A significant vascular variant in oncologic pancreaticoduodenectomy: the arc of Buhler

Abstract

Background The arc of Buhler (AOB), a rare anastomosis connecting the superior mesenteric artery (SMA) to the celiac trunk (CA), was found in a patient suffering from an adenocarcinoma of the pancreatic head. Case presentation Oncologic pancreaticoduodenectomy required resection of the AOB to achieve complete tumor removal. After an uneventful clinical course in the first days, the patient suffered a severe complication. Due to ischemia of the stomach and spleen, complete resection of the stomach, spleen, and remaining pancreas had to be performed. Conclusions The hemodynamic impact of this arterial variant has been discussed mainly for liver perfusion, which remained intact at all times in our case. Because of the serious obstacles mentioned above, we strongly recommend that the presence of AOB be considered in preoperative diagnosis and preservation when possible. If the AOB is likely to be ligated, stenosis of the SMA or CA should be excluded and resolved before surgery.

The clinical and operative impact of the hexafurcation of the celiac trunk - Report of an extremely rare case

“…The arc of Bühler is of significant clinical importance as it forms a collateral pathway for arterial perfusion in case of mesenteric or liver ischemia and could be a life-saving variation (Michalinos et al, 2018). Especially, during pancreatic oncologic operations where the ligation of the gastroduodenal artery is mandatory, the presence of the arc acts as an alternative arterial supply to the liver especially if celiac stenosis coexists (McNulty et al, 2001;Manta et al, 2022b;Schumacher et al, 2022). Liver transplantation could also benefit from this arc in the presence of stenosis in the major splanchnic arteries (Incarbone et al, 2021).…”

“…The clinical significance of the hexafurcation of the CT is evident, during liver, pancreatic, esophagogastric surgery, liver transplantations, organ procurements for transplantation such as liver, pancreas, small bowel or multivisceral ones, lymph node dissection for oncological procedures and vascular surgery (abdominal aortic aneurysm, or even aortic dissection) (McNulty et al, 2001;Saad et al, 2005;Douard et al, 2006;Michalinos et al, 2018;Schizas et al, 2020;Manta et al, 2022b;Schumacher et al, 2022). These variations could complicate the aforementioned procedures with bleeding because of inadvertent injury if the surgical team is not aware of them.…”