Eleven cases of postoperative hepatic infarction following pancreato-biliary surgery

Cross-sectional imaging after pancreatic surgery: The dialogue between the radiologist and the surgeon

Pancreatic surgery is nowadays considered one of the most complex surgical approaches and not unscathed from complications. After the surgical procedure, cross-sectional imaging is considered the non-invasive reference standard to detect early and late compilations, and consequently to address patients to the best management possible. Contras-enhanced computed tomography (CECT) should be considered the most important and useful imaging technique to evaluate the surgical site. Thanks to its speed, contrast, and spatial resolution, it can help reach the final diagnosis with high accuracy. On the other hand, magnetic resonance imaging (MRI) should be considered as a second-line imaging approach, especially for the evaluation of biliary findings and late complications. In both cases, the radiologist should be aware of protocols and what to look at, to create a robust dialogue with the surgeon and outline a fitted treatment for each patient.

Hypervirulent Klebsiella pneumoniae Mediated Hepatic Infarction Septic Shock After Rectal Cancer Surgery: A Case Report

The liver receives blood from both the hepatic artery and portal vein. Hepatic infarction is rare in clinical practice as both the hepatic artery and portal vein can supply blood to the liver. Here, we reported a case of a 75-year-old man who underwent radical laparoscopic surgery for rectal cancer and subsequently developed hepatic infarction. The patient experienced severe infection, as well as circulatory and respiratory failure on the third day after surgery. The patient presented with high fever, chest tightness, shortness of breath, decreased blood oxygen saturation and blood pressure. The leukocyte count decreased from 8.10 × 10^9/L to 1.75 × 10^9/L. Procalcitonin (PCT) levels increased from 1.02 ng/mL to 67.14 ng/mL, and eventually reaching levels over 200 ng/mL. Enhanced abdominal computed tomography (CT) confirmed the presence of hepatic infarction, but no thrombosis was observed in the hepatic artery or portal vein. Metagenomic next-generation sequencing (mNGS) identified hypervirulent Klebsiella pneumoniae (hvKp) in the patient's blood and ascites, one day earlier than the detection results using traditional culture methods. The patient was diagnosed with hepatic infarction combined with septic shock caused by hvKp. This case emphasizes that in the high-risk group of thrombosis, infection can trigger exacerbated hepatic infarction events, particularly in cases after surgical procedures. For severely ill patients with infectious diseases who are admitted to the ICU with worsening symptoms, it is important to collect appropriate samples and send them for pathogen detection using mNGS in a timely manner. This may aid in early intervention and improve clinical outcomes.

Strategic Approach to Aberrant Hepatic Arterial Anatomy during Laparoscopic Pancreaticoduodenectomy: Technique with Video

BACKGROUND

It is critical for every pancreatic surgeon to determine how to protect the aberrant hepatic artery intraoperatively in order to safely implement laparoscopic pancreatoduodenectomy (LPD). "Artery-first" approaches to LPD are ideal procedures in selected patients with pancreatic head tumors. Here, we described our surgical procedure and experience of aberrant hepatic arterial anatomy-LPD (AHAA-LPD) in a retrospective case series. In this study, we also sought to confirm the implications of the combined SMA-first approach on the perioperative and oncologic outcomes of AHAA-LPD.

METHODS

From January 2021 to April 2022, the authors completed a total of 106 LPDs, of which 24 patients underwent AHAA-LPD. We evaluated the courses of the hepatic artery via preoperative multi-detector computed tomography (MDCT) and classified several meaningful AHAAs. The clinical data of 106 patients who underwent AHAA-LPD and standard LPD were retrospectively analyzed. We compared the technical and oncological outcomes of the combined SMA-first approach, AHAA-LPD, and the concurrent standard LPD.

