Proper and left hepatic artery bypass for resection of pancreatic mass involving the celiac axis

Abstract

A healthy 40-year-old woman presented with progressive weight loss during two pregnancies and was found to have a 4.3-cm mass in the body of the pancreas encasing the celiac axis and the splenic and hepatic arteries. Biopsy revealed adenocarcinoma. She underwent chemoradiation, which resulted in decrease in tumor size during 1 year, but it still encased the celiac axis. Preoperative computed tomography scan illustrated encasement of the celiac axis by the tumor (A; the arrow indicates pancreatic mass). She was referred for surgical resection, considering the tumor's stable biologic behavior. A modified Appleby procedure was planned, involving resection of the celiac axis, which entails relying on retrograde flow through the gastroduodenal artery to the proper hepatic artery for perfusion of the liver. 1 However, during the operation, it became evident that she had abnormal hepatic artery anatomy; a replaced left hepatic artery originated directly from the celiac axis, and the proper hepatic artery supplied the right hemiliver. The gastroduodenal artery was small and did not maintain pulsatile hepatic flow when the common hepatic artery was clamped. An arterial bypass to both the left and proper hepatic arteries was thus required for resection of the tumor, which involved both arteries at their origins from the celiac axis. A bifurcated 6-mm ringed polytetrafluoroethylene graft was created in a Y configuration, and the proximal bypass anastomosis was performed in an end-to-side fashion to the right common iliac artery. 2 The graft was laid in the retroperitoneum, and the distal anastomoses were performed in an end-to-end fashion from each of the bifurcated graft limbs to the replaced left and proper hepatic arteries; the graft was protected with an omental flap. An intraoperative photograph of iliohepatic bypass reconstruction is shown in B (the yellow arrow indicates right common iliac artery anastomosis; the white arrows indicate hepatic artery anastomoses). A three-dimensional reconstruction of postoperative computed tomography scan showed patent iliohepatic bypass (D/Cover). The operation was completed with a distal pancreatectomy and splenectomy. The patient did well postoperatively. Pathologic examination revealed a 3.5-cm adenocarcinoma with one positive lymph node, encasement of the celiac axis, and negative margins. Photograph of the patient's tumor specimen, with the arrow indicating encased celiac axis, can be seen in C. The patient suffered a

Aorta to proper hepatic artery bypass with total pancreatectomy and celiac axis resection (TP-CAR) in a patient with locally advanced pancreas adenocarcinoma

“…Such cases represent a very slim subgroup in the published experience with CARs in the English literature: Eight appear as case reports [3] , [4] , [5] , [6] , [7] , [8] , [9] , and 23 as small subgroups within larger studies [10] , [11] , [12] , [13] , [14] , summing up 31 patients altogether. Recently, the first attempt at CAR classification was published [15] .…”

“…The limited published experience on perioperative mortality of pancreatectomy, CAR, and aorto-PHA by-pass provides evidence that it is not high, at 0–7 % [1] , [2] , [3] , [4] , [5] , [6] , [8] , [9] , [10] , [11] , [12] , [13] , [15] . EBL may vary from 105 mL to 1250 mL [6] , [7] , [11] , OR time can be long (660–1035 min) [6] , [7] , [11] , and hospitalization extended: 16 [4] , 19 [3] , 30 [8] , 49 [12] , 73 [6] , or 92 [7] days.…”

“…Such cases are very rare in the literature. They appear as reports of a single patient [3] , [4] , [5] , [6] , [7] , [8] , or two patients [9] . Even in series with a significant number of arterial resections, these particular types of cases remain rare: one [10] , two [11] , five [12] , seven [13] , or eight patients [14] .…”