Modified Appleby with laparoscopic aorto-hepatic bypass for pancreatic adenocarcinoma: expanding the limits

Celiac axis involvement has long defined unresectability in pancreatic ductal adenocarcinoma (PDAC) due to its association with adverse tumor biology and the risk of hepatic ischemia after arterial sacrifice. Contemporary neoadjuvant regimens and refined vascular techniques have challenged this paradigm. We report a 65-year-old woman with locally advanced PDAC of the pancreatic body encasing the celiac trunk, splenic artery, and proximal common hepatic artery. Following FOLFIRINOXbased neoadjuvant therapy, restaging demonstrated a marked biochemical and radiologic response, with no evidence of systemic disease. Given this favorable tumor biology, the patient underwent distal pancreatectomy with en bloc celiac axis resection (modified Appleby procedure) combined with a totally laparoscopic aortohepatic bypass to ensure reliable antegrade hepatic inflow. R0 resection was achieved without intraoperative morbidity. Final pathology revealed a moderately differentiated adenocarcinoma (ypT2N0) with perineural invasion. Postoperative recovery was uneventful, with preserved hepatic function and no ischemic or vascular complications. At 11 months, the patient remains recurrence-free, with sustained graft patency. This report demonstrates that, in highly selected responders to neoadjuvant therapy, radical arterial resection supplemented by minimally invasive vascular reconstruction is feasible, oncologically sound, and may extend the boundaries of curative-intent surgery in locally advanced PDAC within experienced multidisciplinary programs.