PMC5838470_01
Preoperative image findings. (a) Three-dimensional computed tomography scan of the abdomen reveals the replaced common hepatic artery arising from the superior mesenteric artery. (b) Magnetic resonance cholangiopancreatogram shows the annular duct, but no relevant tumor or dilation of the common bile duct and the pancreatic duct. (c) Esophagogastroduodenoscopy shows an ulcer at the ampulla of Vater, and the biopsy results of the ulcer indicate adenocarcinoma. Cannulation of the papilla region could not be performed because of direct invasion of the tumor.
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The CT scan also revealed an anomaly of the CHA arising from the SMA (Figure 1(a)) and annular pancreatic duct. Magnetic resonance cholangiopancreatography (MRCP) confirmed that the annular duct formed a loop in the head of the pancreas (Figure 1(b)). An ulcerative tumor was found around the duodenal papilla region by upper esophagogastroduodenoscopy (Figure 1(c)).
Intraoperative findings. The common hepatic artery is arising from the superior mesenteric artery and runs posterior to the pancreas.
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The CHA arouse from posteriorly to pancreatic head and traveled posteriorly to the portal vein (PV), and then it ran anteriorly to the PV after it branched off the gastroduodenal artery and anterior superior pancreaticoduodenal artery (Figure 2).
Findings of the resected specimen. (a) Cholangiopancreatogram showing cannulation of the resected specimen and injection of urografin from the stump of the main pancreatic duct with the annular duct encircling the descending part of the duodenum and draining at the major papilla ( ). (b) Schematic illustration of the pancreatic duct and replaced common hepatic artery, based on the ventral and dorsal pancreas.
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Cholangiopancreatography of the resected specimen showed that the annular duct was connected to the major papilla (Figures 3(a) and 3(b)).
Microscopic findings. Tumor-forming ulcer at the papilla region, propagating with cord-like and alveolar structures. It consisted of poorly differentiated adenocarcinoma with the formation of a partially glandular structure.
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