Although available risk scores can predict DFS and DSS, none does so with sufficient discriminatory accuracy to identify all episodes of recurrent disease. A non-negligible proportion of patients develop recurrent disease beyond 5 years of follow-up and so surveillance beyond this point may be advantageous.

The understanding of abdominal vascular anatomy and its anatomical variations is of considerable importance in upper abdominal surgery. We present the rare finding of a common hepatic artery arising from the superior mesenteric artery and passing anterior to the pancreatic gland in a patient undergoing a pancreaticoduodenectomy. Anatomical variation of the arterial blood supply to the liver is common, with only 52-80% 1 of patients having 'normal anatomy' where the common hepatic artery (CHA) arises from the coeliac trunk, and divides into gastroduodenal artery and proper hepatic artery, which then divides into right and left hepatic arteries at the hilum of the liver. In 1955 Michels proposed a classification scheme with the 10 most common variants of arterial blood supply to the liver, based on the result of 200 cadaver livers.2 Hiatt et al simplified the scheme in 1994 to just six arterial variants (Table 1). 3 Type 9 in the Michels classification and type 5 in the Hiatt classification describe the variation with the CHA arising from the superior mesenteric artery (SMA), occurring in 1-5%. 1,2 Case HistoryA 73-year-old male patient presented with 14kg weight loss and progressive jaundice over four months. Endoscopic ultrasonography of the pancreas demonstrated a 1.6cm  2.7cm mass in the head of the pancreas and fine needle aspiration confirmed an adenocarcinoma. Preoperative computed tomography demonstrated that the tumour was touching the portal vein, for less than 180°of its circumference over a 1.5cm distance, without invasion. The SMA was clear from the tumour. However, the entire CHA was seen to arise from the SMA, passing anterior to the pancreas, posterior to the first part of the duodenum and up to the hilum of the liver (Figs 1 and 2). There was no accessory or replaced left hepatic artery from the left gastric artery. The splenic arteries arose from the aorta as a separate branch.The patient duly underwent a pylorus preserving pancreaticoduodenectomy. Intraoperative findings (Fig 3) confirmed the presence of a palpable pulse over the pancreatic head. The anatomical position of the CHA required careful dissection from the anterior surface of the pancreatic head, made complicated by the presence of an element of fibrosis. After resection, the artery was left running over the pancreas (Fig 4) and a pedicle of omentum was dissected. This was placed between the hepatic artery and pancreaticojejunostomy anastomosis in an attempt to decrease the risk of arterial complications should the patient develop a postoperative pancreatic fistula.The patient spent one day in the intensive care unit. He was discharged without further complications after seven days and reviewed at two months. Postoperative histology

Operative treatment of CRLMs yields greater survival than non-operative treatment, and is both more effective and less costly.

Enterobius vermicularis is responsible for a variety of diseases but rarely affects the liver. Accurate characterisation of suspected liver metastases is essential to avoid unnecessary surgery. In the presented case, following a diagnosis of rectal cancer, a solitary liver nodule was diagnosed as a liver metastasis due to typical radiological features and subsequently resected. At pathological assessment, however, a necrotic nodule containing E vermicularis was identified. Solitary necrotic nodules of the liver are usually benign but misdiagnosed frequently as malignant due to radiological features. It is standard practice to diagnose colorectal liver metastases solely on radiological evidence. Without obtaining tissue prior to liver resection, misdiagnosis of solitary necrotic nodules of the liver will continue to occur.

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