Gastroduodenal artery: single key for many locks

Comparison of 2 Different Types of Arterial and Biliary Anastomoses While Preserving the Gastroduodenal Artery: A Retrospective Study

OBJECTIVE

Here we investigated 2 different arterial reconstruction procedures with preservation of the gastroduodenal artery (GDA) in orthotopic liver transplantation (OLT).

METHODS

A retrospective cohort study was conducted. The clinicopathological data of 40 pairs of donors and recipients who underwent OLT from May 2018 to August 2023 were analyzed. The GDA of all recipients was preserved during the hepatic arteries reconstruction, which were divided into 2 groups according to different anastomosis locations, namely the end-to-side group (E-S group, n = 17, Branch-patch between the common hepatic and the gastroduodenal artery) and end-to-end group (E-E group, n = 23, between common hepatic and proper hepatic).

RESULTS

Demographics did not differ between both groups (P > .05). The warm ischemia time (WIT) was numerically longer in the E-S group (403.3 ± 103.3 vs 195.2 ± 35.8 s; P < .001), but the cold ischemia time (CIT) was numerically shorter in the E-S group (279.2 ± 74.7 vs 325.2 ± 15.1 min; P = .023). The time of artery reconstruction and duration of surgery was numerically shorter in the E-S group (21.0 ± 3.6 vs 51.0 ± 9.1 min, P < .001; 326.0 ± 103.4 vs 422.7 ± 24.6 min, P = .001). The E-S group had a lower resistance index (RI) (0.5 ± 0.3 vs 0.6 ± 0.1; P = .049).

CONCLUSION

Both groups showed no differences in artery and biliary complications. GDA preservation meets the anatomical and physiological requirements. E-S is superior to E-E by the time of hepatic artery reconstruction and RI.

Ultra-High-Resolution Photon-Counting Detector CT Benefits Visualization of Abdominal Arteries: A Comparison to Standard-Reconstruction

This study aimed to investigate the potential benefit of ultra-high-resolution (UHR) photon-counting detector CT (PCD-CT) angiography in visualization of abdominal arteries in comparison to standard-reconstruction (SR) images of virtual monoenergetic images (VMI) at low kiloelectron volt (keV). We prospectively included 47 and 47 participants to undergo contrast-enhanced abdominal CT scans within UHR mode on a PCD-CT system using full-dose (FD) and low-dose (LD) protocols, respectively. The data were reconstructed into six series of images: FD_UHR_Br48, FD_UHR_Bv56, FD_UHR_Bv60, FD_SR_Bv40, LD_UHR_Bv48, and LD_SR_Bv40. The UHR reconstructions were performed with three kernels (Bv48, Bv56, and Bv60) within 0.2 mm. The SR were virtual monoenergetic imaging reconstruction with Bv40 kernel at 40-keV within 1 mm. Each series of axial images were reconstructed into coronal and volume-rendered images. The signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) of seven arteries were measured. Three radiologists assessed the image quality, and visibility of nine arteries on all the images. SNR and CNR values of SR images were significantly higher than those of UHR images (P < 0.001). The SR images have higher ratings in image noise (P < 0.001), but the FD_UHR_Bv56 and FD_UHR_Bv60 images has higher rating in vessel sharpness (P < 0.001). The overall quality was not significantly different among FD_VMI_40keV, LD_VMI_40keV, FD_UHR_Bv48, and LD_UHR_Bv48 images (P > 0.05) but higher than those of FD_UHR_Bv56 and FD_UHR_Bv60 images (P < 0.001). There is no significant difference of nine abdominal arteries among six series of images of axial, coronal and volume-rendered images (P > 0.05). To conclude, 1-mm SR image of VMI at 40-keV is superior to 0.2-mm UHR regardless of which kernel is used to visualize abdominal arteries, while 0.2-mm UHR image using a relatively smooth kernel may allow similar image quality and artery visibility when thinner slice image is warranted.

Sixteen cases of laparoscopic central pancreatectomy for benign or low-grade malignant tumours in the pancreatic neck and proximal body

BACKGROUND

The purpose of this study is to examine and analyse the outcomes and patient experiences associated with laparoscopic central pancreatectomy.

METHODS

The perioperative data of 16 patients who underwent laparoscopic central pancreatectomy were retrospectively analysed at Ningbo Medical Center Lihuili Hospital (Xingning Branch and Eastern Branch) from September 2017 to July 2023.

