Periarterial divestment following neoadjuvant therapy in patients with locally advanced pancreatic cancer with celiac axis invasion: A safe and effective surgical procedure

Abstract

Background: Modern pancreatic surgery has gradually changed with the introduction of neoadjuvant therapy. For patients with pancreatic cancer involving peripancreatic visceral arteries who have received neoadjuvant therapy, periarterial divestment has gradually gained popularity, which represents an alternative to arterial resection. There is ongoing debate about whether this approach achieves curative tumor resection comparable to that of arterial resection, and the differences in terms of postoperative complications and oncologic outcomes between the 2 surgical procedures.

Methods: We retrospectively analyzed the perioperative and survival outcomes of locally advanced pancreatic cancer patients with celiac axis invasion who underwent distal pancreatectomy in our center from December 2016 to March 2023.

Results: Ninety-five patients underwent neoadjuvant therapy as a priority after diagnosis, among whom 42.1% (n = 40) underwent distal pancreatectomy with celiac axis periarterial divestment, whereas 57.9% (n = 55) underwent distal pancreatectomy with en bloc celiac axis resection. Distal pancreatectomy with celiac axis periarterial divestment showed lower rates of postoperative pancreatic fistula, intraabdominal infection, and postoperative hepatic ischemia compared with distal pancreatectomy with en bloc celiac axis resection, with no significant differences in R0 resection rate, postoperative tumor recurrence, and survival. Furthermore, 46 patients diagnosed with locally advanced pancreatic cancer involving the celiac axis underwent upfront surgery of distal pancreatectomy with en bloc celiac axis resection without neoadjuvant therapy. Neoadjuvant therapy patients exhibited significant advantages in terms of tumor pathologic outcomes and survival compared with those undergoing upfront surgery of distal pancreatectomy with en bloc celiac axis resection.

Conclusion: After neoadjuvant therapy, distal pancreatectomy with celiac axis periarterial divestment in locally advanced pancreatic cancer patients with celiac axis invasion is deemed safe and feasible on the basis of adequate imaging evaluation combined with intraoperative judgment of the surgeons. This technique is recommended to be performed at high-volume pancreatic centers by experienced surgeons.