Appleby procedure – a challenging interdisciplinary treatment for extensive pancreatic body cancer

Abstract

Background: Locally advanced pancreatic body cancer with invasion of the celiac axis is a severe finding that only rarely can undergo curative resection. Methods: We here present a video highlighting the crucial steps of a modified Appleby procedure. A 52-year old patient presented with a mass in pancreas body and infiltration of the celiac axis (CA) and splenic artery (SA). Results: Preoperative angiography and embolization of the common hepatic artery (CHA) is imperative to assure an adequate retrograde hepatic blood inflow via the gastroduodenal arcade. Occasionally, it is necessary an additional embolization of a hypertrophic right gastric artery to avoid flow steal phenomenon, as in this case. The patient underwent radical curative resection after neoadjuvant chemoradiation. Surgery started with mobilization of the tail of the pancreas and spleen. Dissection of hepatoduodenal ligament and identification of the junction of gastroduodenal artery (GDA) and hepatic artery is of utmost importance. For safety reasons, it is recommendable to preliminary clamp the common hepatic artery and to prove a sufficient hepatic arterial flow by Doppler ultrasound. The common hepatic artery is then divided proximal of the junction with the GDA. CA was ligated at the level of the aorta and resected en-bloc with the specimen of distal pancreas and spleen. Conclusion: The intra- and postoperative course was uneventful; the patient could be discharged on postoperative day eleven. The histopathological findings showed an R0 resection.