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Tao W, Peng D, Cheng YX, Zhang W. Clinical significance of aberrant left hepatic artery during gastrectomy: A systematic review. World J Clin Cases 2022; 10:3121-3130. [PMID: 35647120 PMCID: PMC9082717 DOI: 10.12998/wjcc.v10.i10.3121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/12/2021] [Accepted: 02/20/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Vascular variations are frequently encountered during surgery. Approximately thirty percent of these variations are aberrant left hepatic arteries originating from the left gastric artery.
AIM To summarize the safety and feasibility of aberrant left hepatic arteries (ALHA) ligation in gastric cancer patients who underwent laparoscopic-assisted gastrectomy (LAG).
METHODS The literature search was systematically performed on databases including PubMed, Embase, and Cochrane Library. The publishing date of eligible studies was from inception to June 2021.
RESULTS A total of nine studies were included according to the inclusion and exclusion criteria in this review. The variation rate of ALHA ranged from 7.00% to 20.70%, and four studies compared the differences between the ALHA ligation group and the preservation group. Only one study showed worse postoperative outcomes in the ALHA ligation group. In all the included studies, a significant difference was found between the ALHA ligation group and the preservation group in terms of postoperative liver enzymes after LAG. However, there was no significant difference in the number of retrieved lymph nodes between the two groups.
CONCLUSION In conclusion, it is not always safe and feasible for surgeons to ligate the ALHA during LAG surgery, and it is necessary for gastric cancer patients to undergo preoperative examination to clarify the ALHA subtypes, measure the diameter of the ALHA, and determine whether the patients have chronic liver disease.
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Affiliation(s)
- Wei Tao
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Dong Peng
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Yu-Xi Cheng
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Wei Zhang
- Department of Gastrointestinal Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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2
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Egorov VI, Petrov RV, Amosova EL, Kharazov AF, Petrov KS, Zhurina YA, Kondratyev EV, Zelter PM, Dzigasov SO, Grigorievsky MV. [Distal pancreatectomy with resection of the celiac trunk, right or left hepatic artery without arterial reconstruction (extended DP-CAR)]. Khirurgiia (Mosk) 2021:13-28. [PMID: 34608776 DOI: 10.17116/hirurgia202110113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- V I Egorov
- Ilyinskaya Hospital, Krasnogorsk, Russia
| | - R V Petrov
- Ilyinskaya Hospital, Krasnogorsk, Russia
| | | | - A F Kharazov
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | | | | | - E V Kondratyev
- Ilyinskaya Hospital, Krasnogorsk, Russia.,Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - P M Zelter
- Samara State Medical University, Samara, Russia
| | | | - M V Grigorievsky
- Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
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Sano A, Saito K, Kuriyama K, Nakazawa N, Ubukata Y, Hara K, Sakai M, Ogata K, Fukasawa T, Sohda M, Fukuchi M, Naitoh H, Shirabe K, Saeki H. Risk Factors for Postoperative Liver Enzyme Elevation After Laparoscopic Gastrectomy for Gastric Cancer. In Vivo 2021; 35:1227-1234. [PMID: 33622925 DOI: 10.21873/invivo.12373] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 01/15/2021] [Accepted: 01/21/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND/AIM Laparoscopic gastrectomy (LG) is more frequently associated with postoperative liver enzyme elevation (PLEE) than open gastrectomy in phase III clinical trials for Japanese gastric cancer patients. The aim of this study was to determine the risk factors for PLEE after LG for gastric cancer. PATIENTS AND METHODS This study enrolled 153 consecutive patients with gastric cancer who underwent LG. The patient characteristics, the liver retraction method [silicone disc (SD) or Nathanson liver retractor (NLR)], and perioperative outcomes were compared between patients with and without PLEE. RESULTS PLEE was observed in 26 patients (17%). The patients with PLEE exhibited longer operative times (p=0.005) and more frequent use of the NLR for liver retraction (p=0.022). In the multivariate analysis, liver retraction using the NLR (p=0.003) and aberrant left hepatic artery (ALHA) ligation (p=0.042) were independent risk factors of PLEE. CONCLUSION Liver retraction with the SD during LG was shown to be the safer method that is less likely to cause postoperative liver dysfunction. ALHA preservation may contribute to avoiding postoperative liver dysfunction.
