Modified Appleby Procedure with Arterial Reconstruction for Locally Advanced XXXX : A Literature Review and Report of Three Unusual Cases.

@entity1 @entity788 @entity1593 @entity63 @entity5 @entity254 @entity432 @entity715 @entity99 @entity420
BACKGROUND: Pancreatic body and tail ductal @entity420 are often diagnosed with local vascular invasion of the @entity1593 ( @entity1593 ) and its various branches. With such involvement, these @entity5 have traditionally been considered unresectable. The modified Appleby procedure allows for margin negative resection of some such locally advanced @entity5 . This procedure involves distal pancreatectomy with en bloc splenectomy and @entity1593 resection and relies on the presence of collateral arterial circulation via an intact pancreaticoduodenal arcade and the gastroduodenal artery to maintain prograde hepatic arterial perfusion. When the resultant collateral circulation is inadequate to provide sufficient hepatic and gastric arterial inflow, @entity432 ( @entity432 ) is necessary to "supercharge" the inflow. Herein, we review all reported cases of @entity432 with modified Appleby procedures that we have identified in the literature, and we report our experience of three recent cases with @entity432 including two cases with arterial bypasses not requiring interposition grafting. METHODS: Perioperative and oncologic outcomes from our Institutional Review Board-approved database of pancreatic resections at the Thomas Jefferson University were reviewed. Additionally, PubMed search for cases of distal or total pancreatectomy with @entity1593 resection and concurrent @entity432 was performed. RESULTS: From the literature, 12 reports involving 28 @entity1 were identified of distal and total pancreatectomy with @entity432 after @entity1593 resection. The most common @entity432 in the literature, performed in 12 @entity1 , was a bypass from the aorta to the @entity99 ( @entity99 ) using a variety of interposition conduits. In our institutional experience, @entity1 #1 had a primary side-to-end aorto- @entity99 bypass, @entity1 #2 had a primary end-to-end bypass of the transected distal @entity99 in the setting a replaced left hepatic artery, and @entity1 #3 required an aortic to proper hepatic artery bypass with saphenous vein graft and portal venous reconstruction. All @entity1 recovered from their operations without @entity63 complications, and they are currently 16, 15, and 13  months post-op, respectively. CONCLUSIONS: The criteria for resectability in @entity1 with locally advanced pancreatic body and tail @entity5 are expanding due to increasing experience with @entity432 in the setting of the modified Appleby procedure. When performing @entity432 , primary arterial re- @entity254 may be considered preferable to interposition grafting as it decreases the potential for the infectious and @entity715 complications associated with conduits and it reduces the number of vascular anastomoses from two to one. Consideration must also be given to normal variant anatomy of the hepatic circulation during operative planning as the origin of the left gastric artery is resected with the @entity1593 . The modified Appleby procedure with @entity432 , when used in appropriately selected @entity1 , offers the potential for safe, margin negative resection of locally advanced @entity788 .
