Technical Article
Iliac–hepatic arterial bypass for compromised collateral flow during modified Appleby operation for advanced pancreatic cancer

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Abstract

Involvement of the celiac trunk and common hepatic artery are two of the most common forms of vascular invasion by tumours of the distal pancreas, and until recently this finding was considered a contra-indication to resection. We described a modified Appleby operation for locally advanced distal pancreatic cancer with compromised hepatic collateral flow that needed hepatic arterial revascularization, successfully accomplished by left external iliac–hepatic arterial bypass with Dacron prosthesis. Patient recovery was uneventful and he was discharged on the 10th postoperative day. Postoperative angio-CT disclosed a patent arterial bypass. Patient is well and asymptomatic 13 months after operation. At the time of this writing, postoperative CT scan showed no evidence of disease and CA 19-9 level is normal. There is a well established rationale to perform extended resection of pancreatic carcinomas that compromise vascular structures. Modified Appleby procedure can safely be performed, has oncological advantages to palliative procedures and provides relief of pain but is reserved for selected patients. Preservation of hepatic arterial flow has utmost importance to avoid hepatobiliary complications as liver necrosis, liver abscess, gallbladder necrosis or cholecystitis. In this case, hepatic revascularization was particularly challenging, but was successfully accomplished by left external iliac--hepatic arterial bypass. To our knowledge this type of arterial bypass has never been described so far in the English literature and its description may be important for surgeons dealing with advanced pancreatic cancer.

Introduction

Despite advances in chemotherapy and trend towards more aggressive surgical resection, long-term prognosis of pancreatic adenocarcinoma remains poor.1 Involvement of the celiac trunk and common hepatic artery are two of the most common forms of vascular invasion by tumours of the distal pancreas, and until recently this finding was considered a contra-indication to resection. In 1953, Appleby proposed en bloc resection of the celiac trunk with distal pancreatectomy and total gastrectomy for the treatment of locally advanced gastric cancer.2 This operation was first adapted to the resection of tumours of the body and tail of the pancreas in 1976, by Nimura.3 In 1991, Hishinuma performed two distal pancreatectomies with resection of the celiac axis with gastric preservation, named the modified Appleby procedure.1, 4

We described a case of a modified Appleby operation for locally advanced distal pancreatic cancer with compromised hepatic collateral flow that needed hepatic arterial revascularization, successfully accomplished by left external iliac–hepatic arterial bypass with Dacron prosthesis. To our knowledge this type of arterial bypass has never been described so far in the English literature and its description may be important for surgeons dealing with advanced pancreatic cancer.

Section snippets

Preoperative evaluation

A 71-year-old man with pancreatic body cancer after neoadjuvant gemcitabine-based chemotherapy was referred for surgical treatment. Abdominal CT scan was performed and showed a locally advanced tumour (Fig. 1). Complete tumour screening including chest CT and positron emission tomography (PET–CT) was performed and discarded extrapancreatic disease. Laboratory tests were all within normal range, except for increased CA 19-9 level.

Detailed analysis of a sequence of abdominal CT scans performed

Outcome

Patient did not receive transfusion and recovery was uneventful. Patient was discharged on the 10th postoperative day. Abdominal drain was removed on the 12th postoperative day. Postoperative angio-CT disclosed a patent arterial bypass (Fig. 3). Patient is well and asymptomatic 13 months after operation. At the time of this writing, postoperative CT scan showed no evidence of disease and CA 19-9 level is normal.

Background

Modified Appleby procedure has been successfully performed for locally advanced distal pancreatic cancer with involvement of the celiac axis and some long-term survivals have been reported.9, 10, 11 This technique is also efficient to control abdominal and back pain resulted from involvement of the celiac ganglia by pancreatic tumours.6 Furthermore, several studies have suggested that R0 resections are associated with significant improvement in survival when compared to palliative therapy and

Conclusion

There is a well established rationale to perform extended resection of pancreatic carcinomas that compromise vascular structures. Modified Appleby procedure can safely be performed, has oncological advantages to palliative procedures and provides relief of pain but is reserved for selected patients. Preservation of hepatic arterial flow has utmost importance to avoid hepatobiliary complications as liver necrosis, liver abscess, gallbladder necrosis or cholecystitis.3, 13 In this case, hepatic

Conflict of interest

The authors state that they have no conflict of interest.

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