Identification of Variation in the Extrahepatic Arterial System of Thai Cadavers / Identificación de la Variación en el Sistema Arterial Extrahepático de Cadáveres Tailandeses

SUMMARY: Liver transplantation (LT) is the treatment of choice for decompensated liver cirrhosis. In the LT procedure, an adequate arterial supply is required for anastomosis to prevent postoperative necrosis and maintain hepatic parenchymal functions. The extrahepatic arterial system is primarily responsible for carrying oxygenated blood from the heart, 25 % of total cardiac output. Normally, the celiac trunk gives off the common hepatic artery. The common hepatic artery branches into the hepatic artery proper and supplies blood to the hepatic parenchyma. Recognizing the anatomical variations of the hepatic artery proper is essential for the planning and implementation of LT. The extrahepatic arterial variations are hard to study in live humans because of the limitations of human rights. Studying cadavers can solve this problem. This study investigates the distribution of normal, accessory, and replaced hepatic arteries proper by dissecting Thai cadavers (n = 152; males = 82 and females = 70) in the Gross Anatomy Laboratory at the Department of Anatomy, Faculty of Medicine Siriraj Hospital, Mahidol University. The cadavers were preserved in a 10 % formaldehyde solution. The exclusion criteria for liver specimens were cirrhosis, liver carcinoma, including hepatocellular carcinoma and cholangiocarcinoma, and other liver masses. Accordingly, the extrahepatic arterial system was conventionally dissected and identified at the porta hepatis. The extrahepatic arterial system was identified and documented in terms of features of normal distribution and variations, such as accessory or replaced hepatic arteries. There were 75 % normal type, 18.42 % accessory left hepatic arteries (aLHA), 1.32 % replaced left hepatic arteries (rLHA), 0.66 % accessory right hepatic arteries (aRHA), 1.32 % of replaced right hepatic arteries (rRHA), 1.97 % of aLHA and aRHA, and 1.32 % aortic type. The identification of variations in the hepatic artery system is essential to detection of distribution patterns. This knowledge is crucial for promoting LT.

El trasplante hepático (TH) es el tratamiento de elección para la cirrosis hepática descompensada. En el procedimiento de TH, se requiere un suministro arterial adecuado para la anastomosis para prevenir la necrosis postoperatoria y mantener las funciones del parénquima hepático. El sistema arterial extrahepático es el principal responsable de transportar sangre oxigenada desde el corazón, el 25 % del gasto cardíaco total. Normalmente, el tronco celíaco da origen a la arteria hepática común. La arteria hepática común se ramifica en la arteria hepática propia y suministra sangre al parénquima hepático. Reconocer las variaciones anatómicas de la arteria hepática es fundamental para la planificación e implementación del TH. Las variaciones arteriales extrahepáticas son difíciles de estudiar en humanos vivos debido a las limitaciones de los derechos humanos. El estudio de cadáveres puede resolver este problema. Este estudio investiga la distribución de las arterias hepáticas normales, accesorias y aberrantes mediante la disección de cadáveres tailandeses (n = 152; hombres = 82 y mujeres = 70) en el Laboratorio de Anatomía Macroscópica del Departamento de Anatomía, Facultad de Medicina del Hospital Siriraj, Mahidol. Los cadáveres se conservaron en una solución de formaldehído al 10 %. Los criterios de exclusión para las muestras de hígado fueron cirrosis, carcinoma hepático, incluidos el carcinoma hepatocelular y el colangiocarcinoma, y otras masas hepáticas. En consecuencia, el sistema arterial extrahepático se diseccionó e identificó convencionalmente en el hilio hepático. El sistema arterial extrahepático se identificó y documentó en términos de características de distribución normal y variaciones, como arterias hepáticas accesorias. Hubo 75 % tipo normal, 18,42 % arterias hepáticas izquierdas accesorias (aLHA), 1,32 % arterias hepáticas izquierdas aberrantes (LHAr), 0,66 % arterias hepáticas derechas accesorias (aRHA), 1,32 % arterias hepáticas derechas aberrantes (ARHr), 1,97 % de aLHA y aRHA, y 1,32 % de tipo aórtico. La identificación de variaciones en el sistema de la arteria hepática es esencial para la detección de patrones de distribución. Este conocimiento es crucial para promover LT.

