Pylorus-Preserving Pancreatoduodenectomy with Arterial Reconstruction and Right Gastric Vessel Preservation for Pancreatic Head Cancer with Atherosclerotic Celiac Axis Stenosis and Common Hepatic Artery Occlusion: A Case Report.

INTRODUCTION

Pancreatoduodenectomy in patients with celiac axis (CA) stenosis or occlusion carries a risk of ischemic complications because hepatic arterial flow may depend on collateral circulation from the superior mesenteric artery. Although securing hepatic arterial flow is essential, preservation of gastric perfusion has rarely been emphasized. Herein, we report a case of pancreatic head cancer with severe atherosclerotic CA stenosis and common hepatic artery (CHA) occlusion, in which arterial reconstruction (ARc) and preserving the right gastric vessels were combined to maintain both hepatic and gastric perfusion.

CASE PRESENTATION: A 76-year-old man was referred to our hospital after an incidental pancreatic head mass was detected using CT. Dynamic contrast-enhanced CT revealed a 15-mm hypovascular tumor in the pancreatic head with dilation of the main pancreatic duct and no major vascular invasion or distant metastasis. Preoperative imaging revealed severe atherosclerotic CA stenosis and CHA occlusion, with marked development of the pancreatoduodenal arcade, suggesting dependence on collateral flow. The right gastric artery (RGA) was relatively large. A pylorus-preserving pancreatoduodenectomy (PPPD) was performed. The ARc was established between the right common iliac artery (RCIA) and the gastroduodenal artery (GDA) stump using a great saphenous vein graft. The RGA and vein were preserved to maintain gastric perfusion. Intraoperative Doppler ultrasonography and indocyanine green fluorescence imaging confirmed adequate hepatic and gastric perfusion, respectively. The operation time was 582 min, with blood loss of 252 mL. Histopathological examination revealed a moderately differentiated adenocarcinoma with lymph node metastasis (pT1N1M0, Stage IIB). All resection margins were pathologically negative, and an R0 resection was achieved. The postoperative course was uneventful, and postoperative CT demonstrated adequate organ perfusion and bypass graft patency. The patient remained recurrence-free for 5 months after surgery.

CONCLUSIONS

PPPD with an ARc between the RCIA and GDA stump, combined with right gastric vessel preservation, enabled safe resection in a patient with severe CA stenosis and CHA occlusion. Preoperative hemodynamic assessment may help guide individualized revascularization and vessel preservation. However, because direct intraoperative assessment of gastric perfusion under RGA clamping was not performed, the necessity of RGA preservation could not be objectively confirmed in this case.