BACKGROUND: This report describes a 61-year-old patient with locally advanced pancreatic adenocarcinoma involving the portal vein and common hepatic artery, managed with neoadjuvant chemotherapy with leucovorin, fluorouracil, irinotecan, and oxaliplatin (FOLFIRINOX), total pancreatectomy, splenectomy, portal vein and common hepatic artery resection, and combined arterial and portal vein reconstruction.

CASE REPORT: The patient presented with progressive jaundice and an elevated carbohydrate antigen 19-9 (CA 19-9) level of 210 U/mL. Endoscopic ultrasound-guided biopsy confirmed pancreatic ductal adenocarcinoma, and imaging demonstrated major vascular involvement without distant metastases. After 12 cycles of FOLFIRINOX, restaging showed persistent portal vein and common hepatic artery involvement without metastatic disease. Total pancreatectomy and splenectomy were performed with resection of a 4-cm portal vein segment and the common hepatic artery. Portal venous continuity was restored by primary end-to-end anastomosis, and hepatic arterial inflow was reconstructed by splenic artery transposition to the proper hepatic artery. Final pathology demonstrated a 1.3-cm moderately differentiated pancreatic ductal adenocarcinoma, with 2 out of 41 lymph nodes involved and negative surgical margins. A postoperative chylous fistula was managed with percutaneous drainage and parenteral nutrition. At 15 months, a solitary pulmonary metastasis was resected. The patient died 27 months after surgery from severe pneumonia without locoregional recurrence.

CONCLUSIONS: This case illustrates the technical management of simultaneous portal vein and hepatic artery resection during total pancreatectomy, using primary portal vein anastomosis and splenic artery transposition to restore arterial inflow.

Keywords: Adenocarcinoma, Pancreas, Pancreatectomy, Vascular Surgical Procedures