Surgical management of right hepatectomy after coronary artery bypass grafting using the right gastroepiploic artery: a case report and literature review.

BACKGROUND: Coronary artery bypass grafting (CABG) using the right gastroepiploic artery (RGEA) is a well-established, safe procedure. However, problems with RGEA grafts in subsequent abdominal surgeries can lead to fatal complications. This report presents the first case of right hepatectomy for hepatocellular carcinoma after CABG using the RGEA. CASE PRESENTATION: We describe a case in which a right hepatectomy for an 81-year-old male patient with hepatocellular carcinoma was safely performed after CABG using a RGEA graft. Preoperatively, three-dimensional computed tomography (3D- CT) images were constructed to confirm the run of the RGEA graft. The operation was conducted with the standby of a cardiovascular surgeon if there was a problem with the RGEA graft. The RGEA graft had formed adhesions with the hepatic falciform ligament, necessitating meticulous dissection. After the right hepatectomy, the left hepatic lobe descended into the vacated space, exerting traction on the RGEA. However, this traction was mitigated by suturing the hepatic falciform ligament to the abdominal wall, ensuring stability of the RGEA. There were no intraoperative or postoperative complications. CONCLUSION: It is crucial to confirm the functionality and anatomy of the RGEA graft preoperatively, handle it gently intraoperatively, and collaborate with cardiovascular surgeons.

Endovascular treatment of postoperative hemorrhage after pancreatectomy: a retrospective study.

BACKGROUND: Ruptured aneurysm is a serious complication of distal pancreatectomy (DP) or pancreatoduodenectomy (PD) that can be life-threatening if not treated promptly. This study aimed to examine the efficacy of a Viabahn stent graft for stopping bleeding after pancreatectomy. METHODS: Between April 2016 and June 2022, we performed 245 pancreatectomies in our institution. Six patients experienced postoperative bleeding and underwent endovascular treatment. RESULTS: All six cases of bleeding occurred post-PD (3.7%). The bleeding was from gastroduodenal artery (GDA) pseudoaneurysms in three patients, and Viabahn stent grafts were inserted. All three patients did not show liver function abnormalities or hepatic blood flow disorders. One patient with a Viabahn stent graft experienced rebleeding, which required further management to obtain hemostasis. Of the six cases in which there was hemorrhage, one case of bleeding from the native hepatic artery could not be managed. CONCLUSIONS: Using the Viabahn stent graft is an effective treatment option for postoperative bleeding from GDA pseudoaneurysms following PD. In most cases, using this device resulted in successful hemostasis, without observed abnormalities in hepatic function or blood flow.

Wrapping gastroduodenal artery stump with the teres hepatis ligament to prevent postpancreatectomy hemorrhage after pancreaticoduodenectomy.

BACKGROUND: Gastroduodenal artery (GDA) stump erosion hemorrhage is a fatal complication after pancreaticoduodenectomy. This study aimed to determine whether GDA stump wrapping with the teres hepatis ligament during pancreaticoduodenectomy decreased the incidence of postpancreatectomy hemorrhage (PPH). METHODS: We reviewed 307 patients who had undergone pancreaticoduodenectomy between March 2019 and June 2022. The patients were divided into two groups according to application of GDA stump wrapping with the teres hepatis ligament: GDA wrapping group (165 patients) and no-wrapping group (142 patients). The perioperative data were compared between the groups. RESULTS: The clinical characteristics were balanced between the two groups. Grades B and C PPH and GDA-stump-related hemorrhage were significantly reduced in the GDA wrapping group compared with the no-wrapping group (PPH B/C, 13.4% vs 6.1%, P = 0.029; GDA hemorrhage, 5.6% vs 0.6%, P = 0.014). No difference was observed in the incidence of clinically relevant postoperative pancreatic fistula, biliary leak, intra-abdominal abscess, delayed gastric emptying, 90-day mortality, and postoperative hospital stay between the two groups. CONCLUSION: Wrapping GDA stump with the teres hepatis ligament reduced the incidence of GDA-stump-related PPH. Therefore, the wrapping technique is a simple and effective strategy to prevent PPH. Prospective studies are needed to confirm the benefit of this procedure.

Gastroduodenal artery disconnection during liver transplantation decreases non-anastomotic stricture incidence.

