title: Modified Appleby Procedure for Pancreatic Adenocarcinoma: Does Improved Neoadjuvant Therapy Warrant Such an Aggressive Approach?
abstract: With improved neoadjuvant regimens, more aggressive surgical resections may be warranted for patients with locally advanced pancreatic cancer (LAPC) with focal encasement of the celiac axis (CA) and proximal common hepatic artery (HA). We sought to investigate the clinicopathological features and outcomes of the modified Appleby procedure (DP-CAR) in light of improved neoadjuvant therapies.
  
  
  
  A prospectively maintained database of all pancreatectomies performed at Johns Hopkins Hospital, Baltimore, MD, USA, was reviewed to identify all patients who underwent DP-CAR for pancreatic ductal adenocarcinoma (PDAC) between 2004 and 2016. A 3:1 match for patients undergoing distal pancreatectomy (DP) versus DP-CAR was performed on the basis of their clinicopathological features.
  
  
  
  Seventeen patients who underwent DP-CAR were matched to 51 patients who underwent DP for resection of PDAC. Prior to DP-CAR, 15 (88.2 %) patients received neoadjuvant therapy, and the most frequently used regimen was FOLFIRINOX (80.0 %). DP-CAR was associated with longer operative time (404 vs. 309 min; p = 0.003) and elevated postoperative liver transaminases compared with DP. No difference was observed in estimated blood loss and length of hospitalization. R0 resection was achieved in 82.4 % of DP-CAR patients versus 92.2 % of DP patients (p = 0.355). No difference was observed in postoperative outcomes, including overall complications, pancreatic fistula, readmission, and mortality. Median survival for DP-CAR was 20 versus 19 months in the DP group (p = 0.757).
  
  
  
  In light of improved neoadjuvant therapeutic regimens, the modified Appleby procedure is a feasible and safe treatment option for patients with LAPC involving the CA, with morbidity and mortality similar to patients undergoing classic DP.
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA.|University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
authors.forename: Niek A
authors.initials: NA
authors.lastname: Peters
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA.
authors.forename: Ammar A
authors.initials: AA
authors.lastname: Javed
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA.
authors.forename: John L
authors.initials: JL
authors.lastname: Cameron
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA.
authors.forename: Martin A
authors.initials: MA
authors.lastname: Makary
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA.
authors.forename: Kenzo
authors.initials: K
authors.lastname: Hirose
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA.
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Pawlik
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA.
authors.forename: Jin
authors.initials: J
authors.lastname: He
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA.
authors.forename: Christopher L
authors.initials: CL
authors.lastname: Wolfgang
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA. mweiss5@jhmi.edu.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Weiss
mesh_terms: D000368:Aged; D000410:Alanine Transaminase / Q000097:blood; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D001219:Aspartate Aminotransferases / Q000097:blood; D016063:Blood Loss, Surgical; D021441:Carcinoma, Pancreatic Ductal / Q000188:drug therapy / Q000601:surgery*; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D061646:Operative Time; D010180:Pancreatectomy / Q000009:adverse effects / Q000379:methods*; D010190:Pancreatic Neoplasms / Q000188:drug therapy / Q000601:surgery*; D011184:Postoperative Period; D012189:Retrospective Studies; D015996:Survival Rate
chemical_list: D001219:Aspartate Aminotransferases; D000410:Alanine Transaminase