RESULTS

All the operations were successful. The combined SMA-first approaches were used by the authors to manage 24 resectable AHAA-LPD patients. The mean age of the patients was 58.1 ± 12.1 years; the mean operation time was 362 ± 60.43 min (325-510 min); blood loss was 256 ± 55.72 mL (210-350 mL); the postoperation ALT and AST were 235 ± 25.65 IU/L (184-276 IU/L) and 180 ± 34.43 IU/L (133-245 IU/L); the median postoperative length of stay was 17 days (13.0-26.0 days); the R0 resection rate was 100%. There were no cases of open conversion. The pathology showed free surgical margins. The mean number of dissected lymph nodes was 18 ± 3.5 (14-25); the number of tumor-free margins was 3.43 ± 0.78 mm (2.7-4.3 mm). There were no Clavien-Dindo III-IV classifications or C-grade pancreatic fistulas. The number of lymph node resections was greater in the AHAA-LPD group (18 vs. 15, p < 0.001). Surgical variables (OT) or postoperative complications (POPF, DGE, BL, and PH) showed no significant statistical differences in both groups.

CONCLUSIONS

In performing AHAA-LPD, the combined SMA-first approach for the periadventitial dissection of the distinct aberrant hepatic artery to avoid hepatic artery injury is feasible and safe when performed by a team experienced in minimally invasive pancreatic surgery. The safety and efficacy of this technique need to be confirmed in large-scale-sized, multicenter, prospective randomized controlled studies in the future.

Vascular resection for distal cholangiocarcinoma

PURPOSE

Vascular resection (VR) is extended surgery to attain a negative radial margin (RM) for distal cholangiocarcinoma (DCC). The present study explored the significance of VR for DCC, focusing on VR, RM, and findings suggestive of vascular invasion on multidetector-row computed tomography (MDCT).

METHODS

Patients with DCC who underwent resection between 2002 and 2019 were reviewed.

RESULTS

Among 230 patients, 25 received VR. The overall survival (OS) in the VR group was significantly worse than in the non-VR group (16.7% vs. 50.7% at 5 years, P < 0.001). Patients who underwent VR with a negative RM failed to show a better OS than those who did not undergo VR with a positive RM (19.7% vs. 35.7% at 5 years, P = 0.178). Of the 30 patients who were suspected of having vascular invasion on MDCT, 11 did not receive VR because the vessels were freed from the tumor; these patients had a significantly better OS (57.9% at 5 years) than those who underwent VR.

CONCLUSIONS

VR for DCC was associated with a poor prognosis, even if a negative RM was obtained. VR is not necessary for DCC when the vessels are detachable from the tumor.

Preoperative embolization strategy for the combined resection of replaced right hepatic artery in pancreaticoduodenectomy: a small case series

Background

Replaced right hepatic artery (rRHA) is a common vascular variation, and combined resection of this vessel is sometimes needed for the curative resection of pancreatic head malignancy. Safe surgical management has not been established, and there is a small number of reported cases. Here, we reported five cases, wherein preoperative embolization of rRHA was performed for combined resection.

Case presentation

All patients had pancreatic head malignancies that were in contact with rRHA. We performed a preoperative embolization of the rRHA before the scheduled pancreaticoduodenectomy for the combined resection. Arterial embolization was safely accomplished, and the communicating arcade from the left hepatic artery via the hilar plate was clearly revealed in all cases. Four patients underwent the operative procedure, except for one patient who had liver metastasis at laparotomy. No patient suffered from a severe abnormal liver function during the management; however, one patient had multiple liver infarctions during the postoperative course.

Conclusions

Preoperative embolization for the combined resection of rRHA in pancreaticoduodenectomy can be a management option for the precise evaluation of hemodynamics after sacrificing rRHA. In our cases, arterial flow to the right liver lobe was supplied by the left hepatic artery via the bypass route, including the communicating arcade of the hilar plate.

Dealing with hepatic artery traumas: A clinical literature review

BACKGROUND

The hepatic artery (HA) is one of the most threatened vascular structures during hepatopancreatobiliary (HPB) surgeries and interventional procedures. It can be affected by many clinical pictures, especially tumors, due to its anatomical position and neighborhood.

