Hepatobiliary and Pancreatic: Aberrant hepatic arteries and pancreatic surgery

Abstract

A woman, aged 64, was investigated because of upper abdominal discomfort. An upper abdominal ultrasound study and computed tomography (CT) scan showed a cystic mass, 3 cm in diameter, in the head of the pancreas. Endoscopic retrograde cholangiopancreatography revealed a cystic lesion in a major branch of the main pancreatic duct. There was also a filling-defect within the cystic lesion and this was confirmed by endoscopic ultrasound. The diagnosis was that of an intraductal papillary mucinous neoplasm of the head of the pancreas. CT arteriography showed that the right hepatic artery (RHA) was arising from the superior mesenteric artery (SMA) and that the left hepatic artery (LHA) was arising from the inferior pancreaticoduodenal artery (IPDA) (Figure 1). The celiac artery (CA), gastroduodenal artery (GDA) and right gastroepiploic artery (RGEA) are also shown. During the surgical procedure of pancreaticoduodenectomy, the IPDA is usually ligated and cut. However, with the above anatomy, we were concerned about the possibility of significant hepatic ischemia. Because of this, the operation was planned with a view to preserve the IPDA. At laparotomy, intraoperative ultrasound was used to confirm that the LHA and IPDA were not closely applied to the pancreatic tumor. After dividing the pancreas above the portal vein, the LHAand IPDAwere taped and clamped and the pancreas was transected along the vessels without cutting the pancreas tumor. The GDA and small arterial branches were ligated after which clamps on the IPDAand LHAwere released (Figure 2). She was discharged from hospital 2-weeks after surgery without any complication. When operating on tumors in the head of the pancreas, it is important to recognize aberrant hepatic arteries. Relatively common anomalies are an hepatic artery or RHA that arises from the SMA. These anomalous arteries usually run laterally to the portal vein behind the head of the pancreas and enter the right side of the hepatoduodenal ligament, posterolateral to the common bile duct. In the above patient, there was not only an anomalous RHA but also a LHA that arose from the IPDA within the pancreatic parenchyma. This may be the first report of successful pancreatoduodenectomy without injury to these arteries. Pre-operative 3-dimensional CT arteriography is helpful in demonstrating aberrant blood vessels that may alter operative procedures and perhaps reduce operative morbidity and mortality.