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Affiliation(s)
- Akihiko Sano
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan;
| | - Kana Saito
- Department of Surgery, Japan Community Healthcare Organization Gunma Central Hospital, Gunma, Japan
| | - Kengo Kuriyama
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Nobuhiro Nakazawa
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Yasunari Ubukata
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Keigo Hara
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Makoto Sakai
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Kyoichi Ogata
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Takaharu Fukasawa
- Department of Surgery, Japan Community Healthcare Organization Gunma Central Hospital, Gunma, Japan
| | - Makoto Sohda
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Minoru Fukuchi
- Department of Surgery, Japan Community Healthcare Organization Gunma Central Hospital, Gunma, Japan
| | - Hiroshi Naitoh
- Department of Surgery, Japan Community Healthcare Organization Gunma Central Hospital, Gunma, Japan
| | - Ken Shirabe
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Hiroshi Saeki
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
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Lee S, Son T, Song JH, Choi S, Cho M, Kim YM, Kim HI, Hyung WJ. Adverse Effects of Ligation of an Aberrant Left Hepatic Artery Arising from the Left Gastric Artery during Radical Gastrectomy for Gastric Cancer: a Propensity Score Matching Analysis. J Gastric Cancer 2021; 21:74-83. [PMID: 33854815 PMCID: PMC8020005 DOI: 10.5230/jgc.2021.21.e6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 03/12/2021] [Accepted: 03/12/2021] [Indexed: 12/14/2022] Open
Abstract
PURPOSE No consensus exists on whether to preserve or ligate an aberrant left hepatic artery (ALHA), which is the most commonly encountered hepatic arterial variation during gastric surgery. Therefore, we aimed to evaluate the clinical effects of ALHA ligation by analyzing the perioperative outcomes. MATERIALS AND METHODS We retrospectively reviewed the data of 5,310 patients who underwent subtotal/total gastrectomy for gastric cancer. Patients in whom the ALHA was ligated (n=486) were categorized into 2 groups according to peak aspartate aminotransferase (AST) or alanine aminotransferase (ALT) levels: moderate-to-severe (MS) elevation (≥5 times the upper limit of normal [ULN]; MS group, n=42) and no-to-mild (NM) elevation (<5 times the ULN; NM group, n=444). The groups were matched 1:3 using propensity score-matching analysis to minimize confounding factors that can affect the perioperative outcomes. RESULTS The mean operation time (P=0.646) and blood loss amount (P=0.937) were similar between the 2 groups. The length of hospital stay was longer in the MS group (13.0 vs. 7.8 days, P=0.022). No postoperative mortality occurred. The incidence of grade ≥ IIIa postoperative complications (19.0% vs. 5.1%, P=0.001), especially pulmonary complications (11.9% vs. 2.5%, P=0.003), was significantly higher in the MS group. This group also showed a higher Comprehensive Complication Index (29.0 vs. 13.9, P<0.001). CONCLUSIONS Among patients with a ligated ALHA, those with peak AST/ALT ≥5 times the ULN showed worse perioperative outcomes in terms of hospital stay and severity of complications. More precise perioperative decision-making tools are needed to better determine whether to preserve or ligate an ALHA.
