Step-by-Step Pancreaticoduodenectomy in Complete Situs Inversus: Technical Strategy to Preserve Oncologic Principles in a Rare Anatomical Setting.
Alessia Fassari, Bastien Le Floc'h, Hector Prudhomme et al.
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Case in brief
A 68-year-old woman with BRCA1-mutated breast cancer and complete situs inversus presented with general deterioration and symptoms of high intestinal obstruction. Imaging and endoscopic biopsy identified resectable pancreatic head adenocarcinoma invading the duodenum, with a complete common mesentery. After preoperative mapping of vascular anatomy, she underwent open pancreaticoduodenectomy with adaptations for the mirrored anatomy and tumor-involved jejunal vascular trunks. R0 resection was achieved. Postoperative complications included chylous ascites and grade A delayed gastric emptying; she stayed in hospital for 16 days. Pathology showed poorly differentiated pT3N2 adenocarcinoma, with 30 of 33 lymph nodes positive.
What made this case unusual
The combination of complete situs inversus and complete common mesentery complicated pancreaticoduodenectomy, particularly identification and management of jejunal arterial and venous trunks involved by the tumor.
Diagnostic / clinical pearl
In mirrored anatomy with a complete common mesentery, careful preoperative vascular mapping and intraoperative adaptation can support oncologically complete pancreaticoduodenectomy.