Treatment strategy for pancreatic head cancer with celiac axis stenosis in pancreaticoduodenectomy: A case report and review of literature

• Published in: World journal of gastroenterology : WJG Vol. 28; no. 8; pp. 868 - 877
• Main Authors: Yoshida, Eiji, Kimura, Yasutoshi, Kyuno, Takuro, Kawagishi, Ryoko, Sato, Kei, Kono, Tsuyoshi, Chiba, Takehiro, Kimura, Toshimoto, Yonezawa, Hitoshi, Funato, Osamu, Kobayashi, Makoto, Murakami, Kenji, Takagane, Akinori, Takemasa, Ichiro
• Format: Journal Article
• Language: English
• Published: United States Baishideng Publishing Group Inc 28.02.2022
• Subjects: Aged; Arterial Occlusive Diseases - etiology; Case Report; Celiac Artery - diagnostic imaging; Celiac Artery - surgery; Constriction, Pathologic - etiology; Humans; Male; Pancreatic Neoplasms - complications; Pancreatic Neoplasms - surgery; Pancreaticoduodenectomy - adverse effects; Median arcuate ligament; Endovascular stenting; Case report; Pancreaticoduodenectomy; Celiac axis stenosis; Pancreatic head cancer
• ISSN: 1007-9327; 2219-2840
• DOI: 10.3748/wjg.v28.i8.868

During pancreaticoduodenectomy in patients with celiac axis (CA) stenosis due to compression by the median arcuate ligament (MAL), the MAL has to be divided to maintain hepatic blood flow in many cases. However, MAL division often fails, and success can only be determined intraoperatively. To overcome this problem, we performed endovascular CA stenting preoperatively, and thereafter safely performed pancreaticoduodenectomy. We present this case as a new preoperative treatment strategy that was successful. A 77-year-old man with a diagnosis of pancreatic head cancer presented to our department for surgery. Preoperative assessment revealed CA stenosis caused by MAL. We performed endovascular stenting in the CA preoperatively because we knew that going into the operation without a strategy could lead to ischemic complications. Double-antiplatelet therapy (DAPT) - which is needed when a stent is inserted - was then administered in parallel with neoadjuvant chemotherapy (NAC). This allowed us to administer DAPT for a sufficient period before the main pancreaticoduodenectomy procedure while obtaining therapeutic effects from NAC. Subtotal stomach-preserving pancreaticoduodenectomy was then performed. The operation did not require any unusual techniques and was performed safely. Postoperatively, the patient progressed well, without any ischemic complications. Histopathologically, curative resection was confirmed, and the patient had no recurrence or complications due to ischemia up to six months postoperatively. Preoperative endovascular stenting, with NAC and DAPT, is effective and safe prior to pancreaticoduodenectomy in potentially resectable pancreatic cancer.