RESULTS

All surgical procedures were completed without the need for intraoperative conversion to open surgery. In two cases, intraoperative cholangiography was performed, while in four cases, intraoperative fluoroscopic laparoscopic assistance was utilized. The duration of the operations varied from 160 to 360 min, with an average of 281.75 min. The estimated volume of intraoperative bleeding ranged from 50 to 300 mL, with an average of 113.75 mL. The postoperative pathology results revealed that there were two cases of intraductal papillary mucinous neoplasm, six cases of serous cystic neoplasms, one case of mucinous cystic neoplasm, five cases of solid pseudopapillary neoplasms, and two cases of neuroendocrine tumours. The maximum diameter of the tumours ranged from 3.0 to 5.0 cm, with an average of 3.67 cm. There were no instances of postoperative common bile duct stenosis or biliary leakage. Among the cases, five did not exhibit pancreatic fistula, six experienced biochemical leakage, three had grade B pancreatic fistula, and two had grade C pancreatic fistula.

CONCLUSION

Laparoscopic central pancreatectomy, as a method to preserve pancreatic function, entails specific surgical risks and a notable likelihood of postoperative pancreatic fistula, necessitating the expertise of seasoned surgeons for its execution.

Novel embryological classifications of hepatic arteries based on the relationship between aberrant right hepatic arteries and the middle hepatic artery: A retrospective study of contrast-enhanced computed tomography images

BACKGROUND

Variations in hepatic arteries are frequently encountered during pancreatoduodenecomy. Identifying anomalies, especially the problematic aberrant right hepatic artery (aRHA), is crucial to preventing vascular-related complications. In cases where the middle hepatic artery (MHA) branches from aRHAs, their injury may lead to severe liver ischemia. Nevertheless, there has been little information on whether MHA branches from aRHAs. This study aimed to investigate the relationship between aRHAs and the MHA based on the embryological development of visceral arteries.

METHODS

This retrospective study analyzed contrast-enhanced computed tomography images of 759 patients who underwent hepatobiliary-pancreatic surgery between January 2011 and August 2022. The origin of RHAs and MHA courses were determined using three-dimensional reconstruction. All cases of aRHAs were categorized into those with or without replacement of the left hepatic artery (LHA).

RESULTS

Among the 759 patients, 163 (21.4%) had aRHAs. Five aRHAs patterns were identified: (Type 1) RHA from the gastroduodenal artery (2.7%), (Type 2) RHA from the superior mesenteric artery (SMA) (12.7%), (Type 3) RHA from the celiac axis (2.1%), (Type 4) common hepatic artery (CHA) from the SMA (3.5%), and (Type 5) separate branching of RHA and LHA from the CHA (0.26%). The MHA did not originate from aRHAs in Types 1-3, whereas in Type 4, it branched from either the RHA or LHA.

CONCLUSIONS

Based on the developmental process of hepatic and visceral arteries, branching of the MHA from aRHAs is considered rare. However, preoperative recognition and intraoperative anatomical assessment of aRHAs is essential to avoid injury.

The arterial anatomy of the posterior duodenum - A computed tomography angiography analysis with implications for abdominal surgery

The main objective of the present study was to clarify the anatomical characteristics of the GDA. In order to fulfill this objective, novel classification systems of both the origin and branching pattern of the said vessel were created. Being aware of the variable anatomy of the GDA is of great importance when performing hepatopancreaticobilliary procedures. The results of 75 consecutive patients who underwent abdomen computed tomography angiography (CTA) were analyzed. A total of 74 GDA were analyzed. Of these, 42 were from women (56.8%) and 32 were from men (43.2%). The most common direction of origin of the GDA was inferior (n = 38; 51.4%). The origin variation of each GDA was deeply analyzed. Initially, eight types of origin variations were evaluated, of which types 1-3 constituted 83.8%. Furthermore, analogously, branching pattern types were also established. Initially, 11 branching variations were evaluated, of which types 1-3 constituted 87.8%. The GDA is subject to numerous variations, both in the origin and in the branching pattern of the vessel. In order to clarify the anatomical characteristics of this vessel, novel classifications of the origin and branching patterns were made, presenting the most frequent patterns. Our results may be of great use for surgeons performing hepatopancreaticobilliary surgeries, such as the Whipple procedure or vascular reconstructions after cholangiocarcinoma resections. Being aware of the anatomical variations of relevant structures associated with a surgical procedure may help reduce potential intraoperative and/or postoperative complications.

