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Introduction and importance Recent advances in chemotherapy and chemoradiotherapy allow performance of conversion surgery by improving tumor shrinkage in select patients with initially unresectable locally advanced pancreatic cancer (LAPC), thereby providing curative potential. The number of conversion surgeries requiring arterial reconstruction for select patients with initially unresectable LAPC following favorable responses is expected to increase, so providing effective options for safe arterial reconstruction is critical. Case presentation Herein we report a case of successful conversion surgery for initially unresectable LAPC with splenic artery transposition for hepatic arterial reconstruction after gemcitabine/nab-paclitaxel (GnP). A 71-year-old woman was referred to our hospital for evaluation of a pancreatic head mass after developing diabetes. She was diagnosed with unresectable LAPC, which was in wide contact with the common hepatic artery (CHA), proper hepatic artery (PHA), and splenic artery (SA). She received GnP, and after 6 cycles, durations of disease control and normalization of serum carbohydrate antigen 19-9 (CA19-9) exceeded 7 months. She underwent radical subtotal stomach-preserving pancreaticoduodenectomy with CHA-PHA and portal vein (PV) resection (SA-right hepatic artery anastomosis/PV-superior mesenteric vein direct end-to-end anastomosis). Histopathological examination revealed R0 resection with a histological response of Evans grade IIB. No signs of tumor recurrence have been observed for 14 months postoperatively. Clinical discussion No consensus has been reached regarding the optimal treatment regimen, duration, or criteria for conversion surgery in patients with LAPC, especially in cases requiring arterial resection. SA transposition for hepatic arterial reconstruction is generally very consistent, easily accessible, and offers adequate length and diameter for successful arterial anastomosis. Conclusion Even for a SA initially in contact with the tumor, SA transposition for hepatic artery reconstruction is a safe and effective option when tumor contact disappears due to chemotherapy.

Highlights • Splanchnic venous thrombosis caused by superior mesenteric vein thrombosis is rare. • Delayed diagnosis and/or treatment can result in acute intestinal infarction. • Protein C deficiency is rare. • Insufficient awareness can result in mismanagement of splanchnic venous thrombosis. • Coagulation disorders contribute to acute intestinal infarction of unknown cause., Introduction and importance Splanchnic venous thrombosis (SVT) originating in the superior mesenteric vein (SMV) is rare and may cause acute intestinal infarction (AII). Protein C deficiency (PCD) results in thrombophilia. Presentation of case Acute unexplained SVT originating in the SMV and portal vein was detected in 68-year-old man. Pan-peritonitis and AII were diagnosed and emergency surgery performed. Part of the small intestine was necrotic and partial resection without anastomotic reconstruction was performed. Heparin was administered intravenously continuously from postoperative day (POD) 1. Hereditary, heterozygous, type 1 PCD was diagnosed postoperatively. The anastomosis was reconstructed on POD 16. Warfarin was substituted for heparin on POD 22. No recurrent thrombosis occurred during 2 years of follow-up. Clinical discussion Patients with the rare condition of SVT require prompt diagnosis and treatment and may have underlying disease. PCD can cause SVT even in intact veins and anticoagulation therapy should be administered immediately postoperatively. Misdiagnosis and/or delayed treatment of SVT can result in AII, a life-threatening condition with a high mortality rate. Insufficient clinician awareness can result in serious mismanagement of patients with PCD and SVT; emergency patients with AII caused by unexplained SVT should therefore be further investigated for prothrombotic states and assessment of coagulation–fibrinolysis profiles to clarify the underlying mechanism. Conclusion We here present a thought-provoking emergency case of AII associated with acute SVT caused by underlying PCD that was successfully treated by two-stage surgery and anticoagulation therapy. This case provides a timely reminder for emergency clinicians and gastrointestinal surgeons.