AIM

To reveal the evolution and recent developments in the management of HA traumas in the light of the literature.

METHODS

In this article, 100 years of MEDLINE (PubMed) literature and articles including cases and series of HA injuries were reviewed, and the types of injury occurrence, treatment, and related complications and their management were compiled.

RESULTS

The risk of HA injury increases during cholecystectomies and pancreatoduodenectomies, among the most common operations. HA anatomy shows anomalies in approximately 15%-25% of the cases, further increasing this risk. The incidence of HA injury is not precisely known. Approaches that have evolved in recent years in managing patients with HA injury (laceration, transection, ligation, resection) with severe morbidity and mortality risk are reviewed in light of the current literature.

CONCLUSION

In conclusion, complications and deaths due to HA injury are less common today. The risk of complications increases in patients with hemodynamic instability, jaundice, cholangitis, and sepsis. Revealing the variations in the preoperative radiological evaluation will reduce the risks. In cases where HA injury is detected, arterial flow continuity should be tried to maintain with primary anastomosis, arterial transpositions, or grafts. In cases where bile duct injury develops, patients should be directed to HPB surgery centers, considering the possibility of accompanying HA injury. Large-scale and multicentric studies are needed to understand better the early and long-term results of HA ligation and determine preventive procedures.

[Distal pancreatectomy with resection of the celiac trunk, right or left hepatic artery without arterial reconstruction (extended DP-CAR)]

OBJECTIVE

To evaluate safety and postoperative outcomes of DP-CAR with resection of one of the lobar hepatic arteries without arterial reconstruction (extended DP-CAR).

MATERIAL AND METHODS

Perioperative data and survival after 7 extended DP-CARs R0 were retrospectively analyzed. Arterial blood flow in the liver was assessed using intraoperative ultrasound and postoperative CT angiography.

RESULTS

Among 40 DP-CARs, resection of left or right hepatic artery was performed in 7 cases of aberrant anatomy including 1 case of portal vein resection. Mortality and ischemic complications were not observed. The main source of blood supply to the «devascularized» liver lobe was interlobar communicating artery or the arcade of the lesser curvature of the stomach. Incidence of pancreatic fistula was 44%, mean blood loss - 230 (100-650) ml, surgery time - 259 (195-310) min, mean hospital-stay - 14 (9-26) days. Median survival of patients with pancreatic ductal adenocarcinoma was 25 months after combined treatment. Three patients died after 26, 28 and 77 months. Other patients are alive without progression for 109, 24, 23 and 12 months after therapy onset.

CONCLUSION

Extended DP-CAR is advisable and safe procedure if reliable intraoperative control of liver and stomach blood supply is ensured.

Hepatic artery resection without reconstruction in pancreatoduodenectomy

PURPOSE

It has been reported that there are left and right hepatic arterial arcades via the blood vessels around the hilar bile duct; therefore, when the hilar bile duct is preserved, hepatic artery reconstruction may not be necessary. We compared the short-term and long-term outcomes in patients with distal cholangiocarcinoma who underwent pancreatoduodenectomy (PD) with right hepatic artery resection without right hepatic artery reconstruction (RHAR group) with those patients who underwent conventional PD.

METHODS

All data were retrospectively collected from patient records. A 1:4-propensity score-matched case-control study was conducted in patients with distal cholangiocarcinoma who received treatment at Tokyo Women's Medical University from February 1985 to April 2015.

RESULTS

There was no statistical difference in the overall morbidity rate between the two groups. No patient in the RHAR group (10 patients) had liver failure, liver abscess, or cholangitis in the postoperative period; one patient died postoperatively because of a bleeding pseudoaneurysm in the gastroduodenal artery. The PD group (40 patients) had a significantly better median time regarding the recurrence (34 vs. 11 months, p=0.027) and 5-year disease-free survival (35% vs. 10%, p=0.027) rates than the RHAR group, which may be attributed to the presence of a more severe disease in patients in the RHAR group.

