Pancreaticoduodenectomy in patients with an unusual course of the hepatic artery

Czech version

Authors: P. Skalický ¹; M. Loveček ¹; J. Tesaříková ²; M. Gregořík ¹; K. Knápková ²; R. Kovář ³; D. Klos ¹
Authors‘ workplace: 1. chirurgická klinika Fakultní nemocnice Olomouc ¹; 1. chirurgická klinika Lékařské fakulty Univerzity Palackého v Olomouci ²; Radiologická klinika Fakultní nemocnice Olomouc ³
Published in: Rozhl. Chir., 2023, roč. 102, č. 3, s. 111-118.
Category: Original articles
doi: https://doi.org/10.33699/PIS.2023.102.3.111–118

Overview

Introduction: Variations in hepatic artery anatomy are very common in the population. The aim of this study is to evaluate the rates of individual types of hepatic artery variants in the population of patients undergoing pancreaticoduodenectomy (PD), assess the accuracy of preoperative staging CT imaging to identify hepatic artery variants, and evaluate the impact of the hepatic artery variants on perioperative and postoperative morbidity of PD patients.

Methods: A prospective observation study of 147 patients undergoing PD for a pancreatic head pathology at the 1st Department of Surgery, University Hospital Olomouc between 1/2015–12/2018. Preoperative diagnosis of the course of the hepatic artery was made based on staging CT imaging analysis of the abdomen. The result was classified according to the Michels’ scale and correlated with the final perioperative finding. Demographic, histopathological and clinicopathological data were included in a prospectively maintained database.

Results: A total of 147 patients were included in the study, 83 (56.5%) males and 64 (43.5%) females, median age 65.0 (37−83) years. A variant course of the hepatic artery was found in 37 (25.2%) patients. The accuracy of preoperative CT imaging in determining the variant was 100%. The presence of a hepatic artery variant was not statistically significant as a factor in terms of postoperative complications – CD I-II (50.0% vs 47.2%), CD III-IV (8.3% vs 13.8%). Similarly, the 30-day (4.2% vs 2.4%) and 90-day mortality rates (4.2% vs 3.3%) were comparable in both groups.

Conclusion: Preoperative diagnosis of vascular variants based on multidetector CT imaging of the abdomen is routinely available and shows high detection accuracy. There was no difference in postoperative morbidity and mortality in patients with and without a variant hepatic artery undergoing PD.

Keywords:

pancreaticoduodenectomy – hepatic artery variant, complications

Sources

1. Skalický P, Tesaříková J, Gregořík M, et al. Middle and distal bile duct carcinoma, retrospective analysis & short-term and long-term outcomes of surgical therapy. [In Czech] Rozhl Chir. 2022 Fall;101(9):436−442. doi: 10.33699/ PIS.2022.101.9.436-442.

2. Skalicky P, Urban O, Ehrmann J, et al. The short- and long-term outcomes of pancreaticoduodenectomy for distal cholangiocarcinoma. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2022 Dec;166(4):386−392. doi: 10.5507/ bp.2021.043. Epub 2021 Aug 10. PMID: 34467956.

3. Tesarikova J, Skalicky P, Kurfurstova D, et al. Surgical treatment of duodenal adenocarcinoma: ampullary vs. non-ampullary, short- and long-term outcomes. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2022 Sep;166(3):290−296. doi: 10.5507/bp.2021.028. Epub 2021 May 11. PMID: 34012147.

4. Balzano G, Zerbi A, Capretti G, et al. Effect of hospital volume on outcome of pancreaticoduodenectomy in Italy. Br J Surg. 2008;95:357–362. doi: 10.1002/bjs.5982.

5. Hartwig W, Hackert T, Hinz U, et al. Pancreatic cancer surgery in the new millennium: better prediction of outcome. Ann Surg. 2011;254:311–319. doi:10.1097/ SLA.0b013e31821fd334.

6. Pecorelli N, Balzano G, Capretti G, et al. Effect of surgeon volume on outcome following pancreaticoduodenectomy in a high-volume hospital. J Gastrointest Surg. 2012 Mar;16(3):518−23. doi: 10.1007/s11605-011-1777-2.

7. Wente MN, Bassi C, Dervenis C, et al. Delayed gastric emptying (DGE) after pancreatic surgery: A suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2007;142:761−768. doi: 10.1016/j. surg.2007.05.005.

8. Wente MN, Veit JA, Bassi C, et al. Postpancreatectomy hemorrhage (PPH): An International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 2007;142:20−25. doi: 10.1016/j. surg.2007.02.001.

9. Bassi C, Marchegiani G, Dervenis C, et al. International Study Group on Pancreatic Surgery (ISGPS). The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery 2017;161:584−591. doi: 10.1016/j. surg.2016.11.014.