Highlights • Colorectal cancer is seldom accompanied by venous tumor thrombosis in the superior mesenteric vein and little is known about its features. • Venous tumor thrombosis is representative of an aggressive cancer and that may be a strong risk factor for the development of liver metastasis. • Radical resection of the primary cancer combined with venous and adjuvant chemotherapy may be one of the treatment strategies., Introduction Venous tumor thrombosis occasionally accompanies renal cancer, liver cancer, and pancreatic cancer. Colorectal cancer is seldom accompanied by venous tumor thrombosis in the portal vein or the superior or inferior mesenteric veins (SMV, IMV), and little is known about its features. We report a case of ascending colon cancer with tumor thrombosis in the SMV treated with right hemicolectomy and combined resection of the SMV. Presentation of case An 82-year-old man with chief complaints of loss of appetite was admitted to our hospital. He was diagnosed with ascending colon cancer accompanied with tumor thrombosis extending to the SMV. He underwent right hemicolectomy and combined resection of the tumor thrombosis and the SMV. Intestinal blood flow was evaluated by intraoperative indocyanine green (ICG) fluorography. He continued to recover well from surgery. No adjuvant chemotherapy was employed because of the patient’s advanced age and his own will. He was transferred to another hospital on postoperative day 39. Six months after surgery, abdominal CT showed multiple liver metastases. He died 8 months after surgery. Discussion and conclusions Radical resection of the primary tumor and surgical thrombectomy should be considered for the treatment of colorectal cancer without distant metastasis accompanied by tumor thrombosis. However, venous tumor thrombosis is representative of an aggressive cancer and that may be a strong risk factor for the development of liver metastasis. Adjuvant systematic chemotherapy in addition to complete surgical resection may be one of the treatment strategies.

Highlights • Acute MVT is frequently idiopathic in origin. These cases require indefinite outpatient anticoagulation. • MVT results in bowel infarction less frequently than arterial thrombosis, though life-threatening infarction is possible. • Infarction is more common with thrombosis of smaller, more distal mesenteric veins. • Contrast-enhanced [[1], [2], [3], [4], [5], [6], [7], [8]] CT is the preferred diagnostic modality for MVT; lab tests are used to explore ischemia and peritonitis. • CT findings include venous filling defect, hypoattenuated bowel wall thickening, halo sign, and mesenteric edema., Introduction Though mesenteric venous thrombosis (MVT) causes bowel ischemia far less frequently than arterial thrombosis, it still has the potential to cause life-threatening bowel infarction. Presentation of case Presented here is a case of idiopathic MVT of the superior mesenteric vein and multiple distal venous branches causing diffuse peritonitis secondary to small bowel infarction in a 64 year old male. History and physical exam demonstrated severe persistent abdominal pain, hematochezia, and diffuse abdominal tenderness to palpation with guarding. Venous filling defects and segmental enteritis were noted on CT. The patient was treated with immediate IV heparin therapy with subsequent laparotomy and excision of 45 cm of ischemic ileum. The patient had an uncomplicated recovery. Post-operative thrombophilia screen was negative. The patient was discharged on indefinite warfarin therapy. Discussion MVT is often idiopathic in nature, with up to 49% having no identifiable cause. Risk factors include abdominal inflammation and systemic thrombophilias. Importantly, bowel infarction is more common with occlusion of more distal, smaller caliber mesenteric vessels. The standard of diagnosis is contrast-enhanced abdominal CT, and management is prompt anticoagulation with surgical intervention if severe. If the cause remains unclear, outpatient anticoagulation is continued indefinitely. Conclusion This case provides a valuable demonstration of several important MVT concepts – specifically the high rate of idiopathic etiology, the need for indefinite anticoagulation in idiopathic cases, and the increased risk of infarction in occlusion of smaller, more distal mesenteric veins.

Introduction and importance Bleeding from ileal varices is a rare and a life-threatening situation. Its management is difficult and includes endoscopic, surgical and interventional radiology treatment. Here we report a successful emergency surgery for bleeding ileal varices in a patient with cirrhosis due to autoimmune hepatitis. Presentation of a case A 60-year-old woman was admitted for rectal bleeding. She had a history of autoimmune hepatitis. She was treated by endoscopic ligation for oesophageal varices. Eso-gastro-duodenal fibroscopy and colonoscopy failed to reveal the bleeding site. CT scan was then performed showing ileal varices due to a portocaval shunt, there was a communication between the superior mesenteric vein and the right internal iliac vein. As the embolization was not feasible and the bleeding did not stop, an exploratory laparotomy was performed showing two dilated veins on the surface of the ileal wall, communicating with the right internal iliac vein. We performed a ligation of the vessels. Postoperative course was uneventful. Discussion Ectopic varices are a rare case of gastrointestinal bleeding. Most of those patients have portal hypertension and liver cirrhosis. Diagnosing bleeding ileal varices is difficult because endoscopic examination can't always reveal the bleeding site. Interventional radiology is a good option for patients having bleeding ileal varices knowing that they often have advanced liver cirrhosis making them poor candidates for surgery. Haemostasis by endoscopy is often temporary and bleeding frequently recurs. Surgery should be considered if non-invasive treatments failed to ensure the haemostasis. Conclusion Bleeding ileal varices is a rare situation. Interventional radiology and endoscopy can be good options. If not feasible, surgical treatment should not be delayed., Highlights • Ectopic varices are a rare case of gastrointestinal bleeding. • Diagnosing bleeding ileal varices is difficult. • Surgical treatment is the best option to stop the bleeding.

