A 92-year-old female patient was referred to our hospital on May 9, 2016 with a pancreatic tumor. She had complained of 6-months history of abdominal discomfort and progressive jaundice. Her past medical history was unremarkable. There were no significant findings on physical examination with the exception of severe malnutrition. Height was 148 cm and weight was 38.5 kg. Laboratory findings were as follows: lymphocyte count, 1590/mm3; total bilirubin, direct bilirubin, and albumin, 3.03 g/dL; and amylase and IgG-4 were within the normal range. The serum level of carbohydrate antigen (CA)19-9 was 235 mumol/L, and carcinoembryonic antigen (CEA), CA72-4, and CA12-5 were all normal. Abdominal contrast-enhanced computed tomography (CT) scan and magnetic resonance (MR) imaging revealed a 3 x 3 cm solid hypovascular mass in the head of the pancreas (Fig. 1A, B). The common bile duct and the main pancreatic duct on the distal side of the mass were dilated 12 and 7 mm, respectively. PET-CT revealed that a mass with SUVmax 11.6 in the head of pancreas. There was no evidence of lymph node metastasis, peritoneal dissemination, or distant organ metastasis (Fig. 1C, D).
MDT meeting consisted of surgeons, physicians, clinical and medical oncologists, radiologists, pathologists, and clinical nurse specialists (CNSs) were organized to make clinical decisions (Fig. 2). There are 3 results of discussions. First, our tentative diagnosis was resectable pancreatic adenocarcinoma greater than 2.0 cm in size, T2N0M0 clinical stage IB on the TNM classification of the International Union Against Cancer (UICC). Second, the patient was obstructive jaundice and severe malnutrition. ASA was II-stage. Prognostic nutritional index was 38.2. These caused surgical contraindication. Third, percutaneous transhepaticcholangial drainage (PTCD) was used to relieve jaundice and bile reinfusion (Fig. 2). Malnutrition was improved by enteral nutrition and parenteral nutrition 2 weeks later. Prognostic nutritional index increased by 47.45 and TB reduced to 107 mummol/L. Meanwhile, breathing exercise was strengthened during this period.
The informed consent was signed and LPD was successfully performed. Intraoperative frozen section confirmed pancreatic ductal adenocarcinoma (PDAC) without peritoneal metastasis, and R0 resection was achieved. Operation time was 450 minutes, and blood loss was 120 mL. On the 1st postoperative day (POD1), the nurse assists the patient move her limbs on the bed to prevent deep venous thrombosis. On POD2, the nasogastric tuber was removed and the patient achieved out-of-bed activity (Fig. 3A). She started liquid diet on POD3 and CT was performed on POD7 without abdominal effusion fluids. On POD8, drainage tubes were removed and she was discharged on POD13 (Fig. 3B). No pancreatic fistula, pulmonary complication, or bile leakage was found during the hospital stay. Histopathological and immunohistochemical examination of the resected specimen revealed that it is the moderately differentiated pancreatic duct adenocarcinoma without lymph nodes metastasis (Fig. 4).
After operation, the patient refused to receive chemotherapy. Four months later, we followed up the patient. Abdominal CT was conducted to evaluate the regional recurrence. No abnormity was found. The tumor markers including Ca19-9, CEA, Ca125 were in normal range.
Port placement adopted 5 trocars in a V-shape depicted in Fig. 5A. The surgeon stands in the right hand and the 1st assistant in the left side.
Dividing the gastrocolic ligament, exposing the pancreas (Fig. 5A, B)
Excising the right gastroepiploic vessels, ligating the gastroduodenal artery(GDA)
Establishing a portal vein tunnel
Kocher maneuver
Jejunum, stomach dissection (linear stapler): bile duct division (scissors) Pancreatic neck division (Harmonic scalpel with scissors at pancreatic duct)
The uncinate process is dissected along the adventitia of the superior mesenteric artery
The specimen is placed in a bag for retrieval
An end-to-side pancreaticojejunostomy (duct-to-mucosa) with stent (Fig. 5C)
An end-to-side choledochojejunostomy using the 4-0 V-LOC suture is subsequently fashioned
The gastrojejunostomy is performed antecolic using a stapled technique.