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Appanraj P, Mathew AP, Kandasamy D, Venugopal M. CT reporting of relevant vascular variations and its implication in pancreatoduodenectomy. Abdom Radiol (NY) 2021; 46:3935-3945. [PMID: 33738555 DOI: 10.1007/s00261-021-02983-3] [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] [Received: 11/05/2020] [Revised: 01/20/2021] [Accepted: 02/09/2021] [Indexed: 01/09/2023]
Abstract
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.
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Swami A, Yadav T, Varshney VK, Sreesanth KS, Dixit SG. Hepatic Arterial Variations and Its Implication During Pancreatic Cancer Surgeries. J Gastrointest Cancer 2021; 52:462-470. [PMID: 33616844 DOI: 10.1007/s12029-021-00598-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2021] [Indexed: 01/28/2023]
Abstract
PURPOSE Aberrant hepatic artery anatomy is a considerable challenge during pancreatic surgery as it warrants extreme caution for the preservation of vascular supply as well as achievement of R0 resection margin. METHOD We reviewed the literature about the aberrant anatomical variations of the hepatic artery and its relevance during pancreatoduodenectomy and distal pancreatectomy. RESULT Preoperative deliberation of peri-pancreatic vascular anatomy using advanced imaging methods is crucial for surgeons. At the same time, intra-operative suspicion and early identification of aberrant anatomy may help to prevent vascular injury and related complications. Yet, vascular reconstruction may be needed in many situations; several techniques like pre-operative embolization provide new options for management in specific situations. CONCLUSION We have provided here an overview of the anatomical variants of the hepatic artery and their implication during pancreatoduodenectomy and distal pancreatectomy.
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Affiliation(s)
- Ashish Swami
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Taruna Yadav
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Vaibhav Kumar Varshney
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India.
| | - Kelu S Sreesanth
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Shilpi Gupta Dixit
- Department of Anatomy, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Virtual reality with three-dimensional image guidance of individual patients' vessel anatomy in laparoscopic distal pancreatectomy. Langenbecks Arch Surg 2020; 405:381-389. [PMID: 32410077 DOI: 10.1007/s00423-020-01871-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 03/24/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Three-dimensional virtual endoscopy (3DVE) has the potential advantage of enhanced anatomic delineation and spatial orientation during laparoscopic procedures. In the present study, we aimed to evaluate the impact of 3DVE guidance in laparoscopic distal pancreatectomy (LDP). METHODS Thirty-eight patients presenting to our hospital with a variety of pancreatic tumors underwent preoperative computed tomography scanning to clearly define the major peripancreatic vasculature and correlate it with a 3DVE system (SYNAPSE VINCENT: Fujifilm Medical, Tokyo, Japan). This map served as the guide during preoperative planning, surgical education, and simulation and as intraoperative navigation reference for LDP. Operative records and pathological findings were analyzed for each procedure. Operative parameters were compared between the 38 patients in this study and 8 patients performed without 3DVE guidance at our institution. RESULTS The 3DVE navigation system successfully created a preoperative resection map in all patients. Relevant peripancreatic vasculature displayed on the system was identified and compared during the intervention. The mean blood loss in LDP performed under 3DVE guidance versus LDP without 3DVE was 168.5 +/- 347.6 g versus 330.0 +/- 211.4 g, p = 0.008 while and the operative time was 171.9 +/- 51.7 min versus 240.6 +/- 24.8 min, p = 0.001. CONCLUSIONS 3DVE in conjunction with a "laparoscopic eye" creates a preoperative and intraoperative three-dimensional data platform that potentially enhances the accuracy and safety of LDP.
