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Justification for visceral angiography prior to pancreaticoduodenectomy
C M Volpe1, S Peterson, E L Hoover
1Department of Surgery, Buffalo VA Medical Center, SUNY at Buffalo School of Medicine and Biomedical Sciences, New York, USA.
Insights
Aberrant hepatic arteries are common. Preoperative visceral angiography is crucial for identifying these variations before pancreaticoduodenectomy to prevent potentially fatal hepatic injury.
Area of Science:
- Vascular anatomy
- Surgical oncology
- Diagnostic imaging
Background:
- Hepatic arterial anatomy exhibits significant variation in nearly 50% of individuals.
- Common anomalies include the right hepatic artery originating from the superior mesenteric artery (SMA) and the left hepatic artery from the left gastric artery.
- Anomalies of the common hepatic artery are rare, with a replaced common hepatic artery from the SMA occurring in 2.5% of the population.
Observation:
- Injury to hepatic blood supply is more frequent in patients with aberrant arterial anatomy.
- A patient with a replaced common hepatic artery from the SMA underwent successful pancreaticoduodenectomy for pancreatic adenocarcinoma.
- The anomalous vessel's unusual medial course to the common bile duct mimicked the gastroduodenal artery during surgery.
Findings:
- Preoperative visceral angiography identified the replaced common hepatic artery originating from the SMA.
- The anomalous vessel's atypical course required careful surgical planning during the Whipple procedure.
- The patient had a successful outcome despite the complex arterial anatomy.
Implications:
- Knowledge of aberrant hepatic arterial anatomy is vital for surgical planning in pancreaticoduodenectomy.
- Preoperative visceral angiography should be considered routine before pancreaticoduodenectomy to prevent hepatic injury.
- This case highlights the importance of integrating imaging findings into surgical strategy, especially in surgical residency training.
Abstract:
The hepatic arterial anatomy is aberrant in almost 50 per cent of all individuals. The most common anomalies include the right hepatic artery arising from the superior mesenteric artery (25%) and the left hepatic artery arising from the left gastric artery (25%). Anomalies of the common hepatic artery, usually a branch of the celiac artery, are rare. A replaced common hepatic artery originating from the superior mesenteric artery occurs in 2.5% of the entire population. Injury to hepatic blood supply is more common in the presence of aberrant arterial anatomy. Knowledge of aberrant arterial anatomy in patients about to undergo pancreaticoduodenectomy can lead to measures to preserve the vessels, and avoid fatal hepatic injury. We present a patient with a replaced common hepatic artery originating from the superior mesenteric artery successfully treated with a standard pancreaticoduodenectomy for pancreatic adenocarcinoma. The anomalous vessel was identified on visceral angiography, performed as part of the initial preoperative evaluation. At the time of laparotomy, the artery followed a course atypical for replaced hepatic arteries, lying medial to the common bile duct, and closely mimicking the gastroduodenal artery that would normally be divided during a Whipple procedure. This case emphasizes the importance of preoperative visceral angiography and the margin of safety it can provide when that knowledge is used in the operative strategy. Visceral angiography should be considered routine before pancreaticoduodenectomy, particularly in surgical residency training programs.