7% to 29% [7,12,13,19]. In our study, among four (5.3%) patients with ischemic gastropathy, one (1.3%) patient had perforation requiring surgical exploration.…”

“…The incidence of hepatic ischemia varied from 0% to 25% in previous studies [7,17,19,21]. Even in reports with relatively higher rates of hepatic ischemia, severe hepatic infarction or abscesses requiring invasive procedures, such as percutaneous drainage, accounted for only a minor proportion of the patients.…”

“…They argued that preconditioning of the celiac axis by angiographic occlusion would prevent postoperative ischemic complications. A recent study from Russia reported hemodynamic changes after DP-CAR using perioperative CT scans and intraoperative ultrasound [19], but there was no statistical feature regarding postoperative changes in gastric flow, particularly in the right gastroepiploic artery. Considering that there has been no preceding research identifying preventive strategies for gastric perforation, further research is needed to explore potential solutions for ischemic gastropathy following DP-CAR.…”

Modified Appleby: experience improves short-term results, but is it enough?

“…Looking at the oncological results, the R0 rate was lower (58%) than other series, which are surprisingly not cited in the article (81–92%) ( 11 , 12 ). Despite this, overall survival at 3 years was 45.3% and at 5 years 19.4%, with a median overall survival of 28 months.…”

Importance of Anatomical Variation of the Hepatic Artery for Complicated Liver and Pancreatic Surgeries: A Review Emphasizing Origin and Branching

“…Some researchers have explained that there is no need for embolization if the liver has sufficient collateral pathways. The preoperative embolization of CHA in the case of pancreatic head carcinoma with aberrant CHA is safe to prevent ischemia-related complications before the resection of CHA [ 61 , 71 ]. According to some literature, there is no difference in postoperative bleeding complications in patients with aberrant hepatic arteries versus normal hepatic arteries [ 72 , 73 , 74 ].…”