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Affiliation(s)
- Sejin Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Gastric Cancer Center, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Taeil Son
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Gastric Cancer Center, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Jeong Ho Song
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Gastric Cancer Center, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Seohee Choi
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Gastric Cancer Center, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Minah Cho
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Gastric Cancer Center, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Yoo Min Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Gastric Cancer Center, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Hyoung-Il Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Gastric Cancer Center, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Woo Jin Hyung
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Gastric Cancer Center, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
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Real-time identification of aberrant left hepatic arterial territories using near-infrared fluorescence with indocyanine green during gastrectomy for gastric cancer. Surg Endosc 2021; 35:2389-2397. [PMID: 33492510 DOI: 10.1007/s00464-020-08265-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 12/22/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND An aberrant left hepatic artery is frequently encountered during upper gastrointestinal surgery, and researchers have yet to propose optimal strategies with which to address this arterial variation. The objective of this study was to determine whether the areas perfused by an aberrant left hepatic artery can be visualized in real-time using near-infrared fluorescence imaging with indocyanine green. METHODS Patients with gastric adenocarcinoma who underwent minimally invasive radical gastrectomy from May 2018 to August 2019 were enrolled and retrospectively analyzed at a single-center. Patients with an aberrant left hepatic artery and normal preoperative liver function were examined. After the clamping of an aberrant left hepatic artery, indocyanine green was administered via a peripheral intravenous route during surgery. Fluorescence at the liver was visualized under near-infrared fluorescence imaging. RESULTS In 31 patients with aberrant left hepatic arteries, near-infrared fluorescence imaging was used without adverse events associated with indocyanine green. Six (19%) patients were reported to have an aberrant left hepatic artery upon preoperative CT imaging, while all other instances were detected during surgery. Fluorescence excitation on the liver was, on average, visible after 43 s (range, 25-65). Fluorescence across the entire surface of the liver was noted in 20 (65%) patients in whom the aberrant left hepatic artery could be ligated. Aberrant left hepatic arteries were safely preserved in 10 (32%) patients who showed areas of no or partial fluorescence excitation. Guided by near-infrared fluorescence imaging, ligation of aberrant left hepatic arteries elicited no significant changes in postoperative liver function. CONCLUSION Near-infrared fluorescence imaging facilitates the identification of aberrant left hepatic arterial territories, guiding decisions on the preservation or ligation of this arterial variation.
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Preserving a Replaced Left Hepatic Artery Arising from the Left Gastric Artery During Laparoscopic Distal Gastrectomy for Gastric Cancer. World J Surg 2020; 45:543-553. [PMID: 33108491 DOI: 10.1007/s00268-020-05832-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND A replaced left hepatic artery (RLHA) arising from the left gastric artery (LGA) is occasionally encountered during laparoscopic gastrectomy. Although the RLHA is usually divided at the root level as RLHA preservation might result in inadequate lymph node dissection, blood flow disruption by RLHA division may lead to hepatic ischemia. To date, there is no consensus on RLHA preservation. Thus, we aimed to evaluate the efficacy of RLHA preservation by investigating the short-term outcomes of patients with RLHA who underwent laparoscopic distal gastrectomy (LDG). METHODS A total of 106 patients with an aberrant LHA from the LGA were identified as having gastric cancer and underwent LDG from 2012 to 2018. Finally, 55 patients were retrospectively diagnosed with RLHA by preoperative computed tomography and included in this study. Patients were classified into the divided (n = 18) or preserved (n = 37) group. Clinicopathological factors and surgical outcomes were compared between the two groups. RESULTS The RLHA preservation rate in patients who had been preoperatively diagnosed with RLHA was 88%. No significant difference was found in the number of harvested lymph nodes between the groups. The incidence of hepatic infarction was significantly higher in the divided group (16.7% vs. 0%, p = 0.031). Moreover, RLHA division caused postoperative transaminase elevation and was an independent risk factor for postoperative transaminase elevation (odds ratio: 55.8, p < 0.001). CONCLUSIONS Surgical procedures of RLHA preservation reduced postoperative transaminase elevation and hepatic infarction in patients who underwent LDG. Surgeons should confirm the RLHA preoperatively and preserve it to prevent hepatic damage.
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7
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Shin CI, Kim SH. Normal and Abnormal Postoperative Imaging Findings after Gastric Oncologic and Bariatric Surgery. Korean J Radiol 2020; 21:793-811. [PMID: 32524781 PMCID: PMC7289697 DOI: 10.3348/kjr.2019.0822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 01/10/2020] [Accepted: 02/11/2020] [Indexed: 11/15/2022] Open
Abstract
Surgical resection remains the primary choice of treatment and the only potentially curative option for gastric carcinoma, and is increasingly performed laparoscopically. Gastric resection represents a challenging procedure, with a significant morbidity and non-negligible postoperative mortality. The interpretation of imaging after gastric surgery can be challenging due to significant modifications of the normal anatomy. After the surgery, the familiarity with expected imaging appearances is crucial for diagnosis and appropriate management of potentially life-threatening complications in patients who underwent gastric surgery. We review various surgical techniques used in gastric surgery and describe fluoroscopic and cross-sectional imaging appearances of normal postoperative anatomic changes as well as early and late complications after gastric surgery.
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Affiliation(s)
- Cheong Il Shin
- Department of Radiology, Seoul National University Hospital, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Se Hyung Kim
- Department of Radiology, Seoul National University Hospital, Seoul, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea.
