A 66-year-old patient was admitted to the hospital because of painless jaundice and pathologic elevated cholestasis parameters. Conventional sonography revealed a malignancy-suspect tumor of the pancreatic head with dilatation of the common bile duct. Subsequently, endoscopic retrograde cholangiopancreatography was conducted with papillotomy and stenting of the common bile duct. No malignant cells were detected in the biopsies taken, although the suspected diagnosis of a malignant pancreatic head tumor was supported by endoscopic ultrasound. Contrast-enhanced computed tomography of the thorax and abdomen showed no metastases, and therefore curatively intended pancreaticoduodenectomy was evaluated.
3D reconstruction of the upper abdominal vessels from CT data was performed to plan the surgical treatment. There was no evidence of local irresectability, but an arterio-arterial shunt was discovered originating from the dorsal part of the SMA and leading to the common hepatic artery (CHA), just after its branching from the CA (Fig. 1). The vessel joined the SMA and celiac trunk independently of the common arterial anastomosis, therefore it was considered to be the AOB. Furthermore, the celiac trunk appeared to be stenotic. After critical discussion with our radiology department, preoperative stent implantation was not performed as the stenosis of the CA was considered marginal.
A median arcuate ligament compression syndrome (Dunbar syndrome) could also have been the cause of the described stenosis. Because of the leading oncologic diagnosis, no further investigation of asymptomatic CA stenosis was performed.
The AOB showed close proximity to the tumor and possible tumor infiltration (Fig. 2). We planned pancreaticoduodenectomy with the intention of preserving the AOB if technically and oncologically feasible.
Intraoperatively, we found a locally advanced tumor with regional inflammatory changes. After mobilization of the duodenum and pancreatic head, the gastroduodenal artery (GDA) was ligated.
As the dissection progressed toward the pancreatic body, the AOB was identified cranial to the tumor.
Further caudal tumor infiltration could not be excluded, making preservation of the shunt for oncologic resection impossible. After clamping the AOB close to its termination at the CHA, there was no evidence of ischemia of the liver or stomach. This was verified by Doppler ultrasonography. The AOB was resected. The proper hepatic artery (PHA) showed a steady pulse at all times. Pancreatic anastomosis was constructed as a pancreaticogastrostomy. Single-loop reconstruction was performed for bilio-jejunal and gastro-jejunal anastomosis.
The early postoperative course was uneventful. On postoperative day 2, a planned gastroscopy showed no evidence of anastomotic insufficiency or ischemia. Having already received regular meals, the patient developed abdominal pain and elevated infection laboratory markers on postoperative day 9. An immediate CT scan of the abdomen indicated an insufficient pancreatic–gastric anastomosis. Emergency relaparotomy revealed gastric ischemia with insufficiency of the pancreatogastrostomy and gastrojejunostomy and necrosis of the remnant pancreas. In addition, the splenic artery (SA) showed a relatively small diameter and thrombosis. We performed gastrectomy, splenectomy, resection of the remaining pancreatic and reconstruction as esophago-jejunostomy. The patient stabilized quickly with ICU-treatment. After drainage of the pleural effusion, treatment of wound dehiscence, and wound infection, the patient was discharged from the hospital on postoperative day 44.
The result of histologic examination confirmed complete resection of a 37-mm, moderately differentiated ductal adenocarcinoma of the pancreas with infiltration of the duodenum and common bile duct (TNM: pT2, pN 1 (3/21), L 1, Pn 1, G 2, R 0). There was no evidence of tumor infiltration of the resected arterial shunt.