Distal Pancreatectomy with Celiac Axis Resection (DP-CAR) for Pancreatic Cancer. How I do It

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Executive Summary

Distal pancreatectomy with celiac axis resection (DP-CAR), a modified version of the Appleby procedure, is a specialized surgical intervention for a subset of patients with locally advanced (AJCC stage 3) pancreatic cancer. This procedure is indicated when the tumor involves the celiac axis but leaves the aorta, superior mesenteric artery (SMA), and gastroduodenal artery (GDA) tumor-free.

Critical Takeaways:

  • Survival Benefit: DP-CAR offers a median overall survival of 16–32 months, comparable to localized pancreatic cancer, for otherwise unresectable cases.

  • Multimodality Requirement: Successful outcomes depend on neoadjuvant chemotherapy (primarily FOLFIRINOX) to assess tumor biology and achieve stabilization or regression.

  • Volume Sensitivity: Outcomes are highly dependent on hospital volume. Low-volume centers (<1 DP-CAR annually) exhibit significantly higher 90-day mortality rates (18%) compared to high-volume centers (6%).

  • Physiological Basis: Following resection of the celiac axis, liver and stomach perfusion is maintained via retrograde flow from the SMA through the pancreatic head arcade into the GDA.

  • Risk Profile: Major morbidity remains high (approximately 27%), with mortality often linked to gastric or liver ischemia and post-pancreatectomy hemorrhage.

Clinical Indications and Patient Selection

Approximately 30% of pancreatic cancer patients present with locally advanced disease. DP-CAR is reserved for a specific subgroup where margin-negative (R0) resection is possible through celiac axis removal.

Inclusion and Exclusion Criteria

Category

Criteria

Primary Indication

Celiac axis involvement where aorta, SMA, and GDA remain tumor-free.

Mandatory Pre-requisite

Absence of distant metastases (confirmed via CT/MRI within 3–4 weeks).

Vascular Integrity

Patent GDA and pancreatic head arcade (essential for liver perfusion).

Relative Contraindications

Portal vein involvement ≥ 90–180°; concurrent involvement of other major organs.

Preoperative Optimization Protocols

Neoadjuvant Chemotherapy

Neoadjuvant therapy is established as a critical strategy to filter out patients with aggressive tumor biology that would not benefit from highly invasive surgery.

  • Preferred Regimen: 2 to 4 months of FOLFIRINOX.

  • Alternative: Gemcitabine-based combinations (e.g., S-1 or nab-paclitaxel) for those intolerant to FOLFIRINOX.

  • Eligibility for Surgery: Patients must demonstrate RECIST-stable or regressive disease and a reduction in serum CA 19-9 levels by 30–50%.

Preoperative Arterial Embolization

While clear evidence is lacking, some high-volume centers routinely perform preoperative coiling of the common hepatic artery (CHA) 2–3 weeks prior to surgery.

  • Purpose: To stimulate and improve collateral flow to the liver and stomach, potentially reducing postoperative ischemia.

  • Assessment: Allows for preoperative verification of collateral flow sufficiency.

  • Execution: Coils must be placed to allow space between the coils and the GDA origin.

Surgical Methodology

The procedure aims to resect the celiac axis, distal pancreas, and spleen while preserving arterial flow to the liver.

Step-by-Step Open Approach

  1. Staging and Exploration: Laparoscopy to rule out occult metastases. Bilateral subcostal or midline laparotomy follows. Intra-abdominal ultrasound and frozen sections are used to verify vascular involvement, as imaging can be unreliable post-chemotherapy.

  2. Vascular Control: Treitz’ ligament is dissected. An extended Kocher maneuver exposes the IVC, aorta, and origins of the celiac axis and SMA. The CHA is test-occluded with a bulldog clamp to ensure adequate collateral flow via Doppler probe.

  3. Resection of the Celiac Axis: The diaphragmatic crus is divided to clear the celiac origin. The CHA is transected 1 cm proximal to the GDA. The celiac axis is transected at the aorta using vascular staplers or sutures. The left gastric artery (LGA) may be preserved if it is tumor-free and branches proximally.

  4. RAMPS Procedure: The remainder of the procedure follows a Radical Antegrade Modular Pancreato-Splenectomy (RAMPS). This includes medial to lateral resection of the pancreatic tail, spleen, and Gerota’s fascia.


Robot-Assisted Approach

This approach is reserved for extremely high-volume robotic centers. It utilizes robotic vascular staplers and frequent intraoperative robotic ultrasound to identify vascular origins. The specimen is typically extracted via a Pfannenstiel incision.

Postoperative Management and Complications

Management Strategy

  • Enhanced Recovery: Adoption of ERAS (Enhanced Recovery After Surgery) pathways.

  • Pharmacology: Routine use of proton pump inhibitors for 6 months post-surgery.

  • Monitoring: Vigilant observation for signs of ischemia (elevated liver enzymes, serum lactate, or gastric ulceration) and pancreatic fistula.

Major Risks and Morbidity

The invasive nature of DP-CAR results in significant clinical challenges:

  • Ischemia: Gastric and liver ischemia are primary drivers of mortality. Preservation of the right gastric and gastroepiploic arteries is crucial to mitigate this risk.

  • Hemorrhage: Post-pancreatectomy hemorrhage is a leading cause of the 52% of mortality cases associated with technical complications.

  • Vascular Complexity: Standard end-to-end anastomosis for portal vein resections is difficult in DP-CAR due to the pancreatic head remnant, increasing the risk of vascular complications.

Conclusion

DP-CAR is a viable therapeutic option for a select group of patients with locally advanced pancreatic cancer, offering survival outcomes comparable to those with resectable disease. However, the high potential for major morbidity and the technical complexity of the procedure necessitate that it be performed exclusively within high-volume, multidisciplinary pancreatic cancer treatment teams. Preoperative FOLFIRINOX serves as a vital biological sieve, ensuring that only those likely to benefit from the procedure undergo surgery.