Traumatic common hepatic artery injury causing isolated right hepatic ischemia due to a left accessory artery. A case report

IntroductionHepatic arterial liver flow is renowned for its redundancy. Previous studies have demonstrated that the common hepatic artery is not essential for liver survival. We present a case of a 31year-old involved in a high-speed motor vehicle accident whose liver survived thanks to the presence of an accessory hepatic artery.Presentaton of the caseWe present the case of a 31year-old male who sustained a traumatic injury of the proper hepatic artery following a motor vehicle accident. The patient suffered temporary right liver lobe ischemia due to the presence of an accessory left hepatic artery. This resulted in the selective formation of ‘biliary lakes' distinctively within the territory of the right hepatic artery supply.Simultaneously the patient developed a pseudo-aneurysm of the proper hepatic artery which required radiology intervention. At the time of pseudo-aneurysm embolisation, a rich network of arterial collaterals had formed between the accessory left hepatic and the inferior phrenic artery. On follow up the biliary lakes to the right lobe had resolved, but a small area at the periphery of the right lobe had encountered atrophy.DiscussionThis case report is an ‘in vivo’ demonstration of liver resilience to arterial flow re-distribution and demonstrates the ability of the biliary epithelium to recover from and ischemic injury.ConclusionParenchymal liver survival is mostly independent from flow within the common hepatic artery. Acute and chronic liver parenchyma changes following interruption of hepatic artery flow can still occur.     

Aberrant left hepatic arteries arising from left gastric arteries and their clinical importance

BackgroundThe Aberrant Left Hepatic Artery (ALHA) is replaced when it does not originate from the hepatic artery proper and it is the only supply to that part of the liver, while an accessory artery coexists with a normal artery. The aim of this systematic review is to evaluate the incidence of ALHAs including the one arising from the Left Gastric Artery, also named Hyrtl's artery.MethodsA literature search in PubMed, SCOPUS, WOS and Google Scholar was performed. The risk of bias was assessed by means of the AQUA tool. The main outcome was the prevalence of ALHA. Secondary outcomes were the prevalence of the accessory and replaced left hepatic arteries. A subgroup analysis was conducted by geographic region and type of evaluation.ResultsThis review included 57 studies, with a total of 19,284 patients. The majority of the studies involved the use of radiological techniques -especially Angio-CT-and were performed in Asia. The overall risk of bias was moderate. The overall prevalence of the ALHA was 13.52%; the overall prevalence was 8.26% for the Replaced ALHA and 5.55% for the Accessory ALHA. In the 18 studies that employed Michels' classification, Type II had the lowest prevalence (0.36%) and Type VII the highest prevalence (6.62%).DiscussionSome of the studies included did not distinguish between the ‘‘replaced’’ and ‘‘accessory’’ ALHA (34.25%). Some surgical dissection techniques proved insufficient for the localization of other hepatic arteries. These results suggest that an accurate preoperative radiological evaluation is needed to localize replaced arteries.     

起源于肝动脉的副胃左动脉DSA表现

目的观察起源于肝动脉的副胃左动脉(ALGA)的DSA表现。方法回顾性分析500例肝脏肿瘤患者腹腔动脉和肝动脉DSA影像,观察起源于肝动脉的ALGA、并分析其发生率。结果 500例患者中,共39例(39/500,7.80%)发现ALGA,其中起源于肝左动脉弓27例(27/39,69.23%),肝固有动脉5例(5/39,12.82%),迷走肝左动脉7例(7/39,17.95%)。另外发现4例(4/500,0.80%)左膈下动脉起源于肝左动脉,其中3例发出胃上动脉供应胃底。共22例发生ALGA或左膈下动脉胃上支化疗药物误灌注,9例发生碘油乳剂误栓。结论起源于肝动脉的ALGA并不少见,正确认识此类血管变异对肝脏肿瘤和胃部疾病的介入治疗具有重要意义。     

The feasibility of combined resection and subsequent reconstruction of the right hepatic artery in left hepatectomy for cholangiocarcinoma

