Pancreaticoduodenectomy in the presence of a common hepatic artery originating from the superior mesenteric artery. Technical implications

Unraveling a Rare Case of Pediatric Solid Pseudopapillary Neoplasm With a Replaced Common Hepatic Artery Arising From the Superior Mesenteric Artery

Pancreatic solid pseudopapillary epithelial neoplasm (SPEN) is a rare pancreatic tumor with low-grade malignant potential. They often present in young women in their second and third decade of life, with only a small minority concerning children. It has a good prognosis, with a five-year survival rate of up to 97%. A common hepatic artery (CHA) arising from the superior mesenteric artery (SMA) is a rare occurrence. A 12-year-old girl, admitted with features of obstructive jaundice, was evaluated to have a heterogeneously enhancing mass lesion of size 7.5 × 7.2 cm involving the head of the pancreas on contrast-enhanced CT of the abdomen (CECT). CT angiogram showed a CHA trunk arising from the SMA and a type V hepatic arterial variation. Whipple's pancreaticoduodenectomy was done for the patient, and the postoperative period was uneventful. The subsequent histopathology report was confirmatory for SPEN, with an R0 margin of resection. SPENs of the pancreas are extremely rare, and after surgical resection, they often have an excellent long-term prognosis. Variations in hepatic artery anatomy, as in this case, need meticulous dissection to avoid inadvertent vascular insult.

Prepancreatic common hepatic artery arising from superior mesenteric artery: an exceptional but important finding during pancreaticoduodenectomy

PURPOSE

The hepato-mesenteric trunk is an extremely rare condition in which the common hepatic artery (CHA) originates from the superior mesenteric artery (SMA). Usually, CHA passes behind the head of the pancreas. A systematic review was performed to provide guidelines for the perioperative management of patients with this anatomical variation who underwent a pancreaticoduodenectomy (PD). A case report was also included.

METHODS

A systematic search of the literature was conducted and the manuscript was structured following point-by-point the PRISMA guidelines. The risk of bias within individual studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist tools. Case report was structured according to the CARE guidelines.

RESULTS

After an initial selection of 141 titles, 9 articles were included in the study (n = 10 patients). A postoperative surgical complication which required a reintervention occurred only one time. In four patients, CHA had a posterior position relative to pancreas, while in three cases, it was anterior. The remaining three patients had an intrapancreatic course. The CHA was resected in two patients, with an end-to-end reconstruction or using the splenic artery stump. In only three patients, a preoperative multidisciplinary presentation was performed and in four cases, the CHA variation was not described by radiologists in formal CT-scan reports.

CONCLUSION

Although there are no definitive guidelines, improvements in the preoperative knowledge of such a rare anatomical variation may ensure better postoperative outcomes, avoiding intraoperative accidents and life-threatening postoperative complications.

Aberrant left hepatic arteries arising from left gastric arteries and their clinical importance

BACKGROUND

The Aberrant Left Hepatic Artery (ALHA) is replaced when it does not originate from the hepatic artery proper and it is the only supply to that part of the liver, while an accessory artery coexists with a normal artery. The aim of this systematic review is to evaluate the incidence of ALHAs including the one arising from the Left Gastric Artery, also named Hyrtl's artery.

METHODS

A literature search in PubMed, SCOPUS, WOS and Google Scholar was performed. The risk of bias was assessed by means of the AQUA tool. The main outcome was the prevalence of ALHA. Secondary outcomes were the prevalence of the accessory and replaced left hepatic arteries. A subgroup analysis was conducted by geographic region and type of evaluation.

RESULTS

This review included 57 studies, with a total of 19,284 patients. The majority of the studies involved the use of radiological techniques -especially Angio-CT-and were performed in Asia. The overall risk of bias was moderate. The overall prevalence of the ALHA was 13.52%; the overall prevalence was 8.26% for the Replaced ALHA and 5.55% for the Accessory ALHA. In the 18 studies that employed Michels' classification, Type II had the lowest prevalence (0.36%) and Type VII the highest prevalence (6.62%).

