• Digital subtraction angiography
• Hepatic arterial variations
• Multidetector computed tomography

• Humans
• Celiac Artery/diagnostic imaging
• Celiac Artery/abnormalities
• Celiac Artery/anatomy & histology
• Hepatic Artery/diagnostic imaging
• Hepatic Artery/abnormalities
• Hepatic Artery/anatomy & histology
• Multidetector Computed Tomography/methods
• Computed Tomography Angiography
• Angiography, Digital Subtraction/methods
• Male
• Female
• Anatomic Variation

• Humans
• Pancreaticoduodenectomy/adverse effects
• Pancreaticoduodenectomy/methods
• Pancreatectomy/methods
• Biliary Fistula
• Hepatic Artery/surgery
• Pancreas/surgery
• Pancreatic Fistula/etiology
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Postoperative Complications/surgery

• Alma Mater Studiorum - Università di Bologna

• Pancreatic resection
• Surgical outcomes
• Vascular anomalies

• Humans
• Pancreaticoduodenectomy/adverse effects
• Pancreaticoduodenectomy/methods
• Hepatic Artery/surgery
• Retrospective Studies
• Pancreatic Neoplasms/pathology
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Postoperative Complications/surgery

• gda variation
• pancreaticoduodenectomy(pd)
• replaced hepatic artery
• replaced lha
• robotic assisted pancreatic surgery

• Conversion surgery
• Gallbladder cancer
• Hepatopancreatoduodenectomy
• Preoperative embolization

• Hepatic Artery/pathology
• Hepatic Artery/surgery
• Humans
• Neoadjuvant Therapy/methods
• Pancreatic Neoplasms/pathology
• Pancreaticoduodenectomy
• Retrospective Studies
• Pancreatic Neoplasms

Hepatic arterial variations were fully elaborated in anatomical monographs. Here, we aimed to present a rare case with multiple arterial variations of the liver complicated laparoscopic pancreaticoduodenectomy.

We report a 67-year-old woman with a periampullary tumor underwent laparoscopic pancreaticoduodenectomy. Intraoperatively, the aberrant right hepatic artery derived from the gastroduodenal artery (GDA) was observed and had accidentally sacrificed due to untimely ligature of GDA. Three-dimensional reconstruction based on preoperative contrast-enhanced CT performed to better study the anatomy. It demonstrated a replaced right hepatic artery branched from the GDA and supplied right liver lobe. Meanwhile, the middle hepatic artery derived from the common hepatic artery and supplied hepatic segment IV. Additionally, the replaced left hepatic artery emerged from the left gastric artery and fed into left liver lobe.

The origination and course of hepatic arterial anatomy should be thoroughly assessed in planning and performing hepatopancreatobiliary surgeries. Reconstruction images of contrast-enhanced CT are helpful to visualize the vascular variations and its spatial relation with adjacent structures.

• Anatomical variation
• Case report
• Laparoscopic pancreaticoduodenectomy
• Middle hepatic artery
• Replaced left hepatic artery
• Replaced right hepatic artery

The anatomical structure of the pancreaticoduodenal region is complex and closely related to the surrounding vessels. A variant of the hepatic artery, which is not a rare finding during pancreatic surgery, is prone to intraoperative injury. Inadvertent injury to the hepatic artery may affect liver perfusion, resulting in necrosis, liver abscess, and even liver failure. The preoperative identification of hepatic artery variations, detailed planning of the surgical approach, careful intraoperative dissection, and proper management of the damaged artery are important for preventing hepatic hypoperfusion. Nevertheless, despite the potential risks, planned artery resection has become acceptable in carefully selected patients. Arterial reconstruction is sometimes essential to prevent postoperative ischemic complications and can be performed using various methods. The complexity of procedures such as pancreatectomy with en bloc celiac axis resection may be mitigated by the presence of an aberrant right hepatic artery or a common hepatic artery originating from the superior mesenteric artery. Here, we comprehensively reviewed the anatomical basis of hepatic artery variation, its incidence, and its effect on the surgical and oncological outcomes after pancreatic resection. In addition, we provide recommendations for the prevention and management of hepatic artery injury and liver hypoperfusion. Overall, the hepatic artery variant may not worsen surgical and oncological outcomes if it is accurately identified pre-operatively and appropriately managed intraoperatively.

