Surgical anatomy of the hepatic arteries in 1000 cases

Rare variation of the branches of the coeliac trunk and the common hepatic artery in human cadaver: a case report

Background

The liver with its dual blood supply from the portal vein and the common hepatic artery (CHA) is unique among parenchymal organs. CHA accounts for around 30% of blood flow to the liver but has a central role in hepatobiliary perfusion.

Case presentation

We demonstrated a rare case of unusual branching of the CHA during routine dissection of an embalmed female cadaver. Measurements of the diameter and distance of origin of the branches were performed. The coeliac trunk presented with five branches - left gastric, splenic, CHA, right inferior phrenic, and accessory left hepatic arteries. The CHA pentafurcated into the left hepatic (LHA), middle hepatic (MHA), right hepatic (RHA), cystic (CA), right gastric (RGA), and gastroduodenal arteries (GDA). The first branch presented was RGA to the lesser curvature of the stomach. Instead of proper hepatic artery, three branches were observed - LHA, MHA, and posteriorly and between them, RHA. Inferiorly the GDA, with its diameter of 4 mm, represented a direct continuation of CHA. Accessory RHA artery was also identified branching from superior mesenteric artery.

Discussion

Variations of the hepatic arterial blood supply are seen in more than half of the population. The described variations were not previously identified according to the available literature.

Conclusion

Such complex variation, as the one presented in the current case, represents significant deviation from the norm. In the past, they were considered anatomical curiosities but now, in the era of complex liver surgeries and arterial-directed therapies, their relevance is being highly recognized.

Prevalence of coeliac trunk variants: A systematic review with meta-analysis

BACKGROUND

The coeliac trunk (CoT) is an important branch of the abdominal aorta, that typically gives off the left gastric artery (LGA), the splenic artery (SA) and the common hepatic artery (CHA). Variations of the CoT are of great importance in clinical practice. The aim of the current systematic review with meta-analysis is to investigate the prevalence of these variants.

MATERIAL

A systematic review was performed in four online databases to identify studies referring to CoT variants prevalence. A meta-analysis was conducted by using the R programming software to calculate the pooled prevalence of the variants, and to detect possible parameters affecting them by using subgroup analysis.

RESULTS

The typical anatomy was considered the CoT with three branches (type 3) with a pooled prevalence of 83.39 %. The most common variation was the CoT with two branches (type 2) identified in 10.53 %. Rarest types were considered the CoT with four branches (type 4-1.80 %) and the CoT absence (type 1-0.43 %). A statistically significant difference according to the type of study (imaging or cadaveric) was identified for CoT type 1 and type 4. Overall, the most common variation was the hepato-splenic trunk calculated with a pooled prevalence of 6.68 %.

CONCLUSIONS

The current systematic review with meta-analysis investigated the CoT variants and proposed a classification system based on the number of branches emanating from the trunk. Knowledge of these variations is of paramount importance for anatomists, radiologists and surgeons frequently operating the abdominal organs.

Surgical and oncological implications of the presence of hepatic artery anatomical variations in patients undergoing pancreaticoduodenectomy: a single center experience

The presence of an aberrant right hepatic artery (a-RHA) could influence the oncological and postoperative outcomes after pancreaticoduodenectomy (PD). A comparative study was conducted, including patients who underwent PD with a-RHA or with normal RHA anatomy. The primary endpoints were R1 resection in all margins (pancreatic, anterior, posterior, superior mesenteric artery, and portal groove), overall survival (OS), and disease-free survival (DFS). The secondary endpoints were morbidity, mortality, biliary leak (BL), postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), post pancreatectomy hemorrhage (PPH), length of stay (LOS), and operative time (OT). The selection bias was measured using the d-value and limited using entropy balancing analysis. Patients with arterial variants were 84 (37.5%), 39 (17.4%) of whom had a-RHA from SMA. The patients with a-RHA were more frequently symptomatic (d = 0.652), often affected by PDAC (d = 0.369), and judged borderline resectable (d = 0.588). Neoadjuvant therapy was more frequently proposed for patients with a-RHA (d = 0.465). The patients with a-RHA often had the Wirsung dilated compared to those without a-RHA (d = 0.336). After bias correction, the R1 resection rate on the superior mesenteric artery (SMA) margin was higher in the a-RHA group than in patients with normal RHA anatomy (OR 2.3; 1.1-5.2; P = 0.045). OS, DFS, morbidity, mortality, biliary leak (BL), postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), post pancreatectomy hemorrhage (PPH), length of stay (LOS), and operative time (OT) were similar in unmatched and matched population. The presence of a-RHA seems to increase the risk of R1 resection in the SMA margin.

A Robotic Pancreaticoduodenectomy Case Involving a Meandering Main Pancreatic Duct Coursing Posterior to a Replaced Common Hepatic Artery and in Front of the Portal Vein

INTRODUCTION

Anatomical anomalies, such as branches of the celiac artery and superior mesenteric artery (SMA), and pancreatic malformations, including the annular pancreas, are important during pancreaticoduodenectomy (PD). Here, we report a case of an anomaly of the artery and main pancreatic duct (MPD) in which the pancreatic parenchyma surrounded the replaced common hepatic artery (rCHA), and the meandering main pancreatic duct (MMPD) ran behind the rCHA.

CASE PRESENTATION

A 71-year-old woman was diagnosed with intraductal papillary mucinous neoplasm (IPMN) of pancreatic body and the dilation of MPD to 13 mm, which was a factor of high-risk stigmata. Preoperative computed tomography (CT) showed that the rCHA branched from the superior mesenteric artery (SMA) and the pancreatic parenchyma surrounded the rCHA. Moreover, the MPD meandered and ran behind the rCHA. PD was performed. At the time of dissection between the rCHA and pancreatic parenchyma, we had to divide not only the cranial part of the pancreatic parenchyma along the rCHA but also the MPD. The postoperative course was uneventful.

CONCLUSION

This is the first report of the rCHA surrounded by pancreatic parenchyma and MMPD running behind the rCHA and in front of the portal vein.

Numerical assessment of the performance of a new multi side-hole catheter design in liver radioembolization

Numerical fluid-particle dynamics simulations, such as Computational Fluid Dynamics (CFD), are widely used to study blood flow and microsphere transport in medical treatments like radioembolization (RE), a therapy for unresectable liver tumors. RE involves injecting 90Y-labeled microspheres via a microcatheter into a hepatic artery to irradiate cancer cells. This study uses simulations on three patient-specific hepatic arteries to evaluate microsphere distribution in RE, focusing on two catheter designs: a standard end-hole catheter (EHC) and a novel multi side-hole catheter (SHC). Key parameters include cancer scenario and catheter tip position. Three performance indexes are introduced: the matching deviation index (MDI), targeting deviation index (TDI), and tumor-flow deviation index (TFDI). Results show the SHC outperforms the EHC with better MDI (3.67 vs. 8.36 percent points) and TDI (6.04 vs. 10.24 percent points) values, suggesting the SHC's cross-flow effect improves microsphere dispersion and alignment with flow split. The TDI values for SHC often match the TFDI, making the latter a potential performance predictor. The SHC demonstrates superior performance when tumors are located downstream from the catheter tip, while for localized tumors, superselective treatment is recommended, minimizing the catheter's impact on therapy.

Evaluating the surgical and oncological outcomes of hepatic artery variations in minimally invasive pancreaticoduodenectomy: insights from 2023 data at a high-volume pancreatic center

BACKGROUND

Minimally invasive pancreaticoduodenectomy (MIPD) has seen increased adoption due to advancements in surgical techniques and technology. However, the impact of hepatic artery variations (HAV) and clinically relevant HAV (CR-HAV) on MIPD outcomes remains under-investigated. This study aims to explore the differences in surgical and oncological outcomes of MIPD with or without HAV and CR-HAV.

