Stomach preservation in pancreatectomy with celiac axis resection: Prediction and technique via Mayo Clinic classification

Objective: To validate the Mayo Clinic classification for predicting gastric preservation in pancreatectomy with celiac axis resection, identify key technical factors, and show that, after the learning curve, gastric preservation is feasible even in high-risk cases when specific vascular preservation or reconstruction techniques are applied. Background: Neoadjuvant therapy has made locally advanced pancreatic tumors resectable, but vascular invasion poses technical challenges, especially for preserving the stomach during pancreatectomy with celiac axis resection. Methods: Retrospective review of a single-center prospective database. Results: Among 236 pancreatectomies with arterial resection, 81 were pancreatectomy with celiac axis resection (32 distal, 39.5%; 49 total, 60.5%). The celiac axis was resected alone in 31 patients (38%) or with other vessels (62%). Gastrectomy was required in 23 patients (28.4%) because of tumor adherence (13.6%) or gastric ischemia (14.8%). Severe complications occurred in 16 patients (19.8%), with 5 deaths (6.3%) reported. After excluding 11 oncologic gastrectomies, 70 patients were eligible for analysis; 34 (48.6%) were high risk. Gastrectomy occurred in 12 patients (17.1%), more frequently in high- compared with low-risk cases (26.5% vs 8%; P = .0594). The learning curve was completed after 27 procedures. Before this threshold, gastric preservation rates were greater in low-risk patients (84.2%) than high-risk ones (25.0%) (P = .0061). After learning curve, the difference was not significant (100% vs 88.5%). Independent predictors of gastric preservation included preserved/reconstructed arteries (odds ratio, 14.09; P = .0058) and preservation or reconstruction of the left gastric vein (odds ratio, 36.38, P = .0083). Conclusion: The Mayo Clinic classification accurately predicts gastric preservation feasibility in the absence of vascular-preservation strategies. After learning curve, gastric preservation can be achieved even in high-risk patients through targeted vascular preservation or reconstruction.