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8
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Ang RRG, Lee HJ, Bae JS, Zhu CC, Berlth F, Kim TH, Park SH, Suh YS, Kong SH, Kim SH, Yang HK. Safety of Ligation of Aberrant Left Hepatic Artery Originating from Left Gastric Artery in Laparoscopic Gastrectomy for Gastric Cancer. Sci Rep 2020; 10:5856. [PMID: 32246010 PMCID: PMC7125141 DOI: 10.1038/s41598-020-62587-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 02/26/2020] [Indexed: 02/07/2023] Open
Abstract
There are still lot of controversies whether aberrant left hepatic artery (ALHA) originating from left gastric artery should be ligated or preserved during gastric cancer (GC) surgery. We aimed to investigate this issue. We reviewed ALHA cases who had laparoscopic gastrectomy for gastric cancer at Seoul National University Hospital (SNUH) from 2012 to 2016. Type of ALHA variants using Michel's classification of hepatic arterial anatomy and diameter of each vessel were evaluated by 2 radiologists. Postoperative hepatic function and surgical outcome were collected until 6 months after surgery. Results showed that if the diameter of ALHA was larger than 1.5 mm, a transient elevation of SGOT and SGPT on postoperative day 2 was observed in the ligated cases. No differences were observed in operation time, amount of blood loss, overall complication rate, hospital stay, and number of lymph nodes retrieved between the ligated and preserved replaced left hepatic artery (RLHA) and accessory left hepatic artery (acLHA) group. In this study, we conclude that ligation of ALHA seems to be safe as none of the patients suffered adverse outcome. A transient rise in postoperative SGOT and SGPT levels were seen after ligating ALHA >1.5 mm in diameter regardless of subtype.
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Affiliation(s)
- Rene Ronson G Ang
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Department of Surgery, Cebu Doctors' University Hospital, Cebu City, Philippines
- Department of Surgery, University of Cebu Medical Center, Cebu City, Philippines
| | - Hyuk-Joon Lee
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea.
| | - Jae Seok Bae
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Chun-Chao Zhu
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Department of Gastrointestinal Surgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Felix Berlth
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Department of General, Visceral and Cancer Surgery, University of Cologne, Köln, Germany
| | - Tae Han Kim
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Department of Surgery, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Shin-Hoo Park
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Yun-Suhk Suh
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seong-Ho Kong
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Se Hyung Kim
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Han-Kwang Yang
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Aberrant left hepatic arteries arising from left gastric arteries and their clinical importance. Surgeon 2019; 18:100-112. [PMID: 31337536 DOI: 10.1016/j.surge.2019.06.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 06/13/2019] [Accepted: 06/26/2019] [Indexed: 12/20/2022]
Abstract
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.
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Clinical evaluation of the aberrant left hepatic artery arising from the left gastric artery in esophagectomy. Surg Radiol Anat 2018; 40:749-756. [DOI: 10.1007/s00276-018-2022-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 04/09/2018] [Indexed: 12/11/2022]
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Yamamoto M, Zaima M, Yamamoto H, Harada H, Kawamura J, Yamada M, Yazawa T, Kawasoe J. Liver necrosis shortly after pancreaticoduodenectomy with resection of the replaced left hepatic artery. World J Surg Oncol 2017; 15:77. [PMID: 28399882 PMCID: PMC5387288 DOI: 10.1186/s12957-017-1151-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 04/02/2017] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Michihiro Yamamoto
- Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama city, Shiga Prefecture, 524-8524, Japan.
| | - Masazumi Zaima
- Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama city, Shiga Prefecture, 524-8524, Japan
| | - Hidekazu Yamamoto
- Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama city, Shiga Prefecture, 524-8524, Japan
| | - Hideki Harada
- Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama city, Shiga Prefecture, 524-8524, Japan
| | - Junichiro Kawamura
- Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama city, Shiga Prefecture, 524-8524, Japan
| | - Masahiro Yamada
- Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama city, Shiga Prefecture, 524-8524, Japan
| | - Tekefumi Yazawa
- Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama city, Shiga Prefecture, 524-8524, Japan
| | - Junya Kawasoe
- Shiga Medical Center for Adults, 4-30 Moriyama 5-chome, Moriyama city, Shiga Prefecture, 524-8524, Japan
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