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Vascular Anomalies Encountered During Pancreatoduodenectomy: Do They Influence Outcomes?

  • Hepatobiliary and Pancreatic Tumors
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Because of the potential risk of hemorrhage or ischemia, the presence of vascular anomalies adds to the surgical challenge in pancreatoduodenectomy (PD).

Objective

To analyze the literature concerning the influence of aberrant peripancreatic arterial anatomy on outcomes of PD.

Materials and Methods

A systematic search using Medline and Embase for the years 1950–2008.

Results

The most common aberration in hepatic arterial anatomy is the replaced right hepatic artery. Other vascular abnormalities such as replaced common hepatic artery with a hepatomesenteric trunk and celiomesenteric trunk and arcuate ligament syndrome leading to celiac artery stenosis are also associated with post-PD complications. Damage to the biliary branches of the hepatic arteries increases the risk of postoperative biliary anastomotic leak.

Conclusion

The most common abnormalities of the hepatic vasculature include a replaced RHA, replaced LHA, and accessory RHA or LHA. Celiac artery stenosis secondary to median arcuate ligament compression may also be encountered. Every attempt should be made to preserve the aberrant vessel unless their resection is oncologically indicated. Routine preoperative computerized tomography angiography helps to identify the hepatic vascular anatomy and thereby prepares the surgeon to better deal with the vascular anomalies intraoperatively. Increased awareness of the vascular anatomy would decrease the chances of intraoperative vascular injury and consequent postoperative complications such as biliary anastomotic leaks as well as the chances of postoperative hemorrhage.

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References

  1. Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, et al. Postpancreatectomy hemorrhage (PPH):an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery. 2007;142:20–5.

    Article  PubMed  Google Scholar 

  2. van Berge Henegouwen MI, Allema JH, van Gulik TM, Verbeek PC, Obertop H, Gouma DJ. Delayed massive hemorrhage after pancreatic and biliary surgery. Br J Surg. 1995;82:1527–31.

    Article  PubMed  Google Scholar 

  3. Trede M, Schwall G. The complications of pancreatectomy. Ann Surg. 1988;207:39–47.

    Article  CAS  PubMed  Google Scholar 

  4. Rong GH, Sindelar WF. Aberrant peripancreatic arterial anatomy: considerations in performing pancreatectomy for malignant neoplasms. Am Surg. 1987;53:726–9.

    CAS  PubMed  Google Scholar 

  5. Suzuki T, Nakayasu A, Kawabe K, Takeda H, Honjo I. Surgical significance of anatomic variations of the hepatic artery. Am J Surg. 1971;122:505–12.

    Article  CAS  PubMed  Google Scholar 

  6. Woods MS, Traverso LW, Sparing a replaced common hepatic artery during pancreaticoduodenectomy. Am Surg. 1993;59:719–21.

    CAS  PubMed  Google Scholar 

  7. Koops A, Wojciechowski B, Broering DC, Adam G, Krupski-Berdien G. Anatomic variations of the hepatic arteries in 604 selective celiac and superior mesenteric angiographies. Surg Radiol Anat. 2004;26:239–44.

    Article  CAS  PubMed  Google Scholar 

  8. Abdullah SS, Mabrut JY, Garbit V, De La Roche E, Olagne E, Rode A, et al. Anatomical variations of the hepatic artery: study of 932 cases in liver transplantation. Surg Radiol Anat. 2006;28:468–73.

    Article  PubMed  Google Scholar 

  9. Kemeny MM, Hogan JM, Goldberg DA, et al. Continuous hepatic artery infusion with an implantable pump: problems with hepatic arterial anomalies. Surgery. 1986;99:501–4.

    CAS  PubMed  Google Scholar 

  10. Miyamoto N, Kodama Y, Endo H, Shimizu T, Miyasaka K, Tanaka E, et al. Embolisation of the replaced common hepatic artery before surgery for pancreatic head cancer: report of a case. Surg Today. 2004;34:619–22.

    PubMed  Google Scholar 

  11. Hiatt JR, Gabbay J, Busuttil RW. Surgical anatomy of the hepatic arteries in 1000 cases. Ann Surg. 1994;220:50–2.

    Article  CAS  PubMed  Google Scholar 

  12. Furukawa H, Shimada K, Iwata R, Moriyama N. A replaced hepatic artery running through the pancreatic parenchyma. Surgery. 2000;127:711–2.

