- Case Report
- Open Access
Combined resection of the transpancreatic common hepatic artery preserving the gastric arterial arcade without arterial reconstruction in hepatopancreatoduodenectomy: a case report
© The Author(s). 2018
Received: 21 March 2018
Accepted: 19 June 2018
Published: 26 June 2018
Surgeons sometimes must plan pancreatoduodenectomy (PD) for patients with a variant common hepatic artery (CHA) branching from the superior mesenteric artery (SMA) penetrating the pancreatic parenchyma, known as a transpancreatic CHA (tp-CHA).
A 67-year-old man was admitted to our hospital because of liver dysfunction. A duodenal tumor was identified by gastrointestinal endoscopy, and a biopsy revealed a neuroendocrine tumor. Computed tomography showed multiple metastases in the left three sections of the liver. As an anatomical variant, the CHA branched from the SMA and passed through the parenchyma of the pancreatic head, and all hepatic arteries branched from the CHA. Furthermore, the arcade between the left and right gastric artery (RGA) was detected, and the RGA branched from the root of the left hepatic artery. PD and left trisectionectomy of the liver were performed. The tp-CHA was resected with the pancreatic head, and the gastric arterial arcade was preserved to maintain the right posterior hepatic arterial flow. Postoperatively, there were no signs of hepatic ischemia.
When planning PD, including hepatopancreatoduodenectomy, for patients with a tp-CHA, surgeons should simulate various situations for maintaining the hepatic arterial flow. The preservation of the gastric arterial arcade is an option for maintaining the hepatic arterial flow to avoid arterial reconstruction.
The common trunk formed by the common hepatic artery (CHA) and the superior mesenteric artery (SMA) is referred to as the hepatomesenteric trunk; this is only found in 1.5–2.3% of the population [1, 2]. Among such individuals, only a few patients have the CHA passing fully through the pancreatic parenchyma (transpancreatic CHA [tp-CHA]) [1, 3]. During pancreatoduodenectomy (PD) (including hepatopancreatoduodenectomy [HPD]) for patients with tp-CHA, it is necessary to consider the surgical procedure to maintain the hepatic arterial flow, including the preservation of the CHA separating from pancreatic parenchyma , reconstruction of the hepatic artery after combined resection of tp-CHA [4, 5], and the preservation of the collateral circulation after combined resection of tp-CHA , in order to avoid hepatic ischemia and lethal complications [4, 6].
We herein report a case of duodenal neuroendocrine tumor (NET) with multiple liver metastases for a patient with a tp-CHA. The patient was successfully treated with PD and left trisectionectomy with caudate lobectomy combined resection of the tp-CHA and preservation of the gastric arterial arcade in order to maintain the hepatic arterial flow.
Over the years, several authors have described variations in the hepatic arterial anatomy; a CHA arising from the SMA—called the hepatomesenteric type—is a rare clinical entity. Yang et al. and Hiatt et al. reported that this condition was observed in only 31 of 1324 patients and 15 of 1000 patients, respectively [1, 2]. A CHA passing through the pancreatic head parenchyma, tp-CHA, is even rarer; Yang et al.  reported that among 31 patients with the hepatomesenteric type, only 3 had this condition.
When PD is scheduled in such patients with tp-CHA, it is important to maintain the arterial supply to the liver. Surgeons should preoperatively determine whether to preserve or perform combined resection of the tp-CHA. Tp-CHA preservation was selected in several previous reports [4, 5, 7]. This surgical procedure is technically feasible; however, there is a risk of a positive surgical margin or insufficient lymph node dissection and a tendency for increased intraoperative blood loss during the separation of the pancreatic parenchyma. If the tp-CHA is resected, reconstruction is usually necessary in order to maintain the hepatic arterial flow. Previous reports [5, 8, 9] have described successful arterial reconstruction after CHA resection during PD; however, such procedures are associated with an increased risk of thromboembolism, which can lead to a fatal outcome, especially in HPD . In contrast, when collateral circulation develops, surgeons can perform combined resection of the tp-CHA, preserving the collateral circulation without arterial reconstruction. Several reports have recommended preoperative embolization of CHA in order to maintain the hepatic arterial flow through enlarged collateral arteries . Although preoperative embolization can increase the liver arterial flow through collateral arteries, it is not routinely recommended because of the risk of complications, which includes the migration of embolic material [11, 12].
