Preserving a Replaced Left Hepatic Artery Arising from the Left Gastric Artery During Laparoscopic Distal Gastrectomy for Gastric Cancer.

BACKGROUND: A replaced left hepatic artery (RLHA) arising from the left gastric artery (LGA) is occasionally encountered during laparoscopic gastrectomy. Although the RLHA is usually divided at the root level as RLHA preservation might result in inadequate lymph node dissection, blood flow disruption by RLHA division may lead to hepatic ischemia. To date, there is no consensus on RLHA preservation. Thus, we aimed to evaluate the efficacy of RLHA preservation by investigating the short-term outcomes of patients with RLHA who underwent laparoscopic distal gastrectomy (LDG). METHODS: A total of 106 patients with an aberrant LHA from the LGA were identified as having gastric cancer and underwent LDG from 2012 to 2018. Finally, 55 patients were retrospectively diagnosed with RLHA by preoperative computed tomography and included in this study. Patients were classified into the divided (n = 18) or preserved (n = 37) group. Clinicopathological factors and surgical outcomes were compared between the two groups. RESULTS: The RLHA preservation rate in patients who had been preoperatively diagnosed with RLHA was 88%. No significant difference was found in the number of harvested lymph nodes between the groups. The incidence of hepatic infarction was significantly higher in the divided group (16.7% vs. 0%, p = 0.031). Moreover, RLHA division caused postoperative transaminase elevation and was an independent risk factor for postoperative transaminase elevation (odds ratio: 55.8, p < 0.001). CONCLUSIONS: Surgical procedures of RLHA preservation reduced postoperative transaminase elevation and hepatic infarction in patients who underwent LDG. Surgeons should confirm the RLHA preoperatively and preserve it to prevent hepatic damage.

Quadrifurcation Variants of the Celiac Trunk.

BACKGROUND: The celiac trunk (CT) commonly trifurcates into the left gastric artery, common hepatic artery (CHA), and splenic artery (SA). The CHA then sends off the proper hepatic artery and gastroduodenal artery (GDA). The arcades of the head of the pancreas are celiacomesenteric anastomoses between branches of the GDA and the superior mesenteric artery. A quadrifurcation of the CT commonly occurs when a different branch is added to the 3 normal ones. An uncommon quadrifurcation of the CT occurs when only one or 2 of the normal branches of the CT participate. METHODS: The CT quadrifurcations were documented on 112 computed tomography angiograms. RESULTS: Five different types of CT quadrifurcation-3 uncommon (types 1-3) and 2 common (types 4-5)-were found in 15/112 cases (13.39%). A marginal significant association was found between the presence of quadrifurcations and male gender (P = 0.05; Fisher's exact test). Type 1 showed a hepatogastric trunk+SA + right hepatic artery+GDA pattern, type 2 had an HGT + right inferior phrenic artery + CHA + SA pattern, type 3 had a gastrophrenic trunk + left inferior phrenic artery+CHA + SA pattern, type 4 showed an left gastric artery + CHA + SA + left inferior phrenic artery combination, and type 5 had an additional common inferior phrenic trunk. One of the type 4 cases showed a buildup of a mesentericomesenteric anastomotic pancreatic arcade between the inferior pancreaticoduodenal arteries, rather than a celiacomesenteric one. CONCLUSIONS: Anatomic variation of the celiacomesenteric axis is important during hepatobiliary and duodenopancreatic approaches. Therefore, preoperative evaluation is essential because theoretical anatomic possibilities could be real arterial variants.

Unusual development of the celiac trunk and its clinical significance / Desenvolvimento incomum do tronco celíaco e sua importância clínica

Abstract We describe a case of unusual development of the celiac trunk observed in the cadaver of 1-year old male child. The celiac trunk branched into five vessels: the splenic, common hepatic and left gastric arteries, the left inferior diaphragmatic artery, and a short trunk that branched into the right inferior diaphragmatic artery and right accessory hepatic artery. Additionally, the manner of branching of the vessel was unusual: it was possible to distinguish two branching points that corresponded to its s-shaped trajectory. There were also other variations of vascular supply, such as the presence of a left accessory hepatic artery, an additional superior pancreatoduodenal artery, and others. It should be noted that multiple developmental variations can be common in clinical practice and clinicians should be aware of them during diagnostic and interventional procedures.

Resumo Apresentamos um relato de caso de desenvolvimento incomum do tronco celíaco em um cadáver do sexo masculino de 1 ano de idade. O tronco celíaco ramificou-se para cinco vasos: as artérias esplênica, hepática comum e gástrica esquerda, a artéria diafragmática inferior esquerda e um tronco pequeno que se ramificou para a artéria diafragmática inferior direita e para a artéria hepática direita acessória. Além disso, a forma como o vaso se ramificou foi incomum: é possível distinguir dois pontos de ramificação que correspondem à trajetória em formato de S. Também houve outras variações do suprimento vascular, como a presença da artéria hepática esquerda acessória, da artéria pancreaticoduodenal superior acessória e outras. Cabe observar que a variação de desenvolvimento múltipla pode ser comum na prática clínica, e os médicos devem estar cientes dela durante os procedimentos de diagnóstico e intervenção.