CONCLUSION

We concluded that pancreaticoduodenectomy with right hepatic artery resection without reconstruction has a comparable overall morbidity rate with that of a conventional pancreaticoduodenectomy surgery and may be performed as an alternative procedure when tumor invasion of the right hepatic artery is suspected.

Pancreatectomy with Hepatic Artery Resection for Pancreatic Head Cancer

BACKGROUND

To report our experiences and outcome of pancreatectomy with hepatic artery resection (PT-HAR) for advanced pancreatic head cancer.

METHODS

A retrospective study of clinical data from 14 patients with advanced pancreatic ductal adenocarcinoma undergoing PT-HAR in a tertiary academic center between March 2010 and June 2017 was performed. Furthermore, a comparison in a match-pair analysis (1:3) with patients received standard pancreatectomy during the same period was conducted to evaluate the clinical outcome.

RESULTS

The PT-HAR cohort included pancreaticoduodenectomy (n = 11) and total pancreatectomy (n = 3). Of them, six underwent portal/superior mesenteric vein resection and reconstruction and three underwent hepatic artery reconstruction. Four patients without arterial reconstruction developed liver perfusion failure. No perioperative mortality occurred, with a median postoperative hospital stay of 10.5 days (range 6-39). The median overall survival was 30 months (95% confidence interval 9.8-50.2 months), with the 1-, 2-, and 3-year survival rates of 81.8%, 63.6%, and 42.4%, respectively. The matched-pair data analysis showed no significant differences between PT-HAR and standard pancreatectomy, except that liver perfusion failure occurred more frequently after PT-HAR.

CONCLUSIONS

PT-HAR can be performed with acceptable morbidity, mortality, and survival for advanced pancreatic head cancer. Considering the potential risk of liver perfusion failure, only highly selected patients are eligible for PT-HAR without reconstruction.

The findings of the contrast-enhanced CT and risk factors for hepatic infarction after pancreatoduodenectomy

PURPOSE

Hepatic infarction is a relatively rare life-threatening complication after pancreatoduodenectomy (PD). Computed tomography (CT) findings and risk factors for hepatic infarctions after PD were investigated.

METHODS

One hundred-fifty three patients who underwent contrast-enhanced CT (CECT) after PD between January 2011 and August 2016 were retrospectively analyzed. Hepatic infarction was defined as the non-contrast enhanced area expanding to the liver surface without mass effect on CECT. The relationships between infarctions and preoperative laboratory data or surgical procedures using uni- and multivariate analyses were examined.

RESULTS

Twenty-nine patients showed 47 hepatic infarctions on CT. Infarctions most commonly appeared in segment 7 (S7) (17 lesions, 36.2%). Lesions were wedge-shaped in 12 patients and spread over multiple hepatic segments in 11 patients. Univariate analysis identified celiac artery (CA) or common hepatic artery (CHA) resection (p = 0.0029) and portal vein (PV) resection (p = 0.013) as risk factors for infarctions. CA or CHA resection (p = 0.038) remained as a significant factor after multivariate logistic analysis.

CONCLUSIONS

Hepatic infarctions after PD were most frequently seen in S7 and PV penetrating sign was characteristic CT findings. CA or CHA resection or PV resection were revealed as risk factors for hepatic infarctions.

Rare combined variations of accessory left hepatic artery and accessory right hepatic artery: a case report and literature review

Variations in the hepatic artery are commonly described in the literature, which is vital for the success procedure of all hepatobiliary surgery. Usually a variation occurs in either the accessory right hepatic artery (aRHA) or the accessory left hepatic artery (aLHA). However, we report an extremely rare case where the variation occurs in both simultaneously. We over served the aRHA arising from the gastroduodenal artery and branching into the superior pancreatic duodenum artery, while the aLHA arose from the common hepatic artery and branched into right gastric artery. This situation has never been reported in literature. We will discuss the meaning of this hepatic artery variation in a clinical setting.