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Whitley A, Oliverius M, Kocián P, Havlůj L, Gürlich R, Kachlík D. Variations of the celiac trunk investigated by multidetector computed tomography: Systematic review and meta-analysis with clinical correlations. Clin Anat 2020; 33:1249-1262. [PMID: 32012339 DOI: 10.1002/ca.23576] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 01/16/2020] [Accepted: 01/25/2020] [Indexed: 12/14/2022]
Abstract
In recent years multidetector computed tomography (MDCT) has been used to investigate vascular anatomy for scientific and diagnostic purposes. These studies allow for much larger sample sizes than traditional cadaveric studies. The aim of this research was to perform a systematic review and meta-analysis on studies investigating the variations of the celiac trunk using MDCT. Major medical databases were used to find studies investigating celiac trunk anatomy using MDCT. Extracted information included demographic details, number of normal celiac trunks, and number of each variant celiac trunk. Using a random effects meta-analysis the pooled prevalence of each variation was calculated. A total of 36 studies from 14 countries and four continents were included in the meta-analysis. The total number of subjects included was 17,391. The total prevalence of variant celiac trunks was 10.85%. The different types of celiac trunk variations with their prevalences were: gastrosplenic trunk (3.46%), hepatosplenic trunk (3.88%), hepatogastric trunk (0.24%), absent celiac trunk (0.28%), celiacomesenteric trunk (0.46%), hepatosplenomesenteric trunk (0.26%), gastrosplenomesenteric trunk (0.07%), and celiacomesenteric anastomosis (0.09%). A total of 61 cases (0.19%) were either not described or not described adequately to be included in our classification. Major variations of the celiac trunk are not uncommon and should be anticipated before radiological and surgical interventions. Knowledge of celiac trunk anatomy is important in hepatopancreatobiliary surgery, transplantology, and interventional radiology.
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Affiliation(s)
- Adam Whitley
- Department of Surgery, University Hospital Kralovske Vinohrady, Third Faculty of Medicine, Charles University, Prague, Czech Republic.,Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Martin Oliverius
- Department of Surgery, University Hospital Kralovske Vinohrady, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Petr Kocián
- Department of Surgery, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Lukáš Havlůj
- Department of Surgery, University Hospital Kralovske Vinohrady, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Robert Gürlich
- Department of Surgery, University Hospital Kralovske Vinohrady, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - David Kachlík
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic
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Miyata T, Yamamoto Y, Sugiura T, Okamura Y, Ito T, Ashida R, Uemura S, Kato Y, Ohgi K, Kohga A, Uchida T, Sano S, Uesaka K. Combined resection of the transpancreatic common hepatic artery preserving the gastric arterial arcade without arterial reconstruction in hepatopancreatoduodenectomy: a case report. Surg Case Rep 2018; 4:64. [PMID: 29943197 PMCID: PMC6020092 DOI: 10.1186/s40792-018-0474-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 06/19/2018] [Indexed: 11/16/2022] Open
Abstract
Background Surgeons sometimes must plan pancreatoduodenectomy (PD) for patients with a variant common hepatic artery (CHA) branching from the superior mesenteric artery (SMA) penetrating the pancreatic parenchyma, known as a transpancreatic CHA (tp-CHA). Case presentation A 67-year-old man was admitted to our hospital because of liver dysfunction. A duodenal tumor was identified by gastrointestinal endoscopy, and a biopsy revealed a neuroendocrine tumor. Computed tomography showed multiple metastases in the left three sections of the liver. As an anatomical variant, the CHA branched from the SMA and passed through the parenchyma of the pancreatic head, and all hepatic arteries branched from the CHA. Furthermore, the arcade between the left and right gastric artery (RGA) was detected, and the RGA branched from the root of the left hepatic artery. PD and left trisectionectomy of the liver were performed. The tp-CHA was resected with the pancreatic head, and the gastric arterial arcade was preserved to maintain the right posterior hepatic arterial flow. Postoperatively, there were no signs of hepatic ischemia. Conclusions When planning PD, including hepatopancreatoduodenectomy, for patients with a tp-CHA, surgeons should simulate various situations for maintaining the hepatic arterial flow. The preservation of the gastric arterial arcade is an option for maintaining the hepatic arterial flow to avoid arterial reconstruction. Electronic supplementary material The online version of this article (10.1186/s40792-018-0474-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Takashi Miyata
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 4118777, Japan
| | - Yusuke Yamamoto
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 4118777, Japan.