Highlights • Superior mesenteric vein and inferior vena cava injuries are associated with high mortality. • Damage control surgery is an effective strategy to stabilize the patient initially. • Second-look operations allow to identify injuries which might not have been discernable at first. • A mature hospital system with rapid response to trauma is integral when handling gunshot injuries., Introduction Injury to the superior mesenteric vein (SMV) is considerably rare amongst abdominal visceral vascular injuries. Multiple factors play a role in identifying such injuries, leading to the high morbidity and mortality associated. Case presentation We report a twenty-six-year-old male sustaining a SMV injury following a self-inflected gun shot. Initial assessment of the patient reveals hemodynamic instability and intraabdominal hemorrhage. Surgically approaching the patient was performed in two stages. Midline laparotomy was performed to control the active bleeding and stabilize the patient. Kocherizing the duodenum reveals that the source of retroperitoneal bleeding was from the SMV and one of the supra-renal tributaries of the Inferior Vena Cava (IVC). Several stitches were taken in a figure-of-eight manner to control the bleeding. Second-look operation was performed to rule out other injuries and permeant closure of the abdominal wall. Proper psychiatric care was ensured before transferal of the patient in good conditions to another healthcare facility specialized in mental health. Discussion High mortality rates reaching up to 65% are reported in similar cases. Multiple factors have contributed to the patient’s favorable outcome, including rapid trauma response, absences of other associated injuries, and the patient’s baseline healthy status. Conclusion The principle of damage control surgery in trauma is an effective strategy to stabilize the patient and rule out other injuries which might not have been discernible initially.

Highlights • Portal vein thrombosis due to constriction of hepaticojejunostomy is rarely occured, in which increased biliary pressure by obstructive jaundice decreased portal flow. • Re-anastomosis and postoperative thromolytic therapy recovered occluded portal flow., Introduction This case report aims to inform pancreatic surgeons about our perioperative management of intrahepatic portal vein thrombosis caused by an obstruction of hepaticojejunostomy (HJ) after pancreaticoduodenectomy (PD). Case presentation A 65-year-old woman was diagnosed with pancreas head carcinoma involving the superior mesenteric vein (SMV). Pancreaticoduodenectomy combined with SMV resection was followed by HJ. Twisting or narrowing was not evident during anastomosis. Total bilirubin values progressively increased to 13 mg/dL on day 5. At that time, we suspected anastomotic occlusion and found complete portal thrombosis of the left liver. Therefore, emergency re-anastomosis of the HJ was followed by thrombectomy, which was not completely successful and did not completely recover initial portal flow. Thrombolytic drugs improved obstructive jaundice, eradicated the organized thrombosis and recovered the portal flow by day 30. The post-operative course was uneventful. Discussion A thrombosis immediately formed in the portal vein due to biliary obstruction of an anastomotic site. We speculated that biliary dilation and related inflammation caused a relative increase in arterial flow and decreased portal flow at the localized part of the umbilical portion. Although early surgical thrombectomy was attempted soon after the primary operation, the organized thrombosis persisted. However, thrombolytic therapy eradicated the thrombosis. Conclusion Careful anastomosis of HJ during PD was necessary to avoid postoperative biliary stricture. This type of complication affects intrahepatic blood flow, particularly via the portal vein. Although immediate re-anastomosis or thrombectomy is applied, organized thrombosis cannot always be surgically removed.