    Article  CAS  PubMed  Google Scholar 

  13. Nakano H, Kikuchi K, Seta S, Katayama M, Horikoshi K, Yamamura T, et al. A patient undergoing pancreaticoduodenectomy in whom involved common hepatic artery anomalously arising from the superior mesenteric artery was removed and reconstructed. Hepatogastoenterology. 2005;52:1883–5.

    Google Scholar 

  14. Limura A, Oguchi T, Shibata M, Takahashi T. An anomalous case of the hepatic artery arising from the superior mesenteric artery. Okajimas Folia Anat Jpn. 2007;84:61–5.

    Article  Google Scholar 

  15. Winston CB, Lee NA, Jarnagin WR, Teitcher J, DeMatteo RP, Fong Y, et al. CT Angiography for delineation of celiac and superior mesenteric artery variants in patients undergoing hepatobiliary and pancreatic surgery. Am J Roentgenol. 2007;188:W13–9.

    Article  Google Scholar 

  16. Sakorafas GH, Sarr MG, Peros G. Celiac artery stenosis: an underappreciated and unpleasant surprise in patients undergoing pancreaticoduodenectomy. J Am Coll Surg. 2008;206:349–56.

    Article  PubMed  Google Scholar 

  17. Soonawalla Z, Ganeshan A, Friend P. Celiac artery occlusion encountered during pancreatic resection: a case report. Ann R Coll Surg Engl. 2007;89:W15–7.

    Article  PubMed  Google Scholar 

  18. Yang SH, Yin YH, Jang JY, Lee SE, Chung JW, Suh KS, et al. Assessment of hepatic arterial anatomy in keeping with preservation of the vasculature while performing pancreatoduodenectomy: an opinion. World J Surg. 2007;31:2384–91.

    Article  PubMed  Google Scholar 

  19. Volpe CM, Peterson S, Hoover EL, Doerr RJ. Justification for visceral angiography prior to pancreaticoduodenectomy. Am Surg. 1998;64:758–61.

    CAS  PubMed  Google Scholar 

  20. Sakorafas GH, Friess H, Balsiger BM, Buchler MW, Sarr MG. Problems of reconstruction during pancreatoduodenectomy. Dig Surg. 2001;18:363–9.

    Article  CAS  PubMed  Google Scholar 

  21. Dickersin K, Scherer R, Lefebvre C. Identifying relevant studies for systematic reviews. BMJ. 1994;309:1286–91.

    CAS  PubMed  Google Scholar 

  22. Covey AM, Brody LA, Maluccio MA, Getrajdman GI, Brown KT. Variant hepatic arterial anatomy revisited: digital subtraction angiography performed in 600 patients. Radiology. 2002;224:542–7.

    Article  PubMed  Google Scholar 

  23. Michels NA. Blood supply and anatomy of the upper abdominal organs with a descriptive atlas. Philadelphia, PA: Lippincott; 1955.

    Google Scholar 

  24. Michels NA. Newer anatomy of the liver and its variant blood supply and collateral circulation. Am J Surg. 1962;112:337–47.

    Article  Google Scholar 

  25. Balachandran A, Darden DL, Tamm EP, Fraia SC, Evans DB, Charsangavej C. Arterial variants in pancreatic adenocarcinoma. Abdom Imaging. 2008;33:214–21.

    Article  PubMed  Google Scholar 

  26. Biehl TR, Traverso LW, Hauptmann E, Ryan JA Jr. Preoperative visceral angiography alters intraoperative strategy during the Whipple procedure. Am J Surg. 1993;165:607–12.

    Article  CAS  PubMed  Google Scholar 

  27. Kim AW, McCarthy WJ 3rd, Maxhimer JB, Quiros RM, Hollinger EF, Doolas A, et al. Vascular complications associated with pancreaticoduodenectomy adversely affect clinical outcome. Surgery. 2002;132:738–44.

    Article  PubMed  Google Scholar 

  28. Traverso LW, Freeny PC. Pancreaticoduodenectomy. The importance of preserving hepatic blood flow to prevent biliary fistula. Am Surg. 1989;55:421–6.