| | - Teiichi Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 4118777, Japan
| | - Yukiyasu Okamura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 4118777, Japan
| | - Takaaki Ito
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 4118777, Japan
| | - Ryo Ashida
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 4118777, Japan
| | - Sunao Uemura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 4118777, Japan
| | - Yoshiyasu Kato
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 4118777, Japan
| | - Katsuhisa Ohgi
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 4118777, Japan
| | - Atsushi Kohga
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 4118777, Japan
| | - Tsuneyuki Uchida
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 4118777, Japan
| | - Shusei Sano
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 4118777, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 4118777, Japan
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Zaky AM, Wolfgang CL, Weiss MJ, Javed AA, Fishman EK, Zaheer A. Tumor-Vessel Relationships in Pancreatic Ductal Adenocarcinoma at Multidetector CT: Different Classification Systems and Their Influence on Treatment Planning. Radiographics 2017; 37:93-112. [DOI: 10.1148/rg.2017160054] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Replaced common hepatic artery from the superior mesenteric artery: multidetector computed tomography (MDCT) classification focused on pancreatic penetration and the course of travel. Surg Radiol Anat 2016; 38:655-62. [DOI: 10.1007/s00276-016-1618-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 01/02/2016] [Indexed: 12/18/2022]
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Darnis B, Mohkam K, Rode A, Ducerf C, Mabrut JY. Preservation of an intra-pancreatic hepatic artery during pancreato-duodenectomy. J Visc Surg 2015; 152:271-3. [PMID: 26194360 DOI: 10.1016/j.jviscsurg.2015.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- B Darnis
- Service de chirurgie générale et digestive, transplantation hépatique et intestinale, hôpital de la Croix-Rousse, 103, Grande Rue de la Croix-Rousse, 69004 Lyon, France; EMR 37-38, université Claude-Bernard Lyon 1, 69000 Lyon, France.
| | - K Mohkam
- Service de chirurgie générale et digestive, transplantation hépatique et intestinale, hôpital de la Croix-Rousse, 103, Grande Rue de la Croix-Rousse, 69004 Lyon, France; EMR 37-38, université Claude-Bernard Lyon 1, 69000 Lyon, France
| | - A Rode
- Service de radiologie, hôpital de la Croix-Rousse, 103, Grande Rue de la Croix-Rousse, 69004 Lyon, France
| | - C Ducerf
- Service de chirurgie générale et digestive, transplantation hépatique et intestinale, hôpital de la Croix-Rousse, 103, Grande Rue de la Croix-Rousse, 69004 Lyon, France
| | - J-Y Mabrut
- Service de chirurgie générale et digestive, transplantation hépatique et intestinale, hôpital de la Croix-Rousse, 103, Grande Rue de la Croix-Rousse, 69004 Lyon, France; EMR 37-38, université Claude-Bernard Lyon 1, 69000 Lyon, France
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Rammohan A, Palaniappan R, Pitchaimuthu A, Rajendran K, Perumal SK, Balaraman K, Ramasamy R, Sathyanesan J, Govindan M. Implications of the presence of an aberrant right hepatic artery in patients undergoing pancreaticoduodenectomy. World J Gastrointest Surg 2014; 6:9-13. [PMID: 24627736 PMCID: PMC3951809 DOI: 10.4240/wjgs.v6.i1.9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 12/07/2013] [Accepted: 12/19/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze the differences in outcomes and the clinical impact following pancreatoduodenectomy (PD) in patients with and without aberrant right hepatic artery (aRHA).
METHODS: All patients undergoing PD between January 2008 and December 2012 were divided into two groups, one with aRHA and the other without. These groups were compared to identify differences in the intraoperative variables, the oncological clearance and the postoperative morbidity, mortality and hospital stay.