10. Loveček M, Skalický P, Köcher M, et al. Krvácení po pankreatektomii (PPH), prevalence, diagnostika a řešení. Rozhl Chir. 2016 Fall;95(9):350−357. PMID: 27653303.

11. National Comprehensive Cancer Network. Clinical practice guidelines in oncology. Pancreatic adenocarcinoma. Version 2.2012 ed 2012. Available at: http:// www.nccn.org/professionals/physician_ gls/f_guidelines.asp.

12. Bockhorn M, Uzunoglu, FG, Adham M, et al. Borderline resectable pancreatic cancer: A consensus statement by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2014;155(6):977−988. doi: 10.1016/j. surg.2014.02.001.

13. Michels NA. Newer anatomy of the liver and its variant blood supply and collateral circulation. Am J Surg. 1966;112:337– 347. doi: 10.1016/0002-9610(66)90201-7.

14. Hiatt JR, Gabbay J, Busuttil RW. Surgical anatomy of the hepatic arteries in 1000 cases. Ann Surg. 1994;220:50–52. doi: 10.1097/00000658-199407000-00008.

15. Shukla PJ, Barreto S, Kulkarni A, et al. Vascular anomalies encountered during duodenopancreatectomy: Do they influence outcomes? Ann Surg Oncol. 2010;17:186−193. doi: 10.1245/s10434- 009-0757-1.

16. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205−213. doi: 10.1097/01. sla.0000133083.54934.ae.

17. Rong GH, Sindelar WF. Abberant peripancreatic arterial anatomy: considerations in performing pancreatectomy for malignant neoplasms. Am Surg. 1987;53:726−729.

18. Balachandran A, Darden DL, Tamm EP, et al. Arterial variants in pancreatic adenocarcinoma. Abdom Imaging 2008;33:214−221. doi: 10.1007/s00261-007-9235-z.

19. Zhang W, Wang K, Liu S, et al. A single- center clinical study of hepatic artery variations in laparoscopic pancreaticoduodenectomy. Medicine 2020;99(21):1−7. doi: 10.1097/MD.0000000000020403.

20. Woods MS, Traverso LW. Sparing a replaced common hepatic artery during pancreaticoduodenectomy. Am Surg. 1993;59:719−721.

21. Furukawa H, Shimada K, Iwata R, et al. A replaced hepatic artery running through the pancreatic parenchyma. Surgery 2000;127:711−712. doi: 10.1067/ msy.2000.104485.

22. Limura A, Oguchi T, Shibata M, et al. An anomalous case of the hepatic artery arising from the superior mesenteric artery. Okajimas Folia Anat Jpn. 2007;84:61−65. doi: 10.2535/ofaj.84.61.

23. Kahraman G, Marur T, Tanyeli E, et al. Hepaticomesenteric trunk. Surg Radiol Anat. 2001;23:433−435. doi: 10.1007/ s00276-001-0433-z.

24. Sulpice L, Rayar M, Paquet C, et al. Does an aberrant right hepatic artery really influence the short- and long-term results of a pancreaticoduodenectomy for malignant disease? A matched case-controlled study. J Surg Res. 2013;185:620−625. doi: 10.1016/j.jss.2013.07.015.

25. Venara A, Pittet O, Lu TL, et al. Aberrant right hepatic artery with a prepancreatic course visualized prior to pancreaticoduodenectomy. J Gastrointest Surg. 2013;17:1024−1026.

26. Stauffer JA, Bridges MD, Turan N, et al. Aberrant right hepatic arterial anatomy and pancreaticoduodenectomy: recognition, prevalence and management. HPB (Oxford) 2009;11:161−165.

27. Turrini O, Wiebke EA, Delpero JR, et al. Preservation of replaced or accessory right hepatic artery during pancreaticoduodenectomy for adenocarcinoma: impact on margin status and survival. J Gastrointest Surg. 2010;14:1813−1819. doi: 10.1007/s11605-010-1272-1.

28. Yang F, Di Y, Li J, et al. Accuracy of routine multidetector computed tomography to identify arterial variants in patients scheduled for pancreaticoduodenectomy. World J Gastroenterol. 2015 January 21; 1(3):969−976. doi: 10.3748/wjg.v21. i3.969.

29. Biehl TR, Traverso LW, Hauptmann E, et al. Preoperative visceral angiography alters intraoperative strategy during the Whipple procedure. Am J Surg. 1993;165:607−612. doi: 10.1016/s0002- 9610(05)80444-1.

30. Traverso LW, Freeny PC. Pancreaticoduodenectomy. The importance of preserving hepatic blood flow to prevent biliary fistula. Am Surg. 1989;55:421−426.

