Abstract:

Objective

To evaluate the application value of modified “two-step” Appleby operation after neoadjuvant therapy in the treatment of locally advanced pancreatic body cancer.

Methods

Clinical data of two patients with locally advanced pancreatic body cancer admitted to Chongqing People’s Hospital from June 2021 to June 2022 were retrospectively analyzed.The informed consents of all patients were obtained and the local ethical committee approval was received.Both two patients were male， aged 56 and 64 years， respectively.CA19-9 level was 901 and 613 kU/L， and tumor diameter was 8.9 and 3.6 cm，respectively.Two patients were diagnosed with pancreatic ductal adenocarcinoma by endoscopic ultrasoundguided pancreatic biopsy.After MDT consultation， three cycles of neoadjuvant chemotherapy were performed.The regimen consisted of gemcitabine combined with albumin-bound paclitaxel， without targeted immunotherapy.Modified “two-step” Appleby operation was performed within 1-3 weeks after neoadjuvant therapy.The tumor changes， surgical completion， postoperative complications and survival of two patients after neoadjuvant therapy were analyzed.

Results

After neoadjuvant therapy， CA19-9 level was decreased significantly by over 50% in two patients.The tumor size was evidently reduced accompanied with decrease of vascular invasion， and surgical indications were evident.Surgical regimen： at the first step， common hepatic artery pretreatment， laparoscopic ligation of common hepatic artery were performed.Postoperatively，liver function was slightly abnormal and restored to normal within 2 weeks.Imaging examination indicated that the blood supply of liver and gastrointestinal tract was normal.At the second step， modified Appleby operation was performed after comprehensive preoperative preparation.Transient elevation of transaminase level occurred after operation， which was improved after liver-protection treatment.CA19-9 level was further decreased.Imaging examination showed that the blood supply of liver and gastrointestinal tract was normal，and no ischemic lesion was found.Two patients were discharged after recovery.Postoperatively， two patients continued to receive adjuvant chemotherapy of gemcitabine combined with albumin-bound paclitaxel.One patient developed multiple systemic metastases at 13 months after operation， and the other patient had liver metastases at postoperative 15 months.Both two patients survived as of the paper submission date.

Conclusions

Modified Appleby operation after neoadjuvant therapy can improve the R0 resection rate for locally advanced pancreatic body cancer.“Two-step” surgical design can reduce the incidence of postoperative ischemic lesions and perioperative complications， which is safe and feasible in clinical application.

Key words: Pancreatic neoplasms, Locally advanced stage, Neoadjuvant chemotherapy, Conversion therapy, Modified Appleby, Two-step, Distal pancreatectomy with celiac axis resection (DPCAR)