Accessory left hepatic artery arising from common hepatic artery

The knowledge of anatomical variations in hepatic artery are of importance to surgeons and radiologists while performing complicated procedures like liver transplantation and transarterial chemo-embolization for hepatic tumors. The incidence of accessory left hepatic artery is less common than the right accessory hepatic artery. Here we report an anomalous accessory left hepatic artery arising from common hepatic artery in a 55 year old male cadaver.     

Life-threatening gastrointestinal bleeding after liver transplatation due to hepatic artery pseudoaneurysm perforating into the common bile duct. A case report

A 54-year-old male presented with acute rejection and life-threatening gastrointestinal bleeding 2 months following orthotopic liver transplantation. Since no bleeding was identified in the entire gastrointestinal (GI) tract, hematobilia was first suspected and an arteriocholedochal fistula angiographically confirmed. Two days after resection of a pseudoaneurysm of the hepatic artery (HA) with primary repair and closure of the bile duct fistula, hepatic artery thrombosis (HAT) occurred. Various attempts to revascularize the HA eventually failed. Two weeks later, a CT scan showed necrotic areas within the two left lateral segments. At relaparotomy, major parts of the bile duct were found to be necrotic, and the biliary anastomosis was therefore abandoned and necrotic tissue removed. HAT was otherwise well tolerated by the graft and, at a further relaparotomy some weeks later, a hepaticojejunostomy was performed. Two years after transplantation the patient is well with a normally functioning graft.     

胆道手术中副肝管损伤的防治体会：附26例报告

目的: 总结胆道手术中防治副肝管损伤的经验。方法: 回顾分析近10年间发现的26例副肝管病例资料。结果: 26例病例中I型10例，占38.5％，均被切断、结扎，术后无胆汁漏、胆系感染或梗黄发生;II型7例，占26.9％，损伤3例,经相应处理，未发生并发症;III型6例，占23.1％，损伤2例,1例术后发生胆漏,经再次手术治愈。IV型2例，占7.7％，2例均得以保护，未损伤。V型1例，占3.8％，术前得以确诊，未损伤。结论: 为防止副肝管损伤，应加强术前、术中副肝管诊断，尤其是术中胆道造影。不同类型副肝管损伤，处理上应分别对待。对于I型胆囊胆管可切断结扎，II型汇入胆囊管的副肝管应尽量保护，如损伤，根据管径大小，采取不同处理方法。III型、IV型副肝管均应保护，防止损伤，如损伤，采用修补或内引流术，防止术后发生严重并发症。     

Intestinal malrotation and replaced common hepatic artery during duodenopancreatectomy: a case report

Background: Intestinal malrotation is a well-known anomaly in the normal rotation process of the midgut during embryogenesis. Multiple forms are described, resulting in various positional configurations of the small bowel and colon. Replaced common hepatic artery is a rare but not anecdotic variant of the standard hepatic vascularization, associated with surgical implications. Our aim is to explain the impact of their simultaneous presence during this procedure and the difficulty in identifying them preoperatively, despite imaging.

Patients and methods: These two abnormalities were simultaneously observed in our patient who underwent a duodenopancreatectomy for an adenocarcinoma of the head of the pancreas.

Results: In our case, intestinal malrotation and replaced common hepatic artery were discovered preoperatively. Malrotation made the dissection and kocherization more easier. Replaced common hepatic artery required a carefully skeletonized dissection, first posteriorly And then into the pancreatic parenchyma, before being partially resected and then primarily anastomosed.

Conclusion: Preoperative imaging is crucial to define the lesion resectability, the proximity with the tumor, and also to identify these vascular anomalies and their relation with the pancreas parenchyma, in order to adjust the surgical strategy and preserve them, avoiding many complications (massive hepatic necrosis, chronic biliary ischemia, bleedings, etc.). In this context, angioscanner with 3D reconstruction is considered as a gold standard and should always be performed before a duodenopancreatectomy     

左侧肾副动脉共干伴狭窄1例

<正>患者男,78岁,因"头晕、心悸,血压260mmHg/120mmHg"入院。临床诊断为高血压病3级极高危组。肾动脉超声:左肾动脉起始部管径变窄,其余段显示不清。肾动脉CTA(图1):左侧肾动脉近段局限性狭窄,未见明确斑块;左侧肾副动脉,可见2个分支,共同开口,共干长度约7mm,均起自腹主动脉,位于左肾动脉上方;较为粗大一支进入肾门,其近端可见混合斑块形成,管腔重度狭窄;较为细小一支进入左肾上极;右肾动脉未见明显异常。CTA诊断:左侧肾动脉近段局限性狭窄;左侧肾副动脉共干伴狭窄。     

An extremely uncommon variation of left hepatic artery around the esophagus: a case report

Abstract:  An extremely rare case of a replaced left hepatic artery (LHA) around the esophagus in a deceased multi-organ donor is reported. The liver could not be harvested unless either of the LHA or the esophagus was transected. This is the second report of a LHA off the left gastric artery with such a peculiar course around the esophagus. Whether to cut the artery or the hollow viscus in such a situation is controversial; nevertheless, a surgeon must precisely identify all the extrahepatic arteries during liver harvest, to prevent injuries that might result in compromised complete arterialization of the graft.     

