Artery-first Approach for Distal Pancreatectomy with Celiac Axis Resection.

BACKGROUND: Distal pancreatectomy with celiac axis resection (DP-CAR) is essential for achieving R0 resection in pancreatic body cancer but carries mortality rates up to 11%.1-3 Although the artery-first approach minimizes blood loss and facilitates early resectability assessment in pancreaticoduodenectomy,4 reports on its application in DP-CAR remain limited.5 This study describes our artery-first DP-CAR technique and evaluates short-term perioperative outcomes. METHODS: This retrospective, single-center study analyzed consecutive patients undergoing artery-first DP-CAR between 2019 and 2025. The surgical technique utilizes a right-sided approach following a Kocher maneuver. The superior mesenteric artery is isolated first. Subsequently, the celiac artery (CA) is taped, sparing the inferior phrenic artery, and clamped for early inflow control. Clinical and perioperative outcomes were analyzed. RESULTS: Of the 14 patients analyzed, the median operation time was 469 min, and the median blood loss was 286.5 mL. Early assessment of tumor resectability was achieved in all patients. Although early arterial inflow control was successfully achieved in the 12 patients, two patients were identified as statistical outliers regarding blood loss. In these cases, accidental release of the initial CA clamp as surgery progressed caused a loss of inflow control, leading to increased hemorrhage associated with intraoperative splenic congestion. R0 resection was achieved in all patients. The overall 90-day mortality rate was 0%. CONCLUSIONS: Precise anatomical understanding is essential for the artery-first approach in DP-CAR. This approach may enable effective reduction of blood loss through early inflow control and early-stage assessment of tumor resectability.