Addeo Pietro, de Mathelin Pierre, Paul Chloe, Bachellier Philippe
Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Hépatiques et Digestives, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France.
Ann Surg Oncol. 2025 Mar;32(3):1902-1903. doi: 10.1245/s10434-024-16623-9. Epub 2024 Dec 12.
Surgery has recently been introduced into the multimodal management of patients with locally advanced pancreatic adenocarcinomas (LAPCs) thanks to the major pathological response seen with the advent of the multiagent regimen FOLFIRINOX. Distal pancreatectomy with celiac axis resection (DP-CAR) may be complicated by ischemic liver and gastric events. Common hepatic artery reconstruction may prevent the occurrence of ischemic complications and can be an alternative to preoperative embolization of the celiac trunk. METHODS: The patient was a 65-year-old with LAPC of the pancreatic body, with infiltration of the celiac trunk, the splenoportal venous confluence, and the Treitz angle. Preoperative induction chemotherapy with FOLFIRNOX was administered over 12 cycles, resulting in radiological stability and normal carbohydrate antigen (CA) 19-9 levels. Positron emission tomography showed isolated activity of the tumor without distant metastasis. A DP-CARV procedure was performed, and a single saphenous graft was used to reconstruct the common hepatic artery and to create a venous patch to repair the venous confluence. The angle of the Treitz, along with the third and fourth duodenum, were resected and a duodenojejunal anastomosis on the second duodenal portion was performed. The left gastric artery was not reconstructed.
Postoperative course was favorable but was complicated by a hematoma of the right groin necessitating evacuation. Pathology showed a pT4N2R0 pancreatic adenocarcinoma. The postoperative computed tomography scan showed no collection and patency of reconstructed vessels. Six months later, the patient is alive and disease-free, with patent reconstructed vessels.
Common hepatic artery reconstruction during DP-CAR represents a safe surgical option to reduce ischemic events related to celiac trunk resection, particularly in the FOLFIRINOX era. This technique integrated the surgical armamentarium of surgeons dealing with LAPC.
由于多药联合方案FOLFIRINOX出现后可见显著的病理反应，手术最近已被引入局部晚期胰腺癌（LAPC）患者的多模式管理中。胰体尾切除术联合腹腔干切除术（DP-CAR）可能会并发肝脏和胃部缺血事件。肝总动脉重建可预防缺血性并发症的发生，并且可以替代术前腹腔干栓塞术。
该患者为一名65岁的胰体LAPC患者，腹腔干、脾门静脉汇合处和Treitz角均有浸润。术前采用FOLFIRNOX进行12个周期的诱导化疗，结果显示影像学稳定且糖类抗原（CA）19-9水平正常。正电子发射断层扫描显示肿瘤有孤立活性，无远处转移。实施了DP-CARV手术，使用单根大隐静脉移植物重建肝总动脉并制作静脉补片修复静脉汇合处。切除Treitz角以及十二指肠第三和第四部分，并在十二指肠第二部进行十二指肠空肠吻合术。未重建胃左动脉。
术后病程顺利，但右腹股沟出现血肿，需要进行引流。病理显示为pT4N2R0胰腺腺癌。术后计算机断层扫描显示无积液且重建血管通畅。六个月后，患者存活且无疾病，重建血管通畅。
DP-CAR期间进行肝总动脉重建是一种安全的手术选择，可减少与腹腔干切除相关的缺血事件，尤其是在FOLFIRINOX时代。该技术完善了处理LAPC的外科医生的手术手段。