A preliminary study on the prevention of hemorrhage after laparoscopic pancreaticoduodenectomy by wrapping gastroduodenal artery stump in the left external liver lobe and the left caudate lobe / 中华外科杂志

Objective: To investigate the safety and efficacy of embedding the stump of gastroduodenal artery between the left lateral lobe of the liver and the left caudate lobe to prevent bleeding after laparoscopic pancreaticoduodenectomy. Methods: The clinical data of 41 patients who underwent laparoscopic pancreaticoduodenectomy at the second Hospital of Hebei Medical University from October 2021 to April 2022 were analyzed retrospectively.There were 27 males and 14 females, aged (63.0±9.2)years (range: 48 to 78 years), and the body mass index was (24.1±3.2)kg/m2 (range: 15.4 to 31.6 kg/m2). After routine laparoscopic pancreaticoduodenectomy, the stump of gastroduodenal artery was embedded between the left lateral lobe and the left caudate lobe of the liver, and the hepatic parenchyma of the left lateral lobe and the left caudate lobe were sutured with absorbable sutures.The occurrence and recovery of postoperative complications (pancreatic fistula, biliary fistula, postoperative abdominal bleeding, abdominal infection, liver abscess) were observed. Results: All the operations of 41 patients were completed successfully.The operation time was (277.5±52.0) minutes (range: 192 to 360 minutes). The entrapment time of gastroduodenal artery stump was (3.1±0.6) minutes (range: 2.3 to 4.2 minutes), and the intraoperative blood loss (M(IQR)) was 300 (200) ml (range: 50 to 800 ml).The results of ultrasound examination of hepatic artery on the first day after operation showed that the blood flows of hepatic artery were unobstructed.Postoperative pancreatic fistula occurred in 3 cases, including grade B pancreatic fistula in 2 cases (1 case with abdominal infection) and biochemical leakage in 1 case. Three patients with pancreatic fistula were discharged successfully after continuous abdominal drainage. There was no biliary fistula, abdominal bleeding, abdominal infection, liver abscess or postoperative liver dysfunction. Conclusion: The encasement of the gastroduodenal artery stump by the left outer and left caudate lobes of the liver may be an effective way to prevent bleeding from the rupture of the gastroduodenal artery stump after laparoscopic pancreatoduodenectomy, which is easy and safe to perform.

Rotura aneurismática de la arteria hepática común / Ruptured common hepatic artery aneurysm

RESUMEN Los aneurismas de la arteria hepática son una patología poco frecuente. Cuando son sintomáticos, se debe sospechar un sufrimiento aneurismático y su tratamiento está indicado. Presentamos el caso clínico de un paciente con mal terreno cardiovascular, que consultó por un cuadro clínico de dolor epigástrico, repercusión hemodinámica e ictericia. La imagenología evidenció la presencia de un aneurisma de la arteria hepática común complicado con compromiso del origen de la arteria hepática propia y la arteria gastroduodenal. La presencia de una vascularización arterial hepática "no convencional" con una arteria hepática derecha proveniente de la arteria mesentérica superior, en la angiotomografía, permitió cambiar la táctica quirúrgica haciéndose prescindible la realización de un bypass. Este caso resalta la importancia de determinar en el preoperatorio no solo la extensión del aneurisma, sino también la anatomía vascular hepática a fin de planificar mejor la cirugía, disminuyendo así la morbimortalidad de esta enfermedad.

ABSTRACT Hepatic artery aneurysms are rare. Expanding aneurysms should be suspected in case of symptoms and treatment is indicated. We report the case of a patient with a history of cardiovascular disease who sought medical care due to epigastric pain, hemodynamic instability and jaundice. The imaging tests showed the presence of an aneurysm of the common hepatic artery complicated with involvement of the origin of the proper hepatic artery and the gastroduodenal artery. The surgical approach could be changed due to presence of a "non-conventional" hepatic arterial variant with a right hepatic artery originating from the superior mesenteric artery in the computed tomography angiography as bypass surgery was not necessary. This case highlights the importance of determining the extent of the aneurysm in the preoperative period and the anatomy of the hepatic vessels to better plan the surgery, thus reducing morbidity and mortality of this disease.

