Modified Appleby procedure for borderline resectable/locally advanced distal pancreatic adenocarcinoma: A major procedure for selected patients

Background: In distal pancreatic ductal adenocarcinoma (PDAC), distal pancreatectomy with en bloc splenectomy and celiac axis resection (DP-CAR) can allow curative resection in case of tumor extension to celiac axis. Methods: From 2008 to 2013, of 102 patients with localized distal PDAC, 7 patients with celiac axis involvement were planned to undergo DP-CAR with curative intent. All patients received neoadjuvant treatment followed by preoperative coil embolization to enlarge collateral arterial pathways, except if a replaced right hepatic artery arising from superior mesenteric artery was present and sufficient for the blood supply. We herein analyzed indications, technique and outcomes of DP-CAR. Results: After neoadjuvant treatment and arterial embolization, two patients experienced tumor progression and were not operated while five underwent DP-CAR. No patient required arterial reconstruction. Postoperative mortality was nil, but morbidity was 100%, mainly represented by pancreatic fistula. Postoperatively, there was a complete pain relief but chronic diarrhea was observed in all patients. Resections were R0 in three patients. One operated patient was alive and disease free at 60 months whereas median overall survival of patients who underwent resection was 24 months. Conclusions: DP-CAR for borderline resectable/locally advanced distal PDAC is associated with high morbidity and mixed long-term functional results. Neoadjuvant treatment may prevent from unnecessary surgery for patients with progressive disease and may facilitate resection with acceptable long-term survival. (C) 2016 Published by Elsevier Masson SAS.