METHODS

We enrolled 267 consecutive patients who underwent MIPD at Peking Union Medical College Hospital between January and December 2023. HAV was identified preoperatively through enhanced abdominal CT and three-dimensional reconstruction, and classified according to the Michels and Hiatt systems. Clinically relevant hepatic artery variations (CR-HAV) were defined based on their potential impact on the surgical approach. We collected and analyzed perioperative data and oncological outcomes between patients with and without HAV and CR-HAV. Propensity score matching (PSM) was used to minimize baseline confounding. Survival analysis was performed using the Kaplan-Meier method with log-rank tests.

RESULTS

HAV was identified in 26.1% of patients, and CR-HAV in 18.9%. The median operation time was significantly longer in HAV (+) group compared to HAV (-) group (6.72 vs. 5.80 h, p = 0.013). No significant differences were found between HAV/CR-HAV (+) and (-) groups regarding intraoperative blood loss, conversion to laparotomy, postoperative complications, surgical mortality, length of stay, re-operation, and re-admission. Kaplan-Meier survival analysis showed no significant differences in overall survival or progression-free survival between HAV/CR-HAV (+) and (-) groups in the malignant cohort.

CONCLUSION

HAV and CR-HAV do not significantly impact overall or progression-free survival in patients undergoing MIPD. While HAV is associated with longer operation times, other perioperative and oncological outcomes remain comparable between HAV/CR-HAV (+) and (-) groups.

Replaced unclassified right hepatic artery arising from the celiac trunk: A case report

Anatomical variations in hepatic arteries are both common and diverse. According to the classic classification systems, a replaced right hepatic artery typically originates from the superior mesenteric artery, supplying blood to the right liver lobe in the absence of the right branch of the proper hepatic artery. This article reports 2 cases of a rare variation, a replaced right hepatic artery arising directly from the celiac trunk. In these cases, the artery courses posterior to the common hepatic artery and then behind the portal vein within the hepatoduodenal ligament. The first case, involving a 62-year-old male with intraductal papillary mucinous neoplasm (IPMN) of the pancreas, was identified intraoperatively during a pancreaticoduodenectomy. The second case, involving a 58-year-old female with chronic sclerosing cholangitis, was detected through contrast-enhanced computed tomography angiography. Identification of such variations is critical in hepatobiliary and pancreatic surgeries to prevent serious postoperative complications. Injury to a replaced right hepatic artery can lead to biliary-enteric anastomosis dehiscence after pancreaticoduodenectomy or ischemic liver complications. While hepatic arteries display numerous anatomical variations, classic classification systems fail to encompass all these anomalies. A more comprehensive classification system, such as CRL and ex-CRL classification, is necessary to ensure safer surgical outcomes.

A rare case of replaced right hepatic artery with direct aortic origin described angiographically during trans-arterial radioembolization

Normal hepatic arterial anatomy consists of the right hepatic artery and left hepatic artery branching from the common hepatic artery. Despite this being the most common configuration, many variations have been described. Here, we present a rare variant of hepatic arterial anatomy- a replaced right hepatic artery with direct aortic origin. Additionally, the patient was found to have a dorsal pancreatic artery originating from the replaced right hepatic artery This was angiographically identified during mapping for transarterial radioembolization for hepatocellular carcinoma. The unique anatomy in this case and the effect it had on transarterial radioembolization planning described herein demonstrates the necessity of understanding variant hepatic arterial anatomy in endovascular hepatic interventions.

Chinese clinical practice guidelines for pediatric split liver transplantation

Liver transplantation is an effective treatment for end-stage liver disease in children, and its clinical efficacy has been validated. Split liver transplantation (SLT) can effectively expand the donor liver pool for children. SLT for children has unique clinical characteristics and principles. Establishing technical operation specifications for pediatric SLT plays a significant role in improving clinical efficacy. In this paper, clinical practice guidelines on pediatric SLT were established in the aspect of donor and donor liver evaluation, donor-recipient matching, and ductal segmentation and reconstruction of donor liver, aiming to standardize the technical process, optimize surgical operational details, minimize the risk of complications of SLT for children, further promoting the rapid development of pediatric SLT in China.

Laparoscopic management of variant ductal and vascular anatomy in children with choledochal cysts

INTRODUCTION

Variations in biliary ductal and hepatic vascular anatomy increase the complexity of surgery for choledochal cysts (CDC). The laparoscopic approach for the management of paediatric CDCs with variant anatomy is underreported. This study aimed to describe anatomical variations, operative techniques and early outcomes of laparoscopic hepaticojejunostomy (HJ) in children with CDCs and variant anatomy.

PATIENTS AND METHODS

We conducted a retrospective review of 40 children who underwent laparoscopic CDC excision with HJ between 2019 and 2024 in a single surgical unit. Patients were divided into Group I (with anatomical variations, n = 20) and Group II (without variations, n = 20). Data on demographic details, clinical presentation, imaging findings, pre-operative interventions, ductal and vascular anatomical variations, surgical techniques, intraoperative variables, post-operative complications and outcomes were collected and analysed.

RESULTS

Ductal variations were found in 10 patients, with aberrant right posterior sectoral duct being the most common. Vascular variations were identified in 12 patients, with anteriorly crossing the right hepatic artery (RHA) being the most frequent. Group I had a higher mean age (7.32 vs. 3.57 years, P = 0.014) and longer operative times (415 vs. 364 min, P < 0.0001). Conversion to laparotomy was necessary in 10% of Group I and 15% of Group II patients ( P = 0.634). Post-operative complications, primarily minor (Clavien-Dindo Grade I or II), occurred in 40% of Group I and 30% of Group II ( P = 0.495). Group I had a significantly shorter time to full feeds (72 vs. 80 h, P = 0.015). Both groups had similar post-operative hospital stays and follow-up durations. At the last follow-up, all patients, except one with liver failure in Group II, were asymptomatic with no significant biliary dilatation or liver function abnormalities.

CONCLUSION

Laparoscopic management of CDCs with variant ductal and vascular anatomy in children is feasible, safe and effective. Detailed pre-operative imaging, meticulous intraoperative assessment and tailored surgical techniques are crucial for successful outcomes.

Finding the Right Hepatic Artery Branching from the Gastroduodenal Artery in a Patient Undergoing Gastrectomy: A Rare Case of an Anatomical Variant

Numerous vascular anomalies of the hepatic artery have been reported. Protection of the hepatic arterial supply is important during gastrectomy. We herein report a case in which an anatomical variant of the hepatic artery was discovered in a patient undergoing laparoscopic distal gastrectomy with D1+ lymph node dissection for early gastric cancer. A 50-year-old man was referred to our hospital because of epigastric pain and hematemesis, and he was diagnosed with early gastric cancer after hemostasis of a bleeding ulcer. Computed tomography showed an anatomical variation of the right hepatic artery, which branched from the gastroduodenal artery. Moreover, the right gastric artery branched from the right hepatic artery. Our preoperative understanding of this unusual branch of the hepatic artery enabled safe laparoscopic surgery with adequate lymph node dissection. No postoperative complications occurred. This vascular anomaly has not been previously reported in patients undergoing gastrectomy.

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.

Hepatic artery diameter predicts bleeding risk after gastroesophageal varices treatment: a contrast-enhanced CT study

OBJECTIVE

Portal hypertension leads to hepatic artery dilatation and a higher risk of bleeding. We tried to identify the bleeding risk after gastroesophageal varices (GOV) treatment using hepatic artery diameter of contrast-enhanced CT.

