Open Access

Accessory right hepatic artery branched from gastroduodenal artery

  • Kohei Yamashita1,
  • Daisuke Hashimoto1,
  • Rumi Itoyama1,
  • Hirohisa Okabe1,
  • Akira Chikamoto1,
  • Toru Beppu1 and
  • Hideo Baba1Email author
Surgical Case Reports20151:90

DOI: 10.1186/s40792-015-0092-7

Received: 7 May 2015

Accepted: 20 September 2015

Published: 28 September 2015

Abstract

The right hepatic artery usually branches from the common hepatic artery, however, there are cases showing anatomic variations. We present 41-year-old female patient with gallbladder cancer. In this case, the accessory right hepatic artery branched from the gastroduodenal artery, passed in front of the common bile duct and fed into the anterior segment of the liver. Cholecystectomy and resection of the extrahepatic bile duct with hepaticoenterostomy were performed successfully, preserving the accessory right hepatic artery. There are few reports presenting such an extremely rare anomaly of hepatic arteries in the English literature. Additionally, we herein present a review of the English literature regarding anatomic variations of right hepatic artery.

Keywords

Vascular anomaly Hepatic artery Gallbladder cancer

Background

The patterns of the arterial blood supply to the liver have a tendency to show a certain variability [1, 2]. The right hepatic artery (RHA) usually arises from the common hepatic artery (CHA). One of the best known anatomic variations of hepatic arteries is a replaced or accessory RHA (aRHA) branching from the superior mesenteric artery (SMA) [3, 4]. However, we would like to present an extremely rare case of the aRHA branching from the gastroduodenal artery (GDA).

Case presentation

A 41-year-old woman was referred to us for gallbladder cancer. An ultrasonography and a contrast-enhanced computed tomography (CT) scan revealed a papillary hypervascular tumor, 25 × 21 mm, in the gallbladder (Fig. 1a, b). Three-dimensional (3D)-CT angiography showed that the aRHA branched from the GDA, whereas the cholecystic artery could not be detected (Fig. 1c, d). The aRHA passed in front of the common bile duct and fed into the anterior segment of the liver (Fig. 1e). The proper hepatic artery (PHA) was divided distally into the RHA and the middle hepatic artery (MHA). The left hepatic artery (LHA) was replaced on the left gastric artery (LGA). Pancreaticobiliary maljunction was not detected in this case.
Fig. 1

Preoperative findings. A contrast-enhanced CT (a) and ultrasonography (b) revealed a papillary hypervascular tumor, 25 × 21 mm, in the gallbladder. The 3D-CT angiography (c, d) indicated that the aRHA (arrow) branched from the GDA, whereas the cholecystic artery could not be detected. The aRHA (arrow) fed into the anterior segment of the liver (e). CHA common hepatic artery, GDA gastroduodenal artery, PHA popper hepatic artery, aRHA accessory right hepatic artery, LGA left gastric artery, LHA left hepatic artery

The patient underwent operation, and laparotomy revealed that there was no invasion into the liver. The aRHA branching from the GDA was detected being consistent with the preoperative 3D-CT (Fig. 2a). The cholecystic artery was found, arising from the aRHA (Fig. 2b). Finally, the cholecystic artery was cut and resection of the gallbladder, and the extrahepatic bile duct with additional hepaticoenterostomy was performed, preserving the aRHA successfully (Fig. 2c). Whereas the effectiveness of lymphadenectomy for early-stage gallbladder cancer has been controversial [5], we performed resection of the extrahepatic bile duct for lymph node dissection. Macroscopically, the tumor was 2.5 × 2.0 cm (Fig. 2d). Postoperative pathological analysis diagnosed a papillary adenocarcinoma within the mucosal layer of the gallbladder.
Fig. 2

