Dhanapal Baskaran, Shankar Gomathi, Krishnaraj Balamourougan, Govindarajalou Ramkumar, Ruparelia Jigish, Deivasigamani Aniruthan, Sistla Sarath Chandra
Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, IND.
Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, IND.
Cureus. 2018 Mar 26;10(3):e2366. doi: 10.7759/cureus.2366.
Portal annular pancreas is a rare congenital anomaly in which the portal vein and/or the splenoportal confluence are completely encircled by aberrant pancreatic parenchyma. It is an asymptomatic condition and is usually an incidental finding. It is, however, important to a surgeon because the postoperative pancreatic fistula (POPF) rates following pancreatic resection are higher in patients with this anomaly. A 47-year-old male presented with features of obstructive jaundice. He was diagnosed to have periampullary carcinoma, and pancreatoduodenectomy was planned. During surgery, uncinate process was seen extending posterior to the portal vein and was communicating with the body of pancreas to the left of the portal vein. After transection, there were two pancreatic stumps. The pancreatic duct was identified in the stump anterior to the portal vein. No duct was present in the posterior pancreatic stump. We closed the posterior pancreatic stump with interrupted polypropylene sutures and performed a duct to mucosa pancreaticojejunostomy in the anterior stump. On reviewing the preoperative computed tomography (CT) scan, we were able to identify the pancreatic tissue encasing the portal vein superior to the splenic vein. Circumportal pancreas is classified based on the orientation of pancreatic duct to the portal vein and the relationship of the aberrant pancreatic tissue with the splenoportal confluence. Following pancreatoduodenectomy, the surgeon has to manage two pancreatic stumps, one anterior and the other posterior to the portal vein. No standardised technique has been described for management of the pancreatic stumps. Every surgeon planning pancreatic surgery should be aware of this rare anomaly, and look for the same in the preoperative CT scan so that appropriate plan can be made regarding the type of pancreatic anastomosis.
门静脉环周胰腺是一种罕见的先天性异常，其中门静脉和/或脾门静脉汇合处被异常的胰腺实质完全环绕。它是一种无症状的情况，通常是偶然发现。然而，对于外科医生来说它很重要，因为患有这种异常的患者在胰腺切除术后胰瘘（POPF）发生率更高。一名47岁男性出现梗阻性黄疸症状。他被诊断为壶腹周围癌，并计划进行胰十二指肠切除术。手术过程中，可见钩突延伸至门静脉后方，并与门静脉左侧的胰体相连。横断后，有两个胰腺残端。在门静脉前方的残端中识别出胰管。后方胰腺残端没有胰管。我们用聚丙烯间断缝线关闭后方胰腺残端，并在前方残端进行胰管对黏膜的胰空肠吻合术。回顾术前计算机断层扫描（CT）时，我们能够识别出在脾静脉上方包绕门静脉的胰腺组织。门静脉环周胰腺根据胰管与门静脉的走向以及异常胰腺组织与脾门静脉汇合处的关系进行分类。胰十二指肠切除术后，外科医生必须处理两个胰腺残端，一个在门静脉前方，另一个在门静脉后方。目前尚未描述用于处理胰腺残端的标准化技术。每个计划进行胰腺手术的外科医生都应了解这种罕见的异常情况，并在术前CT扫描中寻找它以便能够就胰腺吻合的类型制定合适的计划。
