Clinical Implications of an Aberrant Right Hepatic Artery in Patients Undergoing Pancreaticoduodenectomy

Abstract

Background Sometimes, it seems to be difficult to preserve the aberrant hepatic artery (HA) during pancreaticoduodenectomy (PD), with respect to en bloc lymph node dissection, especially in the case of aberrant right hepatic artery (RHA). Therefore, we evaluated the influence of incomplete en bloc lymph node (LN) dissection when aberrant RHA arises. Methods We reviewed 103 patients with mid-to-distal common bile duct (CBD) cancers who underwent PD by one surgeon at Asan Medical Center from December 1994 to November 2005 (73 men, 30 women; mean age, 61.1 ± 9.4 (range: 40-84) years). The mean follow-up period was 32.7 months. We compared the normal RHA group with the aberrant RHA group. Results Eighty-eight cases showed normal RHA anatomy, including nine cases (8.7%) of aberrant left hepatic artery (LHA) with normal RHA cases (normal HA group). RHA anomalies were observed in 15 cases (14.6%, aberrant HA group). In all cases, there was no direct invasion of cancer to aberrant HA. Among two groups, 43 cases (41.7%) showed recurrence and there was no significant difference in recurrence between two groups (p = 0.202). Three-year and 5-year overall survivals were 33.3% and 28.5% in the normal HA group, whereas 47.1% and 28.3% in the aberrant RHA group, respectively. There also was no statistically significant difference in survival (p = 0.763). Conclusions When performing PD for CBD cancer, aberrant RHA should be preserved if there was no cancerous invasion and it does not seem to affect the recurrence of disease and overall survival of patients.

Tricks and tips in pancreatoduodenectomy

“…The most important HAAV that the surgeon must bear in mind during PD are accessory RHA and displaced or accessory CHA, both arising from the SMA [23] . Displaced or accessory RHA arising from the SMA (10%-21%) is the variation that is most often identified during PD [6,[20][21][22][23] . This vessel passes lateral to and behind the PV and can be felt by palpation, but it may also pass behind or through the pancreas [6,22,23] .…”

“…Displaced or accessory RHA arising from the SMA (10%-21%) is the variation that is most often identified during PD [6,[20][21][22][23] . This vessel passes lateral to and behind the PV and can be felt by palpation, but it may also pass behind or through the pancreas [6,22,23] . Displaced or accessory CHA arising from the SMA, known as the hepatomesenteric trunk, is the second most frequent variation (2%-3%) [6,20] and its course is variable [20,23] .…”

“…Angiography is no longer needed [20] . Several classifications of HAAV have been proposed (Covey, Hiatt, Koops and Michels) [6,20,22,23] . The most frequently described HAAV are an anomalous RHA from the SMA (10%-21%), a displaced left HA (LHA) from the left gastric artery (4%-10%), displaced RHA and LHA, an accessory RHA and/or LHA (1%-8%), a displaced CHA from the SMA or aorta (0.4%-4.5%), and quadrifurcation of the HA itself [20,23] .…”

“…Preoperative assessment of peripancreatic vascular patterns using imaging methods is crucial for surgeons [22] . Multidetector CT is the method of choice, and multidimensional reconstruction may be very useful [6,[21][22][23]25] . Angiography is no longer needed [20] .…”

“…A thorough knowledge of HA anatomy is essential; in the presence of HA anatomical variations (HAAV), accidental ligation may occur during PD, provoking hepatic necrosis, ischemic biliary injury or an anastomotic fistula [6,[20][21][22][23][24] . Preoperative assessment of peripancreatic vascular patterns using imaging methods is crucial for surgeons [22] . Multidetector CT is the method of choice, and multidimensional reconstruction may be very useful [6,[21][22][23]25] .…”