Modified artery-first approach for distal pancreatectomy with celiac axis resection

Abstract

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.

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

“…In the Fig. S2, it is surprising to see that there was no difference in overall survival at 3 years between patients having up-front surgery and those having surgery after neoadjuvant chemotherapy, with a trend towards better survival for patients with upfront surgery, which is in contradiction with the results already reported ( 4 , 5 ) showing increased survival after induction treatment. This maintains the debate about the selection of patients in this series, particularly in the second period studied where pancreatic cancers appeared to be more advanced according to Tab.…”

“…The multicenter European series ( 3 ) published in 2018 included 61 procedures in 20 centers. Some Asian single-center series have a substantial number of patients ( 4 , 5 ), notably the recent series by Wang et al with 106 patients. The largest published series is the multicenter European series republished in 2019, supplemented by American and Asian data, reporting 191 patients ( 6 ).…”