腹腔镜胆囊切除术副肝管损伤的预防及处理(附8例报告)

目的:探讨预防腹腔镜胆囊切除术副肝管损伤及手术中处理的方法。方法:回顾总结腹腔镜胆囊切除术中8例副肝管损伤的临床资料。结果:损伤的副肝管均修补成功,术中确定的副肝管均予保留。结论:术中仔细解剖,尽量避免损伤不明的管状结构,对胆囊三角解剖不清者,中转开腹是减少肝外胆管损伤的必要措施。     

Aberrant right hepatic artery in laparoscopic cholecystectomy.

INTRODUCTION: Presented herein is a case in which an aberrant right hepatic artery (RHA) passes anterior to the infundibulum and fundus of the gallbladder and courses to an unusually anterior hepatic entry. CASE REPORT: A 54-year-old female with a history of biliary colic was scheduled for laparoscopic cholecystectomy. Laparoscopic dissection revealed an aberrant right hepatic artery (RHA) anterior to the infundibulum and fundus of the gallbladder. Further dissection revealed the cystic artery to branch laterally off this RHA over the gallbladder fundus anteriorly. The cystic artery then wrapped posterolaterally on the gallbladder's surface to its neck. After the gallbladder was removed, the aberrant RHA was readily visible traveling across the gallbladder bed and entering the liver at an unusually anterior location. Intraoperative images are included. The procedure was completed laparoscopically without complication. DISCUSSION: The origins and paths of both the cystic and right hepatic arteries have several documented anomalies. We are unaware of any reports of an RHA that transverses the entire neck and fundus of the gallbladder before such an anterior hepatic entry. Conclusion: This case serves as a striking reminder of the variations in extrahepatic biliary and vascular anatomy. Ligation of this uniquely located aberrant RHA could have led to intraoperative hemorrhage or potential hepatic ischemia.     

Clinical significance of reconstruction of the right hepatic artery for biliary malignancy

Background and aims The clinical significance of resectional surgery with reconstruction of the right hepatic artery for biliary malignancy remains unclear.Patients/methods Between 1990 and 2004, six patients (5%) with cholangiocarcinoma and five patients (3%) with gallbladder carcinoma with possible involvement of the right hepatic artery underwent resectional surgery with reconstruction of the right-sided hepatic artery. The surgical procedures included extended left hemihepatectomy (n=4), left trisectionectomy (n=1), central bisegmentectomy (n=1), resection of anterior segment and inferior area of segment 4 (n=2), resection of segment 5 and inferior area of segment 4 (n=1), and extrahepatic bile duct resection (n=2). Segmental resection and reconstruction of the right (n=7), anterior (n=1), or posterior (n=3) hepatic artery was performed by end-to-end anastomosis (n=5), using the right gastroepiploic artery (n=4), the gastroduodenal artery (n=1), or an autologous venous graft (n=1).Results There was no in-hospital mortality. Histopathological arterial involvement was present in seven patients, and the surgical margin was positive in five patients. The median survival was 23 months in R0 patients (n=6), while it was 13 months in R1 patients (n=5) (p=0.16).Conclusion Reconstruction of the right hepatic artery was safely performed in patients with biliary malignancy. Arterial reconstruction can be indicated when the arterial involvement is the only obstacle to obtain negative surgical margins.     