DISCUSSION

Some of the studies included did not distinguish between the ''replaced'' and ''accessory'' ALHA (34.25%). Some surgical dissection techniques proved insufficient for the localization of other hepatic arteries. These results suggest that an accurate preoperative radiological evaluation is needed to localize replaced arteries.

Intestinal malrotation and replaced common hepatic artery during duodenopancreatectomy: a case report

BACKGROUND

Intestinal malrotation is a well-known anomaly in the normal rotation process of the midgut during embryogenesis. Multiple forms are described, resulting in various positional configurations of the small bowel and colon. Replaced common hepatic artery is a rare but not anecdotic variant of the standard hepatic vascularization, associated with surgical implications. Our aim is to explain the impact of their simultaneous presence during this procedure and the difficulty in identifying them preoperatively, despite imaging.

PATIENTS AND METHODS

These two abnormalities were simultaneously observed in our patient who underwent a duodenopancreatectomy for an adenocarcinoma of the head of the pancreas.

RESULTS

In our case, intestinal malrotation and replaced common hepatic artery were discovered preoperatively. Malrotation made the dissection and kocherization more easier. Replaced common hepatic artery required a carefully skeletonized dissection, first posteriorly And then into the pancreatic parenchyma, before being partially resected and then primarily anastomosed.

CONCLUSION

Preoperative imaging is crucial to define the lesion resectability, the proximity with the tumor, and also to identify these vascular anomalies and their relation with the pancreas parenchyma, in order to adjust the surgical strategy and preserve them, avoiding many complications (massive hepatic necrosis, chronic biliary ischemia, bleedings, etc.). In this context, angioscanner with 3D reconstruction is considered as a gold standard and should always be performed before a duodenopancreatectomy.

Pancreatic resection in the era of laparoscopy: State of Art. A systematic review

BACKGROUND

Innovation in surgical devices and improvement in laparoscopic skills have gradually led to achieve more challenging surgical procedures. Among these demanding interventions is the pancreatic surgery that is seen as intraoperatively risky and with high postoperative morbi-mortality rate. In order to understand the complexity of laparoscopic pancreatic surgery, we performed a systematic review of literature.

DATA SOURCE

A systematic review of literature was performed regarding laparoscopic pancreatic resection.

RESULTS

Laparoscopic approach in pancreas resections has been extensively reported as safe and feasible regarding pancreaticoduodenectomy, distal pancreatectomy and pancreatic enucleation. Compared to open approach, no benefit in morbi-mortality has been demonstrated (except for laparoscopic distal pancreatectomy) and no controlled randomized trials have been reported.

CONCLUSIONS

Laparoscopic approach is not workable in all patients and patient selection is not standardized. Additionally, most optimistic reports considering laparoscopic approach are produced by tertiary centres. Currently, two tasks should be accomplished 1°) standardization of the laparoscopic pancreatic procedures 2°) comparative trials to assess endpoint benefits of laparoscopic pancreatic resection compared with open procedures.

The coexistence of both replaced proper hepatic and gastroduodenal arteries due to the common hepatic artery absence

Anatomical variants of the celiac trunk (CT) branches and especially these of hepatic arteries (HAs) are among the most common variants of the arterial tree. The knowledge of the wide variability in hepatic arterial supply is of paramount importance in hepatobiliary, pancreatic, gastric, and esophageal surgery, as well as in liver transplantations. The purpose of this case report is to describe a rare variant discovered during abdominal dissection of a 74-year-old male cadaver of Greek origin, in which the common hepatic artery was absent and its branches, the proper hepatic artery (PHA) and the gastroduodenal artery (GDA) had an aberrant and separate origin. The entire arterial supply to the liver derived from the aberrant PHA, that originating from the superior mesenteric artery and was named as PHA (RPHA). The RPHA, after a course posterior to the portal vein, terminated into the right and left HAs, at the hilum. The GDA originated from the CT, as well as the left gastric and splenic artery. The right gastric artery originated from the PHA, as usual. The current case emphasizes the necessity of preoperative imaging when evaluating the resectability of a tumor in hepatobiliary and pancreatic area taking into account the possible vascular variations. Abdominal surgeon should be aware of any aberrancy to avoid potential iatrogenic injury and lethal complications.

