Total Pancreatectomy for Locally Advanced Pancreatic Adenocarcinoma with Coeliac Trunk Resection and Retrograde Gastric Revascularization Through Aorto-Hepato-Spleno Allograft.

Abstract

Background: Locally advanced pancreatic adenocarcinomas (LA-PDAC) are more frequently operated now than in the past because of new regimen chemotherapy and improvement in surgical technique.¹ Resection of the coeliac trunk (CT) during pancreatoduodenectomy (PD) or total pancreatectomy (TP) is not routinely done owing to the risk of liver and gastric ischaemia.² In this video, a patient with LA-PDAC underwent TP with CT resection and retrograde gastric revascularization through the distal splenic artery.

Patients and methods: A 57-year-old male with LA-PDAC at the head-neck junction with circumferential invasion of the CT and the mesentericoportal axis showed excellent response to chemotherapy (FOLFIRINOX, 12 cycles) and radiotherapy (54 Gy) with normalization of tumour markers. One year later, TP instead of PD was decided to avoid postoperative pancreatic fistula.³ An allograft (en Y) from bank vessels was anastomosed between the aorta and the propre hepatic artery. For gastric revascularization and to avoid the small left gastric artery, the arterial anastomosis was done on the distal part of the splenic artery, allowing retrograde vascularization through short gastric vessels. Segmental venous resection was done.

Results: Venous and arterial liver ischaemia times were 11 min and 31 min, respectively. The postoperative outcome showed asymptomatic pseudoaneurysm on the hepatic anastomosis. Pathology confirmed T1cN1R0. Nine months after surgery, no recurrence was observed.

Conclusion: CT resection may be needed during PD. If the right gastric pedicle cannot be preserved, retrograde gastric revascularization through the splenic artery is an important technical modification. The availability of allografts from bank vessels is very useful, and the outcome is mitigated by TP.