    CAS  PubMed  Google Scholar 

  29. Kahraman G, Marur T, Tanyeli E, Yildrim M. Hepaticomesentric trunk. Surg Radiol Anat. 2001;23:433–5.

    Article  CAS  PubMed  Google Scholar 

  30. Rygaard H, Forrest M, Mygind T, Baden H. Anatomic variants of the hepatic arteries. Acta Radiol Diagn. 1986;27:425–7.

    CAS  Google Scholar 

  31. Adamathwaite JA, Pennington N, Menon KV. Anomalous hepatic arterial anatomy discovered during pancreaticoduodenectomy. Surg Radiol Anat. 2007;29:269–71.

    Article  Google Scholar 

  32. Lawler LP, Fishman EK. Celiomesenteric anomaly demonstration by multidetector CT and Volume rendering. J Comput Assist Tomogr. 2001;25:802–4.

    Article  CAS  PubMed  Google Scholar 

  33. Parnanen PO. Anatomisch-anthropologische untersuchungen uber die aretria coelica. Acta Inst Univ Helsinkiensis. 1945;14:1–154.

    Google Scholar 

  34. Trede M. The surgical treatment of pancreatic carcinoma. Surgery. 1985;97:28–35.

    CAS  PubMed  Google Scholar 

  35. Pfeiffenberger J, Adam U, Drognitz O, Kröger JC, Makowiec F, Schareck W, et al. Celiac axis stenosis in pancreatic head resection for chronic pancreatitis. Langenbecks Arch Surg. 2002;387:210–5.

    Article  PubMed  Google Scholar 

  36. Berney T, Pretre R, Chassot G, Morel P. The role of revascularisation in celiac occlusion and pancreatoduodenectomy. Am J Surg. 1998;176:352–6.

    Article  CAS  PubMed  Google Scholar 

  37. Portolani N, Tiberio GA, Coniglio A, Baiocchi G, Vettoretto N, Giulini SM. Emergency celiac revascularisation for suprameoscolic ischaemia during pancreaticoduodenectomy: report of a case. Surg Today. 2004;34:616–8.

    Article  PubMed  Google Scholar 

  38. Song S-Y, Chung JW, Kwon JW, et al. Collateral pathways in patients with celiac axis stenosis: angiographic-spiral CT correlation. Radiographics. 2002;22:881–93.

    PubMed  Google Scholar 

  39. Kornblith PL, Boley SJ, Whitehouse BS. Anatomy of the splanchnic circulation. Surg Clin North Am. 1992;72:1–30.

    CAS  PubMed  Google Scholar 

  40. Nakano H, Yamamura T, Yamaguchi S, Otsubo T. Celiac axis occlusion of a patient undergoing pancreatiocduoenectomy after distal gastrectomy. Hepatogastroenterology. 2007;54:595–8.

    PubMed  Google Scholar 

  41. Hasegawa K, Sano K, Ishida T, Shin N, Ikeda M, Kokudo N, et al. Hepato-pancreaticoduodenectomy with preservation of the collateral arterial arcade in the head of the pancreas in a patient with celiac axis stenosis. Hepatogastroenterology. 2005;52:742–4.

    PubMed  Google Scholar 

  42. Otani T. Preservation of collateral pathways during pancreaticoduodenectomy in case of celiac axis occlusion. J Hepatobiliary Pancreat Surg. 2005;12:173.

    Article  PubMed  Google Scholar 

  43. Okamoto H, Suminaga Y, Toyama N, Konishi F, Kawahito H. Autogenous vein graft from iliac artery to splenic artery for celiac occlusion in pancreaticoduodenectomy. J Hepatobiliary Pancreat Surg. 2003;10:109–12.

    PubMed  Google Scholar 

  44. Kohler TR, Debas H, Crames M, Strandness DE Jr. Pancreaticoduodenectomy and the celiac artery compression syndrome. Ann Vasc Surg. 1990;4:77–80.

    Article  CAS  PubMed  Google Scholar 

  45. Farma JM, Hoffman JP. Nonneoplastic celiac axis occlusion in patients undergoing pancreaticoduodenectomy. Am J Surg. 2007;193:341–4.

