Pancreatoduodenectomy (PD) is still considered nowadays a challenging operation, being indicated mostly for malignant tumours of the periampullary region and pancreatic head
cancer (1,2). PD is also indicated in advanced gallbladder
carcinoma either in hepatoduodenopancreatectomy operation, or for ablation of the retro pancreatic lymph nodes (3-7). During performing a PD it is very important to asses the
vascular supply of the liver due to its high variability. Thus, in some cases a replaced common hepatic artery (RCHA)
originating from superior mesenteric artery (SMA) is an uncommon finding but could have major implication in
tailoring the technique of PD (8-14).
It is presented the case of a patient with a lymph node recurrence into the retro pancreatic region (after simple cholecystectomy for gallbladder carcinoma), treated by PD; the patient also had a RCHA originating from SMA who was involved in the tumour mass. The PD was associated with en bloc resection of the involved RCHA and the reconstruction was done using the reversed splenic artery.
A 50-year-old male patient was admitted in Centre of General Surgery and Liver Transplantation, Fundeni Clinical Institute in July 2007 for jaundice, upper right abdominal quadrant pain and weight loss (10 kg in the last three months). The medical history of the patient included: laparoscopic cholecystectomy for acute cholecystitis
(fourteen months before, in another surgical unit); histo-pathology of the operative specimen revealed gallbladder adenocarcinoma G1, pT2 (tumour invaded the perimuscular connective tissue but no extension beyond the serosa or into the liver), pNx, M0 (stage II according to TNM classification). No postoperative treatment was indicated at that time. At present time, clinical examination was unremarkable excepting the jaundice. The enhanced abdominal CT-scan described a tumour mass with diameters of 5/4 cm in the area of the pancreatic head, compressing the common bile duct determining dilatation of the intra and extrahepatic bile ducts (diameter of the common bile duct - 1.5 cm); the tumour mass was involving a part of a RCHA originating from SMA (Fig. 1). The haematological investigations revealed cholestasis (serum hyperbilirubinemia = 10 mg/dl, predominating the direct fraction; serum gamma-glutamyltransferase = 929 U/L; serum alkaline phosphatase = 1230 U/L) and hyperglycaemia (serum glucose level a jeune = 214 mg/dl). Serum carbohydrate antigen 19-9 was normal.
With a preoperative diagnosis of tumour mass in the head of pancreas, obstructive jaundice, the patient was assigned for surgery.
The intraoperative exploration, after median laparotomy, showed enlarged lymph nodes mass located behind the head of the pancreas involving the pancreas, distal biliary duct and a RCHA originating from SMA (coursing in front of the
superior mesenteric vein and posterior to the dorsal face of the pancreatic head). A Whipple pancreatoduodenectomy was performed along with common bile duct resection, regional lymph nodes dissection and segmental resection of the involved RCHA. After the RCHA was clamped it was
registered an inadequate blood flow in the liver (confirmed by Doppler ultrasound examination). The proximal stump of the RCHA was sutured and the arterial reconstruction was made using the reversed splenic artery (Fig. 2). The splenic artery was dissected from its emergence from the celiac trunk along 5 to 6 cm, transected at this level; the distal stump was sutured and the proximal stump was anastomosed with the distal stump of the RCHA (t-t anastomosis, interrupted sutures, polypropylene 7/0). The intraoperative blood loss was 500 ml and the operative time was 300 minutes. Macroscopically, the sectioned operative specimen presented an enlarged lymph nodes mass of 6/3 cm (Fig. 3). The standard microscopic
examination (Hematoxilin-Eosine) of the operative specimen revealed lymph nodes metastasis of gallbladder adenocarcinoma G2.
The postoperative course was uneventful, the patient being discharged from the hospital on the 9th postoperative day. Doppler Ultrasound examination revealed good flow into reconstructed RCHA. No liver dysfunction, bile leakage or other complications were observed. The postoperative ultrasound examination of the abdomen was unremarkable excepting a slight homogenous splenomegaly. At 3 months after operation an angiography via celiac trunk was
performed showing normal flow into reconstructed RCHA, no signs of narrowing anastomosis and homogenous spleen vascularisation during arterial time (Fig. 4).
The patient was submitted to the medical oncology unit and 6 cycles of chemotherapy with gemcitabine were
At 12 months after operation, the patient was discovered with local recurrence and multiple hepatic metastases and died two months later.
Gallbladder carcinoma is an aggressive disease, being
diagnosed and treated at an advanced stage with poor
prognosis (15). Incidentally gallbladder carcinoma detected by micros-copic examinations after open or laparoscopic cholecystectomy is recorded in 0.2% to 2.9% of patients undergoing cholecystectomy; 27% to 41% of the gallbladder carcinoma are first diagnosed at microscopic examination (16-20).