• Hepatic artery
• Pancreatectomy
• Pancreaticoduodenectomy
• Arterial reconstruction
• Celiac axis resection
• Outcome
• Prognosis

• Celiac Artery/diagnostic imaging
• Celiac Artery/surgery
• Hepatic Artery/diagnostic imaging
• Hepatic Artery/surgery
• Humans
• Liver/blood supply
• Liver/diagnostic imaging
• Liver/surgery
• Pancreatectomy/adverse effects
• Pancreatectomy/methods
• Pancreatic Neoplasms/surgery
• Pancreaticoduodenectomy
• Postoperative Complications/etiology
• Postoperative Complications/prevention & control
• Postoperative Complications/surgery

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

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

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

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

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

• Hepatic artery
• Injury
• Anomaly
• Ligation
• Resection
• Reconstruction

• Accessory right hepatic artery
• Distal pancreatectomy
• Vascular anomaly

Introduction

Knowledge of celiac artery variations is imperative to perform complex hepato-biliary pancreatic surgical procedures to avoid inadvertent complications. Multi-detector computed tomographic (MDCT) angiography aids in detecting these variations preoperatively. Surgical confirmation is considered the gold standard.

Aims and objectives

Preoperative assessment of celiac artery variations by MDCT angiography and surgical confirmation intraoperatively in resectable hepato-biliary pancreatic cancers.

Patients and methods

MDCT angiography was performed in 40 patients with clinical evidence of resectable hepato-biliary-pancreatic cancers. Three dimensional (3D) reconstructions were performed to confirm the celiac artery variations. Surgery was performed as per the institute’s protocol in all these patients for resection of tumor and confirmation of celiac artery anatomy. Variations were confirmed surgically that were identified through imaging.

Results

MDCT angiography identified normal trifurcated celiac artery anatomy in 33 (82.5%) patients and variant anatomy in seven (17.5%) patients. The most common variation was a replaced right hepatic artery (r-RHA) from the superior mesenteric artery (SMA) in four (10%) of patients. A replaced left hepatic artery (r-LHA) from the celiac trunk, a common hepatic artery (CHA) from the abdominal aorta, and an accessory right hepatic artery (ac-RHA) from the proper hepatic artery itself were identified in one (2.5%) patient each, respectively. All these findings were confirmed intraoperatively. There was a 100% statistical correlation between imaging and surgical findings.

Conclusion

Surgical confirmation of radiological data of celiac artery variations is the gold standard to avoid disastrous complications such as inadvertent vascular bleeds, biliary injuries, and hepatic necrosis. Since the presence of variations warrants the preservation or excision of the arterial system without oncological compromise and minimizing surgical complications.

• celiac artery variations
• hepatobiliary pancreatic malignancies
• mdct angiography
• surgery

• Hepatic artery
• Michels' classification
• Pancreatectomy
• Pancreatic cancer
• Variant anatomy

Introduction: Vascular resection remains a subject of debate in the management of Pancreatic Ductal Adenocarcinoma (PDAC). These French recommendations were drafted on behalf of the French National Institute of Cancer (INCA-2019).

Material and Methods: A systematic literature search, with PubMed, Medline® (OvidSP), EMBASE, the Cochrane Library, was performed for abstracts published in English from January 2008 to June 2019, and identified systematic reviews/metaanalyses, retrospective analyses and case series dedicated to vascular resections in the setting of PDAC. All selected articles were graded for level of evidence and strength of recommendation was given according to the GRADE system.

