PMC4855750_01
(a) is an Esophagogastroduodenoscopy (EGD) image showing the major papilla with a bulky growth consistent with villous adenomatous changes. Endoscopic retrograde cholangiopancreatography (ERCP) in (b) illustrates partial narrowing of the CBD and PD (arrow). Magnetic resonance cholangiopancreatography (MRCP) in (c) suggests narrowing of the distal CBD by the ampullary mass (arrow points towards the mass).
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Barrett's esophagus, was incidentally found on surveillance endoscopy to have a fungating, friable mass in the second portion of her duodenum encompassing the ampulla of Vater (Fig. 1a). Biopsy of this mass was consistent with duodenal adenoma. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a four centimeter multilobulated mass extending at least one cm into both the common bile duct (CBD) and the pancreatic duct (PD) causing partial obstruction of both ducts (Fig. 1b). Magnetic Resonance Cholangiopancreatography (MRCP) confirmed these findings and she was therefore referred for surgical resection (Fig. 1c).
Computed tomography axial images of the abdomen and pelvis showing the replaced gastroduodenal artery (GDA) arising from the superior mesenteric artery (SMA) in (a), then hugging the neck of the pancreas in (b) and continuing on to become the left hepatic artery (LHA) indicated by the arrowhead in (c).
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A preoperative computed tomography (CT) scan of the chest, abdomen and pelvis with CT angiogram and reconstruction of the visceral arterial anatomy was obtained (Fig. 2).
CT angiogram reconstruction of the extrahepatic mesenteric arterial system showing the aberrant arterial anatomy. rGDA = replaced gastroduodenal artery, rLHA = replaced left hepatic artery, CHA = common hepatic artery, SMA = superior mesenteric artery, SA = splenic artery, RHA = right hepatic artery.
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More importantly, the GDA arose from the SMA and travelled from the inferior border of the pancreas over the anterior surface of the pancreatic neck before it terminated as the left hepatic artery (LHA) supplying the left lobe of the liver (Fig. 3).
Intraoperative photograph showing the replaced gastroduodenal artery (rGDA) and its relation to the pancreas and the end result after the specimen was removed. (a) shows the tumor attached to the lateral wall of the PV. (b) shows the final anatomy after removal of the tumor. rLHA = Replaced left hepatic artery, CHA = common hepatic artery, SMA = superior mesenteric artery, SMV = superior mesenteric vein, PV = portal vein, SV = splenic vein, CHD = common hepatic duct.
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PV-SMV-SV confluence (Fig. 4). Post-operatively, the patient recovered uneventfully and was discharged home on day seven.