Accepted Manuscript

Modified Appleby Procedure for Locally Advanced Pancreatic Cancer

Shanley Deal, MD, Derek Nathan, MD, Flavio G. Rocha, MD, FACS

PII: S0002-9610(17)31550-7
DOI: 10.1016/j.amjsurg.2018.01.004
Reference: AJS 12683

To appear in: The American Journal of Surgery

Received Date: 21 November 2017

Revised Date: 1 January 2018
Accepted Date: 2 January 2018

Please cite this article as: Deal S, Nathan D, Rocha FG, Modified Appleby Procedure for
Locally Advanced Pancreatic Cancer, The American Journal of Surgery (2018), doi: 10.1016/
j.amjsurg.2018.01.004.

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Modified Appleby Procedure for Locally Advanced Pancreatic Cancer

Shanley Deal, MDa, Derek Nathan, MDa and Flavio G. Rocha, MD, FACSa*

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Section of General, Thoracic and Vascular Surgery
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Virginia Mason Medical Center
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Seattle, WA
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*Corresponding Author
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Flavio G. Rocha, MD
a. Virginia Mason Medical Center
1100 Ninth Av.
Buck Pavilion, 6th Floor
Seattle, WA 98101
(206) 341-1905 (ph)
(206) 341-0048 (fax)
Email: flavio.rocha@virginiamason.org
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Abstract

Locally advanced pancreas cancer (LAPC) involving the celiac axis is typically
considered unresectable and carries a poor prognosis. We present a case of a patient with
LAPC who underwent a modified Appleby procedure for tumor clearance following
neoadjuvant therapy. Technical aspects include diagnostic laparoscopy to exclude occult
metastatic disease followed by complete mobilization of the pancreas and spleen,

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preservation of the left gastric artery, and resection and reconstruction of the common
hepatic artery. With proper patient selection and preparation, LAPC with celiac axis
involvement can be safely resected with favorable outcomes.

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Introduction

Locally advanced pancreatic cancer is typically unresectable and long-term

survival is rare with 5-year survival rate of 10%1.The Appleby procedure was originally

described by Dr. Lyon H. Appleby, a dedicated Canadian surgeon, in 1949. The

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procedure included dissection and removal of the spleen, pancreas to the left of the

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superior mesenteric vessels, stomach, and pylorus. This includes transection of the celiac

axis and the hepatic artery proximal to the gastroduodenal artery (GDA) take off as

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highlighted in the original article2. Arterial supply to the liver is preserved through

retrograde blood flow via the GDA and thus the celiac axis can be taken with impunity.

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This technique has been adapted for pancreatic neck and body cancers to
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encompass a distal pancreatectomy with celiac axis resection (DP-CAR). Recent series

from experienced pancreatic surgery centers have demonstrated median survival

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approaching three years.3 This is thought to be due to clearance of the retroperitoneal

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tissue, lymph nodes and involved vasculature following a period of neoadjuvant

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chemotherapy with or with radiation. In DP-CAR, hepatic perfusion typically relies on

retrograde blood flow from the superior mesenteric artery to the gastroduodenal artery. If
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the perfusion is not adequate, the common hepatic artery can be reconstructed primarily

or with a vein graft.4 In this case, we were able to preserve the left gastric artery as this is
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our preference to avoid gastric ischemia and its associated complications.5

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Case

We present a case of locally advanced pancreatic ductal adenocarcinoma in a 60

year-old female who was initially deemed unresectable due to tumor encasement of the
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celiac axis. She enrolled in a clinical trial of extended neoadjuvant chemotherapy and was

offered surgical resection after demonstrating a biochemical and metabolic response by

CA 19-9 and PET and lack of radiographic disease progression.

A modified Appleby procedure preserving the left gastric artery was performed

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following a negative diagnostic laparoscopy. The pancreas and spleen were fully

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mobilized and the tumor was found to be clear of the superior mesenteric artery and vein.

A splenectomy was performed separately and the pancreas was transected at the neck

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with the specimen left attached to the bifurcation of the celiac axis (Figure 1). Upon test

clamping the common hepatic artery, the patient was found to have inadequate hepatic

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perfusion by Doppler likely from insufficient collateral flow from the gastroduodenal
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artery. Vascular control was obtained on the celiac artery, left gastric artery and the

common hepatic artery and the tumor was resected en bloc (Figure 2). A primary arterial
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anastomosis was performed between the celiac artery stump and the common hepatic
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artery (Figure 3). This was possible in this patient because she had a long celiac artery,
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about 1.5cm, so even after en bloc resection, a 1cm celiac artery stump remained and the

left gastric artery take off was able to be preserved. Of note, the most common
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configuration of the celiac axis is a bifurcation of the common hepatic artery and splenic

artery with a separate left gastric artery takeoff6. Final pathology confirmed a 2.5 cm
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pancreatic adenocarcinoma with invasion of the splenic artery and vein with negative
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margins and 3/11 positive lymph nodes.

