Distal Pancreatectomy with Celiac Axis and Venous Resection with Hepatic Artery and Venous Reconstruction (DP-CARV) for Locally Advanced Pancreatic Adenocarcinoma.

Abstract

Background: Surgery has recently been introduced into the multimodal management of patients with locally advanced pancreatic adenocarcinomas (LAPCs) thanks to the major pathological response seen with the advent of the multiagent regimen FOLFIRINOX. Distal pancreatectomy with celiac axis resection (DP-CAR) may be complicated by ischemic liver and gastric events.^1,2 Common hepatic artery reconstruction may prevent the occurrence of ischemic complications and can be an alternative to preoperative embolization of the celiac trunk.³ METHODS: The patient was a 65-year-old with LAPC of the pancreatic body, with infiltration of the celiac trunk, the splenoportal venous confluence, and the Treitz angle. Preoperative induction chemotherapy with FOLFIRNOX was administered over 12 cycles, resulting in radiological stability and normal carbohydrate antigen (CA) 19-9 levels. Positron emission tomography showed isolated activity of the tumor without distant metastasis. A DP-CARV procedure was performed, and a single saphenous graft was used to reconstruct the common hepatic artery and to create a venous patch to repair the venous confluence. The angle of the Treitz, along with the third and fourth duodenum, were resected and a duodenojejunal anastomosis on the second duodenal portion was performed. The left gastric artery was not reconstructed.

Results: Postoperative course was favorable but was complicated by a hematoma of the right groin necessitating evacuation. Pathology showed a pT4N2R0 pancreatic adenocarcinoma. The postoperative computed tomography scan showed no collection and patency of reconstructed vessels. Six months later, the patient is alive and disease-free, with patent reconstructed vessels.

Conclusions: Common hepatic artery reconstruction during DP-CAR represents a safe surgical option to reduce ischemic events related to celiac trunk resection, particularly in the FOLFIRINOX era. This technique integrated the surgical armamentarium of surgeons dealing with LAPC.