METHODS

Retrospective retrieval of 258 patients with cirrhosis who underwent contrast-enhanced CT from January 2022 to May 2023 and endoscopy within one month thereafter at Hainan Affiliated Hospital of Hainan Medical University. Cirrhotic patients before GOV treatment were used as the test cohort (n = 199), and cirrhotic patients after GOV treatment were used as the validation cohort (n = 59). The grading and bleeding risk was classified according to the endoscopic findings. Arterial-phase images of contrast-enhanced CT were used for coronal reconstruction, and the midpoint diameter of the hepatic artery was measured on coronal images. The optimal cutoff value for identifying bleeding risk was analyzed and calculated in the test cohort, and its diagnostic performance was evaluated in the validation cohort.

RESULTS

In the test cohort, hepatic artery diameters were significantly higher in high-risk GOV than in low-risk GOV [4.69 (4.31, 5.56) vs. 3.10 (2.59, 3.77), P < 0.001]. With a hepatic artery diameter cutoff value of 4.06 mm, the optimal area under the operating characteristic curve was 0.940 (95% confidence interval: 0.908-0.972), with a sensitivity of 0.887, a specificity of 0.892, a positive predictive value of 0.904, and a negative predictive value of 0.874 for identifying bleeding risk in the test cohort, while in the validation cohort, the sensitivity was 0.885, specificity was 0.939, positive predictive value was 0.920, and negative predictive value was 0.912.

CONCLUSION

Hepatic artery diameter has high diagnostic performance in identifying bleeding risk after GOV treatment.

Challenging arterial pattern of foregut and its potential impact on surgery

Anticipating a wide range of morphological variations of arterial anatomy of foregut derivatives beyond the classical pattern, a precise understanding is pertinent to preoperative diagnosis, operative procedure and to avoid potentially devastating post-operative outcome during various traumatic and non-traumatic vascular insult of foregut. The study aimed to revisit the morphological details and update unusual configurations of arteries of foregut to establish clinico-anatomical correlations. This study described the detailed branching pattern of coeliac trunk (CT) as principal artery of foregut with source & course of hepatic, gastric, duodenal and pancreatic branches in 58 cadaveric dissections. Based on morphology, different types and subtypes were made. The descriptions were explained using figures and pertinent tables. Among classical branches of CT, splenic artery was found as most stable whereas other two branches were found to be most variable with missing common hepatic artery in 11 cases. In addition to classical trifurcation (65.52%), different types of bifurcation (12.07%) and tetrafurcations (22.41%) of CT were observed. Regarding variations of hepatic arteries (27.59%), both non-classical origin and accessory hepatic branches were found. In case of gastric branches, more variant origins were seen with right gastric (50%) as compared to left gastric artery (34.48%). Other morphological variations included non-classical origin of gastro-duodenal artery (18.96%) along with presence of accessory pancreatic (17.13%) and duodenal arteries (6.38%). Awareness of anatomical variations regarding circulatory dynamics of foregut is worth knowing in order to facilitate successful planning of surgery involving upper abdominal organs with least complications.

Evaluation of coeliac trunk and hepatic artery variations in thoracic CT angiography in patients with congenital heart disease

INTRODUCTION

Understanding the variations of abdominal vascular structures is important for preventing complications of abdominal surgical procedures for gastrointestinal disease such as necrotizing enterocolitis or others that may arise in patients with congenital cardiac disease. We analysed the coeliac trunk and its branches in children with congenital heart disease to determine whether there is a greater prevalence of associated vascular abnormalities.

METHODS

We retrospectively analysed thoracic computed tomography (CT) angiograms performed in our hospital in paediatric patients with congenital heart disease. We documented the anatomical variations observed in abdominal sections in which the coeliac trunk and hepatic arteries were included in the field of view. We used the Uflacker classification to describe anatomical variants of the coeliac trunk, and the Michels classification and its modified version (Hiatt classification) to describe the anatomy of the hepatic artery system.

RESULTS

Our study included 178 patients with congenital heart disease. We identified coeliac trunk variants in 10.7% of the patients. Gastrosplenic trunk was to the most prevalent variant, amounting to 5.6% of total cases. We found hepatic artery variations in 19.1% of the patients. According to the Michels classification, the prevalence of accessory left hepatic artery arising from the left gastric artery as 4.5%, compared to 6.7% based on the Hiatt classification.

CONCLUSION

The prevalence of coeliac trunk and hepatic artery variations in patients with congenital heart disease was not greater in our study compared to other series in the literature. Clinicians must be vigilant about the variations detected in multislice CT scans to avoid complications resulting from vascular abnormalities, especially in patients who undergo abdominal surgery.

Are the Classifications Used to Determine Hepatic Artery Variations in Liver Donors Sufficient?

OBJECTIVES

Liver transplant from a living donor is a more challenging procedure than liver transplant from a deceased donor, given that optimal blood supply to both the remaining liver segment in the donor and the graft must be maintained to ensure successful donor hepatectomy. During surgical planning, in addition to calculation of volumetric data with multidetector tomography, the anatomy of the hepatic artery, portal vein, and hepatic vein must also be meticulously determined, with the most commonly used clas-sification methods for hepatic artery variations being the Michels and Hiatt classifications. Although these classification methods can accurately group most patients, we often encounter a large number of patients who cannot be grouped or who exhibit other variations that accompany the defined group.

MATERIALS AND METHODS

We examined the hepatic artery computed tomography angiography tests taken before the operations of 290 living liver donors performed at our hospital between 2012 and 2023 and grouped the hepatic artery variations according to the Michels and Hiatt classifications. We also identified and classified cases that could not be classified into the groups of either classification method.

RESULTS

We identified 144 patients (62.61%) who fit the Michels classification. Eighty-six patients (37.39%) did not conform to the groups defined in either classification system. We identified 173 patients (75.22%) patients who fit the Hiatt classification, and 57 (24.78%) who did not. Notable variations included those in the medial and lateral branches of the left hepatic artery, those in the origin of the right hepatic artery, and the trifurcation of the common hepatic artery into the gastroduodenal artery, right hepatic artery, and left hepatic artery.

CONCLUSIONS

The Michels and Hiatt classification systems are not sufficient for determining hepatic artery variations in many patients. A more comprehensive classification system that includes segmental arteries is needed.

Unique Hepatic Arterial Pattern Associated With the Presence of Accessory Proper Hepatic Artery and Middle Hepatic Artery

Vascular variations of the coeliac trunk are relatively common, with documented occurrences including trifurcation of the common hepatic artery (CHA) and the presence of accessory and replaced hepatic arteries. This case report describes a novel variation wherein the CHA trifurcates into the proper hepatic artery (PHA), gastroduodenal artery, and accessory PHA (APHA). This particular trifurcation pattern has not been previously recorded. The APHA further branches into two arteries that supply the right lobe of the liver. Additionally, a middle hepatic artery (MHA), originating from the PHA, was identified alongside the right and left hepatic arteries. The MHA serves as a hilar artery that drains segment IV of the liver. This anatomical variant does not conform to any existing coeliac trunk classifications. Understanding this unique arterial pattern is crucial for liver transplantation, as well as procedures involving the pancreas, duodenum, and gallbladder, and for interventional techniques such as transcatheter arterial chemoembolization and transarterial radionuclide therapy.

Early bifurcation of the common hepatic artery: A pitfall that should be known and recognized

Early bifurcation of the common hepatic artery (EBCHA) is a rare anatomical variation (1%), that is often overlooked but can lead to accidental ligation of the right branch of the hepatic artery with consequent arterial ischemia of the right liver and potentially very serious complications during pancreaticoduodenectomy, partial hepatectomy, or liver harvesting for transplantation. It may be difficult to diagnose EBCHA using transverse imaging sections. However, on standard CT sections with intravenous contrast injection, three warning signs should allow the image reader to suspect it: presence of two hepatic arteries to the right of the celiac trunk, presence of a retro-portal hepatic artery, and absence of a right hepatic artery arising from the superior mesenteric artery. Analysis of the CT with reconstruction then allows for definitive diagnosis and limits the risk of accidental arterial injury or ligation.

