Pancreaticoduodenectomy in a patient with a rare celiac trun
A 60-year-old patient with no medical history but diabetes mellitus II was referred to our tertiary university hospital (Al-Assad university hospital for intermittent jaundice. The complaint started one year before, in which the patient suffered fatigue and general weakness without weight loss or changes in bowel movement.

One month before admission, he developed pain in the right upper quadrant and intermittent jaundice as well as fatigue and general weakness. Ultrasound showed common biliary duct dilation 2 cm, intrahepatic biliary system dilation. ERCP then was indicated in which swollen ampulla was detected, dilated common biliary duct 2 cm, dilation of intra hepatic ducts, signs of which increased the suspicion of ampulla tumor, so the ampulla was cut, biopsies were taken and 8.5 plastic stent was administrated. ERCP biopsy came out: villous adenomatous of ampulla vater with focal mild to moderate dysplasia. Thus the patient was being prepared for whipple procedure.

In operating room, Kocher incision, no ansarca, no peritoneal metastasis, the decision to perform whipple procedure was made. Gallbladder was resected, kocher maneuver, when isolating the CBD and common hepatic artery, anomalies were found, and the artery system was not that clear, no clear celiac trunk and no clear common hepatic artery. Decision to continue whipple procedure was made, and slow and careful ligation of arteries was performed. Hopefully, the surgical team managed to make the procedure done.

Final pathology report: adenocarcinoma of the ampulla grade 1, duodenal gastric and pancreatic surgical margins were free, all isolated lymph nodes were free 0/18, the lymph nodes are free pT1a, Pn9, Mx. Angiographic CT after procedure confirmed the absence of celiac trunk, the absence of left gastric, the splenic artery arising from aorta directly and common hepatic artery arising from superior mesenteric artery. The patient was discharged one week later with 2 days in ICU,. 6 month follow-up revealed a healthy patient with no recurrence or ischemic complication.

Source: Journal of Surgical Case Reports, Volume 2019, Issue 5, May 2019, rjz148

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