Skip to main content

Advertisement

SpringerLink
Log in

Modified Appleby Procedure for Pancreatic Adenocarcinoma: Does Improved Neoadjuvant Therapy Warrant Such an Aggressive Approach?

  • Pancreatic Tumors
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

With improved neoadjuvant regimens, more aggressive surgical resections may be warranted for patients with locally advanced pancreatic cancer (LAPC) with focal encasement of the celiac axis (CA) and proximal common hepatic artery (HA). We sought to investigate the clinicopathological features and outcomes of the modified Appleby procedure (DP-CAR) in light of improved neoadjuvant therapies.

Methods

A prospectively maintained database of all pancreatectomies performed at Johns Hopkins Hospital, Baltimore, MD, USA, was reviewed to identify all patients who underwent DP-CAR for pancreatic ductal adenocarcinoma (PDAC) between 2004 and 2016. A 3:1 match for patients undergoing distal pancreatectomy (DP) versus DP-CAR was performed on the basis of their clinicopathological features.

Results

Seventeen patients who underwent DP-CAR were matched to 51 patients who underwent DP for resection of PDAC. Prior to DP-CAR, 15 (88.2 %) patients received neoadjuvant therapy, and the most frequently used regimen was FOLFIRINOX (80.0 %). DP-CAR was associated with longer operative time (404 vs. 309 min; p = 0.003) and elevated postoperative liver transaminases compared with DP. No difference was observed in estimated blood loss and length of hospitalization. R0 resection was achieved in 82.4 % of DP-CAR patients versus 92.2 % of DP patients (p = 0.355). No difference was observed in postoperative outcomes, including overall complications, pancreatic fistula, readmission, and mortality. Median survival for DP-CAR was 20 versus 19 months in the DP group (p = 0.757).

Conclusion

In light of improved neoadjuvant therapeutic regimens, the modified Appleby procedure is a feasible and safe treatment option for patients with LAPC involving the CA, with morbidity and mortality similar to patients undergoing classic DP.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

REFERENCES

  1. Siegel RL, Miller KD, Jemal A. Cancer statistics. CA Cancer J Clin. 2016;66(1):7–30.

  2. Al Efishat M, Wolfgang CL, Weiss MJ. Stage III pancreatic cancer and the role of irreversible electroporation. BMJ. 2015;350:h521.

  3. Wolfgang CL, Herman JM, Laheru DA, et al. Recent progress in pancreatic cancer. CA Cancer J Clin. 2013;63(5):318–48.

  4. Vauthey JN, Dixon E. AHPBA/SSO/SSAT consensus conference on resectable and borderline resectable pancreatic cancer: rationale and overview of the conference. Ann Surg Oncol. 2009;16(7):1725–6.

  5. Iacobuzio-Donahue CA, Fu B, Yachida S, et al. DPC4 gene status of the primary carcinoma correlates with patterns of failure in patients with pancreatic cancer. J Clin Oncol. 2009;27(11):1806–13.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Sperti C, Berselli M, Pedrazzoli S. Distal pancreatectomy for body-tail pancreatic cancer: is there a role for celiac axis resection? Pancreatology. 2010;10(4):491–8.

    Article  PubMed  Google Scholar 

  7. Appleby LH. The coeliac axis in the expansion of the operation for gastric carcinoma. Cancer. 1953;6(4):704–7.

    Article  CAS  PubMed  Google Scholar 

  8. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205–13.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery. 2005;138(1):8–13.

    Article  PubMed  Google Scholar 

  10. Wente MN, Bassi C, Dervenis C, et al. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery. 2007;142(5):761–8.

    Article  PubMed  Google Scholar 

  11. Fernandez-Cruz L. Distal pancreatic resection: technical differences between open and laparoscopic approaches. HPB (Oxford). 2006;8(1):49–56.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Makary MA, Fishman EK, Cameron JL. Resection of the celiac axis for invasive pancreatic cancer. J Gastrointest Surg. 2005;9(4):503–7.

    Article  PubMed  Google Scholar 

  13. Huguet F, Andre T, Hammel P, et al. Impact of chemoradiotherapy after disease control with chemotherapy in locally advanced pancreatic adenocarcinoma in GERCOR phase II and III studies. J Clin Oncol. 2007;25(3):326–31.

    Article  CAS  PubMed  Google Scholar 

  14. Weitz J, Kienle P, Schmidt J, Friess H, Buchler MW. Portal vein resection for advanced pancreatic head cancer. J Am Coll Surg. 2007;204(4):712–6.