Intrapancreatic common hepatic artery in pancreatoduodenectomy: a technical note on how to deal with this exceedingly rare arterial variation

Arterial variations in the liver's blood supply play a pivotal role in the success of pancreatoduodenectomy (PD), impacting both its technical execution and oncological outcomes. Among these variations, a common hepatic artery arising from the superior mesenteric artery (SMA) occurs in about 3% of cases. An exceptionally rare variation is the intrapancreatic common hepatic artery (IPCHA). Preserving or reconstructing the IPCHA is vital during PD to prevent liver and biliary necrosis. Particularly for cases of pancreatic cancer with high rates of intrapancreatic perineural spread, preserving IPCHA without compromising radicality presents challenges. We present a detailed report of the technique used for PD in the presence of IPCHA. Surgical technique details include a pylorus-preserving PD with the Cattell-Braasch maneuver, an artery-first approach, and meticulous dissection using "cold" scissors. We emphasize the importance of strategic surgical planning based on high-quality imaging studies, underscoring the need for pancreatic surgeons to be proficient in managing variations in visceral vessels. In conclusion, this case underscores the significance of navigating rare arterial variations in liver supply during PD, highlighting the necessity for meticulous surgical planning and execution.

Impact of hepatic artery variation on surgical and oncological outcomes in robotic pancreaticoduodenectomy

BACKGROUND

In patients with hepatic artery variation (HAV), feasibility and justification of robotic pancreatoduodenectomy (RPD) for periampullary lesions have been not been well established.

METHODS

A total of 600 patients with periampullary lesions receiving RPD or open pancreaticoduodenectomy (OPD) were identified from our prospectively collected computer database. Surgical outcomes, oncological radicality, and survival outcomes after RPD in HAV ( +) and (-) patients were compared.

RESULTS

The incidence of HAV was 16%, including 12.7% in patients with RPD and 23.0% in those with OPD. In the HAV ( +) group, vascular injury rate had no statistical difference between the RPD (3.7%) and OPD (9.1%) patients, P = 0.404. Among the RPD patients, those with HAV ( +) had longer operation time (8.5 ± 2.5 vs. 7.7 ± 2.0 h, P = 0.013) and higher vascular injury (3.8% vs. 0.6%, P = 0.024) when compared with the HAV (-) patients. There was no significant difference between the HAV ( +) and (-) patients with RPD regarding blood loss, open conversion, vascular resection, and surgical mortality and morbidity. There was no survival difference between the HAV ( +) and (-) patients with pancreatic head adenocarcinoma after RPD. There was no survival difference between RPD and OPD in the HAV ( +) group.

CONCLUSIONS

When compared with OPD, RPD is feasible and justifiable without increasing vascular injury rate for patients with HAV ( +). Hepatic artery variation has no negative impact on surgical, oncological, and survival outcomes following an RPD, if it is accurately identified pre-operatively and appropriately managed intraoperatively.

Influence of aberrant right hepatic artery on survival after pancreatic resection for ductal adenocarcinoma of the pancreatic head

PURPOSE

The presence of an aberrant right hepatic artery (aRHA), arising from the superior mesenteric artery, is a common variant of the liver vascular anatomy. Considering that tumor spread occurs along vessels, the question arises, whether the presence of an aRHA influences the oncologic outcome after resection for cancer of the pancreatic head.

METHODS

Patients with ductal adenocarcinoma of the pancreatic head, who underwent resection from 2011 to 2020 at the Frankfurt University Hospital, Germany, were analyzed retrospectively. Surgical records and computed tomography imaging were reviewed for the presence of aRHA. Overall and disease-free survival as well as hepatic recurrence were analyzed according to the presence of aRHA.

RESULTS

aRHA was detected in 21 out of 145 patients (14.5%). The median overall survival was 26 months (95%CI 20.8-34.4), median disease-free survival was 12.1 months (95%CI 8.1-17.3). There was no significant difference in overall survival (26.1 versus 21.4 months, adjusted hazard ratio 1.31, 95%CI 0.7-2.46, p = 0.401) or disease-free survival (14.5 months versus 12 months, adjusted hazard ratio 0.98, 95%CI 0.57-1.71, p = 0.957) without and with aRHA. The hepatic recurrence rate was 24.4.% with conventional anatomy versus 30.8% with aRHA (adjusted odds ratio 1.36, 95%CI 0.3-5.38, p = 0.669). In the multivariable analysis, only lymphatic vessel invasion was an independent prognostic factor for hepatic recurrence.

CONCLUSIONS

The presence of an aRHA does not seem to influence the long-term survival and hepatic recurrence after resection for ductal adenocarcinoma of the pancreatic head.

Application of the superior mesenteric artery-first approach in laparoscopic pancreatoduodenectomy: A literature review

BACKGROUND

Laparoscopic pancreaticoduodenectomy (LPD) is a complicated surgical procedure that has recently been performed safely. A superior mesenteric artery (SMA)-first approach can allow complete mesopancreas resection, maximizing surgical margins and R0 resection rates. Therefore, the SMA-first approach is recommended. This review is a literature summary of recent updates of the SMA approaches for LPD and informs clinical practice of the advantages of its various approach.

METHODS

A systematic literature search was performed on the PubMed (MEDLINE) database using truncated word searches and medical subject headings to identify all pertinent published studies.

RESULTS

After searching PubMed, 303 studies were identified and reviewed, of which 25 described the SMA-first approach, including the anterior, posterior, right, and left approaches, fully described in 5, 6, 13, and 6 articles, respectively.

CONCLUSIONS

The SMA-first approach is the standard surgical technique for LPD. This review summarized each SMA-first approach's distinct advantages and indications.

Pre-operative assessment of living liver donors' liver anatomy and volumes

Decades of experience supports LDLT as a favorable strategy to reduce waitlist mortality. The multiple regenerative pathways of hepatocytes and other hepatic cells justify the rationale behind it. Nonetheless, living liver donation is still underused and its broader implementation is challenging, mostly due to variability in practices leading to concerns related to donor safety. A non-systematic literature search was conducted for peer-reviewed original articles related to pre-operative evaluation of living liver donor candidates. Eligible studies were synthesized upon consensus for discussion in this up-to-date review. Review of the literature demonstrate that the importance of preoperative assessment of vascular, biliary and liver volume to ensure donor safety and adequate surgical planning for graft procurement is widely recognized. Moreover, data indicates that anatomic variants in vascular and biliary systems in healthy donors are common, present in up to 50% of the population. Therefore, comprehensive mapping and visualizations of each component is needed. Different imaging modalities are reported across practices and are discussed in detail. Lastly, assessment of liver volume must take into account several technical and donor factors that increase the chances of errors in volume estimation, which occurs in up to 10% of the cases. Experience suggests that maximizing donor safety and lessening their risks is a result of integrated experience between hepatobiliary and transplant surgery, along with multidisciplinary efforts in performing a comprehensive pre-operative donor assessment. Although technical advances have increased the accuracy of volume estimation, over- or under-estimation remains a challenge that needs further attention.

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.

Anomalies of the right hepatic artery in periampullary cancer treatment: are pathological and clinical outcomes different? A single tertiary referral center retrospective analysis

PURPOSE

Anomalies of the right hepatic artery (RHA) may represent an additional challenge in pancreatoduodenectomy (PD). The aim of this study is to assess the potential impact of variations in hepatic arterial anatomy on perioperative outcomes.

METHODS

PDs performed for periampullary malignancies between 2017 and 2022 were retrospectively enrolled and subdivided in two groups: modal pattern of vascularization (MPV) and anomalous pattern of vascularization (APV). A propensity score matching (PSM) analysis was conducted to homogenize the two study populations. The two groups were then compared in terms of perioperative outcomes and pathological findings.

