Objective: Achieve an R0 resection for patients with T4 tumors involving the celiac and/or superior mesenteric arteries.
Trials:
Conducted in the 1970s and 1980s at:
Memorial Sloan Kettering Cancer Center by Fortner (1984)
National Cancer Institute by Sindelar (1989)
Procedure: Regional pancreatectomy, involving:
Arterial and venous resections en bloc
Extensive pancreatectomy
Regional lymphadenectomy
Vascular reconstruction
Outcome:
Technically demanding
High morbidity and mortality
Few long-term survivors despite extensive surgery
Conclusion: Arterial resection for R0 margin in pancreatic tumors was generally deemed inappropriate for surgery by most pancreatic surgeons.
Exception for Locally Advanced Pancreatic Body Tumors
Tumor Location: Upper portion of the celiac artery.
Conditions for Procedure:
Celiac origin from aorta free of tumor
Intact gastroduodenal artery and proper hepatic artery uninvolved by tumor
Even better if the patient has an aberrant right hepatic artery arising from the superior mesenteric artery uninvolved by tumor.
Procedure:
Resection of the celiac and common hepatic artery en bloc with the tumor
Typically with left-sided pancreatectomy
Modification: Based on the original Appleby procedure (described for gastric cancer)
Relies on retrograde flow in the gastroduodenal artery to supply the liver.
Major Risk: Liver failure is a significant source of morbidity and mortality in patients undergoing this procedure.
Recent Developments:
Arterial bypass graft to enhance gastroduodenal blood flow and reduce liver failure risk.
Outcomes: Select patients may have cancer-specific survival similar to those with resectable tumors.
Arterial Resection Following Neoadjuvant Treatment
Rationale:
Some patients with tumor abutting major arteries can achieve R0 margins post-neoadjuvant treatment.
Surgeons selectively perform arterial resection and reconstruction of the celiac and/or superior mesenteric arteries.
Indication: When the arterial wall is still extensively involved by viable cancer post-neoadjuvant treatment.
Risks:
Higher morbidity and mortality.
Unclear long-term survival benefit.
Considerations:
Majority of pancreatic cancer patients eventually succumb to metastatic disease.
More extensive surgery for stage III disease may not influence prognosis.
Alternative Treatments:
Locoregional control with ablative radiation therapy may reduce the necessity for arterial resection.
Conclusion: Arterial resection and reconstruction should be outside standard therapy and employed selectively by highly skilled surgeons and institutions.