RESULTS: A total of 225 patients underwent PD, of which 43 (19.1%) patients were found to have either accessory or replaced right hepatic arteries (aRHA group). The aRHA was preserved in 79% of the patients. There was no significant difference in the intraoperative blood loss but operative time was prolonged, reflecting the complexity of the procedure [420 ± 44 (240-540) min vs 480 ± 45 (300-600) min, P < 0.05)]. There were no differences in the incidence of postoperative complications (pancreatic leak, pancreatic fistula, delayed gastric emptying and mortality) and hospital stay. Oncological clearance in the form of positive resection margins [13 (7.1%) vs 3 (6.9%)] and lymph node yield were also similar in the two groups.
CONCLUSION: An aRHA is found in approximately one fifth of patients undergoing PD. Preservation is technically possible in most patients and can increase the operative complexity but does not negatively affect the safety or oncological outcomes of the procedure.
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Lee HY, Ha HI, Kim MJ, Lim HK. Compression of the main pancreatic duct by the intrapancreatic-replaced common hepatic artery. Korean J Radiol 2013; 14:412-5. [PMID: 23690706 PMCID: PMC3655293 DOI: 10.3348/kjr.2013.14.3.412] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 02/08/2013] [Indexed: 11/23/2022] Open
Abstract
We describe a unique case of a patient who presented with a linear, transverse, and incidentally-detected main pancreatic duct dilatation that was caused by the intrapancreatic-replaced common hepatic artery, detected on the MDCT, MRCP and endoscopic retrograde cholangiopancreatography. We believe this case to be the first of its kind reported in the literature.
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Affiliation(s)
- Ha-yeon Lee
- Department of Radiology, Hallym University Medical Center, Hallym University Sacred Heart Hospital, Anyang 431-070, Korea
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Padín JM, Ramisch DA, Maraschio M, Samamé J, Farinelli PA, Pfaffen G, Barros Schelotto P, Gondolesi GE. Intrapancreatic common hepatic artery arising from the superior mesenteric artery, a challenging anatomic variation in a multiorgan harvesting. Transplant Proc 2013; 45:820-3. [PMID: 23498827 DOI: 10.1016/j.transproceed.2012.06.083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2012] [Accepted: 06/19/2012] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Understanding abdominal vascular anatomy is crucial for multiorgan recovery. In this case report, we have described a common hepatic artery that arises from the superior mesenteric artery but follows an intrapancreatic course. METHODS The donor was ideal for multiorgan recovery and the recipient was a 29-year-old woman awaiting a second transplant owing to primary nonfunction of her first engrafted organ. The indication for transplantation was secondary biliary cirrhosis. A type I diabetic recipient on dialysis therapy was awaiting the kidney and pancreas. RESULTS The urgent condition of our liver recipient combined with the anatomical finding prioritized liver procurement, therefore the pancreas was discarded. CONCLUSIONS The recognition of all anatomic variations will allow us to improve the use of the scarce resource of deceased donor organs.
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Affiliation(s)
- J M Padín
- Multi-Organ Transplant Institute, University Hospital, Favaloro Foundation, Ciudad Autónoma de Buenos Aires, Argentina.
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Rare hepatic arterial anatomic variants in patients requiring pancreatoduodenectomy and review of the literature. Case Rep Surg 2012; 2012:953195. [PMID: 22900221 PMCID: PMC3413978 DOI: 10.1155/2012/953195] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Accepted: 06/21/2012] [Indexed: 12/17/2022] Open
Abstract
Normal hepatic arterial anatomy occurs in approximately 50–80% of cases; for the remaining cases, multiple variations have been described. Knowledge of these anomalies is especially important in hepatobiliary and pancreatic surgery in order to avoid unnecessary complications. We describe two cases of patients undergoing pancreatoduodenectomy for abnormalities in the head of the pancreas. Preoperative contrast-enhanced cross-sectional imaging demonstrated relevant, rare hepatic arterial variants: (1) a completely replaced hepatic arterial system with a gastroduodenal artery (GDA) arising directly from the celiac axis and (2) a replaced right hepatic artery originating from the superior mesenteric artery and traveling anterior to the pancreatic uncinate process and head. These findings were confirmed during pancreatoduodenectomy. Both of these variants have been rarely described with an incidence of <1.0%. In the present paper, we describe the hepatic arterial anomalies commonly encountered and clarify the important details associated with these variants as they pertain to pancreatoduodenectomy.