腹腔镜胆囊切除术中右肝动脉损伤的预防体会

目的:探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)中右肝动脉损伤的原因及预防措施。方法:2000年1月至2013年12月行6 000余例LC,其中5例发生右肝动脉损伤。结果:本组5例均为术中发现并及时处理。术后2~3 d抽血行肝脏功能等检查,均提示胆红素及酶学指标等有不同程度的升高,但术后1个月内复查均恢复正常。术后2例感觉肝区有轻微胀痛不适;1例发生低热,数天后消失。1例胆道支撑的T管,于术后6个月后拔除。术后患者均获随访,随访6~24个月,平均(20.4±2.1)个月,患者均恢复良好,无并发症发生。结论:LC术中发生右肝动脉损伤往往是多种因素共同作用的结果。有效避免或降低LC术中右肝动脉损伤的发生,关键是术者应时刻保持发生右肝动脉损伤的警惕性,处处小心、步步提防,并根据手术经验采用不同的方式进行预防,术中必须严格遵循LC的相关操作原则。     

Central hepatic bisectionectomy with hepatic artery and biliary tracts reconstruction for the patient with nodular type intrahepatic hilar cholangiocarcinoma: A case report

Introduction and importanceA central hepatic bisectionectomy (CHBS) for a hilar cholangiocarcinoma (CCA) is technically challenging because bilateral biliary reconstruction is required after resection. On the other hand, hepatic artery resection and reconstruction in a major liver resection are also technical procedures. In this report, we describe our radical CHBS with hepatic artery and biliary tracts reconstruction for a patient with nodular type intrahepatic hilar CCA.Case presentationA 76-year-old man was referred for further investigation of an incidental hepatic tumor. The hepatic tumor was located from medial sector to anterior sector with encasement of the anterior branch of the right hepatic artery. Based on these findings, we performed a CHBS with right hepatic artery and biliary tracts reconstruction. The histopathological findings revealed that the tumor consisted of moderately differentiated tubular adenocarcinoma with tumor necrosis without a fibrous capsule. In this area, tumors cells had invaded branches of the hepatic vein; however, there was no destructive invasion to the hepatic artery. Consequently, he was diagnosed with a nodular type intrahepatic hilar CCA with pT2aN0M0.Clinical discussionA CHBS is usually performed with the intent of anatomically preserving a patient’s liver as much as possible. Concomitant resection and reconstruction of the hilar vessels and biliary tracts with CHBS is one of the most technically challenging procedures in liver resections.ConclusionA CHBS with hepatic artery and biliary reconstruction may be a promising alternative if expert surgeons perform it on strictly selected patients.     

Surgical treatment of a huge hepatic artery aneurysm —A case report—

A debilitated 68 year old woman with an epigastric mass previously identified as a hepatic artery aneurysm (HAA) by selective angiography, developed acute epigastric pain radiating to her back. Impending rupture was diagnosed, and the patient successfully underwent surgical repair using a prosthetic patch to close the orifice of the aneurysm. HAA is uncommon, but the risk of rupture is great, being 44 per cent and the mortality rate high, being 35 per cent. Abnormal ultrasonography and CT may suggest the diagnosis, but selective arteriography is definitive. Surgical treatment is indicated in most patients, although embolization is appropriate for intrahepatic aneurysm and extremely poor risk patients.     

Dissecting aneurysms of the anterior cerebral artery and accessory middle cerebral artery. Case report

A 66-year-old woman presented with dissecting aneurysms of the anterior cerebral artery (ACA) and accessory middle cerebral artery (MCA) manifesting as subarachnoid hemorrhage but without radiological evidence of the dissecting aneurysms. Intraoperative observation revealed that the vessel walls were dark purple in color, a typical finding of dissecting aneurysm. The abnormal A1 segment was trapped and the dissecting aneurysm of the accessory MCA was wrapped. In the case of SAH of unknown origin, dissecting aneurysm should always be kept in mind even if the angiogram does not show any abnormal finding. This is the first reported case of dissecting aneurysm of the accessory MCA.     

Successful management of concomitant omphalocele, accessory hepatic lobe, and biliary atresia in a 44-day-old boy

We report the second case in literature of a boy with the association of large omphalocele, accessory hepatic lobe, and biliary atresia, and the first successful treatment. The patient was submitted to a surgical treatment at 44 days of life, including Kasai procedure, correction of the remnant abdominal wall defect, and removal of a hepatic accessory lobe. The boy evolved with normalization of hepatic function tests. After 15 years of follow-up, the patient is completely healthy, weights 45 kg, and is 1.64 m tall.     

