Splenic artery transposition for hepatic arterial reconstruction in conversion surgery of an initially unresectable, locally advanced pancreatic cancer after gemcitabine/nab-paclitaxel: A case report

Abstract

Introduction and importance: Recent advances in chemotherapy and chemoradiotherapy allow performance of conversion surgery by improving tumor shrinkage in select patients with initially unresectable locally advanced pancreatic cancer (LAPC), thereby providing curative potential. The number of conversion surgeries requiring arterial reconstruction for select patients with initially unresectable LAPC following favorable responses is expected to increase, so providing effective options for safe arterial reconstruction is critical.

Case presentation: Herein we report a case of successful conversion surgery for initially unresectable LAPC with splenic artery transposition for hepatic arterial reconstruction after gemcitabine/nab-paclitaxel (GnP). A 71-year-old woman was referred to our hospital for evaluation of a pancreatic head mass after developing diabetes. She was diagnosed with unresectable LAPC, which was in wide contact with the common hepatic artery (CHA), proper hepatic artery (PHA), and splenic artery (SA). She received GnP, and after 6 cycles, durations of disease control and normalization of serum carbohydrate antigen 19-9 (CA19-9) exceeded 7 months. She underwent radical subtotal stomach-preserving pancreaticoduodenectomy with CHA-PHA and portal vein (PV) resection (SA-right hepatic artery anastomosis/PV-superior mesenteric vein direct end-to-end anastomosis). Histopathological examination revealed R0 resection with a histological response of Evans grade IIB. No signs of tumor recurrence have been observed for 14 months postoperatively.

Clinical discussion: No consensus has been reached regarding the optimal treatment regimen, duration, or criteria for conversion surgery in patients with LAPC, especially in cases requiring arterial resection. SA transposition for hepatic arterial reconstruction is generally very consistent, easily accessible, and offers adequate length and diameter for successful arterial anastomosis.

Conclusion: Even for a SA initially in contact with the tumor, SA transposition for hepatic artery reconstruction is a safe and effective option when tumor contact disappears due to chemotherapy.

Keywords: Case report; Conversion surgery; Hepatic arterial resection; Pancreatic cancer.

Fig. 1

Images from pre- and post-chemotherapy coronal enhanced computed tomography. T: tumor; yellow arrow: CHA; yellow arrowhead: PHA; red arrowhead: SA. a, d) Before GnP chemotherapy. The tumor is in wide contact with the CHA, PHA, and SA. b, e) After 2 cycles of GnP. Distance between the tumor and SA is slightly increased. c, f) After 6 cycles of GnP. The tumor has shrunk, and tumor contact with the SA has disappeared, but contacts with the CHA and PHA remain.

Fig. 2

Intraoperative image after tumor resection. Reconstruction involves splenic artery transposition for hepatic arterial reconstruction, and PV-SMV direct end-to-end anastomosis.

Fig. 3

Macroscopic examination of the resected specimen. a) Macroscopic examination of the resected specimen shows a hard mass in the pancreatic head.b) The length of PV resection is 20 mm (blue arrowhead). Yellow arrow: CHA; green arrow: BD (bile duct).

Fig. 4

Tumor mapping on the divided surface. A solid tumor (yellow dotted line) in the pancreatic head shows unclear boundaries with the CHA (red line) and PV (blue line) on the divided surface.

Fig. 5

Histopathological findings from hematoxylin and eosin staining. a, b) Histopathological examination reveals degenerated cancer cells extending to the resected CHA adventitia (arrow).