A developed gastric arcade or pancreaticoduodenal arcade is frequently seen in patients with the stenosis of the CHA due to factors such as compression by the median arcuate ligament . There are only a few cases in which the hepatomesenteric trunk and the tp-CHA and the association between the tp-CHA and the development of a gastric arterial arcade have not been reported. On the other hand, Miyamoto et al. reported the case of a patient with pancreatic head cancer with a CHA arising from the SMA who underwent radical PD combined with the resection of the CHA, in which the hepatic arterial flow was maintained via the gastric arterial arcade . In this report, the patient did not have a developed gastric arterial arcade; however, the hepatic arterial flow via the gastric arterial arcade was sufficient and hepatic ischemia was not detected after the operation. Considering this case, even if the patients with tp-CHA do not have a developed gastric arterial arcade, surgeons may be able to preserve hepatic arterial flow via the gastric arterial arcade alone. If the hepatic arterial flow via the gastric arterial arcade alone is adequate after clamping the PHA, the combined resection of the tp-CHA can be considered, even if the gastric arcade is not developed before surgery. In cases in which the hepatic arterial flow is not adequate, the preservation of the tp-CHA or arterial reconstruction should be considered.
When performing HPD, a PD-first procedure before hepatectomy is generally performed, as this approach is anatomically rational . However, in the present case, performing hepatectomy after PD carried a risk of the arterial supply to the liver being reduced during hepatectomy. Had we chosen a PD-first procedure and the hepatic arterial flow not been maintained after CHA resection, it would have been necessary to perform arterial reconstruction before liver transection. This method is associated with a risk of injury to the reconstructed artery and thrombosis during liver transection. Given the above, we opted to perform hepatectomy before PD in our patient with a tp-CHA undergoing HPD.
In the procedure for separating the tp-CHA from the pancreatic parenchyma entirely, the surgeon should be concerned about the increasing rate of hemorrhage, surgery time, and the risk of injury to the tp-CHA. The surgical reconstruction of the hepatic artery when performing HPD is also associated with a high degree of risk. The association between tp-CHA and gastric arterial arcade was recognized on preoperative CT scans; the development of this collateral circulation may have the potential to prevent ischemia-related liver complications. From these points of view, the preoperative identification of the developed arcade of the gastric arteries helps in planning an appropriate operative procedure, and this procedure seems to be a viable and simple option. To our knowledge, this is the first report of PD combined with resection of a tp-CHA without preoperative embolization. Furthermore, this is also the first report of HPD for a patient with a tp-CHA. The preoperative identification of the developed arcade of the gastric arteries helps in planning the appropriate operative procedure when PD is scheduled for patients with a tp-CHA.
When planning PD for patients with a tp-CHA, a precise preoperative evaluation and the adoption of the surgical strategy and technique for each individual case are critical to preserving the hepatic arterial flow.
Availability of data and materials
Availability of data and materials data sharing is not applicable to this article, as no datasets were generated or analyzed during the current study.
TM, YY, and KU performed the surgery and the perioperative management of the patient. TM and YY drafted the manuscript. TS, YO, TI, RA, SU, YK, KO, AK, TU, and SS performed the perioperative management of the patient. All of the authors have read and approved the final manuscript.
Ethics approval and consent to participate
The study was performed in accordance with the Declaration of Helsinki and conducted in compliance with the appropriate ethics committee of Shizuoka Cancer Center, Shizuoka, Japan.
Consent for publication
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.
The authors declare that they have no competing interests.
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