Advanced gastric cancer with a duplicated hepatic artery: preoperative diagnostic value of multidetector-row computed tomography for surgical resection

Abstract

In patients with T4 gastric cancer, curative surgery can be achieved with concomitant resection of the invaded organs. However, curative resection is not necessarily possible in all cases. In patients with advanced gastric cancer with infi ltration of the pancreatic head and common hepatic artery (CHA), curative surgery is usually impossible, because pancreaticoduodenectomy (PD) with CHA resection leads to an abrupt reduction in the arterial blood supply to the liver and results in severe liver damage. We experienced a case of advanced gastric cancer that infi ltrated these organs, i.e., the pancreatic head and CHA. We were able to perform curative surgery in this patient because preoperative multidetector-row computed tomography (MDCT) revealed the presence of a duplicated hepatic artery. Here, we present a very rare case of advanced gastric cancer in a patient with a duplicated hepatic artery, and we note the value of MDCT for preoperative diagnosis. Case reportA 63-year-old Japanese woman presented to her family physician with appetite loss and general fatigue in June 2003. Gastrointestinal fi berscopy and upper gastrointestinal (GI) series revealed type 2 advanced gastric cancer in the antrum, with pyloric stenosis and duodenal invasion (Fig. 1). The patient was referred to the Cancer Institute Hospital for further examination. Laboratory examination revealed severe anemia (hemoglobin, 8.0 g/ dl) and poor nutritional condition (albumin, 3.3 g/dl). Abdominal MDCT revealed massive gastric cancer directly invading the left hepatic lobe and pancreatic head as well as vascular anomaly. Metastasized lymph nodes also invaded the CHA directly (Fig. 2). Although paraaortic lymph nodes were identifi ed, CT did not reveal any distant metastasis. In general, PD with CHA resection is considered to be impossible, because it Abstract A 63-year-old woman with appetite loss and general fatigue underwent gastrointestinal fi berscopy, which revealed type 2 advanced gastric cancer. Multidetector-row computed tomography revealed a massive gastric cancer invading the left hepatic lobe, pancreatic head, and common hepatic artery, as well as revealing a duplicated hepatic artery in which the right hepatic artery branched directly from the celiac axis, and ran behind the splenic vein. On the other hand, the common hepatic artery ran anterior to the splenic vein. We were able to perform pancreaticoduodenectomy with common hepatic artery resection and left lobectomy as curative surgery because her duplicated hepatic artery enabled us to ligate the common hepatic artery. Her postoperative clinical course was uneventful, and she is in good health 3 years after the surgery, without recurrence. We consider that multidetector-row computed tomography is very useful for the diagnosis of vascular anomaly, preoperative staging and decision making on the appropriate surgical strategy.