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CC BY 4.0 · Surg J (N Y) 2021; 07(04): e301-e306
DOI: 10.1055/s-0041-1736670
Case Report

Anatomical Challenges during Pancreaticoduodenectomy for Adenocarcinoma Head of Pancreas in Presence of Intestinal Rotation Abnormalities: A Report of Two Cases

Gunjan S. Desai 
1   Department of Surgical Oncology, S. L. Raheja (A Fortis Associate) Hospital, Mahim (West), Mumbai, Maharashtra, India
,
Sandip Singh
2   Department of General Surgery, Lilavati Hospital and Research Centre, Bandra (West), Mumbai, Maharashtra, India
,
Prasad M. Pande 
3   Department of Surgical Oncology, S. L. Raheja (A Fortis Associate) Hospital, Mahim (West), Mumbai, Maharashtra, India
,
Prasad K. Wagle 
4   Department of Surgical Gastroenterology, Lilavati Hospital and Research Centre, Bandra West, Mumbai, Maharashtra, India
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Abstract

Purpose Pancreaticoduodenenctomy is a complex surgery and the sequence of steps is affected by anatomical variations involving small intestine and major vascular structures. This article depicts our approach to two such cases and highlights the importance of identifying these variations preoperatively on imaging, so as to modify the surgery plan accordingly.

Cases We report following two cases of pancreatic head adenocarcinoma (1) one with incomplete intestinal rotation with a replaced right hepatic artery and (2) one with intestinal nonrotation. In both cases, the small bowel was aggregated on the right side of the abdomen, making duodenal mobilization challenging. The surgical approach was modified to prevent injury to these vessels. A superior mesenteric artery (SMA)-first approach helped in early isolation of vascular structures especially when vascular anomaly was also present. Interbowel adhesiolysis, limited kocherisation, tracing all vessels to its origin before division, paracolic anastomotic limb after a longer jejunal limb resection in nonrotation cases, and modification in retropancreatic tunnel creation are few of the key surgical adaptations.

Conclusion Asymptomatic Intestinal malrotation is rare in adults and must be identified on preoperative imaging. Resultant intestinal and vascular anatomical variations need meticulous surgical planning and modification of conventional surgical approach for safe performance of PD.

Keywords

Whipple's procedure - incomplete intestinal rotation - pancreatic cancer - intestinal nonrotation

Authors' Contributions

G.S.D.: collecting data, analysis of data, preparing the initial draft of the manuscript, critical revision of the manuscript for intellectual content, technical support, material support, and study supervision.


S.S.: collecting data, analysis of data, and preparing the initial draft of the manuscript.


P.M.P.: critical revision of the manuscript for intellectual content, technical support, material support, and study supervision.


P.K.W.: study concept, critical revision of the manuscript for intellectual content, administrative, technical support, material support, and study supervision.


Ethics Statement

The study was performed after the approval of research protocols by the Ethics Committee of Lilavati Hospital and Research Centre in accordance with international agreements (World Medical Association Declaration of Helsinki “Ethical Principles for Medical Research Involving Human Subjects,” amended in October 2013, www.wma.net)


Informed Consent

Written informed consent was obtained from the patient involved in the study.


Financial Disclosure

The authors declare that this study has received no financial support.


Informed Consent

Informed consent was obtained from the patients for this publication.




Publication History

Received: 11 January 2020

Accepted: 03 September 2021

Article published online:
15 December 2021

© 2021. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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  • References

  • 1 Mansukhani V, Desai G, Shah R, Jagannath P. The role of preoperative C-reactive protein and procalcitonin as predictors of post-pancreaticoduodenectomy infective complications: a prospective observational study. Indian J Gastroenterol 2017; 36 (04) 289-295
    CrossrefPubMedSearch in Google Scholar
  • 2 Schank A, Colonval P, Salame M. Intestinal malrotation and replaced common hepatic artery during duodenopancreatectomy: a case report. Acta Chir Belg 2017; 117 (05) 315-318
    CrossrefPubMedSearch in Google Scholar
  • 3 Mateo R, Stapfer M, Singh G. et al. Pancreaticoduodenectomy in adults with congenital intestinal rotation disorders. Pancreas 2005; 31 (04) 413-415
    CrossrefPubMedSearch in Google Scholar
  • 4 Desai GS, Pande P, Shah RC, Jagannath P. Pancreaticoduodenectomy with replaced common hepatic artery and portal vein reconstruction in primary carcinoma duodenum: a case report and literature review. J Gastrointest Cancer 2019; 50 (03) 684-688
    CrossrefPubMedSearch in Google Scholar
  • 5 Jagannath P, Albuquerque K, de Souza LJ, Mohandas KM, Shantiswaroop V. Reversed rotation of midgut which caused problems during Whipple's procedure. Eur J Surg 1995; 161 (10) 765-766
    PubMedSearch in Google Scholar
  • 6 Gilbert HW, Armstrong CP, Thompson MH. The presentation of malrotation of the intestine in adults. Ann R Coll Surg Engl 1990; 72 (04) 239-242
    PubMedSearch in Google Scholar
  • 7 Daniels BT, Clader DN, Luter PW, Coppinger WR, Good GT. Pancreatico-duodenectomy in incomplete bowel rotation, anatomical peculiarities. Rocky Mt Med J 1957; 54 (05) 445-447
    PubMedSearch in Google Scholar
  • 8 Pickhardt PJ, Bhalla S. Intestinal malrotation in adolescents and adults: spectrum of clinical and imaging features. AJR Am J Roentgenol 2002; 179 (06) 1429-1435
    CrossrefPubMedSearch in Google Scholar
  • 9 Pagkratis S, Kryeziu S, Lin M. et al. Case report of intestinal non-rotation, heterotaxy, and polysplenia in a patient with pancreatic cancer. Medicine (Baltimore) 2017; 96 (49) e8599
    CrossrefPubMedSearch in Google Scholar
  • 10 Sanjay P, Takaori K, Govil S, Shrikhande SV, Windsor JA. ‘Artery-first’ approaches to pancreatoduodenectomy. Br J Surg 2012; 99 (08) 1027-1035
    CrossrefPubMedSearch in Google Scholar
  • 11 Li WT, Sethi S, Christopher AN, Koganti D, Yeo CJ. Duodenal adenocarcinoma in a patient with partial intestinal malrotation. J Pancreat Cancer 2018; 4 (01) 30-32
    CrossrefPubMedSearch in Google Scholar
  • 12 Plackett TP, Takamori R, Izawa M. Pancreaticoduodenectomy in the setting of intestinal malrotation. Hawaii Med J 2011; 70 (11) 237-238
    PubMedSearch in Google Scholar