BACKGROUND: The hepatic artery is the only blood source nourishing the biliary duct and associated with biliary complication after liver transplantation (LT). Gastroduodenal artery (GDA) disconnection increased proper hepatic artery flow. Whether this procedure attenuates biliary non-anastomotic stricture (NAS) is not clear. METHODS: A total of 241 patients with LT were retrospectively analyzed. The patients were divided into the GDA disconnection (GDA-) and GDA preservation (GDA+) groups. Propensity score matching (PSM) was administrated to reduce bias. Logistic regression was conducted to analyze risk factors for biliary NAS before and after PSM. Postoperative complications were compared. Kaplan-Meier survival analysis and log-rank tests were performed to compare overall survival. RESULTS: In all, 99 patients (41.1%) underwent GDA disconnection, and 49 (20.3%) developed NAS. Multivariate logistic regression revealed that GDA preservation (OR = 2.24, 95% CI: 1.11-4.53; P = 0.025) and model for end-stage liver disease (MELD) score > 15 (OR = 2.14, 95% CI: 1.12-4.11; P = 0.022) were risk factors for biliary NAS. PSM provided 66 pairs using 1:2 matching method, including 66 GDA disconnection and 99 GDA preservation patients. Multivariate logistic regression after PSM also showed that GDA preservation (OR = 3.15, 95% CI: 1.26-7.89; P = 0.014) and MELD score > 15 (OR = 2.41, 95% CI: 1.08-5.36; P = 0.031) were risk factors for NAS. When comparing complications between the two groups, GDA preservation was associated with a higher incidence of biliary NAS before and after PSM (P = 0.031 and 0.017, respectively). In contrast, other complications including early allograft dysfunction (P = 0.620), small-for-size graft syndrome (P = 0.441), abdominal hemorrhage (P = 1.000), major complications (Clavien-Dindo grade ≥ 3, P = 0.318), and overall survival (P = 0.088) were not significantly different between the two groups. CONCLUSIONS: GDA disconnection during LT ameliorates biliary NAS incidence and may be recommended for application in clinical practice.

The arterial anatomy of the posterior duodenum - A computed tomography angiography analysis with implications for abdominal surgery.

The main objective of the present study was to clarify the anatomical characteristics of the GDA. In order to fulfill this objective, novel classification systems of both the origin and branching pattern of the said vessel were created. Being aware of the variable anatomy of the GDA is of great importance when performing hepatopancreaticobilliary procedures. The results of 75 consecutive patients who underwent abdomen computed tomography angiography (CTA) were analyzed. A total of 74 GDA were analyzed. Of these, 42 were from women (56.8%) and 32 were from men (43.2%). The most common direction of origin of the GDA was inferior (n = 38; 51.4%). The origin variation of each GDA was deeply analyzed. Initially, eight types of origin variations were evaluated, of which types 1-3 constituted 83.8%. Furthermore, analogously, branching pattern types were also established. Initially, 11 branching variations were evaluated, of which types 1-3 constituted 87.8%. The GDA is subject to numerous variations, both in the origin and in the branching pattern of the vessel. In order to clarify the anatomical characteristics of this vessel, novel classifications of the origin and branching patterns were made, presenting the most frequent patterns. Our results may be of great use for surgeons performing hepatopancreaticobilliary surgeries, such as the Whipple procedure or vascular reconstructions after cholangiocarcinoma resections. Being aware of the anatomical variations of relevant structures associated with a surgical procedure may help reduce potential intraoperative and/or postoperative complications.

Differentiation of multiple visceral artery aneurysm rupture from major bleeding after coronary artery bypass grafting.

BACKGROUND: Visceral artery aneurysm is a very rare disease, but it is clinically important because of the high risk of rupture involved. These ruptures must be differentiated from those that occur during hospitalization after extra-abdominal surgery. METHODS: During hospitalization after off-pump coronary artery bypass grafting, a 77-year-old woman developed hypovolemic symptoms and had decreased hemoglobin. There was no obvious bleeding, but while screening for possible complications after cardiac surgery, abdominal computed tomographic angiography showed multiple visceral artery aneurysms of the gastroduodenal and pancreaticoduodenal arteries along with hemoperitoneum. RESULTS: The patient underwent coil embolization of the visceral artery aneurysm and was discharged without any complications. CONCLUSIONS: In patients with coronary artery disease with risk factors for atherosclerosis, if anemia occurs without apparent bleeding after surgery, visceral artery aneurysm should be considered as a differential diagnosis.

Wrapping the stump of the gastroduodenal artery using the ligamentum teres hepatis during laparoscopic pancreaticoduodenectomy: a center's preliminary experience.