Cholangiojejunal fistula caused by bile duct stricture after intraoperative injury to the common hepatic artery

A 68-year-old man, admitted for the treatment of recurrent cholangitis after a pancreatoduodenectomy (PD) performed 3 years previously was diagnosed as having multiple hepaticolithiasis. On laparotomy, the hepatic artery was not recognized. The anastomosed common hepatic duct was obstructed, and a fistula had been formed between the right hepatic duct and the Roux limb of the jejunum. Lithotripsy was performed from this fistula and it was reanastomosed. Angiography was performed postoperatively and it revealed common hepatic artery injury, most likely to have occurred during the previous PD. The patient's postoperative course was uneventful and he has been asymptomatic for 8 months after the operation, indicating that reanastomosis of the fistula can be an effective method. The stricture of the anastomosis was suspected to be mainly due to cholangial ischemia, because no episode of anastomotic leak or retrograde biliary infection had occurred during the PD perioperative period. There are several reports of late stricture of anastomosis 5 or more years after cholangiojejunostomy. This patient, therefore, requires further long-term follow up. Received: August 16, 2001 / Accepted: November 16, 2001     

Medial thickening of hepatic artery branches in biliary atresia. A morphometric study

Background/Purpose

Medial layer hypertrophy of hepatic arterial branches may be associated with biliary atresia (BA) pathogenesis. This study aimed at evaluating medial layer thickness in hepatic arterial branches at portoenterostomy and liver transplantation.

Methods

The authors evaluated 1274 arterial branches both in BA cases and in control subjects involving a total of 1108 arterioles and 166 arteries. Arterial branch characteristics were morphometrically evaluated in 47 BA patients at the time of portoenterostomy. Controls were patients with intrahepatic cholestasis (n = 3), immature neonates (n = 7), and infants (n = 7) without liver disease. Progression of medial layer thickening between the time of portoenterostomy and transplantation was evaluated in 7 BA patients. Biliary atresia patients at the time of transplantation were compared with non-BA-transplanted patients (n = 4).

Results

The arterial medial layer of BA cases at portoenterostomy was thicker than that of infants without liver disease (P = .03). The arterial medial thickness increased during the interval between portoenterostomy and transplantation (P = .05). Arterioles and arteries with thickened medial layers were found in transplanted BA patients but not in patients transplanted for other liver diseases (P = .05 and P = .01). Thickening of the medial layer of the hepatic arteries was associated with focal distribution of interlobular bile ducts in portal spaces in BA (P = .02).

Conclusions

In BA, there is a progressive thickening of the arterial medial layer, suggestive of vascular remodeling, which is associated to the disappearance of interlobular bile ducts.     

Biliary complications secondary to late hepatic artery thrombosis in adult liver transplant patients

Abstract Biliary complications (BC) are the usual presentation of late hepatic artery thrombosis (HAT) of the liver graft. Our aim was to study the clinical features and outcome of BC secondary to HAT compared to BC which occurred in liver transplant (LT) patients with patent vessels. We present a retrospective study of 224 LTs performed in 204 patients between 1988 and 1996. The mean recipient x s age was 51 years. A choledochocholedochostomy without T-tube was used as biliary reconstruction in most cases (67%); in 12%, a choledochojejunostomy was performed. An iliac conduit was necessary in 15 % of cases and back-table arterial reconstruction was performed in 10 % of cases of anatomic variants in graft arteries. Different donor, recipient and intraoperative variables, as well as treatment and outcome, were studied in the two groups of patients presenting BC with or without HAT. BC occurred in 38 cases (17%) whereas HAT was diagnosed in 11 cases (4.9%). Therefore, 23 % of BC encountered after LT were secondary to HAT. Nine cases of late HAT manifested as BC, septicaemia (88 %) and hepatic bilomas (8 cases). Percutaneous or surgical drainage of hepatic bilomas was performed in all cases, followed by retransplantation in six cases (66%). BC secondary to HAT appeared later than the rest of BC. Donor age was the only significant predisposing factor found in our study. Graft survival is significantly reduced as most patients needed re-transplantation. In conclusion, BC secondary to HAT presented later in livers from older donors in the form of biliary sepsis and hepatic biloma. Retransplantation was ultimately required in most cases and graft survival was significantly diminished.     

Biliary atresia with aneurysmal dilatation of hepatic artery: A rare anomaly

INTRODUCTIONThe coexistent biliary atresia with aneurysmal dilatation of hepatic artery is a rare association. To know these anomalies will avoid many per operative complications. It is also important to mention that these children require liver transplantation in the long run then these vascular anomalies become more relevant.PRESENTATION OF CASEA four month old male child presented with features of biliary atresia. On exploration a cystic expansile mass was detected beneath thread like common bile duct. Subsequent aspiration and studies proved it to be aneurysmal dilatation of hepatic artery.DISCUSSIONWith biliary atresia many vascular and cardiac malformations have been described but aneurysmal dilatation of hepatic artery is a rare association. These anomalies may have impact on aetiopathogenesis of biliary atresia and also future liver transplantation.CONCLUSIONAwareness of rare association of hepatic artery aneurysm with biliary atresia will help in understanding aetiopathogenesis of biliary atresia and planning liver transplantation in such cases.