The patient had a non-eventful recovery and follow-up Doppler ultrasound

demonstrated excellent flow through the anastomosis. She received adjuvant

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chemoradiation but did develop a peritoneal recurrence 18 months after surgery (26

months after diagnosis) and is currently alive with disease on experimental therapy.

Supplementary video to this article can be found at:

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https://vimeo.com/205979400/3c52e014d1

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Discussion

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This radical procedure is still gaining experience at specialized centers with limited

publications in the literature. Three cases were reported in 2003 by Yamaguchi and

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colleagues in Japan with a thorough review of the literature at that time7. The authors
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proposed indications for the use of this modified Appleby procedure including: 1) no

pancreatic head, superior mesenteric artery, or proper hepatic artery invasion, 2) the
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celiac axis can be resected at the root and the common hepatic artery can be resected
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before the gastroduodenal artery take-off, 3) complete retroperitoneal clearance is

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possible and 4) adequate liver perfusion confirmed after clamping the common hepatic

artery. These key technical points have guided surgeons adopting this technique over the
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years. Of note, our case highlights that despite lack of perfusion with clamping of the

common hepatic artery, we still resected because our patient had adequate celiac artery
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length to perform a primary anastomosis to the common hepatic artery to restore flow to
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the liver.

A review of 15 patients with pancreatic adenocarcinoma and arterial encasement

who underwent extended neoadjuvant therapy and were taken to surgery with planned

arterial resections from a single center study was recently published4. Of these patients,
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66% underwent pancreatectomy with arterial resection and 85% achieved an R0

resection. In addition, with a median follow up of 21 months, 62% were living without

disease. This demonstrates that in carefully selected patients with locally advanced

pancreatic cancer with favorable tumor biology after extended neoadjuvant therapy,

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acceptable outcomes may be achieved with careful selection and successful arterial

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resection. The critical components for this therapeutic approach include response to

chemotherapy, careful preoperative planning taking into account the vascular anatomy,

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meticulous resection of the celiac axis with reconstruction of the hepatic artery if needed

and preservation of the left gastric artery if possible.

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Conclusion

A modified Appleby operation with preservation of the left gastric artery and hepatic
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artery resection with reconstruction is technically feasible for locally advanced pancreatic
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cancer, however it should be reserved for highly selected patients in centers with
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expertise.
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References

1. Sohn TA, Yeo CJ, Cameron JL, et al. Resected adenocarcinoma of the pancreas:
616 patients: results, outcomes, and prognostic indicators. J Gastrointest Surg
2000;4:567–79.

2. Appleby L. The coeliac axis in the expansion of the operation for gastric

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carcinoma. Cancer 1953;6:704–7.

3. Ocuin L, Ocuin-Miller J, Novak S, et al. Robotic and open distal pancreatectomy

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with celiac axis resection for locally advanced pancreatic body tumors: a single
institutional assessment of perioperative outcomes and survival. HPB
2016;18(10):835-842

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4. Christians KK, Pilgrim CH, Tsai S, Ritch P, George B, Erickson B, et al. Arterial
resection at the time of pancreatectomy for cancer. Surgery 2014;155(5):919-26.

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5. Okada K, Kawai M, Tani M, et al. Preservation of the left gastric artery on the
basis of anatomical features in patients undergoing distal pancreatectomy with
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celiac axis en-bloc resection (DP-CAR). World J Surg 2014;38(11):2980-5.

6. White, R, Weir-McCall J, Sullivan C, Mustafa A, Yeap P, Budak M, Sudarshan

T, and I Zealley. The Celiac Axis Revisited: Anatomic Variants, Pathologic
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Features, and Implications for Modern Endovascular Management.

RadioGraphics 2015 35:3, 879-898. h
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7. Yamaguchi K, Nakano K, Kobayashi K, Ogura Y, Konomi H, Sugitani A, et al.

Appleby operation for pancreatic body-tail carcinoma: report of three cases. Surg
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Today. 2003;33(11):873-8.
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Highlights

- Modified Appleby procedure for locally advanced pancreatic cancer

- Supplementary video material featuring operative technique

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