RESULTS

Thirty-eight patients (16.3%) out of 232 presented a vascular anomaly: an accessory RHA in 7 cases (3%), a replaced RHA in 26 cases (11.2%), and a replaced HA in 5 cases (2.1%). After PSM, 76 MPV patients were compared to the 38 APV patients. The incidence rate of postoperative complications was comparable between the two study populations (p=0.2). Similarly, no difference was detected in terms of histopathological data, including margin status. No difference was noted in terms of intraoperative hemorrhage and vascular resection.

CONCLUSION

When PDs are performed in high-volume centers, the presence of an APV of the RHA does not relate to a significant impact on perioperative complications. Moreover, no influence was noted on histopathological findings.

Hilar Anatomy in 3035 Living Liver Donors: A Novel Classification for Donor Surgery and Suitability, Hepatic Surgeries, and Hepatobiliary Interventions

BACKGROUND

This study examines the vascular and biliary variations in 3035 liver donors. We propose a novel classification of hepatic arteries, portal veins, and bile ducts and clinically relevant donor classification.

METHODS

Preoperative imaging and operative details of 3035 donors from 2005 to 2020 were reviewed. Hilar anatomical variations were identified and grouped on the basis of incidence and clinical relevance.

RESULTS

Hilar structures are classified according to the numbers supplying or draining the graft: for the hepatic artery, right (R) and left (L), RA1/LA1 (1 artery), RA2/LA2 (2 arteries), and RA3/LA3 (3 arteries), respectively, further defined on the basis of the inflow trunk into C (for common hepatic artery), S (for superior mesenteric artery), and L (for left gastric artery); for the portal vein, RP1 (1 vein) and RP2 (2 veins) for the right lobe; and for the hepatic duct, RB1/LB1 (1 duct), RB2/LB2 (2 ducts), RB3 (3 right ducts), and RB4 (4 right ducts). Donors were classified on the basis of anatomical variations into 3 groups: class 1 and class 2 donors, who can donate liver with acceptable risks, and class 3 donors, who are high-risk donors because they are anatomically unacceptable ( Figures S1 to S4, SDC , http://links.lww.com/TP/C918 ).

CONCLUSIONS

Defining hilar anatomical variations and donor grouping into anatomy-based clinical classes helps in operative planning of donors, hepatobiliary surgeries, and interventional procedures.

Transarterial chemoembolization in a patient with the replaced right hepatic and left gastric arteries arising from the abdominal aorta: a new anatomical variation

PURPOSE

Knowing the anatomical variation of the coeliac trunk (CT) and its detailed interpretation in the preoperative period is important for the prevention of iatrogenic injury during liver surgery or endovascular intervention on the coeliac trunk and its branches.

METHODS

A diagnostic abdominal computed tomography angiography (CTA) was performed in a 61-year-old male patient, who was investigated for a liver cancer and chemoembolization was planned.

RESULTS

CTA reveals that right hepatic artery (RHA) arises directly from the abdominal aorta, at the level of CT. This vessel coursing to the right hepatic lobe, functioning therefore as a replaced right hepatic artery (RRHA). Also, the left gastric artery (LGA) arises directly from the abdominal aorta. This patient successfully underwent chemoembolization from RRHA.

CONCLUSION

We presented a case of new anatomical variation involving the origination of RRHA and LGA from the abdominal aorta.

The role of reconstructive microsurgeons in liver transplantation-a narrative review

Background and Objective

Liver transplantation is a life-saving procedure, but also associated with complications. Hepatic artery thrombosis is one of the most devastating complications, especially for living donor liver transplantation. The application of microsurgical techniques for hepatic artery reconstruction has greatly reduced the risk of hepatic artery thrombosis. In this narrative review, we discuss the technical considerations and challenges faced in microsurgical reconstruction of hepatic artery in liver transplantation.

Methods

PubMed, Web of Science, and Google Scholar were searched for keywords relating to "liver transplantation", "microsurgery", "living donor liver transplantation", "deceased donor liver transplantation", "hepatic artery", "hepatic artery thrombosis", "hepatic artery reconstruction" and "microsurgical anastomosis". Relevant articles pertaining to the technical considerations and challenges of microsurgery in liver transplantation were included.

Key Content and Findings

The conditions of liver transplantation pose unique challenges to the microsurgeon. Nonetheless, there are described strategies that can overcome these conditions, as well as technical details that may improve the outcomes of hepatic artery reconstruction. These strategies start from proper positioning of the patient, conscientious selection of donor and recipient hepatic vessels, and minimizing movements during critical microsurgical anastomosis. Technical details include techniques to overcome vessel delamination, size mismatch, poor quality vessels, and short vessel stump. This review also explores the outcomes of microsurgical hepatic arterial reconstruction.

Conclusions

There are various strategies to mitigate the challenges of microsurgery in liver transplant. Microsurgery improves the outcome of liver transplantation. Microsurgeons will continue to be a priceless resource that all liver transplant teams should have.

A systematic review meta-analysis and meta-regression on the implications of an aberrant right hepatic artery in patients undergoing pancreaticoduodenectomy for the treatment of malignant disease

We investigated the outcomes of pancreaticoduodenectomy in the presence of an aberrant right hepatic artery (aRHA). We systematically reviewed Medline, Scopus, and Web of Science until April 2023 for studies comparing pancreaticoduodenectomy outcomes with and without aRHA. Endpoints included postoperative mortality, R0 resection margins, pancreatic fistulae, hemorrhage, biliary leak/fistulae, delayed gastric emptying, operative duration, and blood loss. Eight retrospective studies involving 1514 patients were included. The risk ratio (RR) for postoperative mortality and odds ratio (OR) for R0 resection between the aRHA and normal anatomy groups were 1.37 (95%CI:0.74-256) (I2=0%, P=0.99) and 1.03 (95%CI:0.67-1.59) (I2=10%, P=0.35). Besides a longer operative duration in the aRHA group, mean difference (MD) 54.64 (95% CI: 8.51-100.77) (I2=94%, P<0.01), there were no significant differences in secondary endpoints. Meta-regression revealed a significant association between aRHA reconstruction and postoperative mortality (β=0.0179, P<0.01). This review displayed non-statistically significant differences in terms of surgical and oncological outcomes between patients with aRHA and patients with normal hepatic artery anatomy undergoing pancreaticoduodenectomy. However, the observed trend of increased postoperative mortality in patients with aRHA, combined with extended surgical duration and the link between aRHA reconstruction and postoperative mortality, prevents drawing definitive conclusions. Further research through high-quality studies is warranted.

Radiological classification of the Heidelberg triangle and its application in laparoscopic pancreaticoduodenectomy for malignancies

BACKGROUND

The TRIANGLE operation benefits patients with pancreatic cancer; however, the Heidelberg triangle, where the operation occurs, contains vessels that can impact safety, especially in laparoscopic pancreaticoduodenectomy (LPD) with the TRIANGLE operation. This study aimed to identify Heidelberg triangle vessel types and their implications in pancreaticoduodenectomy (PD).

METHODS

Retrospective collection of radiographic data was performed from January 2017 to April 2023. Three-dimensional (3D) CT reconstructions were performed on patients. Vascular types in the Heidelberg triangle were classified based on named vessels crossing its interior. The impact of these types on surgical outcomes and complications in PD with the TRIANGLE operation was assessed.

RESULTS

Preoperative CT reconstruction was conducted on 184 pancreatic surgery patients. The findings revealed 99 patients (53.8%) with the type I Heidelberg triangle, lacking named vessels crossing the interior. Type II (n = 85, 46.2%), with named vessels crossing the interior, was identified. Among reconstructed patients who underwent PD with the TRIANGLE operation (n = 103), they were categorized as type I (n = 57) or type II (n = 46). The results showed that LPD patients with type II had significantly higher median intraoperative blood loss (300 mL vs. 200 mL, P = 0.030) and mean examined lymph nodes (17.2 ± 7.6 vs. 13.4 ± 5.2, P = 0.019) compared to those with type I. No significant differences were found in operative time or postoperative complications.