BackgroundCombined resection of the right hepatic artery (RHA) is sometimes required to achieve complete resection of hilar cholangiocarcinoma. The present study aimed to evaluate the feasibility of combined resection and subsequent reconstruction by continuous suture of the RHA during left hepatectomy for cholangiocarcinoma.Materials and methodsWe retrospectively compared the outcomes after left hepatectomy with biliary reconstruction for cholangiocarcinoma between patients with and without RHA resection and reconstruction.ResultsOf the 25 patients who underwent left hepatectomy combined with biliary reconstruction, eight patients (32%) underwent combined resection and reconstruction of the RHA (AR group). The demographic characteristics were not different between the AR and non-AR groups. The amount of intraoperative bleeding was significantly greater in patients with AR (2350 mL vs. 900 mL, p = 0.017). The prevalence of early complications above grade III in Clavien–Dindo classification and late complications were not significantly different between the AR and non-AR groups. In the AR group, complications directly associated with AR, such as thrombosis or reanastomosis, were not observed. On Kaplan–Meier analysis, recurrence-free survival (p = 0.618) and overall survival (p = 0.803) were comparable between the two groups despite the advanced T stages in the AR group.ConclusionsCombined resection and subsequent reconstruction of the RHA during left-sided hepatectomy is a feasible treatment alternative for cholangiocarcinoma.     

Investigation of proper hepatic artery and gastroduodenal artery variations by multidetector computed tomography angiography method

Abstract

Purpose: The purpose of this study is to evaluate the clinical anatomic variations of the proper hepatic artery (PHA) and the gastroduodenal artery (GDA). For this purpose, angiographic images of patients were evaluated.

Materials and methods: We retrospectively reviewed the multiple-detector computed tomography angiography images of 671 patients.

Results: In this retrospective study, 35 different types were identified as associated with PHA and GDA. There were 292 patients (43.52%; 175 females and 117 males) included in normal anatomical classification. Different anatomic variations were detected in 300 patients (44.71%; 129 females and 171 males). In 79 patients, arterial branch follow-up failed. These patients were evaluated as an unidentified group.

Conclusion: We described different vascular variations in the PHAs and GDAs of our patients.     

Common hepatic artery as an inflow site for off-pump coronary artery bypass grafting

We used the common hepatic artery (CHA) as an inflow site for a saphenous vein graft bypass to the right coronary system during off-pump coronary artery bypass grafting. The CHA is a suitable inflow vessel to provide sufficient blood flow and a short-distance bypass in case both the ascending aorta and the gastroepiploic artery are considered inadequate.     

肠系膜上动脉变异肝动脉在肝癌及胃癌手术中的意义

目的 了解源自肠系膜上动脉的变异肝动脉走行特征,指导肝癌及胃癌手术操作.方法 研究选择广西医科大学第一附属医院2008年6月至2010年6月间400例经数字减影血管造影(digital subtraction angiography,DSA)及多层螺旋CT血管造影(multislice spiral computed tomography angiography,MSCTA)检查的肝癌患者以及86例术前经MSCTA检查的胃癌患者.术前通过影像学资料了解源自肠系膜上动脉的变异肝动脉的走行情况.将胃癌根治术中变异肝动脉周围组织分离后,行重组人细胞角蛋白20(recombinant human cytokeratin 20,CK20)、癌胚抗原(carcino-embryonic antigen,CEA)免疫组化判断淋巴结转移的发生.结果 全组486例患者中存在源自肠系膜上动脉变异者63例(12.96％),肝癌患者49例、胃癌患者14例.变异肝动脉走行于胰腺前方的2例(3.17％)、胰腺后方的61例(96.83％).胃癌患者变异肝动脉周围组织CK20、CEA免疫组化均为阴性,提示无转移发生.结论 源自肠系膜上动脉的变异肝动脉走行可分为胰前型和胰后型,以后者占多数.术前了解变异肝动脉的走行对于需行肝门部淋巴结清扫的肝癌及胃癌患者具有一定临床意义.     