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Li J, He Z, Si Z, Hu W, Li Y, Qi H. Gastroduodenal Arterial Reconstruction of the Pancreaticoduodenal Allograft. Transplant Proc 2011; 43:3905-7. [DOI: 10.1016/j.transproceed.2011.10.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Accepted: 10/12/2011] [Indexed: 12/22/2022]
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Shukla PJ, Barreto SG, Kulkarni A, Nagarajan G, Fingerhut A. Vascular anomalies encountered during pancreatoduodenectomy: do they influence outcomes? Ann Surg Oncol 2009; 17:186-93. [PMID: 19838756 DOI: 10.1245/s10434-009-0757-1] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2009] [Indexed: 12/14/2022]
Abstract
BACKGROUND Because of the potential risk of hemorrhage or ischemia, the presence of vascular anomalies adds to the surgical challenge in pancreatoduodenectomy (PD). OBJECTIVE To analyze the literature concerning the influence of aberrant peripancreatic arterial anatomy on outcomes of PD. MATERIALS AND METHODS A systematic search using Medline and Embase for the years 1950-2008. RESULTS The most common aberration in hepatic arterial anatomy is the replaced right hepatic artery. Other vascular abnormalities such as replaced common hepatic artery with a hepatomesenteric trunk and celiomesenteric trunk and arcuate ligament syndrome leading to celiac artery stenosis are also associated with post-PD complications. Damage to the biliary branches of the hepatic arteries increases the risk of postoperative biliary anastomotic leak. CONCLUSION The most common abnormalities of the hepatic vasculature include a replaced RHA, replaced LHA, and accessory RHA or LHA. Celiac artery stenosis secondary to median arcuate ligament compression may also be encountered. Every attempt should be made to preserve the aberrant vessel unless their resection is oncologically indicated. Routine preoperative computerized tomography angiography helps to identify the hepatic vascular anatomy and thereby prepares the surgeon to better deal with the vascular anomalies intraoperatively. Increased awareness of the vascular anatomy would decrease the chances of intraoperative vascular injury and consequent postoperative complications such as biliary anastomotic leaks as well as the chances of postoperative hemorrhage.
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Affiliation(s)
- Parul J Shukla
- Department of Gastrointestinal Surgical Oncology, Tata Memorial Hospital, Mumbai, India.
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Jah A, Jamieson N, Huguet E, Praseedom R. The implications of the presence of an aberrant right hepatic artery in patients undergoing a pancreaticoduodenectomy. Surg Today 2009; 39:669-74. [PMID: 19639433 DOI: 10.1007/s00595-009-3947-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Accepted: 01/07/2009] [Indexed: 12/17/2022]
Abstract
PURPOSE An aberrant right hepatic artery (ARHA) is a common anomaly and its implications for patients undergoing a pancreaticoduodenectomy (PD) have not yet been previously reported. We compared the outcomes following PD in patients with and without an ARHA. A novel classification of the anatomical course of ARHA, and surgical techniques for its identification and preservation are described herein. METHODS All patients undergoing PD between June 1, 2002, and May 31, 2007, were divided into two groups, one with ARHA and the other without. These groups were compared to identify differences in the intraoperative variables, the oncological clearance, the postoperative complications, and the survival. RESULTS A total of 135 patients underwent PD of which 28 (20.8%) patients were found to have either accessory or replaced right hepatic arteries (ARHA group). There were no significant differences in the intraoperative variables (blood loss and operative time) and the incidence of postoperative complications (pancreatic leak and delayed gastric emptying). Oncological clearance (nodal yield and resection margins) and survival were also similar in the two groups. CONCLUSIONS The surgical and oncological outcomes of PD remain unaffected by the presence of ARHA provided that the anatomy is recognized and appropriately managed. Aberrant right hepatic artery can be classified into three types according to their anatomical relationship with the head of the pancreas.
