Ann Hepatobiliary Pancreat Surg.  2021 May;25(2):307-312. 10.14701/ahbps.2021.25.2.307.

Pancreaticoduodenectomy with combined hepatic artery and portal vein resection after laparoscopic division of pancreaticosplenic ligament due to FOLFIRINOX-induced hepatic toxicity related secondary hypersplenism

• Kim JS
• Park JY
• Choi M
• Joo DJ
• Hwang HK
• Lee WJ
• Kang CM

• KMID: 2516500
• DOI: http://doi.org/10.14701/ahbps.2021.25.2.307

Abstract

Pancreatic cancer is one of the dismal malignant disease in gastrointestinal tract. However, since the recent literature reporting median survival of FOLFIRINOX (leucovorin clcium, fluorouracil, irinotecan hydrochloride, oxaliplatin) chemotherapy was more than 12 months in metastatic pancreatic cancer was published, the positive attitude toward the treatment of the advanced pancreatic cancer is gradually expanded among the medical and surgical oncologists. Due to multiple combination of potent chemotherapeutic agents, potential adverse side effects should be concerned when considering FOLFIRINOX. Herein, we report a 55-year old male patient with locally advanced pancreatic cancer who successfully underwent curative resection following by laparoscopic division of pancreaticosplenic ligament due to long-term preoperative use of FOLFIRINOX related hepatic toxicity associated with secondary hypersplenism. The present case suggests the extended radical PD with combined major vascular resection following laparoscopic division of pancreaticosplenic ligament containing splenic artery and vein can improve the safety of curative resection and may expand the potential indication of pancreatic cancer in well-selected long-term use of preoperative FOLFIRINOX induced hepatic toxicity associated with secondary hypersplenism.

Keyword

Pancreaticoduodenectomy; FOLFIRINOX; Hypersplenism; Liver toxicity

Figure

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  Fig. 1 Preoperative CT scan. Invasion of pancreatic head cancer around SMV-SV-PV confluence and CHA was noted at the time of diagnosis (A). Soft tissue infiltration was still noted without progression after neo-adjuvant chemotherapy (B). White Dotted circle indicates tumor area and thick long white arrow indicates cancer infiltrating around common hepatic artery (B, C). Note atrophic change of distal part of the pancreas makes enough space between tip of the pancreas and splenic hilum (yellow arrow). Potential division line of pancreaticosplenic ligament was noted (red dotted line, C). CT, computed tomography; SMV, superior mesenteric vein; SV, splenic vein; PV, portal vein; CHA, common hepatic artery.

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  Fig. 2 Liver volume at initial CT (A), preoperative (B) and the postoperative (POD#7) CT (C). (A=1488.61 cm3, B=1077.97 cm3, C=1294.85 cm3) Note liver atrophy (yellow arrow) after long-term neoadjuvant chemotherapy with relatively enlarge spleen. CT, computed tomography; POD, postoperative days.

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  Fig. 3 Chronological change of blood platelet count according to pancreatic cancer treatment. FOLFIRINOX, leucovorin cal-cium, fluorouracil, irinotecan hy-drochloride, oxaliplatin; CCRT, concurrent chemoradiation the-rapy.

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  Fig. 4 Operative finding: Laparo-scopic division of pancreatico-splenic ligament containing both splenic artery and vein near spleen hilum using Endo-GIA stapler (stapler line-white long arrow). (A, B) Tumor invaded CHA and SMV (C), PHA-CHA (yellow long arrow) and PV-SMV “(white short arrow)”, end to end ana-stomosis (D). Endo-GIA, endo-scopic gastrointestinal anastomo-sis; S, Stomach; Sp, spleen; PT, pancreas tail; C, colon; BD, bile duct; PHA, proper hepatic artery; CHA, common hepatic artery; P, remnant pancreas; SV, splenic vein; T, tumor; SMA, superior mesenteric artery; SMV, superior mesenteric vein.

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