Pancreaticoduodenectomy with common hepatic artery and portal vein resection for locally advanced pancreatic cancer

Abstract

Background: Major arterial involvement used to be considered as a contraindication for resection for locally advanced pancreatic cancer because of its poor long-term outcomes. However, in the era of modern effective chemotherapeutic regimens, the role of arterial resection is to be evaluated. Herein, we illustrate the case of the patients with locally advanced pancreatic cancer with both common hepatic artery (CHA) and portal vein (PV) involved, who underwent successful pancreaticoduodenectomy (PD) with CHA resection and PV resection/reconstruction following preoperative systemic chemotherapy. Methods: The patient was a 74-year-old woman who presented with back pain and elevated CA19.9. The work-up revealed locally advanced pancreatic cancer with CHA involvement. The tumor was deemed unresectable and she received systemic chemotherapy with gemcitabine and nab-paclitaxel with partial response. Given the lack of disease progression, radical resection with major vascular resection/reconstruction was planned. Results: She had a abberant replaced left hepatic artery branching off the left gastric artery and thus CHA was embolized preoperatively to allow collateral arterial flow to the right liver to develop. The radical resections included subtotal stomach preserving PD with CHA resection and PV/splenic vein resection with reconstruction. Splenic venous drainage was reestablished by creating splenorenal shunt. The operative time was 544 minutes and the estimated blood loss was 690 cc. The final pathological stage was pT3N1M0 and all the surgical margins were negative for cancer. Her post-operative course was uneventful. Conclusion: PD with arterial resection for locally advanced pancreatic cancer is technically feasible and the selection criteria for this aggressive operation should be re-defined in the era of modern effective chemotherapy.