Intraductal photodynamic therapy and its combination with intra-arterial chemoinfusion in the treatment of inoperable patients with Klatskin tumor

Background: A palliative or symptomatic treatment is indicated for 7080% of patients with Klatskins tumor because of the advanced lesion volume and the patients grave condition. Hepatic arterial infusion chemotherapy, chemoembolization, radioembolization are successfully used in the treatment of hepatocellular carcinoma and liver metastases. Aim: to estimate the immediate and long-term results of photodynamic therapy (PDT) and its combination with hepatic arterial infusion in inoperable patients with Klatskin tumors. Methods: Between 2010 and 2021, 83 palliative PDT sessions (from 1 to 8, average 2.4) were performed in 82 patients as a single treatment or in combination with hepatic arterial infusion. In all cases, percutaneous transhepatic biliary drainage was previously performed; no chemotherapy was applied. Two groups of 48 patients were stratified according to the ECOG status (23) and the numbers of PDT sessions (no more than two). The treatment group of the combination therapy consisted of 24 patients (13 male, 11 female) aged 38 to 85 (mean 63) years with the ECOG status of 24 (mean 2.4). This group received PDT with hepatic arterial infusion using a GemCis regimen. On average, 1.4 PDT sessions were performed, the treatment started on the 89th (27225) day after the biliary drainage. The hepatic arterial infusion was performed on the 2d3th day after the PDT. The control group received only PDT and consisted of 24 patients (13 male, 11 female) aged 51 to 83 (66 on average) years, with the ECOG status of 23 (mean 2.6). On average, 1.4 PDT sessions were performed, starting on the 106th (32405) day after the biliary drainage. Results: There were no serious adverse events associated with PDT in both groups. Toxic complications of hepatic arterial infusion were observed in 13 of 24 patients (54%): III grade hematological (54%) and gastrointestinal (69%); all were eliminated with medical therapy. Complications of the percutaneous transhepatic biliary drainage in three patients (hemobilia, n=2, and sepsis, n=1) were estimated as grade III by the CIRSE classification (2017) and successfully treated without surgery. In the combination treatment group, the overall mean survival and median survival were higher than those in the control group: 327.939.8 days (10.9 mo) versus 246.931.2 days (8.2 mo) and 275 days versus 244 days. However, these differences did not reach the statistical significance (p=0.12). Conclusions: PDT is a safe method of a palliative treatment of critically ill patients with Klatskin tumor (ECOG 23). PDT alone has limited clinical efficacy. A combination of PDT and hepatic arterial infusion does not cause serious complications and may increase the survival rates.

First jejunal vein, jejunal trunk, and pancreatico-duodenectomy: resolving the literature conundrum

A detailed knowledge of the surgical anatomy of tributaries of the superior mesenteric vein, especially proximal jejunal venous anatomy (first jejunal vein and jejunal trunk), is a key prerequisite for performing a safe pancreatico-duodenectomy. However, the available literature on the anatomical course and surgical relevance of these vessels is scarce, the nomenclature across the articles is heterogeneous, and the resulting evidence is confusing to interpret. Standardized terminology and an in-depth review of these vessels with regard to their course, termination, vascular relations, and variations will help the surgeons in planning and performing this complex surgery safely, especially when a venous resection and reconstruction is planned in cases of borderline resectable pancreatic cancer. A uniform nomenclature and a unifying classification are proposed in this review for these two tributaries to help resolve the literature conundrum. This standardized terminology and anatomical description will assist the radiologists in reporting pancreatic protocol-computed tomography scans and surgeons in selecting the appropriate steps for the different anatomical orientations of these tributaries for the performance of safe pancreatic surgery. This will also help future researchers communicate in well-defined terms in reference to these tributaries so as to avoid confusion in future studies.

Co-Existence of An Unusual Branching Pattern of Celiacomesenteric Trunk With Complete Common Mesentery in a 48-Year-Old Man: A Case Report

Celiacomesenteric trunk (CMT) refers to the common origin of celiac trunk and superior mesenteric artery which is a very rare anatomical variation. CMT is incidentally diagnosed during angiography or abdominal computed tomography scanning. The diagnosis of CMT may inform surgical practice and prevent damage during invasive radiologic procedures, lowering thus the rate of iatrogenic errors. Complete common mesentery is in its turn a rarer congenital anomaly that arises from an abnormal rotation of primitive small intestine during embryonic development. We report a case of a 48-year-old man, suffering from chronic abdominal pain, and postprandial discomfort. The patient underwent an abdominal contrast-enhanced computed tomography that detected a CMT associated with common complete mesentery. According to our review of bibliography, this is the first case report to simultaneously report both congenital anomalies (CMT and common complete mesentery). Furthermore, the CMT described here has not been described in previous classifications and represent a novel anatomical variation of CMT.

