En bloc celiac axis resection (CAR) for pancreatic cancer (PC) is increasingly considered after modern neoadjuvant chemotherapy (NAC). “Appleby” and “DP-CAR” are anatomically inaccurate terms as tumors can extend beyond celiac axis proper requiring concurrent resection of the proper hepatic artery and/or superior mesenteric artery.
A 3-level classification for CAR (Class 1/2/3) was developed after retrospective review of arterial resection database describing anatomical variants that dictate pancreatectomy-type, formal arterial revascularization (RV), and gastric preservation. Perioperative and oncologic outcomes were assessed.
Of 90 CAR’s for PC, 89% patients received NAC, 35% requiring chemotherapeutic switch. There were 41 Class 1, 33 Class 2, and 16 Class 3 CAR’s with arterial and venous RV performed 62% and 66% respectively. 90-day mortality decreased to 4% in last 50 cases (p = 0.035), major morbidity was unchanged (55%). Any hepatic or gastric ischemia occurred in 20% and 10% patients respectively and arterial RV was protective. R0 resection rate (88%) associated with chemoradiation (p = 0.004). Median overall survival was 36.2 months, superior with NAC (8.0 vs. 43.5 months). Predictors of survival after NAC included chemotherapy duration, CA19-9 response, pathologic response, and lymph node status. Major pathologic response (p = 0.036) and extended duration NAC (p = 0.007) were independent predictors on multivariate analysis.
Current terminology for CAR inadequately describes all operative variants. Our classification, based on largest single center series, allows complex operative planning and standardized reporting across institutions. Extent of arterial involvement determines pancreatectomy type, need for arterial revascularization, and likelihood of gastric preservation. Operative mortality has improved, morbidity remains significant, and survival favorable after extended NAC with associated pathologic responses; given these factors, CAR should only be considered in fit patients with objective NAC responses at specialized centers.

Copyright © 2020. Published by Elsevier Inc.