Variations of Arterial Supply of the Liver: C.T. Angiographic Study Among Sudanese Adults

Hepatobiliary surgery through laparoscopic approach is becoming a routine. Knowledge of extrahepatic arterial tree is essential for surgical and imaging procedures. Anatomical complexity is expected since the liver is developed by mergingof lobules with its separate blood supply. This makes a wide range of variations in the pattern of vascular arrangement and so reinforces the need for an accurate understanding of full spectrum of variations. This study aimed to investigate the variations in origin and distribution of extrahepatic arterial supply. Fifty volunteers (32 males and 18 females) aged 20­70 years were randomly recruited from the department of CT scan in Al Amal Hospital, Khartoum North, Sudan. The patients were already candidates for CT angiography with contrast for conditions other than hepatobiliary diseases. The reported data is related to those who accepted to participate in the study. Patients with history of hepatobiliary disease were excluded. 3D views of the scans were treated and the extrahepatic arterial tree was traced in a computer-based software. Key findings suggest that Michel's classification was considered the standard template for description ­ 76% of them showed Michel's type I classification. Types III and V constituted about 2%. About 4% of the cases were represented by types VI and IX. Other types of variations constituted about 12%. To conclude, although type I classification which describes the textbook pattern of hepatic artery distribution was significantly detected among the Sudanese population, other variants were to be considered since they are related to major arteries like aorta and superior mesenteric.

Liver manifestation of circulatory disorders / 中华肝脏病杂志

The liver is abundant in blood supply and receives 25% of the cardiac output via the hepatic artery and portal vein. Circulatory disorders may cause hepatic injury, resulting in congestive hepatopathy(CH) and ischemic hepatitis(IH). Hepatic congestion arising from increased hepatic venous pressure and decreased cardiac output is the common pathophysiological basis of both CH and IH. In addition, extensive arteriovenous shunts affect portal pressure and cardiac function, leading to alterations of hepatic blood supply. The current review summarizes the pathophysiology, clinical manifestations and therapeutic interventions of the above diseases, in order to provide reference for clinical practice.

Evaluación anatómica del tronco celíaco y sus ramas en una muestra de población mestiza colombiana / Anatomical evaluation of the celiac trunk and its branches in a sample of Colombian mestizo population

RESUMEN: El tronco celíaco (TC) es la rama de la arteria aorta abdominal (AA) que aporta la irrigación a la porción distal del esófago, parte media del duodeno, al estómago, páncreas, bazo y suple adicionalmente al hígado; sus diferentes expresiones anatómicas son reportadas en los diferentes grupos poblacionales con incidencia variable. Se evaluó las características morfológicas del TC y sus ramas en 26 bloques del piso supramesocólico de cadáveres masculinos adultos no reclamados, del grupo poblacional mestizo, a quienes se les practico autopsia en el Instituto de Medicina Legal de Bucaramanga - Colombia. Se observo el tipo I del TC en 23 especímenes (88,4 %), del cual correspondió 16 muestras (61,5 %). Al subtipo Ia con bifurcación y formación de tronco hepatoesplénico. Hubo un caso (3,8 %) en donde las ramas del T se originaron de manera independiente de la AA. El TC presentó una longitud promedio de 18,6 DE 7,53 mm y un diámetro externo de 7 DE 1,24 mm. De las ramas del TC, la AE presentó un diámetro promedio de 5,89 DE 1,04 mm sin diferencias estadísticamente significativa con relación al diámetro de la AHC, pero si con relación al diámetro de la AGI (P= 0,70; p<0,001 respectivamente). La gran mayoría de la muestra avaluada muestra la presencia de tronco hepatoesplénico seguido de la trifurcación en una verdadera configuración de trípode. El conocimiento de los patrones de ramificación del TC debe ser tomado en cuenta por cirujanos gastroenterólogos, radiólogos intervencionistas y oncólogos para evitar complicaciones durante los procedimientos quirúrgicos abdominales.