CONCLUSION

The presence of named vessels crossing the interior of the Heidelberg triangle was associated with increased intraoperative bleeding during LPD combined with the TRIANGLE operation. Therefore, targeted preoperative planning is required before the operation, thus improving the safety of the TRIANGLE operation in minimally invasive surgery.

Successful endovascular treatment of acute mesenteric and hepatic ischemia in patient with celiomesenteric trunk occlusion

Acute occlusion of celiomesenteric trunk variants such as a replaced common hepatic artery origin from a superior mesenteric artery can be catastrophic and requires immediate attention to reverse simultaneous mesenteric and hepatic ischemia and prevent death. We report the case of a 73-year-old woman with acute occlusion of her celiomesenteric trunk and proximal superior mesenteric artery who underwent successful endovascular repair with stent graft via brachial access. In the present case report, we describe a surgically relevant classification system of celiomesenteric trunk variants, highlight the feasibility of endovascular intervention in this uncommon scenario, and describe our technique.

A rare clinical case of hepatic artery anatomy in a patient with Siewert III cardioesophageal junction cancer: A case report

INTRODUCTION

The normal anatomy of the celiac trunk (CT) is characterized by splitting into three branches in approximately 80 % of cases. In other cases, multiple anatomical variations can be observed. The purpose of this study was to review the clinical case featuring an extremely rare location of common hepatic artery (CHA) and to emphasize the importance of being familiar with possible anatomical variations of the hepatic artery through preoperative imaging in preparation for oncological surgery.

PRESENTATION OF CASE

A 71-year-old patient presented with Siewert III cardioesophageal junction cancer with liver metastases (T2N2M1, stage IV). Preoperative contrast-enhanced computed tomography (CECT) showed that the CHA branched from the AA. The operation included the proximal resection of the stomach and abdominal esophagus, D2 lymph nodes dissection, peritumoral liver resection, and extramucosal pyloroplasty.

DISCUSSION

We report a rare anatomical variation of replaced common hepatic artery, when it is located as VI type of Hiatt's classification - CHA branching from abdominal aorta (AA). It was discovered during contrast-enhanced computed tomography and illustrated by 3D reconstruction of vascular architectonics of the celiac trunk.

CONCLUSION

This case shows the importance of preoperative preparation using CECT to identify anatomical variations of the CHA, particularly for patients with locally advanced and metastatic cancer.

The Presence of an Aberrant Right Hepatic Artery Did Not Influence Surgical and Oncological Outcomes After Pancreaticoduodenectomy: A Comprehensive Systematic Review and Meta-Analysis

BACKGROUND

The presence of an aberrant right hepatic artery (a-RHA) could influence the oncological and postoperative results after pancreaticoduodenectomy (PD).

METHODS

A systematic review and metanalysis were conducted, including all comparative studies having patients who underwent PD without (na-RHA) or with a-RHA. The results were reported as risk ratios (RRs), mean differences (MDs), or hazard ratios (HRs) with 95% confidence intervals (95 CI). The random effects model was used to calculate the effect sizes. The endpoints were distinguished as critical and important. Critical endpoints were: R1 resection, overall survival (OS), morbidity, mortality, and biliary fistula (BL). Important endpoints were: postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), post pancreatectomy hemorrhage (PPH), length of stay (LOS), and operative time (OT).

RESULTS

Considering the R1 rate no significant differences were observed between the two groups (RR 1.06; 0.89 to 1.27). The two groups have a similar OS (HR 0.95; 0.85 to 1.06). Postoperative morbidity and mortality were similar between the two groups, with a RR of 0.97 (0.88 to 1.06) and 0.81 (0.54 to 1.20), respectively. The biliary fistula rate was similar between the two groups (RR of 1.09; 0.72 to 1.66). No differences were observed for non-critical endpoints.

CONCLUSION

The presence of a-RHA does not affect negatively the short-term and long-term clinical outcomes of PD.

Recent advances in computerized imaging and its vital roles in liver disease diagnosis, preoperative planning, and interventional liver surgery: A review

The earliest and most accurate detection of the pathological manifestations of hepatic diseases ensures effective treatments and thus positive prognostic outcomes. In clinical settings, screening and determining the extent of a pathology are prominent factors in preparing remedial agents and administering appropriate therapeutic procedures. Moreover, in a patient undergoing liver resection, a realistic preoperative simulation of the subject-specific anatomy and physiology also plays a vital part in conducting initial assessments, making surgical decisions during the procedure, and anticipating postoperative results. Conventionally, various medical imaging modalities, e.g., computed tomography, magnetic resonance imaging, and positron emission tomography, have been employed to assist in these tasks. In fact, several standardized procedures, such as lesion detection and liver segmentation, are also incorporated into prominent commercial software packages. Thus far, most integrated software as a medical device typically involves tedious interactions from the physician, such as manual delineation and empirical adjustments, as per a given patient. With the rapid progress in digital health approaches, especially medical image analysis, a wide range of computer algorithms have been proposed to facilitate those procedures. They include pattern recognition of a liver, its periphery, and lesion, as well as pre- and postoperative simulations. Prior to clinical adoption, however, software must conform to regulatory requirements set by the governing agency, for instance, valid clinical association and analytical and clinical validation. Therefore, this paper provides a detailed account and discussion of the state-of-the-art methods for liver image analyses, visualization, and simulation in the literature. Emphasis is placed upon their concepts, algorithmic classifications, merits, limitations, clinical considerations, and future research trends.

Variations of the hepatic artery and bile duct in patients with pancreaticobiliary maljunction: Impact on postoperative outcomes

PURPOSE

Preoperative comprehension of the anatomical variations of the hepatic artery and bile duct is essential for safe laparoscopic surgery for pancreaticobiliary maljunction (PBM). This study aimed to investigate the impact of anatomical variations of the hepatic artery and bile duct on surgical technique and postoperative complications.

METHODS

We conducted a retrospective review of patients with PBM who underwent laparoscopic surgery at our institution between January 2014 and December 2022 to investigate anatomical variations in the hepatic artery and bile duct, surgical technique, and postoperative complications.

RESULTS

We included 112 patients with PBM, with a median age of 4 years (interquartile range, 0-55). Overall, 29 of 112 patients had an aberrant right hepatic artery (ARHA) running ventral to the common hepatic duct (CHD), and they underwent hepaticojejunostomy on the ventral side of the ARHA. Additionally, eight of 112 patients had an aberrant posterior hepatic duct (APHD), which was joined to the CHD in all but one case. The presence of APHD was associated with postoperative bile leak occurrence.

CONCLUSION

Performing hepaticojejunostomy ventral to the ARHA is important to prevent complications. Furthermore, APHD may be a risk factor for postoperative bile leak and requires careful bile duct plasty.

Concepts and techniques for revascularization of replaced hepatic arteries in pancreatic head resections

BACKGROUND

The relationship of pancreatic ductal adenocarcinoma (PDAC) to important peripancreatic vasculature dictates resectability. As per the current guidelines, tumors with extensive, unreconstructible venous or arterial involvement are staged as unresectable locally advanced pancreatic cancer (LAPC). The introduction of effective multiagent chemotherapy and development of surgical techniques, have renewed interest in local control of PDAC. High-volume centers have demonstrated safe resection of short-segment encasement of the common hepatic artery. Knowledge of the unique anatomy of the patient's vasculature is important in surgical planning of these complex resections. Hepatic artery anomalies are common and insufficient knowledge can result in iatrogenic vascular injury during surgery.

