The relationships of the bile duct and the retroduodenal arteries and their importance in the surgical treatment of hemorrhagic duodenal ulcer

Abnormal Persistence of Embryonic Blood Supply of Liver: Anatomist's Delight, Surgeon's Nightmare

The high incidence of hepato-biliary vascular anatomy variations necessitates its evaluation prior to performing liver transplantation, hepatobiliary, pancreatic, gastric and oesophageal surgeries. We report a unique case of persistence of embryonic arteries of the liver, wherein, the liver was supplied by five vessels. In addition to the usual right and left hepatic arteries from the hepatic artery proper, the liver received two accessory right hepatic arteries, one from the gastroduodenal artery, while another arising from superior mesenteric artery and an accessory left hepatic artery, from the left gastric artery. The origin of gastroduodenal artery was found to be unusually high and its abnormal anterior course over the common bile duct further added complexity to the hepatobiliary anatomy. The presence of these aberrant and accessory arteries predisposes to inadvertent injury leading to patient morbidity and sometimes mortality.

Gastroduodenal artery: single key for many locks

Gastroduodenal artery (GDA) commonly arises from common hepatic artery, a branch of celiac axis. It holds a unique anatomical position that connects the foregut and midgut due to its intimate communications with foregut and midgut arterial supply. Its numerous anatomical variations have a significant impact on planning and performance of hepatopancreaticobiliary (HPB) surgery. Its close relation to the first part of duodenum, common bile duct and head of pancreas makes it susceptible for inadvertent bleeding during or after surgery, or due to various HPB pathologies. Also, a large number of vascular interventions rely on GDA and its branches. Careful preoperative planning is the key and a detailed knowledge and awareness of its variant anatomy is of paramount importance, be it liver resections, liver transplant, biliary and pancreatic resections and pancreatic transplant or transarterial procedures involving these arteries. GDA can also be a cause of gastrointestinal hemorrhage due to true or pseudoaneurysms and anatomy has significant implications on its management. The article provides a succinct review on relevance of GDA anatomy and variations and highlights that preoperative planning and intraoperative awareness of variations is the key to performance of safe HPB surgery and interventions.

A simple intra-operative maneuver to decrease a duodenal ulcer hemorrhage temporarily: description and anatomical bases

Intraoperative hemostatic suture to treat a bleeding duodenal ulcer is sometimes difficult when there is massive hemorrhage. The aims of this paper are: (1) to describe a practical and easy intraoperative procedure which quickly decreases a massively bleeding duodenal ulcer, allowing the surgeon to identify the bleeding site clearly and obtain definitive hemostasis by suturing the involved vessels with a low risk of common bile duct lesion; and (2) to study in cadavers the anatomical basis of this surgical procedure already successfully performed on patients. Fourteen patients with massive duodenal ulcer bleeding, after unsuccessful endoscopic hemostasis, were operated on and included in this study. After surgical anterior gastroduodenotomy, the surgeon introduced a finger in a downward and forward direction in the bursa omentalis vestibule through the omental foramen. This simple and quick procedure decreased hemorrhage by compressing the gastroduodenal artery against the first part of the posterior surface of the duodenum. Twenty-four fresh blocks of normal tissue were removed from cadavers and were injected with silicone rubber through the common hepatic artery. The distance between the gastroduodenal artery and the omental foramen was measured. With this maneuver the surgeon can clearly see the exact bleeding site and perform an adequate suture with a minor risk of common bile duct lesion.

Arterial supply of the duodenal bulb: an anatomoclinical study

An anatomic and radio-anatomic study of 15 specimens enabled us to reconsider the arterial vascularization of the duodenal bulb and to propose a new classification based on anatomoclinical criteria. The two arterial pedicles (infra- and supraduodenal) reach the bulb on its posterior aspect; each pedicle is made up of two sorts of blood currents (right and left); the posterior aspect of the bulb seems to be the most vascularized one, explaining, apart from bleeding from gastroduodenal a. erosion, the hemorrhagic character of ulcers of the posterior aspect of the bulb. The predominance of the left-hand currents explains the possible ischemia of the duodenal bulb and/or rupture of the duodenal stump after their interruption.