31. Nelson TM, Pollak R, Jonasson O, et al. Anatomic variants of the celiac, superior mesenteric, and inferior mesenteric arteries and their cilinical relevance. Clin Anat. 1988;1:75−91. doi:10.1002/ CA.980010202.

32. Asano T, Nakamura T, Noji T, et al. Outcome of concomitant resection of the replaced right hepatic artery in pancreaticoduodenectomy without reconstruction.Langenbecks Arch Surg. 2018;403(2): 195−202. doi: 10.1007/s00423-018-1650-9.

33. Crocetti D, Sapienza P, Ossola P, et al. Does aberrant right hepatic artery influence the surgical short- and long-term outcome of pancreatoduodenectomy? In Vivo. 2019 Jul-Aug;33(4):1285−1292. doi: 10.21873/invivo.11601.

34. Noussios G, Dimitriou I, Chatzis I, et al. The main anatomic variations of the hepatic artery and their importance in surgical practice: review of the literature. J Clin Med Res. 2017;9(4):248−252. doi: 10.14740/jocmr2902w.

35. Trede M, Schwall G. The complications of pancreatectomy. Ann Surg. 1988;207:39−47. doi: 10.1097/00000658- 198801000-00009.

36. Hu HJ, Jin YW, Zhou RX, et al. Hepatic artery resection for Bismuth type III and IV hilar cholangiocarcinoma: Is reconstruction always required? J Gastrointest Surg. 2018 Jul;22(7):1204−1212. doi: 10.1007/ s11605-018-3711-3.

37. Nanashima A, Imamura N, Tsuchimochi Y, et al. Combined resection of aberrant right hepatic artery without anastomosis in panceaticoduodenectomy for pancreatic head cancer: a case report. Int J Surg Case Rep. 2016;25:66–70. doi: 10.1016/j. ijscr.2016.05.016.

38. Wang L, Xu J, Sun D, et al. Aberrant hepatic arteries running through pancreatic parenchyma encountered during pancreatoduodenectomy: Two rare case reports and strategies for surgical treatment. Medicine 2016;95(49):e386. doi: 10.1016/j.ijscr.2016.05.016.

39. Redman HC, Reuter SR. Arterial collaterals in the liver hilus. Radiology 1970;94(3):575–9.

40. Mays ET, Wheeler CS. Demonstration of collateral arterial flow after interruption of hepatic arteries in man. N Engl J Med. 1974;290(18):993–996. doi: 10.1056/ NEJM197405022901804.

41. Koehler RE, Korobkin M, Lewis F. Arteriographic demonstration of collateral arterial supply to the liver after hepatic artery ligation. Radiology 1975;117(1):49–544. doi:10.1148/117.1.49.

42. Miyazaki M, Ito H, Nakagawa K, et al. Unilateral hepatic artery reconstruction is unnecessary in biliary tract carcinomas involving lobar hepatic artery: implications of interlobar hepatic artery and its preservation. Hepatogastroenterology 2000;47(36):1526–1530.

43. Yamamoto S, Kubota K, Rokkaku K, et al. Disposal of replaced common hepatic artery coursing within the pancreas during pancreatoduodenectomy: report of a case. Surg Today 2005;35(11):984−987. doi: 10.1007/s00595-005-3040-5.

44. Jah A, Jamieson N, Huguet E, et al. The implications of the presence of an aberrant right hepatic artery in patients undergoing a pancreaticoduodenectomy. Surg Today 2009;39(8):669−674. doi: 10.1007/ s00595-009-3947-3.

45. Lovecek M, Skalicky P, Klos D, et al. Long-term survival after resections for pancreatic ductal adenocarcinoma. Single centre study. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2016 Jun;160(2):280−286. doi:10.5507/ bp.2016.011.

46. Rubio-Manzanares-Dorado M, Marín-Gómez LM, Aparicio-Sánchez D, et al. Implication of the presence of a variant hepatic artery during the Whipple procedure. Rev Esp Enferm Dig. 2015 Jul;107(7):417−422. doi: 10.17235/reed. 2015.3701/2015.

47. Kim PT, Temple S, Atenafu E, et al. Aberrant right hepatic artery in pancreaticoduodenectomy for adenocarcinoma: impact on resectability and postoperative outcomes. HPB 2014;16:204−211. doi: 10.1111/hpb.12120.

48. Miyazaki M, Yoshitomi H, Takano S, et al. Combined hepatic arterial resection in pancreatic resections for locally advanced pancreatic cancer. Langenbecks Arch Surg. 2017;402(3):447–456. doi: 10.1007/s00423-017-1578-5.

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Article was published in

Perspectives in Surgery

2023 Issue 3