Preoperative vascular simulation for distal bile duct cancer with a preduodenal portal vein: A case report

Figure 1 Contrast-enhanced computed tomography findings. A: Multiplanar computed tomography (CT) images (axial, coronal, and sagittal views) showing the portal vein coursing anterior to the duodenum (orange arrows), consistent with a preduodenal portal vein. The yellow dotted lines indicate the duodenal wall; B: Sagittal CT image demonstrating focal stenosis at the origin of the celiac artery (orange arrowhead), suggesting median arcuate ligament syndrome; C: Axial CT image showing multiple spleens (black arrow), consistent with polysplenia.

Figure 2 Three-dimensional reconstruction of vascular anatomy. A: Three-dimensional computed tomography reconstruction demonstrating the portal vein running anterior to the duodenum (green star) and the duodenum (orange diamond); B: Prominent dilatation of pancreaticoduodenal arcade collaterals associated with median arcuate ligament syndrome, and marked hypoplasia of the pancreatic body and tail, indicated up to the level of the yellow arrowhead line.

Figure 3 Schematic illustration of preoperative surgical planning. A schematic drawing generated from a careful review of the original computed tomography dataset, illustrating the anomalous portal vein, hypoplastic pancreas, surgically relevant collateral vessels, and the planned extent of resection. Orange lines indicate the planned transection lines, and orange arrows indicate the planned division of the median arcuate ligament. CA: Celiac artery; LGA: Left gastric artery; MAL: Median arcuate ligament; RGEA: Right gastroepiploic artery; SA: Splenic artery; SV: Splenic vein; RGEV: Right gastroepiploic vein; SMA: Superior mesenteric artery; CBD: Common bile duct; ASPDA: Anterior superior pancreaticoduodenal artery.

Figure 4 Intraoperative findings. A: Ladd’s band associated with intestinal malrotation is identified and divided; B: The portal vein is seen coursing anterior to the duodenum; C: Markedly dilated pancreatic arcade; D: The first branch of the superior mesenteric artery and anterior superior pancreaticoduodenal artery are temporarily clamped with vascular clips to confirm adequate arterial inflow from the proper hepatic artery. ASPDA: Anterior superior pancreaticoduodenal artery; SMA: Superior mesenteric artery.