Surgery is the main therapeutically approach and the single hope for cure in gallbladder carcinoma (21). There are still many controversies regarding the type of surgery according to each stage of the disease (5,15); the depth of tumour penetration is considered the most important
prognostic factor (5,15,19,22). Lymph node metastases are common findings in gallbladder carcinoma but the
percentage of the involved nodes is related to tumour stage (i.e. correlated with the depth of invasion) (15,19). In stage II gallbladder carcinoma the percentage of regional lymph node metastasis ranges from 40% to 60% (3,5,17,19,21). Patients with pT2 tumour discovered after laparoscopic cholecystectomy should undergo a radical cholecystectomy. Even if, the diagnosis is made after microscopic examination of the operative specimen (after simple cholecystectomy), the reintervention is mandatory in pT2 gallbladder carcinoma (i.e. radical cholecystectomy) (15,17,19). The difference between T1 tumour (where simple cholecystectomy is the standard treatment) and T2 tumour (where radical cholecystectomy is mandatory) is not always very easy to asses due to the thin musculature of gallbladder. Thus, multiple histological sections should be taken to asses the tumour involvement into the connective tissue layer (21).
The standard surgery for T2 gallbladder carcinoma is
radical cholecystectomy (i.e. cholecystectomy, hepatic resection of segment IVB and V, and regional lymph node
dissection within the hepatoduodenal ligament, behind the pancreatic head, along common hepatic artery, medial to the celiac trunk) (15,19,21). The 5-years survival in T2
gallbladder carcinoma after simple cholecystectomy versus radical cholecistectomy is around 22-40%, respectively 60-80% (3,5,15,19,21-24).
The role of PD in gallbladder cancer was previously described. For lymph nodes recurrence behind the pancreatic head PD is the single surgical option (3-7).
Assessment of hepatic arterial anatomy while performing a PD is a challenging but mandatory procedure in order to avoid or minimize unnecessary complications (12-14). Over the years, several authors have described variations in the hepatic arterial anatomy (8-10,13,14). The most frequent hepatic arterial anatomy variations are replaced right hepatic artery originating from SMA (9.82-11%) followed by RCHA originating from SMA (1.5-2.8%) (8-10,13,14,25,26). Hepatic arterial supply variations should be assessed preoperatively by computed tomography, magnetic resonance and/or angio-graphy (8,12-14,26,27) but sometimes are found intraoperatively (25). In most of the cases these abnormal arterial
vessels can be safely preserved during PD (11,13,14,25).
Major vascular resections during PD were proposed in order to increase the percentage of R0 resections and, thus, survival of patients. Nowadays, portal vein invasion is no longer a contraindication for PD (28), but arterial involvement still remains controversial, in most of the centres being considered a contraindication for PD (1,29,30). Sometimes it is technically difficult to preserve major
vessels and in this cases resection with or without recons-truction is needed (i.e. due to tumour involvement or anatomic constraints).
The present hepatic arterial abnormality was a type IX according to Michels classification (10), a type 5 according to Hiatt classification (9) and a type III-A according to Higashi and Hirai classification ( RCHA coursing in front of the
superior mesenteric vein but posterior to the dorsal surface of the pancreatic head) (31). Thus, in this case the RCHA was not possible to be preserved during PD as reported by others authors (11) due to its course behind the head of the pancreas and massive involving by tumour mass. Miyamoto at al (32) reported a case of a patient with pancreatic head cancer with RCHA originating from SMA in which a preoperative embolization of RCHA was performed followed by PD with en bloc resection of RCHA, without any arterial reconstruction.
In cases of PD with RCHA originating from SMA there were described many options, depending on the course of RCHA to the pancreatic head. In patients with RCHA coursing into the pancreas, the artery could be preserved by dividing the pancreatic parenchyma (33). RCHA can be also preserved in case of coursing along the ventral face of the pancreatic head (11). When there is a communication of the RCHA with an aberrant left hepatic artery from left gastric artery, the PD can be performed en bloc with RCHA without reconstruction (12). In some cases RCHA resection need to be followed by reconstruction, as in the present case.
Preservation of the entire blood supply to the liver and
biliary tree is important mainly to prevent biliary fistula after PD and, in some cases, hepatic ischemia (11,34). In present case the reconstruction of RCHA was needed due to hepatic ischemia after RCHA clamping. Reconstruction of proper hepatic artery or replaced right hepatic artery during PD were previously described by some authors, using either gastro-
duodenal artery (34-38), or gastroepiploic artery (39), and even gonadal vein graft (40). In present case it was used the splenic artery for RCHA reconstruction. The use of the splenic artery for arterial reconstruction were previously described in liver transplantation (41-43).
The arterial anatomy supplying the liver is highly variable. RCHA originating from SMA is a rare vascular abnormality during PD. Despite the apparent rarity of this vascular
arterial abnormality, it is essential for surgeon to be aware of such aberrant arteries to avoid major complications. The
diagnosis should be carefully asses by preoperative imaging.
En bloc resection of RCHA originating from SMA during PD can be safely performed. In many cases RCHA resection can be performed without reconstruction. In patients in which the reconstruction is required (i.e. tumour involvement), the use of splenic artery could be a feasible, easy and safe option.
Reintervention after laparoscopic cholecystectomy for pT2 microscopically diagnosed gallbladder carcinoma is mandatory and implies radical cholecystectomy, in order to increase the long term survival in these patients.
V. Braşoveanu and T. Dumitraşcu equally contributed to this paper. We are grateful to our colleagues from Heart Institute “C.C. Iliescu”, Bucharest, Romania for their contribution in performing the postoperative angiography. Many thanks to M. Ionescu, M.D. for his support.
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