Chemo-Resistant Locally Advanced Left-Sided Pancreatic Cancer Encasing Portal Venous Confluence, Celiac and Superior Mes
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CASE REPORT
Chemo-Resistant Locally Advanced Left-Sided Pancreatic Cancer Encasing Portal Venous Confluence, Celiac and Superior Mesenteric Arteries: Management Strategy Sukumar Santosh Kumar 1 & Brijesh Kanti Biswas 1 & Raj Shukla 1 & Surabhi Sharma 1 & Deep Kumar Raman 1 & Ramanathan Saranga Bharathi 1 Accepted: 20 September 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
Introduction Locally advanced left-sided pancreatic ductal adenocarcinoma (L-PDAC) involving adjacent retroperitoneum, celiac axis (CA) and its branches necessitates their en bloc resection using modified Appleby procedure [1, 2]. Superior mesenteric artery (SMA) encasement > 180°, venous infiltration along the entire pancreatic width and chemo-resistance, an obstinate combination hitherto unreported, render this procedure exigent. Management strategy adopted to overcome such exigency is elucidated.
Case Report A 68-year-old diabetic male with upper abdominal pain of 2month duration presented with the following: performance status - Zubrod 1, unremarkable examination and laboratory investigations except elevated CA19.9 (125 U/ml) and HbA1c (8.6%). Computerised tomogram (CT) revealed the following: 3.5 cm × 3 cm sized mass in the pancreatic neck and body; atrophic tail with duct dilatation; completely encased CA and branches, with luminal compromise; left hemi-circumferential SMA encasement > 180°, without luminal compromise; left hemi-circumferential encasement of portal venous confluence; and lesser gastric curve infiltration by the tumour (Figs. 1 and 2). Positron emission tomogram (PET) CT revealed no metastasis and tumour SUVmax − 5.58. Endoscopic ultrasound-guided aspiration cytology revealed * Ramanathan Saranga Bharathi [email protected] 1
Command Hospital (Central Command), Lucknow, Uttar Pradesh, India
adenocarcinoma. Three cycles of nab paclitaxel + gemcitabine were administered and response was assessed. PET CT and CA19.9 showed no change indicating unresponsiveness. Tumour board consensus supported trial of resection. The patient was immunised against capsulated organisms. General condition was optimised with apt nutrition, incentive spirometry, exercise regimen, and glycemic control. After staging laparoscopy, modified Makuuchi incision was employed for exposure. Cattell-Braasch manoeuvre enabled pancreatic head mobilisation, vascular control and retroperitoneal lymph node dissection, frozen sections from which were negative. Using a combination of posterior, left posterior and mesenteric artery first approaches, SMA was dissected off the tumour (Fig. 3a, b). Inferior pancreatic duodenal artery (IPDA) and vein (IPDV) were preserved. Using a vascular stapler, lesser gastric curve was freed from the tumour. The involved middle colic vessels and superior layer of meso-colon were resected en bloc. Gastro-duodenal artery (GDA) and common hepatic artery (CHA) were exposed during lymphatic clearance. CHA was clamped proximal to GDA to observe hepatic perfusion (Fig. 3c). Perceiving no colour change, C