同种异体原位肝移植的复杂肝动脉重建经验总结

目的  总结同种异体原位肝移植术中复杂肝动脉重建的相关经验。方法  回顾性分析2015年1月至2019年3月期间行复杂肝动脉重建的7例肝移植受者资料。其中4例经典肝移植,3例背驮式肝移植。观察受者术中的一般情况,包括无肝期、术中出血量、肝动脉吻合时间、手术时间; 观察受者预后情况及并发症发生情况。结果  2例供者变异右肝动脉重建血管,分别用供者腹腔干或肝总动脉与受者肝总动脉吻合; 2例用髂动脉搭桥,然后供者肝动脉与受者腹主动脉吻合; 1例供者肠系膜上动脉与受者肝总动脉端端吻合; 1例供者腹腔干与受者脾动脉吻合; 仅1例因肝动脉吻合后出现急性肝动脉血栓,需再次行肝移植。6例肝移植受者均顺利完成手术,无围手术期死亡,无肝期49~77 min,术中出血量300~1 500 mL,肝动脉吻合时间23~56 min,手术时间5.3~11.1 h。术后住院时间23~56 d,均未出现肝动脉血栓、狭窄。所有受者术后2周内肝功能基本恢复正常,无严重外科并发症发生,移植肝均获得良好的功能。结论  正确辨别肝动脉有否变异,选择适宜的方式处理供、受者肝动脉并重建新肝动脉血供,是肝移植术中的关键步骤。     

The use of left grafts with a replaced or accessory left hepatic artery in adult‐to‐adult living donor liver transplantation: analyses of donor and recipient outcomes

In living donor liver transplantation (LDLT), a left hepatic graft occasionally includes a replaced or accessory left hepatic artery (LHA). The procuring of such grafts requires extensive dissection along the lesser curvature of the stomach to elongate the replaced or accessory LHA on the donor side. On the recipient side, complicated arterial reconstruction is often necessary to use such grafts. We retrospectively reviewed the medical records of 206 adult recipients who underwent LDLT and their respective donors. The recipients and donors were divided into two groups according to the presence of the replaced or accessory LHA. Twenty‐five grafts included a replaced or accessory LHA. Only one hepatic artery‐related complication was observed in the current series, in which a pseudoaneurysm arose at the site of anastomosis between the donor accessory LHA and the recipient LHA. There was no increase in the incidence of postoperative complications in the donors with a replaced or accessory LHA in comparison with the donors without these arteries. The use of left hepatic grafts that included a replaced LHA or accessory LHA did not have any negative impact on the outcomes on either the donor or the recipient side.     

不规则肝切除加肝动脉置泵治疗肝癌疗效分析

目的评价不规则肝切除加肝动脉置泵化疗对肝癌术后复发率及生存率的影响.方法对比分析近15年来66例肝癌患者单纯肝切除(48例)与肝切除加肝动脉置泵化疗(18例)的临床资料.结果单纯手术组与手术联合化疗泵组1、3、5年术后复发率分别为66.7%对38.9%、85.4%对55.6%、93.8%对72.2%,差异有显著性(P＜0.05).两组病人1、3、5年生存率分别为58.3%对88.9%、41.7%对72.2%、12.5%对38.9%,差异有显著性(P＜0.05).结论肝癌不规则肝切除加肝动脉置泵化疗可明显降低术后复发率、提高生存率.     

Ciliated hepatic foregut cyst of the left hepatic vein

Ciliated hepatic foregut cyst is an extremely rare condition observed most frequently in the left hepatic lobe of young men. This report describes an unusual case of ciliated hepatic foregut cyst with involvement of the left hepatic vein in a 68-year-old woman. Preoperative imaging studies demonstrated characteristics of a solid tumor that were suggestive of a leiomyosarcoma of the inferior vena cava. Magnetic resonance venography confirmed a mass in the anterolateral wall of the inferior vena cava or in the left hepatic vein. This report confirms the unusual occurrence of this tumor and the confusing factors related to the diagnostic workup.     

Celiac axis occlusion with replaced common hepatic artery and pancreatoduodenectomy

A rare case of intraductal papillary mucinous tumor of the pancreas associated with a replaced common hepatic artery and celiac axis occlusion, which was treated by pancreatoduodenectomy, is reported. In this patient, the celiac trunk was occluded at its root and the splenic and left gastric artery could be visualized serially via the enlarged collateral artery on superior mesenteric arteriography. At surgery, the collateral artery was carefully preserved and pancreatoduodenectomy was successfully performed without ischemia of the stomach, spleen, and remnant pancreas. Although celiac axis occlusion is an uncommon finding for patients undergoing pancreatoduodenectomy, we recommend performing celio-mesenteric angiography before pancreatoduodenectomy, and, at surgery, clamping of the gastroduodenal artery is required for patients with celiac axis occlusion.     

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.     