METHODS AND RESULTS

Here, we discuss different strategies to resect and reconstruct replaced hepatic arteries during pancreatectomy for PDAC to ensure restoration of adequate blood flow to the liver. Strategies include various arterial transpositions, in-situ interposition grafts and the use of extra-anatomic jump grafts.

CONCLUSION

These surgical techniques allow more patients to undergo the only available curative treatment currently available for PDAC. Moreover, these improvements in surgical techniques highlight the shortcoming of current resectability criteria, which rely mainly on local tumor involvement and technical resectability, and disregards tumor biology.

Hepatocellular carcinoma vascularization: CT angiography variations identifying arteries feeding the tumour

Background

Hepatic arterial anatomy is important in performing many surgical and endovascular procedures. Familiarity with variations in the hepatic arterial anatomy is essential to achieving adequate embolization. In some patients, in addition to anatomic variations of the hepatic arteries, different extrahepatic collateral arteries may provide partial or total vascular supply to hepatocellular carcinoma (HCC), which makes transcatheter arterial chemoembolization (TACE) technically challenging. We aim to evaluate the different feeding vessels of HCC using multi-detector computed tomography angiography (MDCTA) as a pre-procedural step before planning suitable management.

Results

One hundred patients with 150 focal HCC lesions were involved in our study. The anatomy of the blood supply and the morphological characteristics of HCC, including the size, location, and history of previous hepatitis, were quantitatively assessed and statistically analysed. The number of patients who had classic hepatic arterial supply for the HCC lesions in our study was 54 (54%). The number of patients with additional extrahepatic supply is 26, while the number of patients with anatomical vascular variants is 20. Among these 26 patients with extrahepatic (parasitic) blood supply, six patients were supplied by the right inferior phrenic artery, four patients were supplied by the right internal mammary artery, and two patients were supplied by each other type of extrahepatic feeder, which are the left inferior phrenic artery, left internal mammary artery, left gastric artery, cystic artery, right lumbar artery, direct branch from the aorta, omental arteries, right renal artery, and LHA from the LGA. Twelve of the 20 patients with anatomical vascular variants had replaced RHA from the SMA; four patients had replaced LHA from the LGA; two patients had replaced RHA from the GDA; and two patients had replaced CHA from the SMA. Only 50 cases of CT findings were correlated with the data from the interventional procedures of these patients.

Conclusions

Because of the differences in HCC blood supply between typical, parasitic, and anatomical vascular variants, MDCTA has significant clinical significance prior to TACE and any interventional procedure.

Right hepatic artery anomalies in pancreatoduodenectomy-a risk for arterial resection but not for postoperative outcomes

BACKGROUND

Pancreatoduodenectomy (PD) is a complex surgical procedure known for its significant morbidity rates, and the presence of an aberrant hepatic artery (AHA) introduces additional challenges. The impact of AHA on post-PD outcomes has been a subject of conflicting findings in the medical literature. This study aimed to investigate how variations in hepatic arterial anatomy influence intra-operative variables and postoperative morbidity.

METHODS

A retrospective analysis was conducted on 113 PD cases. Patients with variant hepatic arterial anatomy (n=38) were categorized as Group 1, while those without vascular abnormalities comprised Group 2. Perioperative and postoperative outcomes were examined.

RESULTS

Patients in Groups 1 and 2 exhibited similar characteristics, and no notable differences in surgical complications were observed. There was, however, a noticeable trend towards a higher incidence of postpancreatectomy hemorrhage (PPH) in Group 1 (31.6% vs. 20.0%; P=0.17). Furthermore, a statistically significant increase in the rate of arterial resections was noted in patients with vascular anomalies (10.5% vs. 1.33%; P=0.02).

CONCLUSIONS

The prevalence of vascular abnormalities in the hepatic arterial circulation is more frequent than initially anticipated. These anomalies present additional complexities to the already intricate PD procedure, leading to a heightened necessity for arterial resection, albeit without any discernible impact on postoperative complications.

Deceased Donor Liver Transplantation: Techniques and Surgical Anatomy

Deceased liver donor transplantation is increasing in prevalence resulting in larger volumes of posttransplant imaging studies. Radiologists should familiarize themselves with the spectrum of normal posttransplant anatomy. The key findings can be categorized into 4 systems reconstructed during surgery: hepatic venous, portal venous, hepatic arterial, and biliary ductal systems. Here we discuss the imaging findings seen with the most common surgical techniques, those that can be misidentified as complications, and some less common variations resulting from different surgical techniques.

Non-Contrast-Enhanced MR Arteriography of Potential Living-Related Liver Donor: Using Contrast Enhanced CT Arteriography as Standard Reference

BACKGROUND

Contrast-enhanced computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are the primary modalities to assess donors' vessels before transplant surgery. Radiation and contrast medium are potentially harmful to donors.

PURPOSE

To compare the image quality and visualization scores of hepatic arteries on CTA and balanced steady-state free-precession (bSSFP) non-contrast-enhanced MRA (NC-MRA), and to evaluate if bSSFP NC-MRA can potentially be a substitute for CTA.

STUDY TYPE

Prospective.

POPULATION

Fifty-six consecutive potential living-related liver donors (30.9 ± 8.4 years; 31 men).

FIELD STRENGTH/SEQUENCE

1.5T; four bSSFP NC-MRA sequences: respiratory-triggered (Inhance inflow inversion recovery [IFIR]) and three breath-hold (BH); and CTA.

ASSESSMENT

The artery-to-liver contrast (Ca-l) was quantified. Three radiologists independently assigned visualization scores using a four-point scale to potential origins, segments, and branches of the hepatic arteries, determined the anatomical variants based on Hiatt's classification, and assessed the image quality of NC-MRA sequences.

STATISTICAL TESTS

Fleiss' kappa to evaluate the readers' agreement. Repeat measured ANOVA or Friedman test to compare Ca-l of each NC-MRA. Friedman test to compare overall image quality and visualization scores; post hoc analysis using Wilcoxon signed-rank test. P-value <0.05 was considered statistically significant.

RESULTS

Inhance IFIR Ca-l was significantly higher than all BH bSSFP Ca-l (0.56 [0.45-0.64] vs. 0.37 [0.29-0.47] to 0.41 [0.23-0.51]). Overall image quality score of BH bSSFP TI1200 was significantly higher than other NC-MRA (4 [4-4] vs. 4 [3 to 4-4]). The median visualization scores of almost all arteries on CTA were significantly higher than on NC-MRA (4 [3 to 4-4] vs. 1 [1-2] to 4 [4-4]). The median visualization scores were all 4 [4-4 ] on Inhance IFIR with >92.3% observed scores ≥3, except the segment 4 branch (3 [1-4], 53.6%). The identification rates of arterial variants were 92.9%-97% on Inhance IFIR.

DATA CONCLUSIONS

Although CTA is superior to the NC-MRA, all NC-MRA depict the donor arterial anatomy well. Inhance IFIR can potentially be an alternative image modality for CTA to evaluate the arterial variants of living donors.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY: Stage 2.

Short- and long-term outcomes of laparoscopic or robotic radical gastrectomy based on preoperative perigastric artery CTA surgical decision-making: a high-volume center retrospective study with propensity score matching

BACKGROUND

Some studies have demonstrated the short-term recovery course for patients who underwent laparoscopic gastrectomy according to preoperative computed tomography angiography (CTA) assessment. However, reports of the long-term oncological outcomes are still limited.

METHODS

The data of 988 consecutive patients who underwent laparoscopic or robotic radical gastrectomy between January 2014 and September 2018 were analyzed retrospectively at our center, and propensity score matching was used to eliminate bias. Study cohorts were divided into the CTA group (n = 498) and the non-CTA group (n = 490) depending on whether preoperative CTA was available. The primary and secondary endpoints were the 3-year overall survival (OS) and disease-free survival (DFS) rates and the intraoperative course and short-term outcomes, respectively.

