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Case Report Unusual Jejunal Tributaries

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Case Report Unusual Jejunal Tributaries Page 1 of 2 Surgery Case Report Unusual jejunal tributaries of the splenic vein and their surgical importance: a case report SB Nayak*, AP Aithal*, RD Melanie, A Guru, N Kumar Abstract landmarks and portal venous tribu- pose unique technical challenges Introduction taries. for surgeons performing pancrea- Knowledge of variations regarding The superior mesenteric vein toduodenectomy. We present here a the formation, termination and trib- drains the small intestine, caecum very unique course and termination utaries of the portal vein, superior and ascending and transverse parts pattern of two proximal jejunal veins mesenteric vein and splenic vein are of the colon. It ascends in the mesen- and discuss their clinical implica- very useful and of utmost importance tery on the right of the superior tions. for surgeons performing surgeries mesenteric artery. The splenic vein of the pancreas and duodenum. is formed at the hilum of the spleen Case report Normally, the jejunal veins are the and runs a straight course behind During the dissection classes for tributaries of the superior mesen- the pancreas. Finally, the superior undergraduate medical students, teric vein. We report here, a very mesenteric vein joins with the splenic we noted variations in the termina- vein behind the neck of the pancreas tion of the upper jejunal veins in an unusual case where two proximal manuscript. nal jejunal veins drained into the splenic to form the portal vein1. adult male cadaver who was approxi- fi vein instead of the superior mesen- The first order tributaries of the mately 65 years old. The portal vein teric vein. superior mesenteric vein are the ileal was formed behind the neck of the Case report and the jejunal tributaries. The pancreas by the union of the splenic During the dissection classes for jejunal tributary usually runs behind and superior mesenteric veins undergraduate medical students, we the superior mesenteric artery as (Figures 1 and 2). The splenic vein noted variations in the termination it drains the proximal jejunum and received its normal tributaries from of the upper jejunal veins in an adult then enters the posteromedial aspect the spleen, pancreas and stomach. male cadaver who was approximately of the ileal tributary to form the Apart from that, it also received 65 years old. We found that the union main trunk of the superior mesen- two large jejunal tributaries. The of three veins formed the portal vein: teric vein2. These jejunal veins may upper jejunal vein was small and the splenic vein, jejunal veins and the superior mesenteric vein. Conclusion Familiarity with such anatomical variation provides useful informa- tion for surgeons performing abdom- inal surgical procedures. on of the manuscript, as well read and approved Introduction ti The superior mesenteric vein and its tributaries are subject to more variation than the arterial system. Therefore, the surgeons performing pancreatoduodenectomy should be Figure 1: Dissection of the upper Figure 2: Closer view of the forma- familiar with the important venous abdominal vessels. The pancreas tion of the portal vein (PV) by the none declared. ict of Interests: and stomach have been retracted superior mesenteric (SMV) and fl on, design, and prepara upwards. Note the termination of splenic (SV) veins. The pancreas ti the two jejunal veins (JV) into the has been pushed upwards. Note the rules of disclosure. (AME) ethical Ethics Medical on for * Corresponding author terminal part of the splenic vein (SV). termination of the two jejunal veins ti Email: [email protected]; ashwini. [email protected] The superior mesenteric vein (SMV), (JV) into the terminal part of the superior mesenteric artery (SMA), splenic vein. The superior mesen- Melaka Manipal Medical College (Manipal Campus), Manipal University, Manipal 576104, portal vein (PV) and jejunum (JEJ) teric artery (SMA) can be seen in the Karnataka, India can be seen in the figure. figure. Licensee OA Publishing London 2013. Creative Commons Attribution Licence (CC-BY) none declared. Con ng interests: ti FOR CITATION PURPOSES: Nayak SB, Aithal AP, Melanie RD, Guru A, Kumar N. Unusual jejunal tributaries of the splenic vein All authors abide by the Associa All authors contributed to the concep to All authors contributed and their surgical importance: a case report. OA Case Reports 2013 May 01;2(4):36. Compe Page 2 of 2 Case Report terminated into the splenic vein 1 cm Hyoung et al.5 reported a case ical variations would help surgeons away from the formation of the portal where the first jejunal vein directly to perform the complex pancreatic vein, whereas the lower jejunal vein drained into the splenoportal conflu- resection with greater safety. was large and it terminated into the ence. They also report a case wherein splenic vein 5 mm away from the the inferior mesenteric vein drained Co nsent formation of the portal vein. This into the first jejunal branch