Operative findings. The aRHA branching from the GDA was detected (a). The cholecystic artery was found, arising from the aRHA (b). The gallbladder and the extrahepatic bile duct were resected, preserving the aRHA (c). Macroscopically, the tumor was 2.5 × 2.0 cm (d). CHA common hepatic artery, GDA gastroduodenal artery, PHA popper hepatic artery, aRHA accessory right hepatic artery, LGA left gastric artery, LHA left hepatic artery. Arrow: cut end of the bile duct

Michels et al. published autopsy series about hepatic artery variants in 1966 [6], and in which, they indicated that aRHA uncommonly branches from GDA. We reviewed the English literature, in which 6588 cases were analyzed about anatomic variation of hepatic artery, including the presented case [3, 714] (Table 1). This study was approved by the Institutional Review Board of Kumamoto University Hospital. Among 6588 cases, 5696 cases (86.5 %) had standard anatomy. Replaced RHA and aRHA were the most commonly branched from SMA (853 cases, 12.9 %), followed by celiac axis (CA) (16 cases, 0.24 %), aorta (10 cases, 0.15 %), and CHA (6 cases, 0.09 %). Two cases had rare anomalies in which replaced RHA branched from LGA or renal artery. In addition, there were three cases (0.05 %) who had replaced RHA branched from GDA. Hogendorf et al. reported an autopsy case of aRHA branched from GDA [14]. However, to our best knowledge, the presented case is the first report in which aRHA branched from GDA was detected preoperatively.
Table 1

Anatomic variations of replaced and accessory right hepatic artery

Author

Total cases (n)

Origin of RHA or accessory RHA (n)

Standard anatomy

Replaced RHA from SMA

Accessory RHA from SMA

Replaced RHA from CA

Accessory RHA from CA

Replaced RHA from CHA

Replaced RHA from aorta

Accessory RHA from aorta

Replaced RHA from renal artery

Replaced RHA from LGA

Replaced RHA from GDA

Accessory RHA from GDA

Hiatt J. [3]

1000

871

129

0

0

0

0

0

0

0

0

0

Covey A. [7]

600

512

55

33

0

0

0

0

0

0

0

0

0

Gruttadauria S. [11]

701

572

110

5

2

8

1

1

2

0

Koops A. [8]

604

520

60

21

1

1

0

1

0

0

0

0

0

Abdullah S. [12]

932

772

155

5

0

0

0

0

0

0

0

Lopez-Andujar R. [9]

1081

946

118

17

0

0

0

0

0

0

0

0

0

Winston C. [13]

371

347

15

0

4

0

4

0

0

0

0

1

0

Loschner C. [10]

1297

1156

103

37

0

0

0

0

1

0

0

0

0

Hogendorf P. [14]

1

(–)

(–)

(–)

(–)

(–)

(–)

(–)

(–)

(–)

(–)

(–)

1

This report

1

(–)

(–)

(–)

(–)

(–)

(–)

(–)

(–)

(–)

(–)

(–)

1

Total

6588

5696

853

16

6

10

1

1

3

2

RHA right hepatic artery, SMA superior mesenteric artery, CA celiac axis, CHA common hepatic artery, LGA left gastric artery, GDA gastroduodenal artery

Conclusion

In this case, the successful outcome of the operation was made possible by identifying the aRHA preoperatively. The aRHA should be preserved because it fed the anterior segment of the liver. In addition to the abnormal aRHA, this case had a replaced LHA which the use of the preoperative 3D-CT angiography helped to establish beforehand. We believe that this extremely rare arterial pattern should be known by surgeons.

Consent

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Abbreviations

aRHA: 

accessory right hepatic artery

CA: 

celiac axis

CHA: 

common hepatic artery

CT: 

computed tomography

GDA: 

gastroduodenal artery

LGA: 

left gastric artery

LHA: 

left hepatic artery

MHA: 

middle hepatic artery

PHA: 

proper hepatic artery

SMA: 

superior mesenteric artery

Declarations

Acknowledgements

No funding was received for this study.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors’ Affiliations

(1)
Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences

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Copyright

© Yamashita et al. 2015