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Pancreaticoduodenectomy in the Setting of Intestinal Malrotation
Canaan Baer*1, Randall Zuckerman2, Thomas R. Biehl1, Scott Helton1, Flavio G. Rocha1
1Surgery, Virginia Mason Medical Center, Seattle, WA; 2St Vincent's Medical Center, Bridgeport, CT
INTRODUCTION: Intestinal malrotation (IM) is a developmental anomaly resulting from a failure of the embryonic midgut to complete its rotation around the superior mesenteric artery. Although typically recognized in the pediatric population, IM in adults with periampullary lesions present particular challenges for the pancreatic surgeon. Herein, we present our experience with patients with IM requiring pancreaticoduodenectomy.
METHODS: Retrospective review of 5 patients with IM undergoing pancreaticoduodenectomy for periampullary lesions at two institutions. Clinical, radiographic, and pathologic information was obtained from the medical record.
RESULTS: Five patients presented with resectable periampullary neoplasms (2 pancreatic adenocarcinoma, 1 ampullary carcinoma, 1 duodenal adenocarcinoma, and 1 intraductal papillary mucinous neoplasm). On preoperative imaging they were found to have intestinal malrotation with inversion of the superior mesenteric artery (SMA) and vein (SMV) and failure of the duodenum to cross the midline. Successful pancreaticoduodenectomy was performed in all cases with a modified approach. Aberrant vascular and anatomic locations mandated careful parenchymal resection. Although the SMA was more accessible at the head of the pancreas as it passed to the right of the SMV (See Figure), the location of intestinal and pancreatic branches required precise identification of their actual compared to expected course. Particular attention was paid to the dissection of the uncinate process in order to avoid inadvertent injury to arteries supplying the small bowel. The reconstruction was performed in standard fashion in all cases. All patients tolerated their procedures well. Postoperative complications included 1 peripancreatic abscess requiring drainage.
CONCLUSION: Pancreaticoduodenectomy can be performed in patients with intestinal malrotation although a thorough understanding of the vascular anatomy is required to complete the operation safely.
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