SUMMARY: The celiac trunk (CT) is the branch of the abdominal aorta artery (AA) that provides irrigation to the distal portion of the esophagus, the middle part of the duodenum, the stomach, pancreas, spleen and additionally supplies the liver; its different anatomical expressions are reported in the different population groups with variable incidence. The morphological characteristics of the CT and its branches were evaluated in 26 blocks of the supramesocolic floor of unclaimed adult male corpses, of the mestizo population group, who were autopsied at the Institute of Legal Medicine of Bucaramanga - Colombia. Type I CT was observed in 23 specimens (88.4 %), of which 16 samples (61.5 %) corresponded. to subtype Ia with bifurcation and formation of the hepatosplenic trunk. There was one case (3.8 %) in which the branches of the CT originated independently of the AA. The CT had an average length of 18.6 SD 7.53 mm and an external diameter of 7 SD 1.24 mm. Of the CT branches, the splenic artery presented an average diameter of 5.89 SD 1.04 mm without statistically significant differences in relation to the diameter of the AHC, but if in relation to the diameter of the IGA (P = 0.70; p <0.001 respectively). The vast majority of the sample evaluated shows the presence of a hepatosplenic trunk followed by trifurcation in a true tripod configuration. Knowledge of CT branching patterns should be taken into account by gastroenterological surgeons, interventional radiologists, and oncologists to avoid complications during abdominal surgical procedures.

Variaciones anatómicas de la arteria hepática: patrones vasculares observados en 140 hígados de donante cadavérico / Anatomical variations of the hepatic artery: vascular patterns observed in 140 cadaveric donor livers

RESUMEN: El objetivo de este trabajo es analizar las variantes de la arteria hepática observadas en hígados de donantes cadavéricos empleados para trasplante ortotópico de hígado en nuestra población. Se efectuó un estudio retrospectivo de una cohorte de 140 trasplantes entre junio del año 2011 y enero del año 2021. La anatomía vascular arterial de los injertos hepáticos fue clasificada de acuerdo a la descripción de Hiatt. Variante clásica de la arteria hepática - Tipo I: 62 casos (65,7 %). Variante no clásica de la arteria hepática: 48 casos (34,3 %), correspondientes a: Tipo II: 12 casos (8,6 %), Tipo III: 18 casos (12,9 %), Tipo IV: 7 casos (5 %), Tipo V: 10 casos (7,1 %). No se encontró ningún caso de variante Tipo VI. Se halló 1 caso (0,7 %) no descrito en esta clasificación correspondiente a una arteria hepática izquierda accesoria que se originaba de la aorta. El conocimiento preciso de las variaciones más prevalentes, y también de las menos frecuentes, es fundamental para los procedimientos quirúrgicos que se realizan en el abdomen superior.

SUMMARY: The purpose of this article is to analyze the hepatic artery variations observed from the use of cadaveric donor livers for orthotopic transplantation among our population. A retrospective study of a liver transplant cohort including 140 donor livers was conducted between June 2011 and January 2021. The vascular arterial anatomy of the transplanted livers was classified according to Hiatt's classification system. Classic hepatic artery variant: Type I: 62 cases (65.7 %). Non-classic hepatic artery variants: 48 cases (34.3 %), corresponding to: Type II: 12 cases (8.6 %), Type III: 18 cases (12.9 %), Type IV: 7 cases (5 %), Type V: 10 cases (7.1 %). No case of Type VI variant was identified. One case (0.7 %) not included in Hiatt's classification was found, corresponding to an accessory left hepatic artery originating from the aorta. Precise knowledge regarding the most prevalent variations, as well as those that are the least common, is fundamental to upper abdominal surgical procedures.

Diameter measurements and variations of the hepatic arterial system in multidetector computed tomography images / Mediciones de diámetro y variaciones del sistema arterial hepático en imágenes de tomografía computarizada multidetector

SUMMARY: Liver plays an important role in many events such as bile production, blood filtration and metabolic functions. The liver is supplied by the hepatic arterial system. The hepatic arterial system anatomy has a variable structure and the rate of variation is high. In our study, we aimed to determine the diameters and variation of the arteries supplying the liver with multidetector computed tomography images. In this study, hepatic arterial system variations of 500 cases whose abdominal region was imaged with multi- detector computed tomography were evaluated and the diameters of the related arteries were measured. The mean diameters of classical and variational anatomy were determined in this study. According to mean measurements of classical and variational anatomy were abdominal aorta 21.95 mm, celiac artery 7.2 mm, common hepatic artery 4.3 mm, proper hepatic artery 2.93 mm, right hepatic artery 2.92 mm, left hepatic artery 2.51 mm and abdominal aorta 21.85 mm, celiac artery 6.99 mm, common hepatic artery 5.07 mm, proper hepatic artery 3.83 mm, right hepatic artery 2.87 mm ve left hepatic artery 2.09 mm respectively. When evaluated in terms of variations, 85.6 % of the cases had branching according to Type I, 14.4 % of the cases had different branching patterns. Type III (87.5 %) was the most observed variation among them. As a result of the study, it was determined that the arterial diameters vary according to the state of variation and that the arterial diameter of men are greater than that of women.

