A 58-year-old patient with a history of arterial hypertension (AHT) and surgical resection of chondrosarcoma in the distal left fibula and valgus.
She had a 1-month history of nonspecific epigastric discomfort associated with early satiety, jaundice, choluria and pruritus at night, weight loss of 5 kg in this period.
Hepatic tests: total bilirubin: 16.3 mg/dl, direct bilirubin: glycated hemoglobin: 14100 mg/dl (FA): 327 U/L,tico gamma3, 170 leukocytes: 1250 U/xaeptidase (G).
Magnetic resonance imaging of the abdomen showed a 47 mm anterior pancreatic head mass, stenosing the proximal intrapancreatic choledochal duct, causing marked dilatation of the common bile duct up to 22 mm in diameter in the liver.
Patient was asymptomatic.
No evident intraabdominal dissemination.
Chest computed tomography (CT) showed no evidence of thoracic dissemination.
Whipple procedure was performed on June 7, 2014 (pancreatoduodenectomy without pyloric preservation), during tumor resection anatomical variation was observed, where the left hepatic artery energy pancreatic gastroduodenal mass was observed.
The dissection progressed identifying the right hepatic artery from a common hepatic artery distal to the gastroduodenal emergency.
No other artery could be identified from the common hepatic artery other than the right hepatic artery.
The accessory left liver was observed from the left gastric that irrigated the lateral segments (II and III).
Given the need to resect the duodenal artery at its origin due to the proximity to the tumor, it was decided to use the left artery from the right AGD, probably reflecting left gastric flow and access to the gastric area.
Given this finding, it was decided to keep the left hepatic artery in situ and to maintain the right hepatic arterial flow plus the accessory left gastric artery.
Tumor resection was continued without incidents.
Pancreato-yeast anastomosis stricture without stent was performed.
The patient was placed in good postoperative conditions with low output pancreatic fistula type A8.
During the tenth postoperative day the patient had fever associated with increased inflammatory parameters and increased FA and GGT.
A TAP CT scan showed extensive infarction area in the lateral segments of the left hepatic lobe.
The patient presented normalization of inflammatory parameters.
Drainage was removed on postoperative day 21 after confirmation of normal amylase and was discharged in good condition on day 23.
The plan is to control imaging the evolution of its segmental hepatic infarction.
Deferred biopsy showed: Nodular pancreatic head cancer, poorly differentiated ductal adenocarcinoma histological type in duodenal wall, intrapancreatic distal bile duct and peripancreatic fibroconnective tissue.
Lymphatic lymph node metastases in 1 out of 24 lymph nodes examined.
Surgical edge of the pancreas was negative.
AJCC: pTM T3N1Mx.