BACKGROUND: The present study aims to assess the preliminary outcomes of the effectiveness of wrapping the ligamentum teres hepatis (LTH) around the gastroduodenal artery stump for the prevention of erosion hemorrhage after laparoscopic pancreaticoduodenectomy (LPD). METHODS: We reviewed 247 patients who had undergone LPD between January 2016 and April 2019. The patients were divided into two groups according to whether LTH wrapped the stump of the gastroduodenal artery: group A (119 patients) who underwent the LTH wrapping procedure, and group B (128 patients) who did not undergo the procedure. The perioperative data from the two groups were reviewed to assess the effectiveness of the LTH procedure for the prevention of postpancreatectomy hemorrhage (PPH) and other complications. RESULTS: No differences were observed in the clinical characteristics between the two groups. The data from 247 patients were acceptable for analysis: 119 patients underwent wrapping, and 128 patients did not. The incidence of clinically relevant pancreatic fistula (8.4% vs 3.9%), biliary fistula (2.5% vs 1.6%), intra-abdominal infection (10.1% vs 3.9%) and delayed gastric emptying (13.4% vs 16.4%) showed no significant difference between group A and group B. The 90-day mortality and 90-day reoperation rates (0.8% vs 0.8% and 5.0% vs 3.1%) were also similar between group A and group B. Furthermore, postpancreatectomy hemorrhage of Grade B and C occurred in 0 patients (0.0%) in the wrapping group, which was significantly less frequent than the occurrence in the nonwrapping group (7 patients; 5.5%, P = 0.02). CONCLUSIONS: Wrapping the LTH around the gastroduodenal artery stump after LPD does not reduce the incidence of clinically relevant pancreatic fistula, biliary fistula or delayed gastric emptying. However, this procedure has a trend of reducing the rate of PPH of Grade B and C after LPD and is simple to perform.

Aberrant gastroduodenal and proper hepatic arteries.

PURPOSE: Anatomic variants of the celiac trunk and superior mesenteric artery are common, thus knowledge of these variants is important for preoperative planning of abdominal surgery and interventional procedures. METHODS: We report a rare anatomic variant of replaced proper hepatic and gastroduodenal arteries discovered upon CT angiography and diagnostic angiogram. RESULTS: Emergent angiogram performed on a 61-year-old male who presented with signs and symptoms of upper gastrointestinal hemorrhage revealed a rare variant of an absent common hepatic artery and its branches with aberrant origins. The replaced proper hepatic artery originated from the superior mesenteric artery and the replaced gastroduodenal artery originated from a gastrosplenic trunk. CONCLUSION: This case emphasizes the importance of evaluating preoperative imaging to identify vascular variants prior to undergoing abdominal surgery or interventional procedures.

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.

[The Pedicled Teres Hepatis Ligament Flap Wrap Around the Gastroduodenal Artery Stump to Prevent Postoperative Hemorrhage after Laparoscopic Pancreatoduodenectomy (with Video)].

OBJECTIVE: To explore the feasibility and safety of teres hepatis ligament flap plasty around the gastroduodenal artery (GDA) stump to prevent postoperative hemorrhage after laparoscopic pancreatoduodenectomy (LPD). METHODS: A total of 108 patients with GDA stump wrapped by pedicled teres hepatis ligament after LPD in our center were included for analysis from March 2018 to March 2019. After completion of LPD, teres hepatis ligament was dissected from the ventral abdominal cephalad along the ventral attachment, and the teres hepatis ligament was separated from the falciform ligament by ultrasonic scalpel or Ligasure. At the junction to the liver, the teres hepatis ligament is freed from the ventral hepatic surface. The junction between liver and teres hepatis ligament should not be cut off to ensure blood supply. Division of the GDA was performed using a Prolene 4-0 suture stitch or two clamps as a standard (see the Video 1 in Supplemental Contents, http://ykxb.scu.edu.cn/article/doi/10.12182/20200760602). The pedicled teres hepatis ligament then was used to completely cover the skeletonized GDA stump, and part of the common hepatic artery and the proper hepatic artery. The mobilized ligament can be transposed without tension. RESULTS: A total of 108 patients completed the procedure of GDA stump wrapped with pedicled teres hepatis ligament during LPD. There were no complications caused by GDA stump after operation. The main steps to wrap the GDA stump took an average of 10 min. Clinically relevant postoperative pancreatic fistula (CR-POPF) occurred in 8 cases (7.4%) (including 6 cases of grade B pancreatic fistula and 2 cases of grade C pancreatic fistula), and intra-abdominal infection in 8 cases (7.4%), including 3 cases (2.8%) of intra-abdominal abscess, postoperative gastrointestinal ulcer bleeding occurred in 2 cases (1.9%), and no intra-abdominal hemorrhage occurred. CONCLUSION: It is a safe and feasible procedure of wrapping GDA stump with pedicled teres hepatis ligament to prevent postoperative hemorrhage after LPD. The procedure is easy to perform without relevant additional surgical trauma or prolongation of the operation time.