    Article  PubMed  Google Scholar 

  15. Mollberg N, Rahbari NN, Koch M, et al. Arterial resection during pancreatectomy for pancreatic cancer: a systematic review and meta-analysis. Ann Surg. 2011;254(6):882–93.

    Article  PubMed  Google Scholar 

  16. Latona JA, Lamb KM, Pucci MJ, Maley WR, Yeo CJ. Modified appleby procedure with arterial reconstruction for locally advanced pancreatic adenocarcinoma: a literature review and report of three unusual cases. J Gastrointest Surg. 2016;20(2):300–6.

  17. Conroy T, Desseigne F, Ychou M, et al. FOLFIRINOX versus gemcitabine for metastatic pancreatic cancer. N Engl J Med. 2011;364(19):1817–25.

    Article  CAS  PubMed  Google Scholar 

  18. Von Hoff DD, Ervin T, Arena FP, et al. Increased survival in pancreatic cancer with nab-paclitaxel plus gemcitabine. N Engl J Med. 2013;369(18):1691–703.

    Article  Google Scholar 

  19. Khushman M, Dempsey N, Cudris Maldonado J, et al. Full dose neoadjuvant FOLFIRINOX is associated with prolonged survival in patients with locally advanced pancreatic adenocarcinoma. Pancreatology. 2015;15(6):667–73.

    Article  CAS  Google Scholar 

  20. Faris JE, Blaszkowsky LS, McDermott S, et al. FOLFIRINOX in locally advanced pancreatic cancer: the Massachusetts General Hospital Cancer Center experience. Oncologist. 2013;18(5):543–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Ferrone CR, Marchegiani G, Hong TS, et al. Radiological and surgical implications of neoadjuvant treatment with FOLFIRINOX for locally advanced and borderline resectable pancreatic cancer. Ann Surg. 2015;261(1):12–7.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Mayumi T, Nimura Y, Kamiya J, et al. Distal pancreatectomy with en bloc resection of the celiac artery for carcinoma of the body and tail of the pancreas. Int J Pancreatol. 1997;22(1):15–21.

    Article  CAS  PubMed  Google Scholar 

  23. Konishi M, Kinoshita T, Nakagori T, et al. Distal pancreatectomy with resection of the celiac axis and reconstruction of the hepatic artery for carcinoma of the body and tail of the pancreas. J Hepatobiliary Pancreat Surg. 2000;7(2):183–7.

    Article  CAS  PubMed  Google Scholar 

  24. Miyakawa S, Horiguchi A, Hanai T, et al. Monitoring hepatic venous hemoglobin oxygen saturation during Appleby operation for pancreatic cancer. Hepatogastroenterology. 2002;49(45):817–21.

    Google Scholar 

  25. Yamaguchi K, Nakano K, Kobayashi K, et al. Appleby operation for pancreatic body-tail carcinoma: report of three cases. Surg Today. 2003;33(11):873–8.

    Article  PubMed  Google Scholar 

  26. Gagandeep S, Artinyan A, Jabbour N, et al. Extended pancreatectomy with resection of the celiac axis: the modified Appleby operation. Am J Surg. 2006;192(3):330–5.

    Article  PubMed  Google Scholar 

  27. Shimada K, Sakamoto Y, Sano T, Kosuge T. Prognostic factors after distal pancreatectomy with extended lymphadenectomy for invasive pancreatic adenocarcinoma of the body and tail. Surgery. 2006;139(3):288–95.

    Article  PubMed  Google Scholar 

  28. Hirano S, Kondo S, Hara T, et al. Distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic body cancer: long-term results. Ann Surg. 2007;246(1):46–51.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Denecke T, Andreou A, Podrabsky P, et al. Distal pancreatectomy with en bloc resection of the celiac trunk for extended pancreatic tumor disease: an interdisciplinary approach. Cardiovasc Intervent Radiol. 2011;34(5):1058–64.

    Article  PubMed  Google Scholar 

  30. Baumgartner JM, Krasinskas A, Daouadi M, et al. Distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic adenocarcinoma following neoadjuvant therapy. J Gastrointest Surg. 2012;16(6):1152–9.

    Article  PubMed  Google Scholar 

  31. Tanaka E, Hirano S, Tsuchikawa T, Kato K, Matsumoto J, Shichinohe T. Important technical remarks on distal pancreatectomy with en-bloc celiac axis resection for locally advanced pancreatic body cancer (with video). J Hepatobiliary Pancreat Sci. 2012;19(2):141–7.

  32. Jing W, Zhu G, Hu X, et al. Distal pancreatectomy with en bloc celiac axis resection for the treatment of locally advanced pancreatic body and tail cancer. Hepatogastroenterology. 2013;60(121):187–90.

