Some reflexions on the modified Appleby procedure

Resection of pancreatic cancer with vascular invasion is a controversial issue, especially when the arterial trunks, such as the celiac axis, are involved. The modified Appleby procedure deals with the problem of encasement of the celiac trunk. Two patients with locally advanced pancreatic cancer are reviewed: a 65-year-old female and a 78-year-old male with pancreatic cancer and involvement of the celiac trunk and hepatic artery. The male patient received neoadjuvant chemoradiation. The former underwent an extended pancreatectomy with en-bloc resection of the hepatic artery, celiac trunk, gastric serosa and adrenal gland. Liberation of arterial trunk involvement in the second patient was performed. The margins were microscopically clear of tumor (R0) in both patients. The second patient died from cholecystitis owing to arterial insufficiency. CT vascular encasement is not always synonymous with real tumoral vascular invasion. Improvement in the quality of anesthesiological and surgical techniques has allowed vascular resections with lower morbidity. A cholecystectomy should always be performed using the modified Appleby procedure.