Dual endovascular repair (coils and stent) of a true aneurysm of the gastroduodenal artery.

We report a case of an asymptomatic gastroduodenal artery aneurysm diagnosed in a 39 year-old woman. An abdominal ultrasound study showed an aneurysmal dilatation of the gastroduodenal artery with 2 x 2 cm diameter. To confirm this finding, she then underwent a computed tomography scan of the abdomen and pelvis that showed a saccular aneurysm of the gastroduodenal artery. A dual endovascular approach was used to exclude the aneurysm by stent-assisted coil embolization. Complete exclusion of the aneurysm sac was confirmed on final angiography. She was discharged from the hospital on postoperative day 1.

Relatamos um caso de aneurisma de artéria gastroduodenal assintomático diagnosticado em uma mulher de 39 anos. Uma ultrassonografia abdominal mostrou uma dilatação aneurismática associada à artéria gastroduodenal com 2 x 2 cm de diâmetro. Para confirmar esse achado, foi realizada uma tomografia computadorizada do abdome e da pelve, que revelou um aneurisma sacular da artéria gastroduodenal. Uma abordagem endovascular dupla foi utilizada para exclusão do aneurisma mediante embolização com molas assistida por stent. A exclusão completa do saco aneurismático foi confirmada na angiografia final. A paciente recebeu alta hospitalar no primeiro dia de pós-operatório.

False in Name Only-Gastroduodenal Artery Pseudoaneurysm in a Recurrently Bleeding Patient: Case Report and Literature Review.

Although the diagnosis of visceral pseudoaneurysm is unusual, it requires emergent attention due to the risk of rupture. We describe a 70-year-old man with a gastroduodenal artery pseudoaneurysm that manifested as recurrent hemorrhage. We highlight the possible etiologies, clinical presentations, diagnostic tools, and treatment options for this condition. In this instance, the patient was successfully treated by selective angioembolization. A visceral pseudoaneurysm should be considered in patients with abdominal pain and GI hemorrhage. At present, angioembolization is a first-line therapy.

Aberrant gastroduodenal artery with splenic origin.

PURPOSE: Knowledge of the wide variability in celiac trunk branches is of paramount importance when planning an abdominal surgery. METHODS: We, hereby, report a previously undescribed origin of the gastroduodenal artery discovered on an abdominal angio-CT. RESULTS: CT-angiogram performed on a 33-year-old female randomly revealed a new variant of gastroduodenal artery arising directly from the splenic artery along with other vascular aberrations. The latter were previously described in medical literature. CONCLUSION: High-quality preoperative imaging is crucial for identification of visceral artery variations, as those can technically modify the surgical or interventional procedure.

Falciform ligament wrap for prevention of gastroduodenal artery bleed after pancreatoduodenectomy.

BACKGROUND: The present study aims to assess the effectiveness and current evidence of a pedicled falciform ligament wrap around the gastroduodenal artery stump for prevention of erosion hemorrhage after pancreatoduodenectomy (PD). METHODS: Retrospective data were pooled for meta-analysis. At the own center, patients who underwent PD between 2012 and 2015 were retrospectively analyzed based on the intraoperative performance of the wrap. A systematic literature review and meta-analysis was performed that combined the published and the obtained original data. The following databases were searched: Medline, Embase, Web of Science, and the Cochrane Library. RESULTS: At the own center, a falciform ligament wrap was performed in 39 of 196 PDs (20%). The wrap group contained more ampullary neoplasms, but the pancreatic fistula rate was not significantly different from the nonwrap group (28% versus 32%). In median, erosion hemorrhage occurred after 21.5 d, and it was lethal in 39% of the patients. Its incidence was not significantly lower in the wrap group (incidence: 7.7% versus 9.6% in the nonwrap group). The systematic literature search yielded four retrospective studies with a high risk of bias; only one study was controlled. When the five data sets of published and own cases with a falciform ligament wrap were pooled, the incidence of erosion hemorrhage was 5 of 533 cases (0.9%) compared with 24 of 297 cases (8.1%) without the wrap. CONCLUSIONS: The reported incidence of erosion hemorrhage after the falciform ligament wrap is low, but there are still insufficient controlled data to support its general use.