    Google Scholar 

  33. Christians KK, Pilgrim CH, Tsai S, et al. Arterial resection at the time of pancreatectomy for cancer. Surgery. 2014;155(5):919–26.

    Article  PubMed  Google Scholar 

  34. Wang X, Dong Y, Jin J, et al. Efficacy of modified Appleby surgery: a benefit for elderly patients? J Surg Res. 2015;194(1):83–90.

    Article  PubMed  Google Scholar 

  35. Sasson AR, Hoffman JP, Ross EA, Kagan SA, Pingpank JF, Eisenberg BL. En bloc resection for locally advanced cancer of the pancreas: is it worthwhile? J Gastrointest Surg. 2002;6(2):147–57; discussion 157–8.

  36. Hishinuma S, Ogata Y, Tomikawa M, Ozawa I. Stomach-preserving distal pancreatectomy with combined resection of the celiac artery: radical procedure for locally advanced cancer of the pancreatic body. J Gastrointest Surg. 2007;11(6):743–9.

    Article  PubMed  Google Scholar 

  37. Wu YL, Yan HC, Chen LR, Gao SL, Chen J, Dong X. Extended Appleby’s operation for pancreatic cancer involving celiac axis. J Surg Oncol. 2007;96(5):442–6; discussion 447.

  38. Takahashi Y, Kaneoka Y, Maeda A, Isogai M. Distal pancreatectomy with celiac axis resection for carcinoma of the body and tail of the pancreas. World J Surg. 2011;35(11):2535–42.

  39. Yamamoto Y, Sakamoto Y, Ban D, et al. Is celiac axis resection justified for T4 pancreatic body cancer? Surgery. 2012;151(1):61–9.

    Article  PubMed  Google Scholar 

  40. Okada K, Kawai M, Tani M, et al. Surgical strategy for patients with pancreatic body/tail carcinoma: who should undergo distal pancreatectomy with en-bloc celiac axis resection? Surgery. 2013;153(3):365–72.

    Article  PubMed  Google Scholar 

  41. Zhou YM, Zhang XF, Li XD, Liu XB, Wu LP, Li B. Distal pancreatectomy with en bloc celiac axis resection for pancreatic body-tail cancer: is it justified? Med Sci Monit. 2014;20:1–5.

    CAS  PubMed  PubMed Central  Google Scholar 

  42. Beane JD, House MG, Pitt SC, et al. Distal pancreatectomy with celiac axis resection: what are the added risks? HPB (Oxford). 2015;17(9):777–84.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Ham H, Kim SG, Kwon HJ, Ha H, Choi YY. Distal pancreatectomy with celiac axis resection for pancreatic body and tail cancer invading celiac axis. Ann Surg Treat Res. 2015;89(4):167–75.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Kinsella TJ, Seo Y, Willis J, et al. The impact of resection margin status and postoperative CA19-9 levels on survival and patterns of recurrence after postoperative high-dose radiotherapy with 5-FU-based concurrent chemotherapy for resectable pancreatic cancer. Am J Clin Oncol. 2008;31(5):446–53.

    Article  CAS  PubMed  Google Scholar 

Download references

Disclosure

This work was supported by the Dutch KNAW Van Walree Grant.

Author information

Authors and Affiliations

  1. Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA

    Niek A. Peters BSc, Ammar A. Javed MD, John L. Cameron MD, FACS, Martin A. Makary MD, MPH, FACS, Kenzo Hirose MD, FACS, Timothy M. Pawlik MD, PhD, MPH, FACS, Jin He MD, PhD, FACS, Christopher L. Wolfgang MD, PhD, FACS & Matthew J. Weiss MD, FACS

  2. University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands

    Niek A. Peters BSc

Authors
  1. Niek A. Peters BSc
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ammar A. Javed MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. John L. Cameron MD, FACS
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Martin A. Makary MD, MPH, FACS
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Kenzo Hirose MD, FACS
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Timothy M. Pawlik MD, PhD, MPH, FACS
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Jin He MD, PhD, FACS
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Christopher L. Wolfgang MD, PhD, FACS
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Matthew J. Weiss MD, FACS
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Matthew J. Weiss MD, FACS.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Figure 1 – Overall survival after DP-CAR and DP (PDF 282 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Peters, N.A., Javed, A.A., Cameron, J.L. et al. Modified Appleby Procedure for Pancreatic Adenocarcinoma: Does Improved Neoadjuvant Therapy Warrant Such an Aggressive Approach?. Ann Surg Oncol 23, 3757–3764 (2016). https://doi.org/10.1245/s10434-016-5303-3

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-016-5303-3

Keywords

Search

Navigation