    Article  PubMed  Google Scholar 

  46. Lindner HH, Kemprud E. A clinicoanatomic study of the arcuate ligament of the diaphragm. Arch Surg. 1971;103:600–5.

    CAS  PubMed  Google Scholar 

  47. Bron KM, Redman HC. Splanchnic artery stenosis and occlusion. Incidence; arteriographic and clinical manifestations. Radiology. 1969;92:323–8.

    CAS  PubMed  Google Scholar 

  48. Horton KM, Talamini MA, Fishman EK. Median arcuate ligament syndrome: evaluation with CT angiography. Radiographics. 2005;25:1177–82.

    Article  PubMed  Google Scholar 

  49. Shrikhande SV, Barreto G, Shukla PJ. Pancreatic fistula after pancreaticoduodenectomy: the impact of a standardized technique of pancreaticojejunostomy. Langenbecks Arch Surg. 2008;393:87–91.

    Article  PubMed  Google Scholar 

  50. Shukla PJ, Barreto SG, Mohandas KM, Shrikhande SV. Defining the role of surgery for complications after pancreatoduodenectomy. ANZ J Surg. 2009;79:33–7.

    Article  PubMed  Google Scholar 

  51. Barreto SG, D’Souza MA, Shukla PJ, Shrikhande SV. The gray zone between post-pancreaticoduodenectomy collections and pancreatic fistula. Pancreas. 2008;37;422–5.

    Article  PubMed  Google Scholar 

  52. Yeo CJ, Cameron JL, Sohn TA, Lillemoe KD, Pitt HA, Talamini MA, et al. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. Ann Surg. 1997;226:248–57.

    Article  CAS  PubMed  Google Scholar 

  53. Nelson TM, Pollak R, Jonasson O, Abcarian H. Anatomic variants of the celiac, superior mesenteric, and inferior mesenteric arteries and their clinical relevance. Clin Anat. 1988;1:75–91.

    Article  Google Scholar 

  54. Horiguchi A, Ishihara S, Ito M, Nagata H, Asano Y, Yamamoto T, et al. Multislice CT study of pancreatic head arterial dominance. J Hepatobiliary Pancreat Surg. 2008;15:322–6.

    Article  PubMed  Google Scholar 

  55. Brennan DD, Zamboni GA, Raptopoulos VD, Kruskal JB. Comprehensive preoperative assessment of pancreatic adenocarcinoma with 64-section volumetric CT. Radiographics. 2007;27:1653–66.

    Article  PubMed  Google Scholar 

  56. Fletcher JG, Wiersema MJ, Farrell MA, Fidler JL, Burgart LJ, Koyama T, et al. Pancreatic malignancy: value of arterial, pancreatic, and hepatic phase imaging with multi-detector row CT. Radiology. 2003;229:81–90.

    Article  PubMed  Google Scholar 

  57. Graf O, Boland GW, Warshaw AL, Fernandez-del-Castillo C, Hahn PF, Mueller PR. Arterial versus portal venous helical CT for revealing pancreatic adenocarcinoma: conspicuity of tumor and critical vascular anatomy. AJR Am J Roentgenol. 1997;169:119–23.

    CAS  PubMed  Google Scholar 

  58. Lu DS, Vedantham S, Krasny RM, Kadell B, Berger WL, Reber HA. Two-phase helical CT for pancreatic tumors: pancreatic versus hepatic phase enhancement of tumor, pancreas, and vascular structures. Radiology. 1996;199:697–701.

    CAS  PubMed  Google Scholar 

  59. McNulty NJ, Francis IR, Platt JF, Cohan RH, Korobkin M, Gebremariam A. Multi-detector row helical CT of the pancreas: effect of contrast-enhanced multiphasic imaging on enhancement of the pancreas, peripancreatic vasculature, and pancreatic adenocarcinoma. Radiology. 2001;220:97–102.

    CAS  PubMed  Google Scholar 

  60. Boland GW, O’Malley ME, Saez M, Fernandez-del-Castillo C, Warshaw AL, Mueller PR. Pancreatic-phase versus portal-vein phase helical CT of the pancreas: optimal temporal window for evaluation of pancreatic adenocarcinoma. AJR Am J Roentgenol. 1999;173:605–8.

