Does Aberrant Right Hepatic Artery Influence the Surgical Short- and Long-term Outcome of Pancreatoduodenectomy?

Abstract

Background: Variations in vascular anatomy in pancreaticoduodenectomy for adenocarcinoma of the pancreatic head, aberrant right hepatic artery (αRHA) being the most frequent, may influence oncological outcome, surgical complexity, intra-and postoperative complications, and overall 5-year disease-free and survival rates. Materials and Methods: Between January 1988 and January 2018, 297 consecutive patients underwent pancreaticoduodenectomy at our Institutions and were divided into two groups: Group 1 patients were affected with αRHA; group 2 were without this vascular anomaly. The groups were retrospectively compared to identify differences in preoperative characteristics and intraoperative course, postoperative morbidity and mortality and long-term disease-free interval and overall survival. Cox regression analysis was used to investigate the role of variables statistically significant at univariate analysis in the short-and long-term outcomes. Results: Overall 44 (15%) patients had αRHA. No differences in patient characteristics were reported. The mean operative time was 451±58 minutes for group 1 and 317±27 minutes for group 2 (p<0.001), whereas mean blood losses were 729±488 ml and 508±119 ml, respectively (p<0.001). Group 1 patients had a longer stay in intensive care when compared to patients of group 2 (mean 5±2 versus 4±2 days, respectively; p<0.001). Furthermore group 1 patients had a significant longer hospitalization when compared to those of group 2 (mean 17±5 versus 15±3 days, respectively; p<0.006). No other significant differences were observed between the two groups. Cox regression analysis showed that independently of the presence of αRHA, the factors negatively affecting the 5-year survival rate were blood loss (p<0.001) and length of stay in intensive care (p<0.001). Discussion: αRHA increases the surgical complexity of pancreatoduodenectomy, negatively affecting intraoperative blood loss, length of operation, length in intensive care and hospitalization, but does not influence long-term survival and disease-free rates.

Preservation of aberrant right hepatic arteries does not affect safety and oncological radicality of pancreaticoduodenectomy—own results and a systematic review of the literature

“…Regarding long term survival, the studies by Eshuis et al, Crocetti et al, and Kim et al already proved that survival was not affected by aRHA (16,18,26). Our results support these data and reveal the longest median survival of 29 months among all studies included in the systematic review (Figure 4).…”

“…For example, Asano et al had to resect aRHA in 18% of the patients with this anomaly and reported a prolongation of surgery of about 33 minutes (23). Crocetti et al reconstructed 25% of aRHA, which prolonged operating time with 34 minutes (26). Rammohan et al ligated aRHA in 19% and reconstructed it in additional 2% resulting in a 60 minutes difference in the operating time (19).…”

“…The excellent oncologic radicality of PD in patients with malignant disease with 90% tumor free margin and the highest average number of harvested lymph nodes per patient compared to all other studies, despite aRHA preservation in 100% of cases, remains the most important finding of this study and makes the difference to other recent publications. The study by Crocetti et al is a fine example of the effects of aggressive strategy with high resection rates in cases of aRHA: in their study a resection of aRHA with reconstruction was performed in 25%, which yielded a very high R0 rate of up to 95% (26). However, the price for this aggressive strategy was high: a mortality of 16%, prolonged operative time by more than 2 hours, increased blood loss, prolonged ICU and total hospital stay.…”

“…The lymph node yield, the rate of tumor-free resection margin and long-term survival were also not affected by the presence of aRHA in oncologic patients. Six studies found significantly longer duration of surgery in patients with aRHA (7,8,(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26).…”

Precision anatomy for safe approach to pancreatoduodenectomy for both open and minimally invasive procedure: A systematic review

“…Others also reported that the frequency of aberrant RHA was 13.8%-20.7% after Hiatt's classification, and these results were similar to those reported by Hiatt. 12,18,[34][35][36][37][38][39][40][41] Although aberrant RHA classified by Hiatt's types originate from SMA, there are other rare variations of aberrant RHA that originate from the aorta, left gastric artery, celiac artery, and gastroduodenal artery. 39 The main origin of aberrant RHA was SMA, celiac artery, and aorta, and the frequency was reported to be 74.1%-80.7%, 18.0%-19.2%, and 7.9%, respectively.…”