Distal Pancreatectomy with En Bloc Celiac Axis Resection (DP-CAR) for Advanced Pancreatic Body Cancer
Pancreatic body cancer often involves extensive invasion of the celiac and/or the common hepatic artery and/or their plexuses. Distal pancreatectomy with en bloc celiac axis resection (DP-CAR), which is an extended surgical procedure for locally advanced cancer of the pancreatic body, is performed for complete resection of these tumors. The procedure usually includes resection of the distal pancreas and spleen, together with en bloc resection of the celiac and common hepatic arteries, celiac plexus ganglions, the nerve plexus around the superior mesenteric artery, and retroperitoneal fat with the left adrenal gland and perirenal fat surrounding the left kidney. In this procedure, the entire alimentary tract is preserved, and no arterial reconstruction is required since the collateral pancreatic arcade to the liver, biliary system, and stomach from the superior mesenteric artery remains intact. Preoperative coil embolization of the common hepatic artery could be beneficial in encouraging development of the collateral arterial flow. Although the procedure of DP-CAR is technically demanding, a high rate of negative surgical margin resection can be achieved with cautious selection of candidates using preoperative multi-detector row computed tomography (MDCT).
A relatively high morbidity rate due to postoperative pancreatic fistula and ischemic gastropathy has been reported. A recent report on the long-term outcomes following DP-CAR in 50 patients has described a 5-year disease-specific survival rate of 24.3% and median survival time of 24.7 months. Postoperative metastasis occurs predominantly in the liver. Surgery immediately relives preoperative intractable cancer-related pain due to eradication of the nerve system and the ganglions.
DP-CAR offers a high margin-free resectability rate and may potentially achieve complete local control in selected patients. However, prospective studies including a large cohort for ensuring adequate patient selection, modification of the procedure, and perioperative treatments are required to improve the effectiveness of DP-CAR.
KeywordsPancreatic body cancer Arterial involvement Celiac axis resection Distal pancreatectomy
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