RESULTS

431 patients were included in each group after PSM. Compared with the non-CTA group, the CTA group had more harvested lymph nodes and less operative time, blood loss, intraoperative vascular injury and total cost, especially in the subgroup analysis with BMI ≥ 25 kg/m2 patients. There was no difference in the 3 year OS and DFS between the CTA group and the non-CTA group. When further stratified by BMI < 25 or ≥ 25 kg/m2, the 3-year OS and DFS were significantly higher in the CTA group than in the non-CTA group in terms of BMI ≥ 25 kg/m2.

CONCLUSIONS

Laparoscopic or robotic radical gastrectomy based on preoperative perigastric artery CTA surgical decision-making has the possibility of improving short-term outcomes. However, there is no difference in the long-term prognosis, except for a subgroup of patients with BMI ≥ 25 kg/m2.

Replaced Segment 6 Artery From the Gastroduodenal Artery: A Challenging and Rare Anatomical Variation of Hepatic Artery in Pancreaticoduodenectomy

Variations in the hepatic artery's anatomy can significantly impact planning and executing pancreatic and hepatobiliary surgeries. Of these, the commonest are variations of right and left hepatic arteries originating from superior mesenteric and left gastric arteries, respectively. The anomalous origin of the right hepatic artery from the gastroduodenal artery (GDA) is among the rarest and most challenging anatomy, especially in patients undergoing pancreatoduodenectomy (PD) since GDA ligation is a mandatory step, which may threaten the liver blood supply. We present a 62-year-old male with suspected distal cholangiocarcinoma and plan a robot-assisted pancreatoduodenectomy. Preoperative computed tomography evaluation revealed an anomalous segment 6 artery arising from the GDA and coursing posterolaterally to the common bile duct in the hepatoduodenal ligament. Also, the patient had a replacement left hepatic artery originating from the left gastric artery. The described vascular anomaly has not been previously reported in patients undergoing PD. Awareness of vascular anomalies is the key to performing oncologically radical surgery without increasing bleeding and ischemic complications in patients undergoing complex procedures like PD.

Donor hepatic artery reconstruction based on human embryology: A case report

BACKGROUND

Embryonic hepatic artery anatomy simplifies its identification during liver transplantation. Injuries to the donor hepatic artery can cause complications in this process. The hepatic artery's complex anatomy in adults makes this step challenging; however, during embryonic development, the artery and its branches have a simpler relationship. By restoring the embryonic hepatic artery anatomy, surgeons can reduce the risk of damage and increase the procedure's success rate. This approach can lead to improved patient outcomes and lower complication rates.

CASE SUMMARY

In this study, we report a case of donor liver preparation using a donor hepatic artery preparation based on human embryology. During the preparation of the hepatic artery, we restored the anatomy of the celiac trunk, superior mesenteric artery, and their branches to the state of the embryo at 5 wk. This allowed us to dissect the variant hepatic artery from the superior mesenteric artery and left gastric artery during the operation. After implanting the donor liver into the recipient, we observed normal blood flow in the donor hepatic artery, main hepatic artery, and variant hepatic artery, without any leakage.

CONCLUSION

Donor hepatic artery preparation based on human embryology can help reduce the incidence of donor hepatic artery injuries during liver transplantation.

Anatomical Variations in the Celiac Trunk: A Short Review

OBJECTIVE

The objective of the current study was the examination of possible variants of the celiac trunk.

METHODS

An advanced review of the literature search was undertaken by means of the PubMed database and Google Scholar, searching for new studies published up to October 2022. Additional articles provided useful information in relation to the aim of this review. Hence, articles that met the inclusion criteria were included in this review and the collected data were organized into a table.

RESULTS

The search of the literature retrieved 10 articles that referred to the anatomical variations of the celiac trunk. According to the available literature, the most common anatomical variations are: hepatosplenic trunk where the left gastric artery originates from the abdominal aorta, hepatosplenic trunk, where the left gastric artery originates from the splenic artery, and hepatogastric trunk and splenic artery origin from the superior mesenteric artery. Many other anatomical variations of the celiac trunk may exist, such as tetrafurcation, pentafurcation and hexafurcation, that refer to the division of the celiac trunk into four, five or six branches, respectively, and should be reported as they can affect surgical approaches and the development of the appropriate treatment strategy in patients.

CONCLUSION

Every visceral surgeon, interventional radiologist and abdominal imager should be familiar with these variants.

Exploring Anatomical Variations of Abdominal Arteries Through Computed Tomography: Classification, Prevalence and Implications

BACKGROUND AND AIMS

Variations in the branches of the abdominal aorta are relatively prevalent and can impact certain surgeries. The accurate identification and differentiation of these variations pre- and intraoperatively are crucial to avoid negative clinical sequelae. This study aimed to investigate the prevalence of variations in some branches of the abdominal aorta and to identify the most frequent variants as well as any rare variants not previously classified in the existing classification systems. The study's findings may help improve the understanding and management of these variations.

MATERIALS AND METHODS

This retrospective study was conducted at the Department of Radiology at An-Najah National University Hospital (NNUH) and included 550 abdominal computed tomography (CT) angiographic scans for patients (51.5% males, 48.5% females) performed between January 2017 and January 2023.

RESULTS

Variations were most common in the hepatic arteries (34.7%), followed by the renal arteries (31.3%). Variations in the celiac trunk were the least frequent (9.8%). The gastro-splenic trunk (type V) was the most common celiac trunk variant. The most common hepatic artery variant was the replacement of the right hepatic artery (type III). Accessory renal arteries were more frequent on the left side and among males (P = 0.01). The celiac trunk variations had a significant association with the hepatic artery variations (P = 0.001) and the renal artery variations (P = 0.011), respectively.

CONCLUSION

There is a high prevalence of anatomical variations in the described vessels, and it matches the results in the reported literature. Our findings also suggest the possible coexistence of variants. We have also encountered rare variants, especially in the hepatic arterial system. Some of the hepatic arterial system variants are not included in the older classification systems, calling for an extension of the old systems (Michel's and Hiatt classification systems) or replacement with the newer (CRL or EX-CRL classification systems) to account for rare variants not previously classified. Radiologists and surgeons should be proficient in identifying and differentiating these variations to take precautions and actions for each variant individually.

Evaluation of celiac artery and common hepatic artery variations by CT-angiography and new classification model

PURPOSE

Knowledge of anatomical variations is important in all interventional procedures. This study aims to evaluate the variations and prevalence of celiac trunk (CeT) and its branches.

METHODS

The computerized tomography-angiography (CT-A) findings of 941 adult patients were evaluated retrospectively. Variations of the CeT and common hepatic artery (CHA) were evaluated according to the number of branches and their origin. Findings were compared with classical classification methods. A new classification model has been defined.

RESULTS

Normal (complete) trifurcation was detected in 856 (90.9%) of them, where left gastric artery (LGA), splenic artery (SpA) and CHA branches were derived from the CeT. Among 856 complete trifurcation cases, 773 (90.3%) had non-classical trifurcation patterns. The rate of classic trifurcation was 8.8%, while non-classic trifurcation was 82.1% in all cases. In one case (0.1%), LGA and left hepatic artery together and right hepatic artery and SpA together appeared as a double bifurcation. Complete celiacomesenteric trunk was observed only in 4 (0.42%) cases. In seven cases (0.7%), LGA, SpA and CHA were coming out of abdominal aorta (AAo) independently. CHA normal anatomy (Michels Type I) was detected in 618 (65.5%) patients. We found that 49 (5.2%) of our cases were ambiguous according to the Michels Classification. We have described five different variations of hepatic arteries directly arising from the AAo.

CONCLUSION

Preoperative recognition of anatomical variations of CeT, superior mesenteric artery and CHA is of primary importance in both surgical and radiological procedures. With careful evaluation of CT-angiographies, it is possible to detect rare variations.