The necessity for preoperative coil embolization remains controversial. Several investigators have reported DP-CAR without preoperative coil embolization of the common hepatic artery (CHA) [14]. However, several severe accidents occurred intraoperatively or at the early phase after surgery, it may decrease the risk of critical ischemia-related complications. The safety and efficacy issues are essential to be evaluated in clinical trials. Preoperative coil embolization of the CHA should be performed as collaborative work between the surgeons and interventional radiologists. Surgeons should precisely indicate the planned ligation/division site to the interventional radiologists while the latter ensure that the coil is safely placed in the requested position without causing coil migration into the arteries that are intended to be preserved [41, 42]. The diameter of the inferior pancreaticoduodenectomy usually increases about 1.5–2 times from the procedure.

The surgical instruments used in DP-CAR are basically similar to those of ordinary pancreatic resection. The aortic clamps should be prepared in case of injury or short ligation margin of celiac trunk. Doppler ultrasonography should be routinely prepared for intraoperative evaluation of intrahepatic arterial and portal flow. Where there is a need to suture damaged aortic wall around the root of celiac axis, 6-0 prolene^® with nonabsorbable pad made of polytetrafluoroethylene called pledget^® (Covidien, USA) are helpful to decompress the damage from arterial suture.

The specific procedure for DP-CAR is as follows: firstly, the right gastroepiploic artery/vein and right gastric artery/vein are encircled by vessel tape for preservation purpose. Before the transection of the neck of the pancreas, the bifurcation of the gastroduodenal artery (GDA) and the common hepatic artery (CHA) are first to be exposed, followed by the exposure of the origin of the proper hepatic artery (PHA). At this point, it is necessary to harvest the periarterial nerve plexus around the bifurcation to confirm negative cancer cell infiltration. This is to evaluate the resectability in patients whose tumor is adjacent this region. Kocher’s maneuver should be performed in case of accidental bleeding from the portal venous system. The gastrocolic trunk is preserved for venous returning from the stomach. Transection of the pancreas is performed with wide surgical margin from the tumor to confirm negative cancer cell infiltration. In patients whose tumor involves the portal vein, the resection and reconstruction of the portal vein are performed antecedently. After the pancreatic transaction, the dissection of the retroperioteum must be performed from the right side to the left side in the manner of a radical antegrade modular pancreatosplenectomy procedure. This is because the surgical field for this procedure is better and safer for surgeon and assistant in case of accidental bleeding [43]. By en bloc dissecting the lymph nodes around the CHA, the right celiac ganglion and celiac nerve plexus (the origin of the celiac axis) is exposed. Then, palpation is performed to confirm blood flow through the PHA, the right gastric artery, and the right gastroepiploic artery. Intrahepatic arterial flow is also checked by intraoperative Doppler ultrasonography after clamping the end of the CHA in patients who had undergone preoperative embolization of the CHA. The CHA is divided just proximal to the origin of the GDA (Fig. 14.3). In cases with dog-leg branching of PHA and GDA, both arteries are preserved by carefully avoiding the ligation of bifurcation site (Figs. 14.4 and 14.5). Lifting the cut end of the distal pancreas and the CHA into the left caudal side, the superior mesenteric artery (SMA) is dissected from the surrounding lymph node and nerve plexus toward its origin. The inferior pancreaticoduodenal artery (IPDA) arising from the SMA or the first jejunal artery is carefully preserved. The dissecting layer around the SMA is connected to that of the celiac axis (CA) from the caudal side to dorsal side. The origin of the celiac axis is identified circumferentially just above the aorta and as divided. It is important to note the origin and the direction of inferior phrenic arteries when dissecting around the CA in front of the aorta (Fig. 14.6).

The rate of morbidity after this procedure is not low as shown in Table 14.2. The presence of postoperative hemorrhage from the resected stump of the common hepatic artery due to a pancreatic fistula after DP-CAR is difficult to rescue using interventional radiology (IVR) techniques because of the common hepatic artery resection. To that end, a novel procedure to reduce the risk of pancreatic fistula formation is urgently needed for DP-CAR. This is especially the case for patients with thick pancreatic parenchyma, in which the pancreatic transection with a large cross-section surface is usually located on the right side of the portal vein [44, 45]. In addition, DP-CAR is associated with significant morbidities such as severe gastropathy or hepatic ischemia. Total gastrectomy is performed if severe ischemia of the stomach is observed during operation and if surgeons could not exclude the possibility of future necrosis of the remnant stomach in several institutions. Unplanned arterial reconstruction is required in patients with accidental injury [2]. The possible ischemic gastropathy includes irregular, shallow, and wide ulcerations usually in the cardia of the stomach thought to be ischemic in the origin and delayed gastric emptying after surgery. We experienced ischemia of the stomach which required total gastrectomy in a patient who underwent DP-CAR on the postoperative day 2 (Fig. 14.7a, b). Particular care should be taken for simultaneous division of the left gastric and left inferior phrenic arteries for the progress of stomach ischemia intra/postoperatively. The issue would directly affect the postoperative recovery and the schedule for adjuvant chemotherapy. On hepatic ischemia, recent studies reported low incidence of clinically relevant hepatic infarction requiring drainage of abscess, and that abnormal liver function are usually observed to recover within several days. However, there is no evidence of decreased risk of these ischemia-related complications from preoperative embolization of the common hepatic artery. Preoperative angiography should be carried out and variations of the inferior pancreaticoduodenal artery (IPDA) should be examined to ensure safety of the procedure. Postoperative necrotic cholecystitis occurrence is also reported potentially due to the spasm of the gastroduodenal artery and/or proper hepatic artery reported from various institutions (Fig. 14.8). One main concern is the onset of diarrhea after the removal of the plexus around the celiac axis and the superior mesenteric artery. This is because diarrhea would influence the nutritional status and quality of life after surgery. In many studies, diarrhea after this procedure is reported to be within a controllable degree to maintain QOL and nutritional status by medication, usually with loperamide hydrochloride, and occasionally with a tincture of opium [2].