The American Surgeon | 2019
Confusing Arteries: Multiple Vascular Malformation during Pancreaticoduodenectomy
Abstract
The presence of vascular malformations increases the technical difficulty during surgery and causes unexpected incidents to occur. Vascular malformation may potentially result in serious complications and should be especially carefully considered in pancreaticoduodenectomy (PD), because this is one of the most complicated surgeries. Herein, we report a rare case of multiple vascular malformations that induced serious complications during PD. A 64-year-old female was hospitalized with a fever and abdominal pain in the right upper quadrant. The concomitant symptoms were tea-colored urine and jaundice. There were no other remarkable findings detected on physical examination, except for tenderness in the right upper quadrant while the abdomen was still soft. Laboratory tests showed a white blood cell count of 7.94 · 10/L, C-reactive protein level of 16.33 mg/L (normal range, 0–8 mg/L), alanine aminotransferase of 129.8 U/L (normal range, 7–40 U/L), aspartate aminotransferase of 68.7 U/L (normal range, 13–35 U/L), direct bilirubin of 11.3 mmol/L (normal range, 0.1–6.8 mmol/L), alkaline phosphatase of 299.9 U/L (normal range, 50–135 U/L), g-glutamyl transferase of 655.5 U/L (normal range, 7–45 U/L), lactic dehydrogenase of 265.1 U/L (normal range, 109–245 U/L), carcinoma antigen 19 to 9 of 75.48 U/mL (normal range, 0–37 U/mL), and carcinoma antigen 50 of 28.6 U/mL (normal range, 0–25 IU/mL). A contrast-enhanced CT (CECT) scan of the abdomen showed that both the gallbladder and common bile duct (CBD) were markedly dilated, and there was a solid neoplasm located in the CBD. CECT also revealed that the paths of the hepatic arteries were abnormal; the right hepatic artery (RHA) went to the posterior side of the CBD (Fig. 1). Furthermore, the gastroduodenal artery (GDA) was obscured in the arterial phase. The patient was presumptively diagnosed with extrahepatic cholangiocarcinoma. Surgical exploration revealed that the tumor had invaded the distal CBD, and so PD was performed. We saw that the RHA circumvoluted the CBD and traveled to the posterior side of the CBD after branching from the proper hepatic artery (PHA, Fig. 2). The distal end of the RHA went even deeper into the porta hepatis than the portal vein (Fig. 2). More importantly, the GDA was absent. All arteries and the portal vein were successfully protected from iatrogenic injury. The liver function and coagulation function were tested postoperatively and revealed that alanine aminotransferase was 223 U/L (normal range, 7–40 U/L), aspartate aminotransferase was 97 U/L (normal range, 13–35 U/L), and prothrombin time was normal. Pathological examination showed adenocarcinoma of the CBD. The patient had an uneventful recovery with no complications. There are various kinds of the arterial anatomy around the biliary system, and these variations can cause substantial problems during surgeries. The most common arterial malformation around the biliary system is the presence of a cystic artery.1, 2 This cystic artery can arise from the RHA, left hepatic artery, or the PHA. The RHA is easily injured because of anatomic malformations, and this can result in substantial liver injury.3 It is important to maintain vigilance regarding possible arterial anatomical malformations, and sufficient preoperative evaluation is important to avoid iatrogenic injury. In the present case, we recognized in the CECT scan that the RHAwas located in an uncommon site, and the GDA was obscured. Although the CECT scan did not provide sufficient details of the arterial anatomy, it still alerted us to the possibility of arterial malformations. We consider that the undefined CECT scan increased our vigilance in Zhiyang Zhu and Jianhua Yu contributed equally to this work. Address correspondence and reprint requests to Baochun Lu, M.D., Department of Hepatobiliary Surgery, Shaoxing People’s Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), 568 North Zhongxing Road, Shaoxing, Zhejiang Province, China 312000. E-mail: [email protected].