RESUMEN: El hígado juega un papel importante en diferentes eventos, tal como la producción de bilis, la filtración de sangre y las funciones metabólicas. El hígado está irrigado por el sistema arterial hepático. La anatomía del sistema arterial hepático tiene una estructura variable y la tasa de variación es alta. En nuestro estudio, nuestro objetivo fue determinar los diámetros y la variación de las arterias que irrigan el hígado con imágenes de tomografía computarizada multidetector. Se evaluaron las variaciones del sistema arterial hepático de 500 casos y se obtuvieron imágenes con tomografía computarizada de detectores múltiples abdominales y se midieron los diámetros de las arterias relacionadas. Se determinaron los diámetros medios de la anatomía clásica y variacional. Según las medidas medias de la anatomía clásica y variacional fueron aorta abdominal 21,95 mm, arteria celíaca 7,2 mm, arteria hepática común 4,3 mm, arteria hepática propia 2,93 mm, arteria hepática derecha 2,92 mm, arteria hepática izquierda arteria 2,51 mm y parte abdominal de la aorta 21,85 mm, arteria celíaca 6,99 mm, arteria hepática común 5,07 mm, arteria hepática propia 3,83 mm, arteria hepática derecha 2,87 mm y arteria hepática izquierda 2,09 respectivamente. Cuando se evaluó en términos de variaciones, el 85,6 % de los casos tenían ramificaciones según el Tipo I, el 14,4 % de los casos tenían diferentes patrones de ramificación. El tipo III (87,5 %) fue la variación más observada entre ellos. Como resultado del estudio, se determinó que los diámetros arteriales varían según el estado de variación y que el diámetro arterial de los hombres es mayor que el de las mujeres.

Tratamento endovascular de aneurisma de artéria hepática assintomático: relato de caso / Endovascular treatment of an asymptomatic hepatic artery aneurism: case report

Resumo Relatamos o caso de um paciente masculino, 77 anos, portador de hipertensão arterial, sem outras comorbidades ou fatores de risco para coronariopatia. Apresentava-se assintomático e, durante exame de ultrassonografia abdominal de rotina, foi diagnosticada uma massa vascular hepática de, aproximadamente, 5 cm de diâmetro. Foi solicitada angiotomografia computadorizada abdominal, que evidenciou aneurisma de artéria hepática de até 5,2 cm de calibre máximo, 7,2 cm de extensão no maior eixo longitudinal e calibre máximo da luz verdadeira de 3,0 cm. Optou-se por realização de correção endovascular do aneurisma com implante de três endopróteses vasculares revestidas Lifestream 7x58 mm, 8x58 mm e 8x37 mm sequenciais, com sucesso, conseguindo-se direcionamento do fluxo pelas próteses, levando à exclusão do aneurisma. O paciente evoluiu assintomático, mesmo 2 anos após o implante, sem intercorrências clínicas. Controle com dúplex arterial, realizados 6 e 12 meses após o procedimento, evidenciaram bom fluxo pelas endopróteses, sem "leak" para o saco aneurismático.

Abstract We report a case of an asymptomatic, 77-year-old, male patient with arterial hypertension and no other comorbidities or risk factors for coronary disease. During a routine abdominal ultrasound examination, he was diagnosed with a hepatic vascular mass with an approximate diameter of 5 cm. Abdominal computed angiotomography was requested, showing an aneurysm of the hepatic artery, with maximum diameter of up to 5.2 cm, longest longitudinal axis of 7.2 cm, and a maximum true lumen caliber of 3.0 cm. We opted for endovascular aneurysm repair with implantation of three sequential Lifestream covered vascular stents (7x58mm, 8x58mm, and 8x37mm), successfully diverting the flow through the stents and excluding the aneurysm. The patient remains asymptomatic and free from clinical complications 2 years after the procedure. Control examinations with arterial duplex ultrasound 6 and 12 months after the procedure showed good flow through the stents with no leakage into the aneurysmal sac.

