Introduction : Locally advanced pancreatic ductal adenocarcinoma (LA-PDAC) invading the celiac artery (CeA) and the gastroduodenal artery (GDA) is considered unresectable. We developed a new procedure of pancreaticoduodenectomy with celiac axis resection (PD-CAR) for such LA-PDACs.

Methods : Cases of LA-PDAC that invaded the CeA and GDA, but not the SMA and right hepatic artery (RHA), were included. Preoperative Chemoradiotherapy, consisted of radiation therapy (50 Gy) and chemotherapy(GEM+S-1) for at least 5 months, was given. Before the operation, arterial embolization by interventional radiology (IVR) was performed to alter the blood flow to the stomach, liver, pancreas, and spleen. PD-CAR, which included at most one arterial reconstruction salvaging hepatic and gastric arterial flow, was planned.

Results : From January 2015 to December 2018, 112 patients underwent pancreatectomy with curative intent for PDAC. Of these patients, 13 were first diagnosed as having unresectable LA-PDAC. Of these 13 patients, PD-CAR was performed for 4 patients with R0 resection. For arterial reconstruction, 2nd jejunal artery (J2A) - hepatic arterial reconstruction was done for 3 cases, and the other did not need arterial reconstruction due to preservation of the LGA. Mean operative time was 669 minutes, and mean blood loss was 1003 g. The median postoperative hospital stay was 52.7 days. The postoperative morbidity rate was 75% (3/4) including Clavien-Dindo classification III-IV complications, which were hepatic infarction, partial splenic infarction, sepsis, and severe diarrhea. There was no perioperative mortality.

Conclusions : Using preoperative IVR appropriately, PD-CAR, which preserves the tail of the pancreas, upper stomach, and spleen with at most one arterial reconstruction,