Elucidating early CT after pancreatico-duodenectomy: a primer for radiologists

Abstract

Pancreatico-duodenectomy (PD) represents the standard surgical treatment for resectable malignancies of the pancreatic head, distal common bile duct, periampullary region and duodenum, and is also performed to manage selected benign tumours and refractory chronic pancreatitis. Despite improved surgical techniques and acceptable mortality, PD remains a technically demanding, high-risk operation burdened with high morbidity (complication rates 40–50% of patients). Multidetector computed tomography (CT) represents the mainstay modality to rapidly investigate the postoperative abdomen, and to provide a consistent basis for an appropriate choice between conservative, interventional or surgical treatment. However, radiologists require familiarity with the surgically altered anatomy, awareness of expected imaging appearances and possible complications to correctly interpret early post-PD CT studies. This paper provides an overview of surgical indications and techniques, discusses risk factors and clinical manifestations of the usual postsurgical complications, and suggests appropriate techniques and indications for early postoperative CT imaging. Afterwards, the usual, normal early post-PD CT findings are presented, including transient fluid, pneumobilia, delayed gastric emptying, identification of pancreatic gland remnant and of surgical anastomoses. Finally, several imaging examples review the most common and some unusual complications such as pancreatic fistula, bile leaks, abscesses, intraluminal and extraluminal haemorrhage, and acute pancreatitis.

Teaching Points

• Pancreatico-duodenectomy (PD) is a technically demanding surgery burdened with high morbidity (40–50%).

• Multidetector CT is the mainstay technique to investigate suspected complications following PD.

• Interpreting post-PD CT requires knowledge of surgically altered anatomy and expected findings.

• CT showing collection at surgical site supports clinico-biological diagnosis of pancreatic fistula.

• Other complications include biliary leaks, haemorrhage, abscesses and venous thrombosis.

Major pancreatic resections: normal postoperative findings and complications

Objectives

(1) To illustrate and describe the main types of pancreatic surgery; (2) to discuss the normal findings after pancreatic surgery; (3) to review the main complications and their radiological findings.

Background

Despite the decreased postoperative mortality, morbidity still remains high resulting in longer hospitalisations and greater costs. Imaging findings following major pancreatic resections can be broadly divided into “normal postoperative alterations” and real complications. The former should regress within a few months whereas complications may be life-threatening and should be promptly identified and treated.

Imaging findings

CT is the most effective postoperative imaging technique. MRI and fluoroscopy are used less often and only in specific cases such as assessing the gastro-intestinal function or the biliary tree. The most common normal postoperative findings are pneumobilia, perivascular cuffing, fluid collections, lymphadenopathy, acute anastomotic oedema and stranding of the peri-pancreatic/mesenteric fat. Imaging depicts the anastomoses and the new postoperative anatomy. It can also demonstrate early and late complications: pancreatic fistula, haemorrhage, delayed gastric emptying, hepatic infarction, acute pancreatitis of the remnant, porto-mesenteric thrombosis, abscess, biliary anastomotic leaks, anastomotic stenosis and local recurrence.

Conclusions

Radiologists should be aware of surgical procedures, postoperative anatomy and normal postoperative imaging findings to better detect complications and recurrent disease.

Teaching Points

• Morbidity after pancreatic resections is high.

• CT is the most effective postoperative imaging technique.

• Imaging depicts the anastomoses and the new postoperative anatomy.

• Pancreatic fistula is the most common complication after partial pancreatic resection.