    Google Scholar 

  61. Brennan D, Zamboni G, Sosna J, Callery MP, Vollmer CM, Raptopoulos VD, et al. Virtual Whipple: preoperative surgical planning with volume-rendered MDCT images to identify arterial variants relevant to the Whipple procedure. AJR Am J Roentgenol. 2007;188:W451–5.

    Article  PubMed  Google Scholar 

  62. Sakorafas GH, Farnell MB, Nagorney DM, Farley DR, Que FG, Donohue JH, et al. Management of peri-pancreatic vasculature during pancreatoduodenectomy: tips to avoid severe hemorrhage. Eur J Surg Oncol. 1999;25:524–8.

    Article  CAS  PubMed  Google Scholar 

  63. Yamamoto S, Kubota K, Rokkaku K, Nemoto T, Sakuma A. Disposal of replaced common hepatic artery coursing within the pancreas during pancreatoduodenectomy: report of a case. Surg Today. 2005;35:984–7.

    Article  PubMed  Google Scholar 

  64. Kurosaki I, Hatakeyama K, Nihei KE, Oyamatsu M. Celiac axis stenosis in pancreaticoduodenectomy. J Hepatobiliary Pancreat Surg. 2004;11:119–24.

    Article  PubMed  Google Scholar 

  65. Bull DA, Hunter GC, Crabtree TG, Bernhard VM, Putnam CW. Hepatic ischemia, caused by celiac axis compression, complicating pancreaticoduodenectomy. Ann Surg. 1993;217:244–7.

    Article  CAS  PubMed  Google Scholar 

  66. Nara S, Sakamoto Y, Shimada K, Sano T, Kosuge T, Takahashi Y, et al. Arterial reconstruction during pancreatoduodenectomy in patients with celiac axis stenosis-utility of Doppler ultrasonography. World J Surg. 2005;29:885–9.

    Article  PubMed  Google Scholar 

  67. Fortner JG, Watson RC. Median arcuate ligament obstruction of celiac axis and pancreatic cancer. Ann Surg. 1981;194:698–700.

    Article  CAS  PubMed  Google Scholar 

  68. Takach TJ, Levesay JJ, Reul GJ Jr, et al. Celiac compression syndrome: tailored therapy based on intraoperative findings. J Am Coll Surg. 1996;183:606–10.

    CAS  PubMed  Google Scholar 

  69. Machado MC, Penteado S, Montagnigni AL, et al. An alternative technique in the treatment of celiac axis stenosis diagnosed during pancreaticoduodenectomy. HPB Surg. 1998;10:371–3.

    Article  CAS  PubMed  Google Scholar 

  70. Manabe T, Baba N, Setoyama H, et al. Venous bypass grafting for celiac occlusion in radical pancreaticoduodenectomy. Pancreas. 1991;6:368–71.

    Article  CAS  PubMed  Google Scholar 

  71. Thompson NW, Eckhauser FE, Talpos G, Cho KJ. Pancreaticoduodenectomy and celiac disease. Ann Surg. 1981;193:399–406.

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Gastrointestinal Surgical Oncology, Tata Memorial Hospital, Mumbai, India

    Parul J. Shukla MS, FRCS & Ganesh Nagarajan MS

  2. Department of Radio-diagnosis, Tata Memorial Hospital, Mumbai, India

    Aniruddha Kulkarni MD

  3. Department of General and Digestive Surgery, Flinders Medical Centre, Adelaide, Australia

    Savio G. Barreto MS

  4. Department of Gastrointestinal Surgery, Centre Hospitalier Intercommunal, Poissy, France

    Abe Fingerhut MD, FACS, FRCS

  5. Department of Surgery, University of Athens, Hippokration Hospital, Athens, Greece

    Abe Fingerhut MD, FACS, FRCS

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  1. Parul J. Shukla MS, FRCS
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  2. Savio G. Barreto MS
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  3. Aniruddha Kulkarni MD
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  4. Ganesh Nagarajan MS
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  5. Abe Fingerhut MD, FACS, FRCS
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Correspondence to Parul J. Shukla MS, FRCS.

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Shukla, P.J., Barreto, S.G., Kulkarni, A. et al. Vascular Anomalies Encountered During Pancreatoduodenectomy: Do They Influence Outcomes?. Ann Surg Oncol 17, 186–193 (2010). https://doi.org/10.1245/s10434-009-0757-1

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