Preduodenal portal vein, intestinal malrotation, polysplenia, and interruption of the inferior vena cava: a review of anatomical anomalies associated with gastric cancer

A case of incomplete duplication of the portal vein associated with multiple congenital anomalies

Double portal veins are a duplication of the portal vein and normal portal vein with an accessory portal vein. We report a case of a 63-year-old asymptomatic female with double portal veins. There was fat accumulation observed in the area which was supplied by the first portal vein in normal position, and fatty sparing of the liver was observed in the area which was supplied by the second portal vein in the preduodenal position. The 2 portal veins were equal in size. Furthermore, the patient presented with multiple congenital anomalies, including double inferior vena cava, splenic lobulation, and accessory liver lobe. Therefore, double portal veins in our case were thought to be an incomplete duplication of the portal vein with multiple congenital anomalies.

Laparoscopic distal gastrectomy for gastric cancer patient with intestinal malrotation: report of a case

Background

Intestinal malrotation, which arises from incomplete rotation of the embryonic midgut, is one of the congenital anomalies usually diagnosed in infancy. On the other hand, intestinal malrotation detected in asymptomatic adults is very rare. It is frequently diagnosed incidentally during abdominal surgery. We report a case of asymptomatic intestinal malrotation diagnosed during laparoscopic distal gastrectomy for gastric cancer.

Case presentation

A 59-year-old female was diagnosed with early-stage gastric cancer during health screening and admitted to our hospital for radical surgical treatment. Physical examinations and blood tests revealed nothing of note. The type 0-IIc gastric cancer was located in the posterior wall of the mid-body of the stomach. The histological type was poorly differentiated adenocarcinoma.

Esophagogastroduodenoscopy and computed tomography (CT) suggested that the depth of tumor invasion was the submucosal layer without regional lymph node swelling. The clinical stage according to the TNM 7th edition was cT1b N0 M0, cStage I.

Laparoscopic distal gastrectomy with D1+ lymph node dissection and Billroth-I method reconstruction was planned. During the infrapyloric lymph node dissection, a part of the pancreatic head showed unusual adherence to the first part of the duodenal wall. For safe and accurate lymphadenectomy while avoiding pancreatic injury, we deliberately focused on tracing the dissectible layer between the pancreatic parenchyma and fatty tissues including lymph nodes.

Also, we changed the reconstruction procedure from Billroth-I to Roux-en-Y. After distal gastrostomy, we could not find the ligament of Treitz or jejunum on the left side below the transverse colon. Based on a review of the CT image, this patient was diagnosed with intestinal malrotation.

Although the detection of malrotation during the operation was incidental, we could complete radical surgery and Roux-en-Y reconstruction safely. The type of malrotation was non-rotation (90°). She was discharged from our hospital without any complications.

Conclusion

We encountered a case of adult asymptomatic intestinal malrotation with gastric cancer. Even when encountering such a case during laparoscopic gastrectomy, reviewing CT images carefully to reconsider the anatomical anomalies, and tracing the dissectible layer accurately with adequate countertraction can facilitate safe and successful surgery.

Variant arterial supply to the lesser curvature of the stomach and duodenum from double inferior phrenic arteries

A rare case of the left accessory inferior phrenic artery (IPA) supplying the lesser curvature of the stomach and the right accessory IPA supplying the duodenum was observed during interventional radiography. To our knowledge, variation arteries supplying the stomach and duodenum have never been reported in English literature; herein, we report the first case of variant arterial supply to the lesser curvature of the stomach and duodenum from double IPAs.

Hepatic resection for hepatocellular carcinoma in a patient with situs ambiguous with polysplenia: report of a case

We report a case of successful resection of hepatocellular carcinoma (HCC) in a patient with situs ambiguous with polysplenia (PS), a rare congenital anomaly. A 62-year-old Japanese man was admitted to our hospital for investigation and treatment of a hepatic tumor. Imaging studies revealed two HCCs, 2.5 and 0.7 cm in diameter, in the anterior section and segment 3 of the reversed liver, respectively. He also had multiple spleens in the right side of the abdomen, right side of the stomach, and duodenum, as well as azygous continuation of the inferior vena cava (IVC) with absence of the retro-hepatic IVC, a truncated pancreas, rare variation of the hepatic artery, and dextrocardia. We performed anterior sectionectomy of the liver and partial resection of segment 3. We found only two previous reports of HCC in patients with situs ambiguous with PS, but our patient is the first to have undergone anatomical hepatic resection of the reversed liver. Accurate anatomical assessment is essential during surgery on such patients.

Preduodenal portal vein in adult with polysplenia syndrome revisited with a case report

Preduodenal portal vein (PDPV) is a rare developmental anomaly. In infants, this is often associated with duodenal obstruction or biliary atresia. It is generally asymptomatic in adults (Ooshima et al., Hepato-Biliary-Pancreat Surg 5(4):455-458, 1998). Here, we report a singular case of adult PDPV that was discovered accidentally during emergency laparotomy for peritonitis due to gastric perforation in a 38-year-old lady. A plethora of congenital anomalies was uncovered, which is consistent with the reported cases of classical polysplenia syndrome, viz., multiple spleens of equal volume, visceral heterotaxia, right (Rt.)-sided stomach, a left (Lt.)-sided or a large midline liver, malrotation of intestine, a short pancreas, PDPV and IVC abnormalities (Gayer et al., Abdom Imaging 24:178-184, 1999). In addition, abnormalities like anamolous origin of Lt. gastric and splenic arteries from the abdominal aorta with absent celiac trunk, hepatic artery arising from the superior mesenteric artery, hepatic veins draining directly to Rt. atrium, etc. along with hypertrophic and lipomatous interatrial septum have also been detected during further investigations. As of now, we have come across 29 cases of adult PDPV reported in world literature and we are reporting our unique case with a review of literature on anomalies of visceral organs associated with PDPV.

Polysplenia syndrome: a review of the relationship with viscero-atrial situs and the spectrum of extra-cardiac anomalies

Polysplenia syndrome is classified as one of the situs ambiguous or heterotaxy syndromes and is classically termed left isomerism or bilateral left-sidedness. However, polysplenia is a controversial and complex entity with no fixed pathognomonic features but rather a broad spectrum of abnormalities. In many published case series, polysplenia was neither associated with viscero-atrial heterotaxy nor with duplication of left-sided structures. The relationship between polysplenia and viscero-atrial situs is not clear. Several recent case reports describe the association of polysplenia with situs inversus totalis or with pancreatic; venous and other anomalies or with several types of malignancy. This article provides the reader with a review of the literature as well as our own experience aiming at better understanding of the polysplenia syndrome, its relationship with viscero-atrial situs and the spectrum of associated extra-cardiac anomalies.