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.

Strategies for a successful hepatic artery anastomosis in liver transplantation: A review of 51 cases

INTRODUCTION@#Hepatic artery reconstruction is a critical aspect of liver transplantation. The microsurgeon faces several challenges when reconstructing the hepatic artery-the donor hepatic artery stalk is short and often a poor match for the usually hypertrophic recipient vessels. Previous inflammation impedes vessel dissection, and recipient vessels have a tendency to delaminate with manipulation. We review 51 consecutive liver transplantations to highlight these problems and propose strategies for a successful reconstruction of the hepatic artery.@*METHODS@#A prospective study involving all adult patients undergoing liver transplantation at the Singapore General Hospital from January 2015 to December 2018 was undertaken. All hepatic artery anastomoses were performed by 2 microsurgeons at 10x magnification. Patients were started on a standard immunosuppressive regimen. Postoperative ultrasound scans on days 1, 3, 5, 7, 9 and 14 were used to confirm arterial patency.@*RESULTS@#There were 51 patients who underwent liver transplantation during the study period. Of this number, 31 patients received deceased donor grafts and 20 received living donor grafts. A total of 61 anastomoses were performed (5 dual anastomosis, 4 radial artery interposition grafts) with 1 case of hepatic artery thrombosis that was successfully salvaged. The mean (range) postoperative resistive index and hepatic artery peak systolic velocity were 0.69 (0.68-0.69) and 1.0m/s (0.88-1.10m/s), respectively.@*CONCLUSION@#Hepatic artery thrombosis after liver transplantation is poorly tolerated. The challenges of hepatic artery reconstruction in liver transplantation are related to vessel quality and length. The use of microsurgical technique, appropriate recipient vessel selection, minimisation of vessel manipulation with modified instruments, variation in anastomosis techniques, and use of radial artery interpositional grafts are useful strategies to maximise the chances of success.

Rotura de aneurisma de la arteria hepática como causa infrecuente de dolor abdominal y hemorragia digestiva / Ruptured hepatic artery aneurysm: an infrequent cause of abdominal pain and gastrointestinal bleeding

Resumen La hemorragia digestiva alta se define como el sangrado originado en el tracto digestivo superior, proximalmente al ángulo de Treitz, y constituye la urgencia gastroenterológica más importante. Tiene una incidencia que varía, según el área estudiada, entre 48 y 160 casos por 100 000 habitantes y año. Aunque puede ser causada por numerosas etiologías, no debemos olvidar aquellas menos comunes, ya que pueden condicionar una alta mortalidad, como es el caso de la rotura de un aneurisma de la arteria hepática. A continuación, mostramos un caso representativo.

Abstract Upper gastrointestinal bleeding is defined as bleeding originating in the upper digestive tract proximal to the Treitz angle and is the most important gastroenterological emergency. Its incidence varies, depending on the area studied, between 48 and 160 cases per 100,000 inhabitants per year. Although it can be caused by numerous etiologies, we must not forget the less common ones such as a ruptured hepatic artery aneurysm since they can condition high mortality. We present a representative case.

Hallazgos y propuesta de sistematización de las variaciones quirúrgicamente importantes de la arteria cística en un estudio in vivo en 2000 colecistectomías laparoscópicas ambulatorias / Findings and proposal for systematization of surgically important variations of the cystic artery based on an in vivo study of 2000 outpatient laparoscopic cholecystectomies

Realizar un estudio anatómico in vivo con la especial y pequeña disección quirúrgica durante una colecistectomía laparoscópica sobre las variaciones de la arteria cística. Estudio prospectivo de 38 meses, en 2000 pacientes consecutivos sometidos a colecistectomía laparoscópica programada, sin signos de inflamación aguda, ni alteración que impida disección y correcta evaluación del triángulo hepatocístico. Se disecó quirúrgicamente identificándose la arteria cística y posible duplicación, eran clínicamente importantes aquellas con diámetro mayor a 1,5 mm, requerían maniobra hemostática. Se anotaron los hallazgos en planilla especial a los fines del presente estudio. En 1831 casos había arteria única en medio del triángulo hepatocístico. Hubo 169 variaciones (8,45 %). En 97 casos: doble vascularización, con una arteria en situación normal y otra ubicada lateralmente al triangulo hepatocístico. En 44 pacientes había una arteria única lateralmente al conducto cístico que no lo cruzaba nunca. En 22 casos existía una arteria cruzando el colédoco y el cístico entrando en el triángulo. En 6 oportunidades una doble arteria, una en el triángulo hepatocístico y otra lateralmente que no cruzaba el cístico ni colédoco. En una oportunidad se observó una sola arteria importante que salía directamente de la placa cística entre segmento 4 y 5, y en otro caso solo pequeñas arterias proveniente de la placa cística. Podemos dividirlas en arterias únicas o dobles, en base exclusiva a la necesidad de maniobra hemostática. Podemos decir que las variaciones estarán presentes en aproximadamente 1/12 casos y necesitará una maniobra hemostática especial en 1/20 casos.

