Appleby Operation for Locally Advanced Tumour of the Pancreatic Body and Tail - A Video Demonstration

Introduction: Patients with locally advanced pancreatic cancer and arterial infiltration of the coeliac artery are often classified as irresectable and therefore treated palliatively. For a highly selected group of patients, a complete resection (R0) of a pancreatic carcinoma including resection of the coeliac trunk without arterial reconstruction can mean a survival advantage. The expertise of the surgeon in vascular and pancreatic surgery as well as the proficiency of the entire surgical and anaesthesiological team and the appropriate infrastructure of the hospital are prerequisites for the success of such complex operations. Concerning the local finding of infiltration of the aorta, the gastroduodenal artery and the mesenteric superior artery should be excluded, to ensure R0 resection and perfusion of the liver via the gastroduodenal artery after resection. Moreover, the patient has to be fit for a large abdominal operation and extrapancreatic metastases have to be excluded, especially in ductal adenocarcinoma of the pancreas. In this video, the principles of the Appleby operation are shown in a case of locally advanced neuroendocrine carcinoma of the pancreas with infiltration of the coeliac artery. Indication: Locally advanced pancreatic neuroendocrine carcinoma with infiltration of the coeliac artery without distant metastasis after neoadjuvant therapy. Procedure: Extended multiorgan pancreatic corpus and tail resection including resection of coeliac artery, portal vein resection, splenectomy, resection of left adrenal gland, subtotal gastrectomy and oversewing of the pancreatic head, end-to-end reconstruction of the portal vein and gastro-jejunostomy (Roux-Y) and duodeno-jejunostomy. Conclusion: Given the appropriate experience, the Appleby procedure is a technically demanding resection in pancreatic carcinomas involving the coeliac artery without arterial anastomosis. In selected cases this operation might have advantages compared to palliative treatment.