Highlights • A rare variation of Abernethy malformation with Associated small bowel anomaly. • A case of emergency surgery in a patient with these anomalies. • Pre-operative imaging and intra-operative findings are presented. • The embryology of these anomalies pertaining to the case are discussed., Introduction Abernethy malformations are extremely rare congenital anomalous portosystemic shunts. We report the case of a patient with a rare variant Abernethy malformation between the superior mesenteric vein and left renal vein, associated with a massive jejunal diverticulum. Presentation of case A 37-year-old Caucasian female presented to our emergency department with severe abdominal pain and proceeded to laparotomy for a presumed small bowel obstruction. At laparotomy she was found to have a massive diverticulum at the duodeno-jejunal junction, which was intimately associated with a venous malformation and the anomalous portosystemic shunt. Whilst mobilising the diverticulum, the patient developed catastrophic haemorrhage from the malformation. The patient underwent a complicated post-operative course however was eventually stabilised. Discussion We discuss the anatomy and pathophysiology of anomalous portosystemic shunts and propose an embryological origin for our patients’ anomalies. Conclusion Abernethy malformations are rare however may be associated with other intra-abdominal pathology and extreme caution is required when operating on these patients.

Highlights • Acute portal and superior mesenteric vein thrombosis (SMV) are a rare but potentially lethal conditions. • Superior Mesenteric Vein Thrombosis is accompanied by non-specific symptoms, making the diagnosis rather challenging. • The initial management of SMV thrombosis usually involves the initiation of anticoagulants. • Operative management is reserved for underlying bowel compromise where peritoneal signs are exhibited., Introduction and case presentation Acute portal and superior mesenteric vein thrombosis(SMV) is a rare but potentially lethal condition that is often characterized by generalized and non-specific symptoms. A high index of suspicion is warranted for early diagnosis and management. We present a case of 54 year old male who presented with generalized abdominal pain which was later accompanied by hemodynamic instability and radiological diagnosis of portal vein and superior mesenteric vein thrombosis. Discussion The management of SMV can be divided into medical and surgical therapy. Patients who have clear signs of peritonitis will require emergent surgery. Interventions for life-threatening portal vein thrombosis are limited and poorly described in the literature. Conclusion We report a case of extensive portal vein thrombosis(PVT) advancing proximally to involve the superior mesenteric vein. Rapid portal vein patency and improved hepatic function was achieved with the direct use of tissue plasminogen activator infusion via operatively placed middle colic vein catheter.

Highlights • Midgut volvulus is usually diagnosed in first weeks of life, or even, in many cases, before birth. • Incidence of midgut malrotation among pediatrics is 1 in 500 livebirths. • Incidence of adult midgut malrotation is reported between 0.0001% and 0.19%. • This is case rare presentation in which a 34 year old man was presented. With diagnosis of midgut volvulus underwent laparotomy., Introduction The incidence of midgut vovulus is rare in adults. However, a significant number of cases were seen in infant and children. Presentation of case We report a case of a 34-year-old male who presented to the emergency room with persistent periumbilical abdominal pain without any other symptoms. Contrast-enhanced CT showed clearly the typical finding of midgut volvulus like whirlpool sign, corkscrew sign, and the superior mesenteric vein to the left of superior mesenteric artery. The patient was planned for Ladd’s procedure and emergency laparotomy performed successfully with an uneventful postoperative recovery. Discussion Managing midgut volvulus is based on presentation. In symptomatic cases surgery is the treatment, but in asymptomatic cases, treatment is controversial. Conclusion Although midgut volvulus is rare in adults, it should be considered as an intestinal obstruction.

Highlights • Pancreatitis, panniculitis and polyarthritis syndrome is a very rare manifestation of pancreatitis with panniculitis and polyarthritis with intraosseous fat necrosis. • A rare differential diagnosis of unclear polyarthritis, panniculitis or osteonecrosis. • Surgical treatment, if possible can lead to complete remission., Introduction Pancreatitis, panniculitis and polyarthritis syndrome is a very rare extra-pancreatic complication of pancreatic diseases. Presentation of case While in most cases this syndrome is caused by acute or chronic pancreatitis, we report a case of a 62-year-old man presenting with extensive intraosseous fat necrosis, polyarthritis and panniculitis caused by a post-pancreatitis pseudocyst with a fistula to the superior mesenteric vein and extremely high blood levels of lipase. This became symptomatic 2.5 years after an episode of acute pancreatitis and as in most cases abdominal symptoms were absent. Treatment by surgical resection of the pancreatic head with the pseudocyst and mesenteric fistula led to complete remission of all symptoms. Discussion A review of the literature revealed that all publications are limited to case reports. Most authors hypothesize that an unspecific damage can cause a secretion of pancreatic enzymes to the bloodstream leading to a systemic lipolysis and fat tissue necrosis, especially of subcutaneous tissue, bone marrow, inducing panniculitis, polyarthritis and osteonecrosis. Even if caused by an acute pancreatitis abdominal symptoms are often mild or absent in most cases leading to misdiagnosis and poor prognosis. Conclusion While symptomatic treatment with NSAR and cortisone showed poor to moderate response, causal treatment can be successful depending on the underlying pancreatic disease.

