Preoperative Diagnostic Angiogram and Endovascular Aortic Stent Placement for Appleby Resection Candidates: A Novel Surgical Technique in the Management of Locally Advanced Pancreatic Cancer.
Background. Pancreatic adenocarcinoma of the body and tail usually presents late and is typically unresectable. The modified Appleby procedure allows resection of pancreatic body carcinoma with celiac axis (CA) invasion. Given that the feasibility of this technique is based on the presence of collateral circulation, it is crucial to confirm the presence of an anatomical and functional collateral system. Methods. We here describe a novel technique used in two patients who were candidates for Appleby resection. We present their clinical scenario, imaging, operative findings, and postoperative course. Results. Both patients had a preoperative angiogram for assessment of anatomical circulation and placement of an endovascular stent to cover the CA. We hypothesize that this new technique allows enhancement of collateral circulation and helps minimize intraoperative blood loss when transecting the CA at its takeoff. Moreover, extra length on the CA margin may be gained, as the artery can be transected at its origin without the need for vascular clamp placement. Conclusion. We propose this novel technique in the preoperative management of patients who are undergoing a modified Appleby procedure. While further experience with this technique is required, we believe that it confers significant advantages to the current standard of care.
Division of General Surgery, Jewish General Hospital, McGill University, 3755 Côte-Ste-Catherine Road, Montreal, QC, Canada H3T 1E2 ; Department of Surgery, King Abdulaziz University, P.O. Box 80215, Jeddah 21589, Saudi Arabia.
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Trabulsi
Division of General Surgery, Jewish General Hospital, McGill University, 3755 Côte-Ste-Catherine Road, Montreal, QC, Canada H3T 1E2.
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Pelletier
Division of Vascular Surgery, Jewish General Hospital, McGill University, 3755 Côte-Ste-Catherine Road, Montreal, QC, Canada H3T 1E2.
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Abraham
Division of General Surgery, Jewish General Hospital, McGill University, 3755 Côte-Ste-Catherine Road, Montreal, QC, Canada H3T 1E2.
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Vanounou