Izumi Hideki, Yoshii Hisamichi, Fujino Rika, Takeo Shigeya, Kojima Yukiko, Kaneko Junichi, Mukai Masaya, Chino Osamu, Makuuchi Hiroyasu
Department of Gastrointestinal Surgery, Tokai University Hachioji Hospital, 1838 Ishikawa, Hachioji, Tokyo, 192-0032, Japan.
Department of Gastrointestinal Surgery, Tokai University Tokyo Hospital, 1-2-5 Yoyogi, Shibuya, Tokyo, 151-0053, Japan.
Surg Case Rep. 2024 Jul 29;10(1):176. doi: 10.1186/s40792-024-01974-y.
Pancreaticoduodenectomy (PD) is considered a challenging surgery for resecting the gastroduodenal artery (GDA), right gastric artery (RGA), and lymph node tumors. In cases of pancreatic head cancer surgery, vascular anastomosis or right gastroepiploic artery (RGEA)/GDA preservation is necessary after postoperative gastric tube reconstruction for esophageal cancer. Therefore, we report for the first time an extremely rare case of PD in a patient with pancreatic head cancer and median arcuate ligament syndrome (MALS) after gastric tube reconstruction following esophageal cancer surgery, in which the entire pancreatic head arcade was preserved.
The patient was a 76-year-old man who had undergone esophageal cancer surgery after sternal gastric tube reconstruction 7 years ago. He was referred to our hospital because of the suspicion of intraductal papillary mucinous carcinoma (IPMC) owing to an enlarged cystic lesion and a substantial component in the uncinate process of the pancreas. Preoperative three-dimensional computed (3D-CT) tomography angiography showed celiac axis stenosis and pancreatic head arcade dilation. The diagnosis was IPMC without evidence of invasion; therefore, gastric tube blood flow was maintained by preserving the GDA and RGEA. Due to MALS, the GDA blood flow was supplied through the pancreatic head arcade, necessitating its preservation. The GDA-RGEA, right gastroepiploic vein, and anterior superior pancreaticoduodenal artery were taped over the entire pancreatic head for preservation. The inferior pancreaticoduodenal artery (IPDA) was also taped on the dorsal pancreas and the posterior or anterior IPDA, which further bifurcates were taped to preserve them. Subsequently, PD was performed.
We report a case of PD after gastric tube reconstruction for esophageal cancer with MALS, in which the pancreatic head arcade vessels were successfully preserved using 3D-CT to confirm the operation of the vessels.
胰十二指肠切除术（PD）被认为是切除胃十二指肠动脉（GDA）、胃右动脉（RGA）和淋巴结肿瘤的一项具有挑战性的手术。在胰头癌手术中，食管癌术后胃管重建后需要进行血管吻合或保留胃网膜右动脉（RGEA）/GDA。因此，我们首次报告了1例食管癌手术后胃管重建后发生胰头癌和正中弓状韧带综合征（MALS）的患者接受PD的极其罕见病例，该病例中整个胰头血管弓得以保留。
患者为一名76岁男性，7年前接受了胸骨后胃管重建食管癌手术。因胰腺钩突部囊肿病变增大及实质性成分，怀疑为导管内乳头状黏液性癌（IPMC）而转诊至我院。术前三维计算机断层扫描（3D-CT）血管造影显示腹腔干狭窄和胰头血管弓扩张。诊断为无侵袭证据的IPMC；因此，通过保留GDA和RGEA维持胃管血流。由于MALS，GDA血流通过胰头血管弓供应，因此需要保留该血管弓。在整个胰头上对GDA-RGEA、胃网膜右静脉和胰十二指肠上前动脉进行束带结扎以保留。胰十二指肠下动脉（IPDA）也在胰腺背侧进行束带结扎，IPDA进一步分支的后支或前支也进行束带结扎以保留。随后进行了PD手术。
我们报告了1例食管癌胃管重建后合并MALS行PD手术的病例，术中通过3D-CT确认血管走行，成功保留了胰头血管弓血管。