肝动脉鞘切除术对门静脉高压症肝动脉血流量影响的研究

因肝硬化门静脉高压择期行脾切除门奇断流术２０例按入院先后分为两组（各１０例）。加肝总动脉鞘切除作处理组。术前、术后２周、术后３个月用超声多普勒直固有动脉、门静脉血流量。处理组术后２周肝固有动脉血流量交术前增３０％，术后３个月仍维持较术前增加１８％的量，最高可达４０％。病人住院时间较对照组平均少５天。门 干血流量未受肝固有动脉血流量增加的影响。门奇断流术不减少病人肝门静脉血流量，手术中加作肝总动脉鞘     

Preservation of an aberrant left hepatic artery during laparoscopic nissen fundoplication.

OBJECTIVE: Laparoscopic Nissen fundoplication is performed in neonates and children for significant gastroesophageal reflux. An aberrant left hepatic artery encountered during laparoscopic Nissen fundoplication makes dissection around the esophageal hiatus more difficult if the artery is not transected. Although some suggest division of the aberrant left hepatic artery, this is associated with risk of significant hepatic injury from ischemia. We routinely preserve the aberrant left hepatic artery and sought to determine (1) the incidence of aberrant left hepatic artery and (2) the results following preservation of the aberrant left hepatic artery. METHODS: Between January 2000 and October 2002, 195 laparoscopic Nissen fundoplications were performed. We documented intraoperative findings of each procedure, and reviewed postoperative radiographic studies and clinic visits. RESULTS: In 30 patients (15%), an aberrant left hepatic artery was identified. All dissections were performed laparoscopically with the Nissen fundoplication positioned cephalad to the aberrant left hepatic artery. Postoperatively, 2 patients (6%) have had evidence of wrap failure. The remainder of the patients has had normal radiographic studies or no clinical evidence of reflux during clinic visits. CONCLUSION: During laparoscopic Nissen fundoplication in neonates and children, an aberrant left hepatic artery may be encountered in approximately 15% of patients. When an aberrant left hepatic artery is identified, it should be preserved to avoid the potential risk of hepatic ischemic injury.     

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.     

Hemobilia as a result of right hepatic artery pseudoaneurysm rupture: An unusual complication of laparoscopic cholecystectomy

INTRODUCTION

Laparoscopic cholecystectomy has many complications which may be seen due to anatomical variations, lack of experience of the surgeon or three dimensional visualization, or insufficient exposure of the surgical field; including vascular injuries. Here we present a case of pseudoaneurysm of the right hepatic artery leading to hemobilia after rupturing into the biliary system.

PRESENTATION OF CASE

A 43-year-old male patient presented to our clinic 3 weeks post laparoscopic cholecystectomy with right upper quadrant pain, melena and hematemesis. After stabilizing the patient, Doppler ultrasonography, abdominal computer tomography and selective right hepatic artery angiography were performed and a pseudoaneurysm was established on the anterior posterior bifurcation of right hepatic artery. Right hepatic artery ligation and a T-tube placement after choledocotomy were performed. The patient recovered completely.

DISCUSSION

Pseudoaneurysms of the hepatic artery may arise as a complication of laparoscopic cholecystectomy. Clip encroachments, mechanical or thermal injury during the procedure are likely to be precipitating factors. Today, transarterial embolization (TAE) is the gold standard for the management of hemobilia, and if it fails, the next step in management is surgical. Surgery is limited to extra-hepatic or gallbladder bleeding, and for TAE failure.

CONCLUSION

In cases of GI bleeding the awareness of the surgeon should be drawn to a clinical suspicion of hemobilia and an underlying hepatic artery pseudoaneurysm that can arise as a complication. CT angiography should be performed for early diagnosis and management in such patients.     

选择性左肝动脉结扎在腹腔镜肝切除术中的应用

目的:探讨选择性左肝动脉结扎用于腹腔镜肝切除术的可行性。方法:回顾分析2008年10月至2009年7月我院为19例左肝内外胆管结石、血管瘤患者行腹腔镜肝切除术中行选择性左肝动脉结扎的临床资料。结果:19例手术均获成功,术中出血20~200ml,平均80ml,手术时间90~420min,平均240min,术后住院4~9d,平均5.9d,术后病理示无恶变,无肝脏衰竭、出血、胆漏及膈下脓肿等并发症发生。结论:腹腔镜左肝切除术中选择性左肝动脉结扎术能减少术中出血,安全可行。     

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