PMC4917395_01
Enhanced CT showing pancreas head carcinoma invading the common bile duct and SMV (black arrow) (a) and node swelling indicating metastasis (white arrow) (b).
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Endoscopic fine-needle aspiration showed pancreas head carcinoma, which had invaded the lower common bile duct. Enhanced CT showed the pancreas head carcinoma severely invading the superior mesenteric vein (SMV), and regional node swelling was observed (Fig. 1a and b).
A second enhanced CT after chemotherapy showed a slightly decreased aRHA (black arrow); however, invasion of SMV still remained as well (white arrow) (a). The CT also revealed an aRHA arising from the SMA toward the right liver (white arrow heads) (b). The tiny communicating artery between the left and right liver via the hilar plate was observed (black arrowhead) (a).
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As a result, tumor size was partially reduced; however, invasion of the SMV remained unchanged (Fig. 2a and b). On one hand, the aRHA was considered to have been invaded by the pancreas head cancer, and on the other hand, the very small communicating artery via hepatic hilar plate was seen in the CT's coronary and axial views (Fig. 2a and Fig. 4).
Magnetic resonance imaging showed a tumor occlusion of both the common bile duct and the main pancreatic duct (white arrow).
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Obstruction of the common bile duct and the main pancreatic duct by the tumor invasion was unchanged as well (Fig. 3).
After transection of the common hepatic duct (black arrow), each hepatic artery was taped and a clamping test of the aRHA was performed to confirm intrahepatic flow (white arrow). LHA = left hepatic artery, MHA = middle hepatic artery.
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During the operation, the common hepatic duct was first transected, and each hepatic artery was encircled by a tape (Fig. 5).
The final view of PD showed tumor invasion between portal vein and SMV of 2 cm in length (black arrow). The combined resection of SMV was performed at 3 cm in length. The vein was directly anastomosed with 6-0 polypropylene suture (white arrow).
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Eventually, PD with combined resection of aRHA and SMV (3 cm in length) was achieved, and anastomosis of portal vein and SMV was conducted (Fig. 6a and b).
Macroscopic finding of resected specimen showed the resected SMV.
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R0 resection without tumor exposure at the dissected plane could be achieved macroscopically by the resected specimen (Fig. 7).