Modified Appleby procedure for pancreatic body cancer: Retrograde gastric and hepatic perfusion via a replaced left hepatic artery – A vascular paradigm shift: A case report

Pancreatic body cancers encasing the celiac axis present a formidable surgical challenge, historically deemed inoperable due to the risk of gastric and hepatic ischemia. The modified Appleby procedure, involving distal pancreatectomy with en bloc celiac axis resection, offers curative potential in carefully selected cases. We report a rare and uncharted vascular variant that enabled safe execution of this procedure with preservation of organ perfusion. A 58-year-old male presented with epigastric discomfort, weight loss, and a 4-cm pancreatic body tumor encasing the celiac axis. Contrast-enhanced CT and 3D angiography revealed a replaced left hepatic artery (LHA) originating from the left gastric artery (LGA), with strong collateral flow from the superior mesenteric artery (SMA). During surgery, the gastroepiploic arcade was sacrificed. However, intraoperative Doppler confirmed a novel collateral circuit-SMA → GDA → PHA → segment 4 → segments 2/3 → LGA via replaced LHA-preserving both hepatic and gastric perfusion. The procedure was completed without complications. Postoperative recovery was uneventful apart from transient delayed gastric emptying. Histology confirmed a moderately differentiated pancreatic ductal adenocarcinoma with R0 resection. This is the first reported case demonstrating effective retrograde gastric perfusion via a replaced LHA following celiac axis resection. It highlights how variant anatomy, if preserved, can be safely leveraged to extend resectability criteria in pancreatic cancer. Meticulous vascular mapping and intraoperative perfusion assessment can unlock curative surgical options in anatomically complex pancreatic tumors.