Background : Surgery for locally advanced distal pancreas tumors can be challenging especially if these encroach the major vessels such as the celiac axis and its branches. However, in select cases, a more radical procedure can be done to resect these tumors including the celiac artery for gastric cancers. We report a case of a 71 year old female who underwent distal pancreatectomy with splenectomy and en bloc celiac artery resection (modified Appleby) for distal pancreatic carcinoma.

Methods : The patient presented with one month history of jaundice, epigastric pain with radiation to the back, and weight loss. CT scan findings showed a solid mass measuring 2.5 x 4.8 x 2.3 cm (APxTxCC) involving the pancreatic body and tail with encasement of the splenic artery and celiac artery. The superior mesenteric artery and portal vein are otherwise free from the tumor. There were no liver nodules seen. She was scheduled for distal pancreatectomy with splenectomy and intraoperative ultrasound to assess the involvement of the celiac artery and possible en bloc resection. After exposure of the pancreas and making sure to preserve the gastroepiploic vessels, ultrasound was done and there was note of encasement of the celiac artery. Splenectomy was done first. The pancreatic body and tail were dissected off medially up to the part of the tumor encasing the celiac artery. Subsequent parenchymal transection was done along the pancreatic neck to facilitate easier and safer dissection along the area near the celiac artery, aorta, and SMA. The GDA patency was ensured with palpation and with the use of ultrasound doppler before en bloc celiac artery resection. The stomach was observed for any signs of ischemia prior to closing. The patient had an uneventful postoperative course and was discharged.

Results : Histopathologic report showed Ductal Adenocarcinoma, Moderately Differentiated measuring 5.5 cm in widest diameter with positive perineural invasion and positive one out of four peripancreatic lymph nodes. All lines of resection, the spleen, omentum, gall bladder, and one pericholedochal lymph node were all negative for tumor invasion. She was referred to medical oncology for adjuvant chemotherapy.

Conclusions : Modified Appleby Procedure for locally advanced distal pancreatic cancer can be technically challenging but has very good surgical and oncologic outcome for elderly patients at least in the short term. Increased sample size and long term follow up after adjuvant therapy needs to be done to determine feasibility and routine use in locally advanced distal pancreatic cancers with celiac artery involvement.