2021 Volume 54 Issue 2 Pages 125-132
In pancreaticoduodenectomy for a patient with celiac axis (CA) occlusion, cutting off the collateral pathways may lead to ischemia of organs originally supplied by the CA. A 72-year-old man was diagnosed with cancer of the ampulla of Vater upon examination for jaundice. Contrast-enhanced CT showed focal occlusion of the proximal CA with a “hooked appearance” and development of an anomalous arterial arcade of the pancreatic head. The case was complicated by CA occlusion due to compression by the median arcuate ligament (MAL). Surgery was performed with subtotal stomach-preserving pancreaticoduodenectomy, and intraoperative blood flow was evaluated using Doppler US. Clamping of the gastroduodenal artery interrupted blood flow in the common hepatic artery (CHA), so an incision was made in the MAL. However, we could not restore blood flow in the CHA, and thus, resection that preserves the collateral circulation from the superior mesenteric artery via the anterior inferior and superior pancreaticoduodenal arteries was performed. The patient has made satisfactory progress without ischemic events and has survived without recurrence for 2 years at the time of writing. This case shows that collateral circulation-preserving pancreatoduodenectomy for patients with CA occlusion can be safely performed with careful case selection and can be considered as an alternative to revascularization procedures.