Imaging of post-operative pancreas and complications after pancreatic adenocarcinoma resection

Pancreatic ductal adenocarcinoma is one of the leading causes of cancer-related deaths. With surgical resection being the only definitive treatment, improvements in technique has led to an increase in number of candidates undergoing resection by inclusion of borderline resectable disease patients to the clearly resectable group. Post-operative complications associated with pancreaticoduodenectomy and distal pancreatectomy include delayed gastric emptying, anastomotic failures, fistula formation, strictures, abscess, infarction, etc. The utility of dual-phase CT with multiplanar reconstruction and 3D rendering is increasingly recognized as a tool for the assessment of complications associated with vascular resection and reconstruction such as hemorrhage, pseudoaneurysm, vascular thrombosis, and ischemia. Prompt recognition of the complications and distinction from benign post-operative findings such as hepatic steatosis and mesenteric fat necrosis on imaging plays a key role in helping decrease the morbidity and mortality associated with surgery. We discuss, with case examples, some of such common and uncommon findings on imaging to familiarize the abdominal radiologists evaluating post-operative imaging in both acute and chronic post-operative settings.

Rare anatomic variation of the right hepatic artery and accessory right hepatic artery supplying hepatocellular carcinoma: A case report and literature review

INTRODUCTION

Each hepatic artery is functionally essential for providing blood supply to the liver, and so are variant arteries. Variant arteries, including the accessory right hepatic artery (ARHA) and replaced right hepatic artery (RRHA) are commonly described in the literature. However, they usually occur independently. Here, we report an extremely rare case that involved both an ARHA and an RRHA arising from the gastroduodenal artery (GDA) and superior mesenteric artery (SMA), respectively. To date, this situation has never been reported in the literature.They were preoperatively identified during magnetic resonance imaging (MRI) examination in a 69-year-old male patient with hepatocellular carcinoma. And they were further verified by following conventional angiography for transcatheter arterial chemoembolization (TACE) for the patient. In addition, the patient's tumor was primarily supplied by these 2 variant arteries. After the successful TACE procedure, the patient had a well postoperative recovery.

CONCLUSIONS

By analyzing this case and performing a systematic review of the literature, the important clinical implications of the ARHA and RRHA will be investigated and discussed. Main lessons learned from this case thorough understanding of the normal anatomy of the hepatic artery and its anatomic variation is crucial for surgeons and interventional radiologists; preoperative computed tomography, MRI, and intraoperative angiography play an important role in detecting the variant hepatic artery; identifying these anomalous hepatic arteries before operation can effectively avoid unintentional injury during surgery, such as massive hemorrhage or hepatic infarction.

How to deal with hepatic artery injury during pancreaticoduodenectomy. A systematic review

BACKGROUND

Operative injury to the hepatic artery is a serious complication of pancreaticoduodenectomy and guidelines to manage this complication are lacking.

METHODS

A systematic search performed in PubMed database identified eleven studies overall including 20 patients having sustained injury to the hepatic artery during pancreaticoduodenectomy (n=18) or total pancreatectomy (n=2). One further unpublished personal observation following pancreaticoduodenectomy was also included.

RESULTS

Sixteen of 21 patients (76%) experienced serious complications including liver necrosis/abscess (n=14), acute liver failure (n=3), and biliary anastomotic dehiscence (n=6). Eleven patients (52%) were reoperated and 5 patients died (24%). Arterial injury was recognized and repaired immediately in five patients, four recovering uneventfully and one dying from acute liver failure (20%). In contrast delayed or conservative treatment in 16 patients was associated with serious early morbidity in 15 patients (94%), leading to death in 4 patients and late biliary complications in four others.

CONCLUSIONS

Accidental interruption of arterial flow to the liver during pancreaticoduodenectomy often results in serious short and long-term consequences. Immediate restoration of arterial flow is indicated whenever technically feasible and may prevent early life-threatening complications as well as late biliary stenosis.

Aberrant hepatic arteries running through pancreatic parenchyma encountered during pancreatoduodenectomy: Two rare case reports and strategies for surgical treatment

BACKGROUND

Aberrant hepatic arteries (HAs) encountered during pancreatoduodenectomy are difficult to manage.