A rare anastomosis between the common hepatic artery and the superior mesenteric artery: a case report

For decades, anastomoses between unpaired branches of the abdominal aorta have attracted the attention of anatomists, surgeons and radiologists, due to their significance in many clinical procedures. This report presents a rare anastomosis between the common hepatic artery and the superior mesenteric artery, which gave off three branches to the jejunum. The diameter of the anastomosis measured at the point of its branching off the common hepatic artery and at the level of union with the superior mesenteric artery was 4.46 and 4.19 mm, respectively. Moreover, the anastomosis gave off the branch to the head of the pancreas. Both embryological background and potential clinical implications of this variation are discussed. Knowledge of these vascular connections may be important for diagnostic and surgical procedures.

Liver necrosis shortly after pancreaticoduodenectomy with resection of the replaced left hepatic artery

BACKGROUND

Surgeons, in general, underestimate the replaced left hepatic artery (rLHA) that arises from the left gastric artery (LGA), compared with the replaced right hepatic artery (rRHA), especially in standard gastric cancer surgery. During pancreaticoduodenectomy (PD), preservation of the rRHA arising from the superior mesenteric artery (SMA) is widely accepted to prevent critical postoperative complications, such as liver necrosis, bile duct ischemia, and biliary anastomotic leakage. In contrast, details of complication onset following rLHA resection remain unknown. We report two cases of postoperative liver necrosis shortly after rLHA resection during PD for advanced gastric cancer.

CASE PRESENTATION

Both cases had advanced gastric cancer with infiltration of the pancreatic head. In case 1, the rLHA comprised segment 2/3 artery (A2 + A3), which arose from the LGA. The rRHA originated from the SMA, and the segment 4 artery (A4) was a branch of the rRHA. We conducted PD with combined en bloc resection of both the rLHA and rRHA, and anastomosis between the distal and proximal stumps of the rRHA and LGA, respectively. The divided A2 + A3 was not reconstructed. In case 2, the rLHA comprised segment 2 artery (A2) only, which arose from the LGA. The segment 3/4 artery and the RHAs originated from the proper hepatic artery. We undertook PD with combined en bloc resection of A2 without vascular reconstruction. In both patients, serious necrosis of the lateral segment of the liver occurred within 6 days after PD. Case 1 recovered with conservative management, whereas case 2 required lateral segmentectomy of the liver. Pathologically, the necrotic area in case 2 was apparently circumscribed and confined to segment 2 of the liver, potentially implicating rLHA resection during PD as causing hepatic necrosis.

CONCLUSIONS

During PD, rLHA resection can cause serious liver necrosis. Therefore, this artery should be preserved as far as oncologically acceptable. In cases that require rLHA resection during PD due to tumor conditions, surgeons should carefully monitor postoperative course while keeping in mind the possible necessity of urgent hepatectomy.

The Main Anatomic Variations of the Hepatic Artery and Their Importance in Surgical Practice: Review of the Literature

Anatomical variations of the hepatic artery are important in the planning and performance of abdominal surgical procedures. Normal hepatic anatomy occurs in approximately 80% of cases, for the remaining 20% multiple variations have been described. The purpose of this study was to review the existing literature on the hepatic anatomy and to stress out its importance in surgical practice. Two main databases were searched for eligible articles during the period 2000 - 2015, and results concerning more than 19,000 patients were included in the study. The most common variation was the replaced right hepatic artery (type III according to Michels classification) which is the chief source of blood supply to the bile duct.