Enhanced Vascular Collateralization Through the Pancreaticoduodenal Arcade Secondary to Median Arcuate Ligament Compression of the Celiac Axis in the Setting of Pancreatic Body Adenocarcinoma: The Ideal Scenario for the Modified Appleby Procedure.

Abstract

Background: A modified Appleby procedure for pancreatic body tumors relies upon collateral vessels maintaining blood flow to the proper hepatic artery (PHA) through the pancreaticoduodenal arcade (PDA) off of the superior mesenteric artery (SMA). Compression of the celiac axis by the median arcuate ligament (MAL) promotes the expansion of collateral vessels without preoperative intervention. Case Presentation: A 51-year-old male with asymptomatic compression of the celiac artery presented with new onset insulin-dependent diabetes mellitus. He underwent imaging that demonstrated a locally advanced pancreatic body tumor that encased the superior mesenteric vein and portal vein confluence and involved the common hepatic artery. He had an adequate response to neoadjuvant FOLFIRINOX chemotherapy and underwent an uncomplicated modified Appleby procedure with a margin negative resection. Hepatic blood flow was adequate through the PHA as a result of collateralization of blood flow through the PDA off the SMA. The enhanced collateralization appeared to have occurred secondary to compression of the celiac axis by the MAL. Conclusions: Herein we present a unique case in which improved collateral blood flow through the PDA and the gastroduodenal artery to the PHA occurred due to celiac artery compression by the MAL. This vascular anomaly fortuitously improved the ability to achieve an R0 resection of a locally advanced pancreatic adenocarcinoma of the body of the pancreas by a modified Appleby procedure.