MEHTODS

Two cases with rare types of aberrant HA running through the pancreatic parenchyma were reviewed.

RESULTS

The first case, a 68-year-old man, was admitted with obstructive jaundice. A tumor of the pancreatic head and aberrant HAs were suspected on computed tomography (CT) scan. At laparotomy, a new variation was identified; namely, 2 aberrant arteries-a right replaced HA and middle HA (RMHA) that both originated from the superior mesenteric artery (SMA) and ran via intrapancreatic paths posterior and anterior to the pancreatic head, respectively. Branches of the RMHA to the pancreas were ligated and severed and the trunk preserved. The RMHA was mistakenly identified as an aberrant left HA (RLHA), whereas the RLHA was overlooked and not dissected intraoperatively. CT angiography performed 11 days postoperatively identified that the RLHA originated from the left gastric artery (LGA).The second case had a variation of Michels IX. A 58-year-old woman presented with obstructive jaundice and a distal cholangiocarcinoma was suspected on the basis of enhanced CT scan. At laparotomy, the common hepatic artery (CHA) was found to originate entirely from the SMA and run posterior to the pancreatic head via an intrapancreatic path. The segment of CHA in the pancreatic parenchyma was removed and reconstructed with the LGA.

CONCLUSIONS

Preoperative identification of aberrant HAs helps in planning appropriate operative procedures and minimizing unnecessary complications. Both preservation and reconstruction of these arteries are technically safe and feasible; however, preservation is preferable.

Ischemic liver lesions mimicking neoplasm in a patient with severe chronic mesenteric ischemia

Chronic mesenteric ischemia most frequently presents with abdominal pain, weight loss, and food fear. Ischemic involvement of the liver is infrequent because of the dual blood supply via the portal vein and hepatic artery. Hepatic infarction has been associated with embolization, thrombosis, arterial injury, prothrombotic states, and impairment of portal venous flow. We report a patient with chronic mesenteric ischemia and severe mesenteric arterial disease who presented with large liver masses suspicious for neoplasm. Tissue samples from two hepatic biopsies confirmed ischemic lesions. After open surgical mesenteric revascularization, the patient had complete symptom improvement and nearly complete regression of the liver lesions.

Hypoxic hepatitis

Hypoxic hepatitis (HH), an acute liver injury also known as 'ischaemic hepatitis' or 'shock liver', is frequently observed in intensive care units. HH is heralded by a massive but transient rise in serum aminotransferase activities caused by anoxic necrosis of centrilobular liver cells. Cardiac failure, respiratory failure and toxic-septic shock are the main underlying conditions accounting for more than 90% of cases, but HH may also occur in other circumstances. Until recently, liver ischaemia, i.e. a drop in hepatic blood flow, was considered the leading, and even the sole, hemodynamic mechanism responsible for HH, and it was generally held that a shock state was required. In reality, other hemodynamic mechanisms of hypoxia, such as passive congestion of the liver, arterial hypoxaemia and dysoxia, play an important role while a shock state is observed in only 50% of cases. Accordingly, 'ischaemic hepatitis' and 'shock liver' are misnomers. Therapy of HH depends primarily on the nature of the underlying condition. The prognosis is poor, with more than half of patients dying during the hospital stay.

Article Commentary: Aberrant Hepatic Arterial Anatomy and the Whipple Procedure: Lessons Learned

Appreciation and study of hepatic arterial anatomical variability is essential to the performance of a pancreaticoduodenectomy to avoid surgical complications such as bleeding, hepatic ischemia/failure, and anastomotic leak/stricture. Awareness of this variability permits the surgeon to adapt the surgical technique to deal with anomalies identified preoperatively or intraoperatively thereby preventing unnecessary surgical morbidity and mortality. The objective of our study is to provide a comprehensive review of the anatomic arterial anomalies and discuss surgical strategies that will equip the surgeon to deal with all anomalies that may be encountered a priori or en passant during the course of a Whipple procedure.