Cattell-Braasch maneuver combined with local hypothermia during superior mesenteric artery resection in pancreatectomy

A 71-year-old male was admitted with obstructive jaundice at the end of June 2015. A CT scan of the thorax and abdomen demonstrated a mixed-type IPMN with a 50-mm cystic/solid lesion in the head of the pancreas associated with a 3-cm long and more than 50 % circumferential encasement of the SMA (Fig. 1). No distant metastases were detected. The patient was discussed at the Karolinska University Hospital’s multidisciplinary conference. The tumor was considered not primary resectable by oncological means and the patient commenced chemotherapy. He underwent concomitant endoscopic ultrasound-guided tumor biopsy and bile duct stenting. Histology showed IPMN cancer. At the end of July, the patient started neo-adjuvant treatment with FOLFIRINOX [5] that was completed 4 months later without significant toxicity. A new CT scan, demonstrated at the multidisciplinary conference, showed no occurrence of distant metastases and a partial response with a reduced tumor size, however with remaining encasement of the SMA (Fig. 2). As the patient had stable disease, he underwent surgical exploration by a senior pancreatic surgeon (MDC) in December 2015. No distant metastases or ascites were found at the time of surgery. An extended Kocher maneuver was performed with a total mobilization of the right colon and of the small bowel, e.g., Cattell-Braasch maneuver [7]. An aorto-caval lymphadenectomy was done “en bloc” with the mobilization of the head of the pancreas. The origin of the SMA from the aorta was identified and was tumor-free (Fig. 3). An anterograde artery-first approach was done [7, 8] and an accessory right hepatic artery (RHA) originating from SMA was detected and preserved (Fig. 4). Two centimeters distal of the origin of the RHA no clear cleavage plane between the tumor and SMA was found for a distance over 2.5 cm with a free margin of the artery distally at the root of the mesentery (Fig. 5). At this point, the patient was considered resectable. Considering the extension of the disease in the entire gland (mixed-type IPMN) [9], as well as trying to prevent pancreatic leakage in a patient with arterial resection and reconstruction, a decision to do a total pancreatectomy was made. After skeletonization of the hepato-duodenal ligament, transection of the jejunum and duodenum 2 cm distally to the pylorus, a retrograde distal pancreatico-splenectomy was done and the head of the pancreas dissected from the superior mesenteric/portal vein in a complete tumor-free plane. The specimen now remained attached only by the 2.5 cm long contact with the SMA at the level of the uncinate process (Fig. 6). Sterile ice in a surgical towel was placed in the lower sub-mesocolic abdomen in order to reduce the warm ischemia effect and after intra-venous injection of 5000 IU of heparin, the SMA vas clamped proximally and distally to the tumor. The SMA was resected 1 cm proximally and distally to the tumor contact, respectively (for an overall length of about 4 cm), and an end-to-end anastomosis was done using interrupted suture with 5/0 Prolene® (Fig. 7). The overall clamping time of the SMA was 12 min. After reperfusion, the surgical towel with sterile ice was removed and the bowel was inspected to be normal, without signs of edema. In this patient, an extended lymphadenectomy was also performed for technical reasons (i.e., preparation of the SMA for resection and reconstruction) and for staging reasons after the neo-adjuvant treatment (i.e., for assessment of aorto-caval lymph node status). A trans-mesocolic hepatico-jejunostomy and an ante-colic duodeno-jejunostomy were performed and two passive drains were placed. The patient received extended antibiotic and anti-mycotic post-operative prophylaxis and 5000 IU of low-molecular-weight heparin twice a day for 2 weeks. Low dose aspirin was introduced on day 5 after surgery. A CT-scan post-operatively showed normal canalization of the SMA (Fig. 8). The histology confirmed IPMN cancer (pT3N1) with a post-chemotherapy regression grade 3 (10) and without invasion of the arterial wall. The post-operative course was uneventful and the patient was discharged on day 8. Interestingly, no post-operative diarrhea occurred.