Replaced gastroduodenal artery: Added benefit of the "artery first" approach during pancreaticoduodenectomy-A case report

How to deal with right hepatic artery coming from the superior mesenteric artery during minimally invasive pancreaticoduodenectomy: A systematic review

BACKGROUND

Anatomical variations in the liver arterial supply are quite common and can affect the surgical strategy when performing a minimally invasive pancreaticoduodenectomy (MIPD). Their presence must be preemptively detected to avoid postoperative liver and biliary complications.

DATA SOURCES

Following the PRISMA guidelines and the Cochrane protocol we conducted a systematic review on the management of an accessory or replaced right hepatic artery (RHA) arising from the superior mesenteric artery when performing an MIPD.

RESULTS

Five studies involving 118 patients were included. The most common reported management of the aberrant RHA was conservative (97.0%); however, patients undergoing aberrant RHA division without reconstruction did not develop liver or biliary complications. No differences in postoperative morbidity or long-term oncological related overall survival were reported in all the included studies when comparing MIPD in patients with standard anatomy to those with aberrant RHA.

CONCLUSIONS

MIPD in patients with aberrant RHA is feasible without increase in morbidity and mortality. As preoperative strategy is crucial, we suggested planning an MIPD with an anomalous RHA focusing on preoperative vascular aberrancy assessment and different strategies to reduce the risk of liver ischemia.

Pancreaticoduodenectomy preserving aberrant gastroduodenal artery utilized in a previous coronary artery bypass grafting: A case report and review of literature

RATIONALE

Pancreaticoduodenectomy (PD) is a technically demanding procedure with high rates of morbidity and mortality. Therefore, preoperative evaluation of anatomy is indispensable. Multi-detector row computed tomography (CT) enables us to precisely understand arterial anatomy. It is a well-known fact that anatomical variants are often present in the hepatic artery (HA) but rarely in the gastroduodenal artery (GDA). We present the case of a patient with ampullary cancer with a rare anatomical anomaly, "replaced GDA (rGDA) " arising from the superior mesenteric artery, along with a history of coronary artery bypass grafting (CABG) using right gastroepiploic artery (RGEA).

PATIENT CONCERNS

A 69-year-old male patient was referred to our department for further investigation of elevated hepatobiliary enzymes. He presented with no symptoms besides intermittent fever of 38°C. He had an operative history of CABG using the RGEA.

DIAGNOSIS

Abdominal CT and esophagogastroduodenoscopy showed an ampullary tumor and biopsy specimen from the lesion revealed adenocarcinoma. CT angiography revealed the rGDA instead of a normal common HA.

INTERVENTION

We performed a safe PD, preserving the rGDA and the RGEA to maintain hepatic and cardiac perfusion.

OUTCOMES

Owing to the presence of a refractory pancreatic fistula, the length-of-hospital stay was extended, and he was discharged on postoperative day 72 without vascular complications. At present, the patient is in good physical condition and does not present with cardiovascular complications as well as tumor recurrence at 6 months after surgery.

LESSONS

This is possibly the first case of a patient who underwent PD and has a proper HA following a GDA arising from a superior mesenteric artery (rGDA) and has a previous operative history of CABG using the gastroepiploic artery. The coexistence of the history of cardiovascular surgery made PD for this patient considerably more challenging.In the case of a rare anatomical anomaly, a coronary artery bypass via the RGEA should not be considered as an obstacle when R0 resection is achievable.

CT reporting of relevant vascular variations and its implication in pancreatoduodenectomy

Pancreatoduodenectomy (PD) also known as Whipple procedure is done for malignant lesions involving the distal CBD, duodenum, ampulla and pancreatic head. In the absence of peritoneal and distant metastases, resectability of the lesion is mainly determined by the relationship of the lesion with the vascular structures in the vicinity. Vascular variations of the celiac artery branches are common and PD, a complex surgical procedure, becomes more challenging if the vascular variations are present. In borderline resectable lesions advances in neoadjuvant therapies and refined surgical techniques are pushing the boundaries of resection. Extended PD is done in borderline resectable lesions when resection and reconstruction of portal vein involved by the primary mass and dissection of extended lymph nodal stations are intended. In this era where more borderline cases are undergoing surgery, it is essential for the radiologist to understand the procedure and the implications of variations in vascular anatomy. Though there are many radiology literatures available on the diagnostic and resectability criteria related to normal vessel anatomy there are very few on the importance of the variant arterial anatomy. The purpose of this review is to familiarize the readers with these variant vessels which can help the surgeons in their intraoperative identification and consequently improve surgical outcomes.

Gastroduodenal artery: single key for many locks

Gastroduodenal artery (GDA) commonly arises from common hepatic artery, a branch of celiac axis. It holds a unique anatomical position that connects the foregut and midgut due to its intimate communications with foregut and midgut arterial supply. Its numerous anatomical variations have a significant impact on planning and performance of hepatopancreaticobiliary (HPB) surgery. Its close relation to the first part of duodenum, common bile duct and head of pancreas makes it susceptible for inadvertent bleeding during or after surgery, or due to various HPB pathologies. Also, a large number of vascular interventions rely on GDA and its branches. Careful preoperative planning is the key and a detailed knowledge and awareness of its variant anatomy is of paramount importance, be it liver resections, liver transplant, biliary and pancreatic resections and pancreatic transplant or transarterial procedures involving these arteries. GDA can also be a cause of gastrointestinal hemorrhage due to true or pseudoaneurysms and anatomy has significant implications on its management. The article provides a succinct review on relevance of GDA anatomy and variations and highlights that preoperative planning and intraoperative awareness of variations is the key to performance of safe HPB surgery and interventions.

Replaced gastroduodenal artery with continuation as accessory left hepatic artery: a rare anatomical variant

Background

Presented here is a rare case of a gastroduodenal artery (GDA) replaced to the superior mesenteric artery with continuation into an accessory left hepatic artery. To the authors’ knowledge, this rare anomaly is not described previously. Replaced GDA is reported, however without continuation into an accessory LHA.

Case presentation

A 74-year-old male with recurrent peptic ulcer disease presented with acute onset melena. This anomaly was discovered during abdominal angiography performed for treatment of a hemorrhagic duodenal ulcer. Initial celiac and common hepatic artery (CHA) subselection and angiography demonstrated no branch vessels. Angiography via the superior mesenteric artery demonstrated free extravasation into the duodenum and distal perfusion of the left hepatic lobe.

Conclusions

This is a rare variant of hepatic arterial anatomy. Importantly, this variant challenges a previously described anatomical model that attempts to explain observed CHA variation.