Abstract
Whipple's pancreatoduodenectomy is a complex surgical procedure and any aberrant arterial anatomy may have serious surgical implications. The objective of our study was to analyse the frequency of aberrant hepatic artery and compare the outcomes in patients with normal anatomy. Clinical data and computed tomography scans of 45 consecutive patients who underwent Whipple's procedure from 2007 to 2016 were reviewed. Group 'A' included patients with aberrant hepatic artery while group 'B' with normal anatomy. Aberrant hepatic artery was present in 11 (24%) patients and type V was the most common variant (n=5, 45%). Morbidity rate in group A was 82% and group B was 62% (p= 0.288), while 30-day mortality rate was 18% and 9% respectively (p=0.582). There was no difference in the oncological clearance in both the groups. Aberrant hepatic artery does not seem to influence the morbidity, mortality and tumour resection margins in patients undergoing Whipple's procedure.
Highlights
The incidence of hepatic arterial anomalies has been reported from 20% to 40% in patients who underwent pancreatoduodenectomy (PD), which adds to the difficulty of an already technically challenging procedure.[1]
The variation in the hepatic artery anatomy was first described by Michels[2] in 1966, which was further updated by Hiatt et al in 1994.3 The most frequent arterial variant is the aberrant right hepatic artery (RHA) arising from the superior mesenteric artery (SMA), followed by aberrant left hepatic artery originated from left gastric artery.[4]
During surgery hepatic artery arising from SMA may be inadvertently injured, leading to bile duct ischaemia resulting in compromised biliary enteric anastomosis since the major supply of common bile duct is from RHA
Summary
The incidence of hepatic arterial anomalies has been reported from 20% to 40% in patients who underwent pancreatoduodenectomy (PD), which adds to the difficulty of an already technically challenging procedure.[1]. RHA from SMA has high chances of being encompassed by cephalo-pancreatic tumours.[6] During surgery hepatic artery arising from SMA may be inadvertently injured, leading to bile duct ischaemia resulting in compromised biliary enteric anastomosis since the major supply of common bile duct is from RHA. An attempt to preserve such arterial supply may compromise the R0 resection of the tumour leading to a positive margin of resection with negative influence on the oncological outcomes. Presence of such anomalous anatomy may prolong the operative time and increase postoperative morbidity and mortality
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