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Affiliation(s)
- Asif Jah
- Department of Hepatobiliary and Transplant Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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16
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Stauffer JA, Bridges MD, Turan N, Nguyen JH, Martin JK. Aberrant right hepatic arterial anatomy and pancreaticoduodenectomy: recognition, prevalence and management. HPB (Oxford) 2009; 11:161-5. [PMID: 19590642 PMCID: PMC2697872 DOI: 10.1111/j.1477-2574.2009.00037.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2008] [Accepted: 01/17/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND Aberrant arterial anatomy is a common finding during foregut surgery. Anomalies to the right hepatic lobe are especially relevant during pancreaticoduodenectomy (PD) and their recognition serves to protect the blood supply to the liver and bile ducts. We report our experience with aberrant right hepatic arterial anatomy (ARHAA) found during PD. METHODS All patients who underwent PD between February 2003 and June 2007 were retrospectively reviewed and those with ARHAA were identified. Preoperative imaging studies were assessed by one radiologist, graded according to the presence of ARHAA and compared with the original interpretations. RESULTS We found ARHAA in 31 of 191 patients (16.2%). Operative management included dissection and preservation in 24, transection and reconstruction in four, and transection and primary anastomosis in three patients. Reconstruction of ARHAA was carried out through interposition grafts in two patients and implantation into the gastroduodenal stump in two patients. No cases of arterial thrombosis, liver infarction, abscess formation or biliary fistula were demonstrated in the immediate postoperative period. Review of preoperative imaging interpretations found that only nine of 23 reports indicated the presence of ARHAA; however, the retrospective review of the images found that ARHAA was readily apparent in 24 patients. DISCUSSION Recognition of aberrant vasculature to the liver before PD is important. Preoperative imaging studies will often be adequate to identify these anomalies, but interpreting radiologists may not be aware of its clinical significance. Surgeons performing PD must be adept at managing ARHAA safely.
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Affiliation(s)
- John A Stauffer
- Section of General Surgery, Mayo ClinicJacksonville, FL, USA
| | | | - Naciye Turan
- Section of General Surgery, Mayo ClinicJacksonville, FL, USA
| | - Justin H Nguyen
- Division of Transplant Surgery, Mayo ClinicJacksonville, FL, USA
| | - J Kirk Martin
- Section of General Surgery, Mayo ClinicJacksonville, FL, USA
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Yang SH, Yin YH, Jang JY, Lee SE, Chung JW, Suh KS, Lee KU, Kim SW. Assessment of hepatic arterial anatomy in keeping with preservation of the vasculature while performing pancreatoduodenectomy: an opinion. World J Surg 2008; 31:2384-91. [PMID: 17922256 DOI: 10.1007/s00268-007-9246-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pancreatic surgeons often must make decisions regarding hepatic artery (HA) resection while performing a pancreatoduodenectomy (PD). The purpose of this report was to review and summarize HA resection experience with a focus on vascular preservation during PD and to develop a useful guideline for pancreatic surgeons in dealing with these needs. METHODS We reviewed 1324 cases that had available computed tomographic and angiographic findings and summarized the problematic HA variations encountered in PD. In reviewing our PD series (n = 254), we have created a set of guidelines that enable a pragmatic approach to the unique variations in HA and the risks of cancer invasion. RESULTS Challenging HA variations during PD were found in 20.1% of the cases and included the common HA arising from the superior mesenteric artery (SMA) (2.34%), a replaced right HA (RHA) from the SMA (9.82%), an RHA or left HA from the gastroduodenal artery (0.97%), and the right anterior or right posterior HA from the SMA (1.06%), among others. In our PD series, the problematic HAs (15.8%) were preserved, except for a single case (0.4%) in which PD involved en bloc resection of the RHA from the SMA due to a cancerous invasion and without right hemihepatectomy. CONCLUSIONS Surgeons should have knowledge of the anatomically variable vasculature of the HA when planning for PD. Preoperative imaging studies can aid and should be performed in anticipation of the potential HA variations during PD.