Results: Neoadjuvant treatment should be performed rather than direct surgery in borderline and locally advanced non-metastatic PDAC with venous and/or arterial infiltration (T4 stage). Patients who respond or those with stable disease and good performance status should undergo surgical exploration to assess resectability because cross-sectional imaging often fails to identify the extent of the remaining viable tumor. Combining vascular resection with pancreatectomy in these cases increases the feasibility of curative resection which is still the only option to improve long-term survival. Venous resection (VR) is recommended if resection is possible in the presence of limited lateral or circumferential involvement but without venous occlusion and in the absence of arterial contact with the celiac axis (CA; cephalic tumors) or the superior mesenteric artery (SMA; all tumor locations) (Grade B). The patients should be in good general condition because mortality and morbidity are higher than following pancreatectomy without VR (Grade B). In case of planned VR, neoadjuvant treatment is recommended since it improves both rate of R0 resections and survival compared to upfront surgery (Grade B). Due to their complexity and specificities, arterial resection (AR; mainly the hepatic artery (HA) or the CA) must be discussed in selected patients, in multidisciplinary team meetings in tertiary referral centers, according to the tumor location and the type of arterial extension. In case of invasion of a short segment of the common HA, resection with arterial reconstruction may be proposed after neoadjuvant therapy. In case of SMA invasion, neoadjuvant therapy may be followed by laparotomy with dissection and biopsy of peri-arterial tissues. A pancreaticoduodenectomy (PD) with SMA-resection is not recommended if the frozen section examination is positive (Grade C). In case of distal PDAC with invasion of the CA, a distal pancreatectomy with CA-resection without arterial reconstruction may be proposed after neoadjuvant therapy and radiologic embolization of the CA branches (expert opinion).

Conclusion: For PDAC with vascular involvement, neoadjuvant treatment followed by pancreatectomy with venous resection or even arterial resection can be proposed as a curative option in selected patients with selected vascular involvement.

• French recommendations
• arterial resection
• pancreatic adenocarcinoma
• recommendations (guidelines)
• venous resection

• Pancreatoduodenectomy
• aberrant right hepatic artery
• vascular anomalies

Pancreaticoduodenectomy is the usual surgical option for curative treatment of periampullary cancer and carries a significant mortality. Arterial anomalies of the celiac axis are not uncommon and might lead to iatrogenic lesions or requiring arterial resection/reconstruction in a pancreatoduodenectomy.

Determine the prevalence of arterial variations having implications in pancreatoduodenectomy.

Celiac trunk and hepatic arterial system anatomy was retrospectively evaluated in 200 abdominal enhanced computed tomography studies.

Normal anatomy of hepatic arterial system was found in 87% of cases. An anomalous right hepatic artery was identified in 13% of cases. In 12 cases there was a substitute right hepatic artery arising from superior mesenteric artery and in two cases an accessory right hepatic artery with similar origin. A hepatomesenteric trunk was identified in seven cases and in five there was a right hepatic artery directly from the celiac trunk. All cases of anomalous right hepatic artery had a route was behind the pancreatic head and then, posteriorly and laterally, to the main portal vein before reaching the liver.

Hepatic artery variations, such as anomalous right hepatic artery crossing posterior to the portal vein, are frequently seen (13%). These patients, when undergoing pancreatoduodenectomy, may require a change in the surgical approach to achieve an adequate resection. Preoperative imaging can clearly identify such variations and help to achieve a safer pancreatic head dissection with proper surgical planning.

Anatomical variations of hepatic arteries may be problematic in pancreaticoduodenectomy (PD). We experienced pancreatic head cancer in a patient with rare variation of hepatic artery and performed PD successfully with the resection of this artery. A 75-year-old woman showed pancreatic head tumor on CT. Preoperative CT detected rare variation of hepatic artery; posterior segmental branch of right hepatic artery (RHA-PB) originating from posterior inferior pancreaticoduodenal artery. The image also demonstrated that there was a junction between RHA-PB and anterior branch of right hepatic artery (RHA-AB). We performed PD for suspected pancreatic head cancer. We divided RHA-PB for complete resection of cancer because we preoperatively knew that there was the junction between RHA-PB and RHA-AB. She was discharged uneventfully, and there was no evidence of local recurrence throughout the whole course. Careful preoperative assessment of hepatic blood supply is the key to perform successful PD even in this troublesome situation.

• Pancreatic head cancer
• Pancreaticoduodenectomy
• Preoperative anatomical assessment
• Replaced right hepatic artery

• Hepatic artery
• Ischemia
• Massive hepatic necrosis
• Pancreaticoduodenectomy