Pancreatectomia distal com ressecção em bloco do tronco celíaco para adenocarcinoma de corpo de pâncreas localmente avançado (operação de Appleby): relato de caso

Abstract

Pancreatic cancer remains one of the most feared of the gastrointestinal tract malignancies. The only reasonable chance for long-term survival is curative surgical resection, although this treatment is appropriate for only a small minority of patients because the majority present with advanced disease. Less than 20% of patients with adenocarcinoma of the neck, body and tail of the pancreas have resectable lesions. The standard resection for tumors of the body and tail of the pancreas is a distal pancreatectomy with concomitant splenectomy10,11,12. Most patients lose the chance for surgical resection because of distant metastases, regional invasion into adjacent organs, or involvement of major vessels. Tumor involvement of common hepatic artery and/or celiac trunk is one of the main reasons which preclude radical resection10. Fortner introduced the concept of regional pancreatectomy with vascular resection, describing type I and II where venous or arterial segment were resected, respectively5. However, distal pancreatectomy with en-bloc resection of the celiac trunk has broadened the operative spectrum in pancreatic surgery. This procedure was first reported by Appleby in 1953 to achieve complete nodal clearance around the celiac trunk for advanced gastric cancer2. Subsequently, Mayumi et al. and Kimura et al. adopted this approach with or without the preservation of the stomach for locally advanced adenocarcinoma of pancreatic body8,9. Recent reports from expert centers showed clearly that vascular resection did not increase morbidity and mortality, and can offer these patients the possibility of radical surgery3,4,6. Nonetheless, the presence of vascular invasion on preoperative staging is still considered by many as a contraindication for surgery and the concept of resection of the celiac trunk also implies the risk of relevant hepatic or gastric ischemia.11 Revascularization strategies have recently been described to assure the preservation of the hepatic arterial flow and to avoid hepatobiliary complications, such as liver necrosis, liver abscesses, gallbladder necrosis or cholecystitis. In these situations the revascularization from the celiac trunk to the hepatic artery using prosthesis would be useful when compromised hepatic flow is detected during the operation4,14. The aim of this study is to present a case of pancreatic body cancer invading the celiac trunk treated by extended distal pancreatectomy with enbloc resection of the celiac trunk and revascularization using prosthesis.