Tanaka Hideharu, Imai Hisashi, Higashi Toshiya, Murase Katsutoshi, Matsuhashi Nobuhisa, Yoshida Kazuhiro
Department of Surgical Oncology, Gifu University Hospital, 1-1 Yanagido, Gifu, Gifu, 501-1194, Japan.
Department of General and Cardiothoracic Surgery, Gifu University Hospital, 1-1 Yanagido, Gifu, Gifu, 501-1194, Japan.
Int J Surg Case Rep. 2021 Jan;78:192-196. doi: 10.1016/j.ijscr.2020.12.041. Epub 2020 Dec 23.
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.
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.
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.
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.
化疗和放化疗的最新进展通过改善部分初始不可切除的局部晚期胰腺癌（LAPC）患者的肿瘤缩小情况，使得进行转化手术成为可能，从而提供了治愈的潜力。对于部分初始不可切除的LAPC患者，在获得良好反应后需要进行动脉重建的转化手术数量预计会增加，因此提供安全的动脉重建有效方案至关重要。
在此，我们报告一例成功的针对初始不可切除的LAPC进行的转化手术，该手术在吉西他滨/纳米白蛋白结合型紫杉醇（GnP）治疗后采用脾动脉移位进行肝动脉重建。一名71岁女性在患糖尿病后因胰头肿块被转诊至我院评估。她被诊断为不可切除的LAPC，该肿瘤与肝总动脉（CHA）、肝固有动脉（PHA）和脾动脉（SA）广泛粘连。她接受了GnP治疗，6个周期后，疾病控制持续时间和血清糖类抗原19-9（CA19-9）恢复正常超过7个月。她接受了保留幽门的根治性胰十二指肠切除术，同时进行了CHA-PHA和门静脉（PV）切除（脾动脉-右肝动脉吻合/门静脉-肠系膜上静脉直接端端吻合）。组织病理学检查显示R0切除，伊文斯组织学反应为IIB级。术后14个月未观察到肿瘤复发迹象。
对于LAPC患者，尤其是需要进行动脉切除的病例，关于转化手术的最佳治疗方案、持续时间或标准尚未达成共识。脾动脉移位用于肝动脉重建通常非常合适，易于操作，并且为成功的动脉吻合提供了足够的长度和直径。
即使对于最初与肿瘤粘连的脾动脉，当肿瘤因化疗而粘连消失时，脾动脉移位用于肝动脉重建也是一种安全有效的选择。
