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Background Pancreaticoduodenectomy after esophageal resection is technically difficult, because blood flow of the gastric conduit should be preserved. Celiac axis stenosis (CAS) is also a problem for pancreaticoduodenectomy, because arterial blood supply for the liver comes mainly through the collateral route from the superior mesenteric artery (SMA) via the gastroduodenal artery (GDA). Herein, we report the case of a patient with pancreatic head cancer who underwent a pancreaticoduodenectomy after esophagectomy with concomitant CAS. Case presentation A 76-year-old man with pancreatic head cancer was referred to our department. He had a history of esophagectomy with retrosternal gastric conduit reconstruction for esophageal cancer. Computed tomography showed severe CAS and a dilated collateral route between the SMA and the splenic artery (SPA). We prepared several surgical options depending on the intraoperative findings, and performed radical pancreaticoduodenectomy with concomitant resection of the distal gastric conduit. The right gastroepiploic artery (RGEA) of the remnant gastric conduit was fed from the left middle colic artery (MCA) with microvascular anastomosis. Despite CAS, when the GDA was dissected and clamped, good blood flow was confirmed, and the proper hepatic artery did not require reconstruction. The patient was discharged on postoperative day 90. Conclusions We successfully performed radical pancreaticoduodenectomy after esophagectomy with concomitant CAS, having prepared multiple surgical options depending upon the intraoperative findings.

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Pancreatic mucinous cystic neoplasm (MCN) has two histological components: tumor epithelia and ovarian-like stroma (OLS). To examine the progression and changes in pancreatic MCNs, we analyzed the distribution, amount, immunohistochemical phenotype, presence of theca cells of OLS, and tumor epithelium in 45 surgically resected MCN cases, comparing them with tumor sizes. The OLS data of female MCN cases were also compared between those who were ≤ 51 years old and those > 51 years old to see the effect of menopause on MCN histology. Non-mucinous type epithelium was present in all low-grade MCNs, but its ratio decreased with tumor size (p < 0.001), suggesting that epithelial mucinous changes are a progression phenomenon. The intralobular distribution of OLS was observed in 28.8% of MCN cases and was related to smaller tumor size (p < 0.0001), suggesting intralobular involvement of early MCNs. The nuclear expression of β-catenin and the cytoplasmic expression of α-smooth muscle actin (SMA) was observed in almost all OLS. OLS tended to be lesser among female cases aged > 51 years than those ≤ 51 years old, however it did not reach statistical significance. This is the first study to show the intralobular distribution of OLS.

Pancreatic mucinous cystic neoplasm (MCN) harbors two histological components, tumor epithelia and ovarian-like stroma (OLS). To examine the tumorigenesis of pancreatic MCNs, this study analyzed the distribution, amount, immunohistochemical phenotype, presence of theca cells of the OLS, and the alteration of tumor epithelium of 29 surgically resected MCN cases and compared them with tumor sizes. Non-mucinous type epithelium was present in all low-grade MCNs but its ratio decreased with tumor size (p < 0.05), suggesting that epithelial mucinous changes are a progression phenomenon. The intralobular distribution of OLS was observed in 27.6 % of MCN cases and its existence related to a smaller size (p< 0.05), suggesting intralobular generation of MCNs. Nuclear expression of β-catenin was observed for OLS of everywhere, suggesting consistent activation of the Wnt pathway for OLS. Three MCN cases (10.3%) contained a-smooth muscle actin (SMA)-negative OLS, where OLS surrounding dilated pancreatic ducts or MCN cysts were a-SMA-positive and otherwise negative, suggesting that a-SMA-positivity is an acquired phenomenon of OLS. With this study, we could hypothesize that pancreatic MCNs may generate intralobularly. Epithelial mucinous change and a-SMA-positivity of OLS may be progression phenomena. This is the first study to show the intralobular distribution of OLS.