Ascending Cholangitis secondary to migrated embolization coil of gastroduodenal artery pseudo-aneurysm a case report.

BACKGROUND: Gastroduodenalartery (GDA) pseudo-aneurysms are very rare. Their clinical importance lies in the eventuality of rupture, causing bleeding and ultimately exsanguination. CASE PRESENTATION: We report the case of a man, with prior history of biliary surgery, presenting with haemobilia secondary to a rupture of GDA pseudo-aneurysm eroding the main bile duct. The patient was treated with coil embolization. This technique is considered to be safe. However, on the long term, some complications may occur. In our case, the patient presented with cholangitis subsequent to coil migration in the lower bile duct. This situation was managed using endoscopic retrograde cholangiopancreatography (ERCP) allowing coil extraction with favorable evolution. CONCLUSIONS: GDA pseudo-aneurysms are very rare. Bleeding, secondary to the rupture of these lesions, is a serious complication that could lead to death. Diagnosis and treatment of ruptured GDA pseudo-aneurysms rely on angiography. This method is considered to be safe. Cholangitis secondary to coil migration in the main bile duct is exceedingly rare,but remains an eventuality that physicians should be cognizant of.

The coexistence of both replaced proper hepatic and gastroduodenal arteries due to the common hepatic artery absence.

Anatomical variants of the celiac trunk (CT) branches and especially these of hepatic arteries (HAs) are among the most common variants of the arterial tree. The knowledge of the wide variability in hepatic arterial supply is of paramount importance in hepatobiliary, pancreatic, gastric, and esophageal surgery, as well as in liver transplantations. The purpose of this case report is to describe a rare variant discovered during abdominal dissection of a 74-year-old male cadaver of Greek origin, in which the common hepatic artery was absent and its branches, the proper hepatic artery (PHA) and the gastroduodenal artery (GDA) had an aberrant and separate origin. The entire arterial supply to the liver derived from the aberrant PHA, that originating from the superior mesenteric artery and was named as PHA (RPHA). The RPHA, after a course posterior to the portal vein, terminated into the right and left HAs, at the hilum. The GDA originated from the CT, as well as the left gastric and splenic artery. The right gastric artery originated from the PHA, as usual. The current case emphasizes the necessity of preoperative imaging when evaluating the resectability of a tumor in hepatobiliary and pancreatic area taking into account the possible vascular variations. Abdominal surgeon should be aware of any aberrancy to avoid potential iatrogenic injury and lethal complications.

Superior mesenteric origin of the proper hepatic artery: embryological and clinical implications.

The hepatic arteries are subject to a great deal of anatomical variation, potentially complicating hepatobiliary surgical procedures as well as general gastrointestinal procedures that involve foregut and midgut structures. We report a case of a rare variant of the proper hepatic artery discovered during dissection of an 84-year-old male cadaver. In this individual, the common hepatic artery was absent and the proper hepatic artery was replaced directly to the superior mesenteric artery. The gastroduodenal artery and the right inferior phrenic artery took origin from the celiac trunk. In addition, there was no identifiable right gastric artery. The celiac trunk gave off three branches: the splenic, left gastric, and gastroduodenal arteries. The entire arterial blood supply to the liver, therefore, was derived from the superior mesenteric artery. Patterns of regression of the ventral branches and the partial disappearance of the ventral anastomotic arteries during embryonic development play a major role in the variations of the gut arteries. An intraoperative encounter with this particular variant carries a significant risk of iatrogenic injury with potentially devastating ischemia and necrotic results. Accurate depiction and definition of the hepatic arterial anatomy are crucial. Variations like the one described here underscore the importance of pre-operative imaging and knowledge of the embryological origins of variation.

Associated gastroduodenal artery aneurysm aortic aneurysm: the diagnostic contribution of contrast-enhanced ultrasound in correlation with computed tomography angiography.

Splanchnic aneurysms are rare conditions, with localization at the level of the gastroduodenal artery being encountered in only 1.5 % of the cases. Due to the high mortality risk, early detection and optimal treatment are required. We stress the importance of ultrasonography as a primary method of detection as well as the role of contrast-enhanced ultrasound in characterization of visceral aneurysms. Due to its noninvasive nature, the examination could be used for follow-up after therapeutic procedures or in cases were a curative intervention is not possible.