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Affiliation(s)
- Sung Hoon Yang
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Hospital, Chongno-Gu, Seoul, Korea.
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Yamamoto S, Kubota K, Rokkaku K, Nemoto T, Sakuma A. Disposal of replaced common hepatic artery coursing within the pancreas during pancreatoduodenectomy: report of a case. Surg Today 2006; 35:984-7. [PMID: 16249858 DOI: 10.1007/s00595-005-3040-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2003] [Accepted: 01/18/2005] [Indexed: 01/19/2023]
Abstract
A replaced common hepatic artery (RCHA) originating from the superior mesenteric artery (SMA) is a rare anomaly. We herein report such a case in a 62-year-old man who was scheduled to undergo a pancreatoduodenectomy for lower bile duct cancer. Computed tomography (CT) showed the RCHA to run along the ventral side of the pancreas. Abdominal angiography showed an RCHA originating from the SMA, which communicated with an aberrant left hepatic artery from the left gastric artery. No gastroduodenal artery was observed, but instead a direct ramification of a right gastroepiploic artery was seen. Similar cases from the English literature were reviewed. The RCHA was confirmed to course first along the ventral side of, and then within, the pancreas. Clamping of the RCHA did not influence the arterial flow in the liver, and the RCHA was subsequently divided without reconstruction. In three of the five reviewed cases in which the RCHA coursed either within or along the ventral side of the pancreas, no gastroduodenal artery was found, but instead a direct ramification of a right gastroepiploic artery was observed. A combination of CT and angiographic findings can help in both the diagnosis of an anomalous RCHA coursing either within or along the ventral side of the pancreas as well as in selecting optimal operative procedures. Pancreatoduodenectomy was performed with a curative resection according to our usual practice except for the fact that we preserved the aberrant left hepatic artery.
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Affiliation(s)
- Satoshi Yamamoto
- Department of Gastroenterological Surgery, Dokkyo University School of Medicine, Mibu, Tochigi, Japan
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Ibukuro K. Vascular anatomy of the pancreas and clinical applications. INTERNATIONAL JOURNAL OF GASTROINTESTINAL CANCER 2003; 30:87-104. [PMID: 12489583 DOI: 10.1385/ijgc:30:1-2:087] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The development of recent technology, especially the helical computed tomography (CT) scan, allows us to observe small peripancreatic vessels which previously could be demonstrated only by angiography (1), and therefore make three-dimensional (3-D) volume rendered CT angiographic reconstruction possible (2). The neighboring structures as well as the pancreatic vessels are clearly visualized on the axial CT scan. Therefore, it is necessary to define the peripancreatic vessels on the axial images, as well as on angiography to make an accurate diagnosis of pancreatic disease so that we can also estimate the dynamic flow of the peripancreatic vessels. In this chapter, I would like to use the cadaver dissections of pancreatic vessels to explain each pancreatic vessel based on previous anatomic and radiologic references and finally demonstrate the clinical cases in terms of the pancreatic vessels. The pancreatic arteries and veins are explained based on the anatomic and radiologic references. Principal pancreatic vessels are demonstrated on cadaver dissection. The pancreas head is supplied by the anterior and posterior pancreaticoduodenal arteries forming arcades in the pancreaticoduodenal sulcus and is drained by the pancreaticoduodenal veins. The pancreas body and tail are supplied by the dorsal, inferior, and caudate pancreatic arteries, and are drained by the inferior and left pancreatic veins. Clinical applications in terms of the pancreatic vessels such as basis for interpretation of the angiography and the CT scan, treatment of pancreatitis and pancreatic cancer, detection of small insulinoma are stated.
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Affiliation(s)
- K Ibukuro
- Department of Radiology, Mitsui Memorial Hospital, Tokyo 101-8643, Japan.
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