Abstract
Abstract Background: A modified Appleby procedure for pancreatic body tumors relies upon collateral vessels maintaining blood flow to the proper hepatic artery (PHA) through the pancreaticoduodenal arcade (PDA) off of the superior mesenteric artery (SMA). Compression of the celiac axis by the median arcuate ligament (MAL) promotes the expansion of collateral vessels without preoperative intervention. Case Presentation: A 51-year-old male with asymptomatic compression of the celiac artery presented with new onset insulin-dependent diabetes mellitus. He underwent imaging that demonstrated a locally advanced pancreatic body tumor that encased the superior mesenteric vein and portal vein confluence and involved the common hepatic artery. He had an adequate response to neoadjuvant FOLFIRINOX chemotherapy and underwent an uncomplicated modified Appleby procedure with a margin negative resection. Hepatic blood flow was adequate through the PHA as a result of collateralization of blood flow through the PDA off th...
Highlights
A modified Appleby procedure for pancreatic body tumors relies upon collateral vessels maintaining blood flow to the proper hepatic artery (PHA) through the pancreaticoduodenal arcade (PDA) off of the superior mesenteric artery (SMA)
This is a unique case in which compression of the celiac axis by the median arcuate ligament (MAL) may have led to the advantageous development of enlarged collateral vessels from the SMA through the PDA
The vascular anatomy obviated the need for preoperative common hepatic artery (CHA) embolization and allowed for a successful margin negative modified Appleby procedure without complication
Summary
The modified Appleby procedure involves distal pancreatectomy with en bloc splenectomy and en bloc celiac axis resection for locally advanced tumors of the body and tail of the pancreas. Presentation A 51-year-old male presented with newly diagnosed insulin-dependent diabetes mellitus and a markedly elevated Hgb-A1C Evaluation for this condition by computerized tomography (CT) scan revealed a central pancreas tumor encasing the superior mesenteric vein (SMV) and portal vein (PV) confluence and abutting the celiac axis (involving the CHA). The proximal celiac artery origin was flattened toward the aorta with evidence of post-stenotic dilatation, likely secondary to compression by the MAL (Fig. 2) His laboratory values after neoadjuvant therapy and the initiation of insulin therapy were notable for a CA19-9 of 55 U/mL (down from 527 U/mL) and a Hgb-A1C of 5.8% (down from 11.7%).
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