in 4% Written informed consent was gave the appearance that the union of patients and believe that such a obtained from the patient for publi- of three veins formed the portal vein: type of variation may be a congenital cation of this case report and accom- the splenic vein, jejunal veins and the anatomic variation rather than a panying images. A copy of the written superior mesenteric vein (Figure 2). collateral route5. Graf et al.7, in their consent is available for review by the Both the jejunal veins passed anterior study, reported that the first jejunal Editor-in-Chief of this journal. to the superior mesenteric artery and vein drained into the left intestinal ran upwards behind the body of the branch of the superior mesenteric References pancreas, crossing its lower border. vein in 19 of 54 patients. In a study 1. Standing S, Harold E, Jeremiah CH, Since two jejunal veins drained into conducted by Pavlos et al.4, 5.3% of Johnson D, Williams A, Collins A. Gray’s the splenic vein, the superior mesen- cases did not have a common trunk anatomy. 39th ed. Edinburgh, London: teric vein was reduced in size. of the superior mesenteric vein Churchill Livingstone; 2005.p1604. 2. Katz MH, Fleming JB, Pisters PW, Lee JE, with both the ileal and jejunal veins Evans DB. Anatomy of the superior Discussion draining together into the spleno- mesenteric vein with special reference Pancreatoduodenectomy, the treat- portal confluence. Gorantla et al.8 to the surgical management of first- manuscript. nal ment of pancreatic cancer, offers reported a case where the portal order branch involvement at pancrea- fi many technical challenges. The vari- vein was formed by the union of the ticoduodenectomy. Ann Surg. 2008 ability in the mesenteric veins poses a splenic vein, superior mesenteric Dec;248(6):1098–102. challenge for surgeons during pancre- vein and inferior mesenteric vein. 3. Vauthey JN, Dixon E. AHPBA/SSO/SSAT atoduodenectomy, especially in cases To the best of our knowledge, there consensus conference on resectable and with borderline resectable pancreatic have been no studies in the past that borderline resectable pancreatic cancer: cancers3. During pancreatic resections exhibit such a type of anatomical rationale and overview of the conference. Ann Surg Oncol. 2009 Jul;16(7):1725–6. with venous reconstruction, the variation where the jejunal veins, 4. Papavasiliou P, Arrangoiz R, Zhu F, Chun superior mesenteric vein and splenic superior mesenteric vein and its YS, Edwards K, Hoffman JP. The anatomic 4 tributaries must be carefully ligated . vein are joined to form the portal course of the first jejunal branch of the The complexity of these procedures vein. Thus, such a variation is very superior mesenteric vein in relation to further highlights the importance of unique and significant. Knowledge the superior mesenteric artery. Int J Surg extensive pre-operative knowledge of of such variations in portal anatomy Oncol. 2012;2012:538769. the mesenteric venous anatomy5. is important in the pre-operative 5. Kim HJ, Ko YT, Lim JW, Lee DH. Radio- Normally, the jejunal veins travel work-up prior to liver transplanta- logic anatomy of the superior mesenteric posterior (dorsal) to the superior tion or resection. vein and branching patterns of the first mesenteric artery, but they may jejunal trunk: evaluation using multi- also course anterior (ventral) to the detector row CT venography. Surg Radiol Conclusion Anat. 2007 Feb;29(1):67–75. artery which is seen in up to 20% of The anatomical course of the jejunal 6. Sakaguchi T, Suzuki S, Morita Y, Oishi K, on of the manuscript, as well read and approved 2 ti cases . In our case, we also observed veins is highly variable but readily Suzuki A, Fukumoto K, et al. Analysis of that the jejunal veins ran anterior identifiable using standard computed anatomic variants of mesenteric veins by to the artery. The knowledge of this tomography imaging. Hence, this 3-dimensional portography using multi variant anatomy is very important should aid the surgeons in planning detector-row computed tomography. Am for performance of pancreatoduo- for pancreatoduodenectomy with J Surg. 2010 Jul;200(1):15–22. denectomy, specifically with respect or without venous reconstruction. 7. Graf O, Boland GW, Kaufman JA, to mobilisation of the superior Detailed knowledge of the vascular Warshaw AL, Fernandez del Castillo C, Mueller PR. Anatomic variants of mesen- none declared. ict of interests: mesenteric vein for identification anatomy of the root of the mesen- fl teric veins: depiction with helical CT of the superior mesenteric artery. on, design, and prepara tery is necessary for performance ti venography. AJR Am J Roentgenol. 1997 Thus, to safely perform a mesenteric of complex surgical procedures that May;168(5):1209–13. rules of disclosure. (AME) ethical Ethics Medical on for approach to the artery, the surgeon involve the pancreas and lymph node 8. Gorantla VR, Potu BK, Pulakunta ti should be pre-operatively aware of metastases from midgut carcinoid T, Vollala VR, Addala PK, Nayak SR.
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