Intra-arterial chemotherapy in the treatment of inoperable patients with Klatskin's tumor: preliminary results

Aim. To evaluate the safety and efficacy of hepatic arterial infusion (HAI) in patients with Klatskin tumor. Materials and methods. Between 2010-2021, 14 of 119 patients with inoperable Klatskin tumor were treated with HAI of GEMICS. All patients had obstructive jaundice and received percutaneous transhepatic biliary drainage (PTBD). Chemotherapy was started when serum bilirubin level became normal (average on the 106th day from PTBD). In total, 19 (from 1 to 4 per patient) HAI cycles were performed. Results. PTBD complications such as cholangitis (n=2) and local peritonitis (n=1) developed in 3 patients (21%) and were successfully treated using minimally invasive techniques. Toxicity of chemotherapy were observed in 8 of 14 patients (57%): I-II degree hematological (43%) and gastrointestinal (50%); all were cured by medical therapy. The overall mean survival was 286 days (9.6 months), median survival 283 days (9.4 months). Conclusions. Our preliminary results showed that HAI in patients with Klatskin tumor is safe, but has limited effectiveness. The combination of arterial infusion with other methods such as radiotherapy, intra-ductal photodynamic therapy, radiofrequency ablation, target therapy, should be investigated.

Role of Radiology in the Preoperative Detection of Arterial Calcification and Celiac Trunk Stenosis and Its Association with Anastomotic Leakage Post Esophagectomy, an Up-to-Date Review of the Literature

Simple Summary

Esophageal cancer is the sixth deadliest among all cancers worldwide. Multimodal treatment, including surgical resection of the esophagus, offers the potential for cure even in advanced cases, but esophagectomy is still associated with serious complications. Among these, anastomotic leakage has the most significant clinical impact, both in terms of prognosis and health-related quality of life. Identifying patients at a high risk for leakage is of great importance in order to modify their treatment and, if possible, avoid this complication. This review aims to study the current literature regarding the role of radiology in detecting potential risk factors associated with anastomotic leakage. The measurement of calcium plaques on the aorta, as well as the detection of narrowing of the celiac trunk and its branches, can be easily assessed by preoperative computed tomography, and can be used to individualize perioperative patient management to effectively reduce the rate of leakage.

Abstract

Surgical resection of the esophagus remains a critical component of the multimodal treatment of esophageal cancer. Anastomotic leakage (AL) is the most significant complication following esophagectomy, in terms of clinical implications. Identifying risk factors for AL is important for modifying patient management and improving surgical outcomes. This review aims to examine the role of radiological risk factors for AL after esophagectomy, and in particular, arterial calcification and celiac trunk stenosis. Eligible publications prior to 25 August 2021 were retrieved from Medline and Google Scholar using a predefined search algorithm. A total of 68 publications were identified, of which 9 original studies remained for in-depth analysis. The majority of these studies found correlations between calcifications in the aorta, celiac trunk, and right post-celiac arteries and AL following esophagectomy. Some studies suggest celiac trunk stenosis as a more appropriate surrogate. Our up-to-date review highlights the need for automated quantification of aortic calcifications, as well as the degree of celiac trunk stenosis in preoperative computed tomography in patients undergoing esophagectomy, to obtain robust and reproducible measurements that can be used for a definite correlation.

Pancreaticoduodenectomy preserving aberrant gastroduodenal artery utilized in a previous coronary artery bypass grafting: A case report and review of literature

RATIONALE

Pancreaticoduodenectomy (PD) is a technically demanding procedure with high rates of morbidity and mortality. Therefore, preoperative evaluation of anatomy is indispensable. Multi-detector row computed tomography (CT) enables us to precisely understand arterial anatomy. It is a well-known fact that anatomical variants are often present in the hepatic artery (HA) but rarely in the gastroduodenal artery (GDA). We present the case of a patient with ampullary cancer with a rare anatomical anomaly, "replaced GDA (rGDA) " arising from the superior mesenteric artery, along with a history of coronary artery bypass grafting (CABG) using right gastroepiploic artery (RGEA).

