Post-pancreatectomy Liver Injury After Mayo Clinic Class Ia Celiac Axis Resection: Illustration of This Newly Described Entity with Delayed Hepatic Artery Revascularization.
Jonathan Garnier, Philippe Amabile, Anaïs Palen et al.
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Case in brief
A 59-year-old patient with locally advanced pancreatic body cancer received extended neoadjuvant FOLFIRINOX and underwent pancreatosplenectomy with Mayo Clinic class Ia celiac artery resection. Hepatic arterial reconstruction was initially omitted because flow through the gastroduodenal artery to the proper hepatic artery remained present, though dampened. A rapid postoperative alanine aminotransferase rise prompted re-exploration. Biopsy showed acute steatohepatitis and extensive ischemic necrosis, consistent with clinically relevant post-pancreatectomy liver injury in the setting of metabolic dysfunction-associated steatotic liver disease. A bypass from the right renal artery to the common hepatic artery was performed; liver enzymes fell promptly and biochemical parameters normalized by postoperative day 7.
What made this case unusual
Despite maintained, Doppler-confirmed hepatic arterial flow after celiac artery resection, the patient developed clinically relevant ischemic liver injury. The authors hypothesized that arterial inflow was inadequate for a vulnerable steatotic liver with increased intrahepatic resistance.
Diagnostic / clinical pearl
After celiac artery resection, preserved hepatic arterial flow does not exclude clinically important liver injury; a rapid postoperative aminotransferase rise may warrant urgent assessment for inadequate hepatic perfusion.