Radiological–Surgical Methods to Identify Celiac–Mesenteric Anomalies of the Hepatic Artery Before Duodenopancreatectomy

Abstract

IntroductionUp to 45% anatomical variations are found in hepatic arterial system. Identifying these anatomical anomalies before or during surgery would prevent additional morbidity in performing a duodenopancreatectomy. They are routinely identified before surgery using CT imaging, but on certain occasions they are not reported and are only discovered during the surgical operation. The initial retroperitoneal access by the superior mesenteric artery (SMA) will avoid a fairly useless intervention if there is superior mesenteric artery invasion, and will identify the anatomical variations originating in the superior mesenteric artery. These anomalies acquire importance in that their unnoticed injury could lead to severe vascular compromise and/or perioperative bleeding. ObjectivesTo analyze celiac–mesenteric anomalies of the hepatic artery before duodenopancreatectomy using the information from multidetector computed tomography (MDCT) using a non-standardized method, a standardized method with multidimensional reconstruction, and maximum intensity projection (MIP), after initial surgical access to the SMA. Patients and methodsA retrospective study of the clinical, histopathological and surgical variables was conducted on patients with an indication for duodenopancreatectomy in our Department from 2008 until April 2010. A study was performed on the reports made after image acquisition by MDCT. A blind, three-dimensional, MIP reconstruction was performed on all the patients to identify arterial anomalies. A description is given of hepatic artery anomalies after initial access to the SMA. ResultsA total of 61 patients were included in the study. The mean age was 65±11 years, with 33 (54%) males and 28 (46%) females. Vascular anomalies, right hepatic artery (RHA) (SMA) substitute (subst), 5 (8%); RHA (SMA) accessory (acc), 4 (7%); left hepatic artery (LHA) (left gastric artery) (LGA) acc 3 (5%); common hepatic artery (CHA) (SMA) subst 3 (5%); RHA (SMA) acc+LHA (LGA) acc 2 (3%); CHA (aorta) subst, 1 (2%); RHA+RGA+2 LHA (celiac trunk), 1 (2%); and CHA (SMA)+LHA (LGA) acc. ConclusionOn being able to identify arterial anomalies with a mixture of preoperative radiological and methodological criteria, with three-dimensional reconstruction, MIP, and initially performing a dissection of the superior mesenteric artery could avoid duodenopancreatectomies that may not benefit the patient and compromise bleeding.