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Review
. 2022 Feb 28;28(8):868-877.
doi: 10.3748/wjg.v28.i8.868.

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

Eiji Yoshida  1 , Yasutoshi Kimura  2 , Takuro Kyuno  1 , Ryoko Kawagishi  1 , Kei Sato  1 , Tsuyoshi Kono  1 , Takehiro Chiba  1 , Toshimoto Kimura  1 , Hitoshi Yonezawa  1 , Osamu Funato  1 , Makoto Kobayashi  1 , Kenji Murakami  3 , Akinori Takagane  1 , Ichiro Takemasa  4
Affiliations
Review

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

Eiji Yoshida et al. World J Gastroenterol. .

Abstract

Background: 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.

Case summary: 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.

Conclusion: Preoperative endovascular stenting, with NAC and DAPT, is effective and safe prior to pancreaticoduodenectomy in potentially resectable pancreatic cancer.

Keywords: Case report; Celiac axis stenosis; Endovascular stenting; Median arcuate ligament; Pancreatic head cancer; Pancreaticoduodenectomy.

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Conflict of interest statement

Conflict-of-interest statement: The authors declare that they have no conflicts of interest.

Figures

Figure 1
Figure 1
Pre-treatment imaging findings. A: There was a tumor, with poor contrast, in the pancreatic head on computed tomography (CT) imaging. Red arrowheads: the tumor; B and C: Three-dimensional reconstruction imaging showed developed collateral pathways around the pancreatic head. One connected the superior mesenteric artery (SMA) and common hepatic artery (CHA) via the gastroduodenal artery (GDA) and another connected the SMA and splenic artery (SPA) via the dorsal pancreatic artery (DPA); D: The sagittal view of the CT showed celiac axis (CA) stenosis due to compression by MAL which developed caudally. Yellow arrows: GDA; yellow arrowheads: CHA; yellow asterisks: DPA; yellow dotted arrows: SPA; red asterisks: MAL; red arrow: CA; red dotted arrow: SMA.
Figure 2
Figure 2
Preoperative endovascular stenting. A: In preoperative aortography, the superior mesenteric artery (SMA) was visualized immediately, but the celiac axis (CA) was not visualized. Black asterisks: SMA; B: The microguidewire reached the CA via a collateral pathway from the SMA using a triple coaxial system; C: Final aortography confirmed CA patency and antegrade blood flow. Red arrowhead: Root of the CA; yellow arrowhead: Root of the SMA; yellow line: Running of wire.
Figure 3
Figure 3
Clinical course timeline. DAPT: Double-antiplatelet therapy; HBT: Heparin-bridging therapy; SAPT: Single-antiplatelet therapy; CA19-9: Carbohydrate antigen 19-9; GEM: Gemcitabine; SSPPD: Subtotal stomach preserving pancreaticoduodenectomy.
Figure 4
Figure 4
Intraoperative view and postoperative computed tomography images. A: Subtotal stomach preserving pancreaticoduodenectomy was performed. White arrowhead: stump of gastroduodenal artery; B and C: Postoperative computed tomography imaging confirmed patency of the celiac axis.
Figure 5
Figure 5
Pathological findings. Tumor mapping on the divided surface of specimens. The resected specimen showed a shrunken invasive tumor with a 12-mm diameter in the pancreatic head. Red circle: Viable tumor site.
See this image and copyright information in PMC

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