Modified Appleby's operation in distal pancreatic cancer: A case report

Lee, Jeong Eon; Park, Sang Jae; Kim, Sun Whe; Park, Yong Hyun

Abstract

The prognosis of distal pancreatic cancer is even poorer than that of pancreatic head cancer because of its late symptom onset and tendency of aggressive retroperitoneal invasion at diagnosis. Since the first Appleby's operation in 1952, it has been performed in stomach cancer by several surgeons. But the survival benefit is still controversial. Appleby's operation includes total gastrectomy, splenectomy, distal pancreatectomy, celiac trunk division with ligation of common hepatic artery(CHA) and retroperitoneal lymph node dissection. In 1976, Nimura first adopted this method for distal pancreatic cancer. We report a case of modified Appleby's operation for distal pancreatic cancer. The patient was 44- year old female. Her chief complaint was epigastric pain for 2 weeks. Preoperative liver function test was within normal range and CA19-9 was elevated to 200 U/ml. Preoperative CT angiography showed 4.5x3cm sized, pancreatic mass in body and tail area invading splenic artery and celiac trunk from its left side. In operation, splenectomy and distal pancreatectomy was initially performed. After ligation of CHA, we confirmed intact proper hepatic artery(PHA) flow by doppler and then divided CHA. After confirmation of intact gastric blood flow, left gastric artery(LGA) was divided. Celiac axis(CA) was divided near its origin. Then we dissected retroperitoneal lymph nodes. There was minor pancreatic leakage controlled by conservative management. CA19-9 was normalized to 33 U/ml on the 16th postoperative day. She was discharged on the 28th postoperative day and underwent adjuvant chemotherapy and radiotherapy. There is no evidence of recurrence for 15 months of follow-up. We suggest that modified Appleby's operation should be considered for radical resection of distal pancreatic cancer which is invading CA or major CA branch but not involving PHA and superior mesenteric artery(SMA), if the CA root is resectable and PHA flow is intact from SMA after ligation of CHA.