Locally advanced colorectal tumors represent about 5–22% of all colorectal cancers at the time of presentation. Specifically in the case of right colon cancer, the percentage of adjacent structure involvement ranges between 11% and 28%. Organs that are most frequently invaded by right colonic tumors are the duodenum and the pancreatic head. We report the case of a 36-year old man with locally advanced right colonic cancer, invading the head of the pancreas and the superior mesenteric vein, who was successfully treated in our department with right hemicolectomy, pancreatoduodenectomy and short resection of the superior mesenteric vein with an end-to-end anastomosis, and remains alive and well, free of disease, nine years after the operation.

INTRODUCTIONPortal venous aneurysms are a rare finding. The reported incidence is on the rise with increasing use of modern imaging techniques in clinical practice. However, there is still much to be elicited regarding their aetiology, natural history, and management.PRESENTATION OF CASEAn 80-year-old woman presented with abdominal pain and nausea. Investigations showed a hypoechoic area in the region of the head of pancreas on ultrasound, which was found to be a portal venous aneurysm on CT. In view of her multiple comorbidities, a conservative approach was taken.DISCUSSIONPortal venous aneurysms represent approximately 3% of all venous aneurysms with a reported prevalence of 0.43%. They may be congenital, due to failure of complete regression of the right vitelline vein, or acquired secondary to portal hypertension. The primary presentation of portal vein aneurysm is abdominal pain, followed by incidental detection on imaging, with a minority of patients presenting with gastrointestinal bleeding. Complications of PVA include thrombosis, biliary tract obstruction, inferior vena cava obstruction, and duodenal compression. On the whole PVAs are stable and have a low risk of complications with 88% of patients showing no progression of aneurysm size or complications on subsequent follow up scans.CONCLUSIONWe recommend that portal venous aneurysms be assessed using colour Doppler ultrasonography in the first instance with CT scans reserved for indeterminate cases or symptomatic patients. Due to the slow progression of such aneurysms, surgery is recommended only for symptomatic patients or those with complications secondary to portal venous aneurysms.

Highlights • Whipple procedure (pancreatoduodenectomy) is an extensive procedure carrying risk of a number of postoperative complications. • Thrombosis of superior mesenteric vein is a complication that requires aggressive therapeutical approach. • Mesenteroovarian anastomosis is one of the options if thrombectomy is not feasible., INTRODUCTION Pancreatoduodenectomy is an extensive procedure carrying risk of a number of postoperative complications. Of these the most common are surgical site infections (SSI), bleeding, delayed gastric emptying, and anastomotic leakage. However, the most serious complications are ones, that are rare, clinically hardly diagnosed, and if untreated, leading to the death of a patient. Among the latter complications is thrombosis of superior mesenteric vein. Its clinical signs are unspecific and diagnostics complicated. Treatment requires aggressive approach. If this is absent, intestinal necrosis with septic state, Multiple Organ Dysfunction Syndrome (MODS) and Multiple Organ Failure (MOF) lead to a death of a patient. PRESENTATION OF CASE Authors present a case of a patient after pancreatoduodenectomy, complicated by the thrombosis of superior mesenteric vein. Patient was managed by resection of the necrotic bowel, venous decompression by venous bypass from superior mesenteric vein to the right ovarian vein, and open abdomen with negative pressure wound therapy (NPWT). Patient suffered severe abdominal sepsis with need for intensive organ support. Abdomen was definitely closed on fourth NPWT redress. Patient healed without any further complications, is well and was released to the ambulatory setting. DISCUSSION Superior mesenteric vein (VMS) thrombosis is a rare complication. It diagnosis requires high level of vigilance and once diagnosed, aggressive therapy is essential. Two goals of surgical treatment exist: resection of the necrotic bowel and facilitation of the blood outflow. CONCLUSION Mesenteroovarian anastomosis is one of the options in treatment of thrombosis of VMS if thrombectomy is not feasible.