Hepatic arterial system anomalies encountered during pancreaticoduodenectomy - our experience.

We present our experience of incidence and management of aberrant hepatic arterial anatomy encountered during pancreaticoduodenectomy (PD). Patients undergoing PD between December 2014 and November 2016 at the Shaukat Khanum Memorial Cancer Hospital, Lahore were included in this short report. Preoperative imaging and operative findings of these patients were reviewed to evaluate the hepatic arterial anatomy and classified according to Hiatt classification. Sixty-four PD were performed with aberrant arterial anatomy identified in 24 (37.5%) of the cases. Most common anomaly was replaced right hepatic artery (rRHA) arising from the superior mesenteric artery seen in seven (11%) of the patients. Aberrant vessels were recognised and preserved in 23 cases. In one patient, the rRHA was coursing through the pancreatic parenchyma needing resection and reconstruction with uneventful postoperative recovery. Hepatic arterial anomalies are common and it is possible to preserve these vessels with careful surgical dissection using artery first technique.

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

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.

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

BACKGROUND: The 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. METHODS: A 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. RESULTS: This 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%). DISCUSSION: Some 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.

Unusual anatomical variation: tetrafurcation of the celiac trunk.

The celiac trunk is one of the main sources of vascularization of the supracolic abdominal compartment. It arises from the abdominal aorta, at the level of T12-L1 vertebrae and classically branches into the splenic artery, common hepatic artery, and left gastric artery. We report here an atypical branching pattern of the celiac trunk, found during the dissection of a 60-year-old female's formalin-fixed cadaver. The atypically celiac trunk gave rise to four branches: a common trunk for left and right inferior phrenic arteries, an accessory left gastric artery, the common hepatic artery, and a splenogastric trunk. Knowledge in detail about normal anatomy and variation in the branching pattern of the celiac trunk is important in surgical, oncological, and radiological interventional procedures and must be taken into account to avoid possible complications.

Hepato-spleno-mesenteric trunk, in association with an accessory left hepatic artery, and common trunk of right and left inferior phrenic arteries, independently arising from left gastric artery: case report using MDCT angiography.

The authors report the case of a 53-year-old male found to have an extremely rare case of a triple anatomical variation highlighted by multidetector computed tomography (MDCT) angiography, with the presence of a hepato-spleno-mesenteric trunk (HSMT) in association with an accessory left hepatic artery (ALHA) and a common trunk origin of right (RIPA) and left (LIPA) inferior phrenic arteries from left gastric artery (LGA) arising independently from the abdominal part of aorta (AA). The HSMT with an endoluminal diameter of 10.9 mm at its origin, and a length of 4 mm arose from the anterior wall of the AA at the level of 1∕2 upper part of the L1 vertebral body. From the distal portion of HSMT, give birth to the hepato-splenic trunk (HST) and to the superior mesenteric artery (SMA). HST, with a diameter at origin of 9.2 mm and 22.3 mm long, has an upward trajectory and done with the anterior face of AA an open angle to the top of 69°. From the distal part of the HST, arise common hepatic artery (CHA) and splenic artery (SA). The LGA, with an endoluminal diameter of 4.2 mm at origin, arose directly from the anterior wall of the AA at the level of the lower 1∕3 of T12 vertebral body, 8.2 mm above the origin of the HSMT. It ran upwards in front of the AA and after 59.5 mm gave rise to an ALHA. At 18.6 mm from its aortic origin, LGA gives birth to an inferior phrenic artery trunk (IPAT), which has at origin an endoluminal diameter of 2.6 mm and a length of 2.4 mm. The RIPA and LIPA have to origin a diameter of 2.3 mm and 1.7 mm, respectively. Knowledge of this anatomical variation is important for anatomists, interventional radiologists, vascular medicine experts, oncologists, vascular, and hepatic surgeons.

Common hepatic artery arising from the left gastric artery: a case report using MDCT angiography and a brief review of the literature.

We report a very rare case of a 67-year-old male with the presence of a common hepatic artery (CHA) arising from the left gastric artery (LGA) in association with a presence of a gastro-splenic trunk (GST), found incidentally on multidetector computed tomography (MDCT) angiography, used to investigate peripheral vascular disease. The GST arises from the anterior aspect of the abdominal aorta (AA), at the level of lower 1∕3 of L1 vertebral body. The GST has a slightly concave trajectory to the right, and ends dividing into splenic artery (SA) and LGA. In the initial part of its trajectory, the SA it is wedged at 180°, pointing to the left, to the splenic hilum. The LGA has two different portions: the first dilated, initially oriented towards the higher, and then aligns to the infero-lateral left and gives birth to the second portion; the narrow portion, oriented initially horizontally, and then lower to the right. Dilated portion of LGA is continued with CHA. The CHA trunk is cuddling in a horizontal plane, at 180°, and is then oriented towards the fissure of the ligamentum venosum for entering in the liver parenchyma. At 51.7 mm from the origin, the CHA gives rise to the left hepatic artery (LHA), and after another 58 mm to the right hepatic artery (RHA), and finally continues with the gastroduodenal artery (GDA). Knowledge of this anatomical variation should be considered in planning and performing vascular surgery in the supramesocolic floor of the abdominal cavity.