Gastrojejunostomy and Ladd's procedure for the management of obstructive preduodenal portal vein and intestinal malrotation in an adolescent: A case report

A potential cause of bowel obstruction in the setting of intestinal malrotation is preduodenal portal vein (PDPV). It is a rare congenital anomaly that can be associated with duodenal atresia, duodenal web, or annular pancreas. A 14-year-old female with a long history of failure to thrive presented to the hospital with abdominal pain. She described the pain as intermittent, responsive to pain medication, with radiation to the back. Her mother provided a history of approximately 10–15lbs of unintentional weight loss in 3–4 months, and intermittent symptoms that had been ongoing for over one year. She underwent a computed tomography (CT) of the abdomen/pelvis with intravenous contrast and was found to have intestinal malrotation with splenosis, inverse relationship of the superior mesenteric artery and superior mesenteric vein, the appendix in the left lower quadrant, and uterine didelphys. She underwent an upper gastrointestinal (UGI) study with small bowel follow-through that confirmed the malrotation, without bowel obstruction or volvulus. Due to persistent symptoms, she was taken to the operating room for an exploratory laparoscopy. We found that she had a PDPV, which was likely the cause of her symptoms. The PDPV was very close to the pylorus. After careful dissection, we were unable to obtain adequate duodenal length proximal to the PDPV to do a duodeno-duodenostomy. Therefore, we decided to proceed with gastrojejunostomy, followed by a Ladd's procedure. She had an uncomplicated recovery and was discharged home on postoperative day 10. Nine months after the operation, she remains asymptomatic. PDPV can present as the primary cause of duodenal obstruction. A gastrojejunostomy appears to be an effective treatment for cases in which a duodeno-duodenostomy is not doable.