The knowledge of the vascular anatomy of the concerned region is an important prerequisite for planning surgical intervention. The awareness of the existing vascular anomalies enhances the insight regarding that region. We report a patient undergoing preoperative evaluation with CTA finding of Superior Mesenteric Artery (SMA) originating from the celiac artery. This celiac-mesenteric trunk is rare (<1%).
The online version of this article (doi:10.1186/1477-7819-9-71) contains supplementary material, which is available to authorized users.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
MW-lead author and primary surgeon for the patient. RN-assisted in writing the paper. SV-gathered and edited all the images. AC-assistant surgeon and edited the final paper. All authors read and approved the final manuscript.
Case Presentation
A 74-year-old woman was referred by her gastroenterologist with painless jaundice. She presented with several months of decreased appetite and a three week history of light colored stool with dark urine. An endoscopic ultrasound was performed and revealed a hypoechoic, irregular, 3.4 cm mass in the head of the pancreas. The common bile duct and pancreatic duct were obstructed from the mass. No vascular invasion, celiac or peri-celiac lymph nodes were noted. Two biliary stents were placed and no biopsies were taken during the procedure.
Prior to considering the patient a candidate for surgery, a high resolution computed tomography (CT) scan was performed with pancreatic protocol in non-contrast, arterial and venous phase to determine resectablity. CT scan was consistent with a double duct sign with markedly dilated pancreatic and common bile duct and intrahepatic biliary dilation secondary to mass on the pancreatic head. An interesting variant in anatomy was also identified, which was important for proper surgical planning. The superior mesenteric artery was found to be originating from the celiac axis. (Figure 1, 2, 3)
Figure 1
CT demonstrating abnormal celiac origin.
Figure 2
CT reconstruction showing vascular anomaly.
Figure 3
CT reconstruction showing vascular anomaly.
×
×
×
Anzeige
Pancreaticoduodenectomy is utilized selectively in the management of patients with neoplastic lesions of the pancreas and periampullary region. In these patients, the role of CT angiography (CTA) is important in determining tumor respectability and it allows one to evaluate for variant arterial anatomy. Preoperative knowledge of variant anatomy can assist in selection of treatment options and facilitate in surgical dissection and avoid iatrogenic injury.
The celiac artery supplies the liver, spleen, pancreas, and some of the stomach and duodenum. The superior mesenteric artery (SMA) supplies the small intestine, ascending colon, and a large portion of the transverse colon. Variation of arterial anatomy is common and occurs in nearly half of the population [1]).
We report a patient undergoing preoperative evaluation with CTA finding of Superior Mesenteric Artery (SMA) originating from the celiac artery. This celiac-mesenteric trunk is rare (<1%), however has been described [2].
In the embryo, the three paired arteries of the trunk originate from the aorta. Posterior arteries are parietal, lateral arteries are urogenital, and anterior arteries are intestinal. In human embryos the primitive intestinal arteries (vitelline arteries) are connected by a Tandler's anterior longitudinal anastomosis [3]. When the connection between celiac trunk and SMA remains presents, it tends to form a small vertical arch just behind the body of the pancreas. The rarely reported arterial anastomosis between the celiac trunk and SMA is known as the arc of Bühler's according to McNulty et al. [4]. An arc of Bühler was identified in 4 patients (3.3%) out of 120 combined celiac and superior mesenteric artery angiograms, in a study by Saad et al. [5]. In one study the arc of Bühler was identified in 14 cases among 340 selective celiac and superior mesenteric arteriographic studies [6]. They also stated that the arc of Bühler between the celiac and superior mesenteric arteries has to be considered as an embryological persistence 10th and 13th primitive arteries, which is associated with the persistence of ventral longitudinal anastomosis [2, 6]).
Anzeige
In our patient the CTA also demonstrated a subtotal occlusion of the origin of the celiac axis. There was significantly enlarged inferior mesenteric artery, which is likely due to the retrograde perfusion of SMA and celiac arteries.
Conclusion
It is important to understand the vascular anatomy of a region in planning a surgical intervention. When performing a pancreaticoduodenectomy, an awareness of the vasculature is necessary in case vasculature reconstruction needs to be performed because of tumor involvement of the vessels. Knowing the existing vascular anomalies enhances the insight regarding that area and helps to prevent mistakes due to a lack of awareness. Our patient underwent a pancreaticoduodenectomy. There was no vessel involvement found during the case. The patient tolerated the procedure well and was discharged in a timely fashion, without complication.
Consent
Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
MW-lead author and primary surgeon for the patient. RN-assisted in writing the paper. SV-gathered and edited all the images. AC-assistant surgeon and edited the final paper. All authors read and approved the final manuscript.
Die Therapie von Echinokokkosen sollte immer in spezialisierten Zentren erfolgen. Eine symptomlose Echinokokkose kann – egal ob von Hunde- oder Fuchsbandwurm ausgelöst – konservativ erfolgen. Wenn eine Op. nötig ist, kann es sinnvoll sein, vorher Zysten zu leeren und zu desinfizieren.
Der OP in der Zukunft wird mit weniger Personal auskommen – nicht, weil die Technik das medizinische Fachpersonal verdrängt, sondern weil der Personalmangel es nötig macht.
Seit November 2023 gibt es evidenzbasierte Empfehlungen zum perioperativen Management bei gastrointestinalen Tumoren (POMGAT) auf S3-Niveau. Vieles wird schon entsprechend der Empfehlungen durchgeführt. Wo es im Alltag noch hapert, zeigt eine Umfrage in einem Klinikverbund.
Auch wenn sich Krankenhäuser nachhaltig und grün geben – sie tragen aktuell erheblich zu den CO2-Emissionen bei und produzieren jede Menge Müll. Ein Pilotprojekt aus Bonn zeigt, dass viele Op.-Abfälle wiederverwertet werden können.
Update Chirurgie
Bestellen Sie unseren Fach-Newsletterund bleiben Sie gut informiert.
Das Karpaltunnelsyndrom ist die häufigste Kompressionsneuropathie peripherer Nerven. Obwohl die Anamnese mit dem nächtlichen Einschlafen der Hand (Brachialgia parästhetica nocturna) sehr typisch ist, ist eine klinisch-neurologische Untersuchung und Elektroneurografie in manchen Fällen auch eine Neurosonografie erforderlich. Im Anfangsstadium sind konservative Maßnahmen (Handgelenksschiene, Ergotherapie) empfehlenswert. Bei nicht Ansprechen der konservativen Therapie oder Auftreten von neurologischen Ausfällen ist eine Dekompression des N. medianus am Karpaltunnel indiziert.
Das Webinar beschäftigt sich mit Fragen und Antworten zu Diagnostik und Klassifikation sowie Möglichkeiten des Ausschlusses von Zusatzverletzungen. Die Referenten erläutern, welche Frakturen konservativ behandelt werden können und wie. Das Webinar beantwortet die Frage nach aktuellen operativen Therapiekonzepten: Welcher Zugang, welches Osteosynthesematerial? Auf was muss bei der Nachbehandlung der distalen Radiusfraktur geachtet werden?
Inhalte des Webinars zur S1-Leitlinie „Empfehlungen zur Therapie der akuten Appendizitis bei Erwachsenen“ sind die Darstellung des Projektes und des Erstellungswegs zur S1-Leitlinie, die Erläuterung der klinischen Relevanz der Klassifikation EAES 2015, die wissenschaftliche Begründung der wichtigsten Empfehlungen und die Darstellung stadiengerechter Therapieoptionen.
