The patient was a 66-year-old female referred to us for the management of pancreatic head carcinoma. At age 45, she had undergone a TG combined with a DP and a splenectomy for gastric cancer that had also involved the pancreatic tail (Fig. 1). A tumor on the pancreatic head was discovered during a follow-up for repeated adhesive intestinal obstructions. A computed tomography (CT) scan revealed a 15-mm hypovascular tumor on the head of the pancreas. It had an irregular border and was observed to be infiltrating the superior mesenteric vein (SMV). The patient’s CA 19–9 and CEA levels were found to be 24.0 U/ml (normal range, 0–37 U/ml) and 5.0 ng/ml (normal range, 1.0–6.5 ng/ml), respectively. Considering the patient’s post-TG status, a diagnostic endoscopic ultrasonography, or an endoscopic approach for a biopsy could not be attempted. Therefore, the diagnosis of a borderline resectable pancreatic cancer was made based on the National Comprehensive Cancer Network (NCCN) guidelines [6]. Neo-adjuvant chemotherapy with tegafur, gimeracil, and oteracil potassium (S-1) as well as radiotherapy (dosage, 50.4 Gy/28Fr) was attempted preoperatively. However, the treatment did not produce a marked change in tumor size (Fig. 2).
We planned a post-TG PD that would enable us to preserve the pancreatic body and thereby its functions, in order to prevent the sequelae of postoperative severe malnutrition and disorders of glucose metabolism, and which would also allow us to administer adequate postoperative adjuvant chemotherapy to the patient. However, as the splenic artery had been resected in the earlier procedure, it was necessary to identify the blood vessels perfusing the region including the pancreatic body. A preoperative angiography (AG) was performed, which showed that the dorsal pancreatic artery (DPA) supplying the pancreatic body, had branched from the replaced right hepatic artery (Fig. 3a). Although angiography via both superior mesentic artery (SMA) and celiac artery was performed, the great pancreatic, caudal pancreatic, and the inferior pancreatic arteries could not be identified (Fig. 3b). Based on these results, we concluded that the patient’s DPA was responsible for maintaining the blood flow to the pancreatic body.
A pancreatic body-preserving PD along with an SMV resection was performed. Using intraoperative deep manipulation, the DPA was carefully left intact. In order to prevent injury to the DPA, we only performed partial lymph node dissection around the SMA. We utilized intraoperative ultrasonography to accurately identify the tumor margin and thus delineate the line of resection on the pancreas. The pancreatic parenchyma was preserved to the maximum extent while ensuring that a safe, margin-negative resection was performed. Following the resection, the patient was administered an intravenous injection of 7.5-mg indocyanine green (ICG) to check the blood supply to the pancreatic remnant. The unimpaired blood flow was confirmed when the pancreatic body demonstrated an immediate fluorescence in response (Fig. 4). A subsequent Roux-en-Y reconstruction (pancreatojejunostomy, cholangiojejunostomy, jejunojejunostomy) using a new Roux limb was performed (Fig. 5). The operation was completed in 459 min, during which period, a 250-ml blood loss was recorded. Histopathological examination of the resected specimen showed an R0 resection with safe margins (Fig. 6), no lymph node metastasis, and a moderate effect of the preoperative therapeutic measures. The tumor was staged grade IIa, as per Evan’s histological classification [7], and T3N0M0 and stage IIA according to the 7th edition TNM classification published by the Union for International Cancer Control (UICC) for pancreatic cancer. Furthermore, the pancreatic cancer was diagnosed as a moderately differentiated tubular adenocarcinoma, ly0, v2, ne1, mpd0, and T3N0M0 Stage IIA according to the General Rules for the Study of Pancreatic Cancer (7th edition).
The course of recovery was uneventful, and the patient was discharged on postoperative day 13. The stable blood supply to the remnant pancreas was confirmed on an enhanced CT scan (Fig. 7). The patient had required insulin therapy for a short duration postoperatively but eventually was able to achieve good glycemic control using an oral hypoglycemic agent. At discharge, the patient weighed 35.2 kg (body mass index, 15.4 kg/m2) and had lost 1.7 kg, as compared to her preoperative weight. Adjuvant chemotherapy with S-1 was then administered for 6 months. The transition in the levels of tumor markers and HbA1c values during the course of treatment have been graphically represented in Fig. 8. The patient passed away 21 months after the operation and 24 months after the start of preoperative therapy, due to a recurrence of peritoneal metastasis.