PATIENT CONCERNS

A 69-year-old male patient was referred to our department for further investigation of elevated hepatobiliary enzymes. He presented with no symptoms besides intermittent fever of 38°C. He had an operative history of CABG using the RGEA.

DIAGNOSIS

Abdominal CT and esophagogastroduodenoscopy showed an ampullary tumor and biopsy specimen from the lesion revealed adenocarcinoma. CT angiography revealed the rGDA instead of a normal common HA.

INTERVENTION

We performed a safe PD, preserving the rGDA and the RGEA to maintain hepatic and cardiac perfusion.

OUTCOMES

Owing to the presence of a refractory pancreatic fistula, the length-of-hospital stay was extended, and he was discharged on postoperative day 72 without vascular complications. At present, the patient is in good physical condition and does not present with cardiovascular complications as well as tumor recurrence at 6 months after surgery.

LESSONS

This is possibly the first case of a patient who underwent PD and has a proper HA following a GDA arising from a superior mesenteric artery (rGDA) and has a previous operative history of CABG using the gastroepiploic artery. The coexistence of the history of cardiovascular surgery made PD for this patient considerably more challenging.In the case of a rare anatomical anomaly, a coronary artery bypass via the RGEA should not be considered as an obstacle when R0 resection is achievable.

CT reporting of relevant vascular variations and its implication in pancreatoduodenectomy

Pancreatoduodenectomy (PD) also known as Whipple procedure is done for malignant lesions involving the distal CBD, duodenum, ampulla and pancreatic head. In the absence of peritoneal and distant metastases, resectability of the lesion is mainly determined by the relationship of the lesion with the vascular structures in the vicinity. Vascular variations of the celiac artery branches are common and PD, a complex surgical procedure, becomes more challenging if the vascular variations are present. In borderline resectable lesions advances in neoadjuvant therapies and refined surgical techniques are pushing the boundaries of resection. Extended PD is done in borderline resectable lesions when resection and reconstruction of portal vein involved by the primary mass and dissection of extended lymph nodal stations are intended. In this era where more borderline cases are undergoing surgery, it is essential for the radiologist to understand the procedure and the implications of variations in vascular anatomy. Though there are many radiology literatures available on the diagnostic and resectability criteria related to normal vessel anatomy there are very few on the importance of the variant arterial anatomy. The purpose of this review is to familiarize the readers with these variant vessels which can help the surgeons in their intraoperative identification and consequently improve surgical outcomes.

Fatal arterial hemorrhage after pancreaticoduodenectomy: How do we simultaneously accomplish complete hemostasis and hepatic arterial flow?

BACKGROUND

Although arterial hemorrhage after pancreaticoduodenectomy (PD) is not frequent, it is fatal. Arterial hemorrhage is caused by pseudoaneurysm rupture, and the gastroduodenal artery stump and hepatic artery (HA) are frequent culprit vessels. Diagnostic procedures and imaging modalities are associated with certain difficulties. Simultaneous accomplishment of complete hemostasis and HA flow preservation is difficult after PD. Although complete hemostasis may be obtained by endovascular treatment (EVT) or surgery, liver infarction caused by hepatic ischemia and/or liver abscesses caused by biliary ischemia may occur. We herein discuss therapeutic options for fatal arterial hemorrhage after PD.

AIM

To present our data here along with a discussion of therapeutic strategies for fatal arterial hemorrhage after PD.

METHODS

We retrospectively investigated 16 patients who developed arterial hemorrhage after PD. The patients’ clinical characteristics, diagnostic procedures, actual treatments [transcatheter arterial embolization (TAE), stent-graft placement, or surgery], clinical courses, and outcomes were evaluated.

RESULTS

The frequency of arterial hemorrhage after PD was 5.5%. Pancreatic leakage was observed in 12 patients. The onset of hemorrhage occurred at a median of 18 d after PD. Sentinel bleeding was observed in five patients. The initial EVT procedures were stent-graft placement in seven patients, TAE in six patients, and combined therapy in two patients. The rate of technical success of the initial EVT was 75.0%, and additional EVTs were performed in four patients. Surgical approaches including arterioportal shunting were performed in eight patients. Liver infarction was observed in two patients after TAE. Two patients showed a poor outcome even after successful EVT. These four patients with poor clinical courses and outcomes had a poor clinical condition before EVT. Fourteen patients were successfully treated.

CONCLUSION

Transcatheter placement of a covered stent may be useful for simultaneous accomplishment of complete hemostasis and HA flow preservation.