An aberrant right hepatic artery arising from the gastroduodenal artery: a pitfall encountered during pancreaticoduodenectomy

Abstract

Purpose Among the variations of the right hepatic artery (RHA), the identification of an aberrant RHA arising from the gastroduodenal artery (GDA) is vital for avoiding damage to the RHA during surgery, since ligation of the GDA is necessary during pancreaticoduodenectomy (PD). However, this variation is not frequently reported. The purpose of this study was to focus on an aberrant RHA arising from the GDA, which was not noted in the classifications reported by Michels and Hiatt. Methods A total of 574 patients undergoing a PD between Jan 2001 and Dec 2015 at a tertiary care hospital in Switzerland (n = 366) and between Jan 2009 and May 2015 at a hospital in Japan (n = 208) were included in the analysis. Of these, preoperative CT angiography or/and MRI angiography findings were available for 532 patients. We retrospectively analyzed the hepatic artery variations, patient demographics, and surgical outcomes. Results Among the 532 patients who received a PD, an RHA originating from the GDA was observed in 19 cases (3.5%). Eleven patients (2.1%) had both an aberrant RHA and an aberrant left hepatic artery (LHA) (Hiatt Type 4). Six patients (1.2%) had a replaced CHA arising from the SMA (Hiatt Type 5). We could, therefore, correctly identify the aberration in all cases. Conclusions We observed rarely reported but important aberrant RHA variations arising from the GDA. To prevent injury during PD in patients with this type of aberrant RHA, intensive preparations using CT and/or MRI imaging before surgery and intraoperative liver Doppler ultrasonography are considered to be essential.

Accessory right hepatic artery and aberrant bile duct in the hepatocystic triangle: a rare case with clinical implications

“…These variations included ARHA branching from SMA and an accessory left hepatic artery arising from the left gastric artery. Using CT angiography or/and MRI angiography findings in 532 patients, Yamaguchi et al [21] observed a case of aberrant right hepatic artery arising from the gastroduodenal artery. They recommended the use of preoperative CT and/or MRI and intraoperative liver Doppler ultrasound for the prevention of injury during pancreaticoduodenectomy in patients with this type of hepatic artery variation.…”

Evaluation of CT Scans Reports in Pancreatic Tumors at Ouagadougou (Burkina Faso)

“…Failure to recognize these variants can lead to severe disorders of the liver vascularization after pancreatic cephalic end surgery. Indeed, Yamaguchi et al [16] noted a rate of 93% of intraoperative anatomical variants mentioned on preoperative imaging studies. These were essentially the birth of a right hepatic artery from the gastroduodenal artery in 3.5% of cases, the presence of a right and left hepatic artery in 2.1% of cases and a common hepatic artery arising from the superior mesenteric artery in 1.2% of cases.…”

Pancreaticoduodenectomy: how to handle a replaced right hepatic artery

“…Pyras and colleagues reported a 19.3% rate, which means that hepatobiliary pancreatic surgeons not uncommonly encounter an a-RHA. A rarer case, an a-RHA arising from the gastroduodenal artery (3.6%, 19/532) was Editorial Pancreaticoduodenectomy: how to handle a replaced right hepatic artery reported in 2021 (7). Before performing a PD, the team of hepatobiliary pancreatic surgeons should share information regarding the specific hepatic arterial and gastroduodenal arterial anatomy observed on multidetector-row CT and other imaging modalities.…”

“…Asano and colleagues reported that 1 of 9 (11%) patients undergoing concomitant resection of an a-RHA was accidentally injured during PD. The a-RHA is not a rare anatomic variant; Hiatt types III–VI account for 12.9% ( 6 ), ranging from 12% to 22% according to various reports ( 6 , 7 ). Pyras and colleagues reported a 19.3% rate, which means that hepatobiliary pancreatic surgeons not uncommonly encounter an a-RHA.…”

“…Before performing a PD, the team of hepatobiliary pancreatic surgeons should share information regarding the specific hepatic arterial and gastroduodenal arterial anatomy observed on multidetector-row CT and other imaging modalities. As an additional safety measure, Yamaguchi and colleagues further suggest intraoperative liver Doppler ultrasonography examination to confirm bilateral intrahepatic artery flow in both the right and left hepatic arteries before cutting and clamping the gastroduodenal artery ( 7 ). The Japanese Society of Hepato-Biliary-Pancreatic Surgery recommends the hepatic artery flow confirmation to be a board-certified expert hepato-biliary-pancreatic surgeon ( 8 ).…”