Aberrant hepatic artery in patients undergoing pancreaticoduodenectomy.

BACKGROUND: It is very important to keep the integrity of the hepatic artery blood supply in patients treated by pancreaticoduodenectomy. Knowing and identifying hepatic artery anomalies is helpful to avoid injuring them during the procedure of pancreaticoduodenectomy in patients with ampullary tumors (including cancer in the pancreatic head).

METHODS: Aberrant hepatic artery in patients with ampullary tumors was identified by multislice computed tomography (CT) and digital subtraction angiography (DSA) in our institute between April 2002 and June 2006. Clinical data of patients treated with pancreaticoduodenectomy were reviewed. Hepatic artery anomalies were classified by the Michels method.

RESULTS: 15 patients treated with pancreaticoduodenectomy had hepatic artery anomalies (9 males, 6 females; mean age 58.3 years, range 25-72 years). Patients were given preoperative examination consisting of contrast-enhanced CT (n = 15) and celiomesenteric angiography (n = 10). Pylorus-preserving pancreaticoduodenectomy (PPPD) was performed in 7 patients, and radical pancreaticoduodenectomy in the other 8 cases. Hepatic artery anomalies were diagnosed as Michels type II (n = 3), with a replaced left hepatic artery arising from the left gastric artery; Michels type III (n = 6), with a replaced right hepatic artery branching off the superior mesenteric artery; Michels type V (n = 2), with a dual arterial supply with an accessory left hepatic artery that arose from the left gastric artery; Michels type VI (n = 3), with a dual arterial supply with an accessory right hepatic artery that arose from the superior mesenteric artery, and Michels type IX (n = 1), with the common hepatic artery originating from the superior mesenteric artery. The aberrant hepatic arteries were correctly identified on CT scan in 10 cases, with an accuracy of 67% (10/15). The anomalies were detected by DSA in all the 10 cases, and the accuracy was 100% (10/10). All the aberrant hepatic arteries except one were successfully preserved during the operation, with no surgical mortalities and postoperative complications in 6 patients (40%).

CONCLUSIONS: It is inferredthat hepatic artery anomalies are not rare in patients with ampullary tumors. Preoperative CT and angiography should play a critical part in the preoperative evaluation of hepatic artery anomalies whenever and wherever available. and IAP.