This is an anatomical study with the special and small dissection of a laparoscopic cholecystectomy on the surgically important variations of the cystic artery. A prospective, 19-month study was conducted in 2000, including consecutive patients undergoing programmed laparoscopic cholecystectomy, without signs of acute inflammation, or alteration, that would prevent dissection and correct evaluation of the cystohepatic triangle. It was surgically dissected, identifying the main cystic artery and its possible collateral arteries. Those with a diameter greater than 1.5 mm being considered as clinically important, requiring haemostatic maneuver (clipping and / or electrocoagulation). The findings were recorded on a special form for the purposes of this study. The classic, single-artery arrangement in the middle of the cystohepatic triangle was found in 1831 cases. The variations found were 169 (8.45 %). In 97 cases there was double vascularization, with one artery in normal position and another outside the cystic duct. In 44 patients, a single artery that did not cross the cystic was observed. In 22 cases an artery outside the cystic but crossing it before the duct. In 6 cases a double artery, one in the cystohepatic triangle and another outside the triangle, did not cross the cystic or the bile duct. In one instance, a single major artery was seen emerging directly from the cystic plaque between segments four and five. These can be divided into single or double arteries, based exclusively on the need for hemostatic maneuver. Knowledge of anatomical variations of the cystic artery is important for the surgeon. The variation presents in 1 of 12 cases, and requires a special hemostatic maneuver in 1 of 20 cases.

Risk factors associated with hepatic artery thrombosis: analysis of 1050 liver transplants / Fatores de risco associados à trombose de artéria hepática: análise de 1050 transplantes de fígado

ABSTRACT Background: Hepatic artery thrombosis is an important cause of graft loss and ischemic biliary complications. The risk factors have been related to technical aspects of arterial anastomosis and non-surgical ones. Aim: To evaluate the risk factors for the development of hepatic artery thrombosis. Methods: The sample consisted of 1050 cases of liver transplant. A retrospective and cross-sectional study was carried out, and the variables studied in both donor and recipient. Results: Univariate analysis indicated that the variables related to hepatic artery thrombosis are: MELD (p=0.04) and warm time ischemia (p=0.005). In the multivariate analysis MELD=14.5 and warm ischemia time =35 min were independent risk factors for hepatic artery thrombosis. In the prevalence ratio test for analysis of the anastomosis as a variable, it was observed that patients with continuous suture had an increase in thrombosis when compared to interrupted suture. Conclusions: Prolonged warm ischemia time, calculated MELD and recipient age were independent risk factors for hepatic artery thrombosis after liver transplantation in adults. Transplanted patients with continuous suture had an increase in thrombosis when compared to interrupted suture. Re-transplantation due to hepatic artery thrombosis was associated with higher recipient mortality.

RESUMO Racional: Trombose de artéria hepática é importante causa de falência de enxerto e complicações biliares. Fatores de risco para trombose estão relacionados aos aspectos técnicos da anastomose arterial e fatores não cirúrgicos. Objetivo: Avaliar os fatores de risco para o desenvolvimento de trombose de artéria hepática. Métodos: A amostra consta de 1050 casos de transplante hepático. Foi realizado estudo retrospectivo e transversal, e as variáveis foram avaliadas em doadores e receptores. Resultados: A análise univariada mostrou que as variáveis relacionadas a trombose de artéria hepática são: MELD e tempo de isquemia quente. Na análise multivariada, o MELD=14.5 e tempo de isquemia quente =35 min foram fatores de risco independentes para trombose de artéria hepática. No teste de prevalência para avaliação do tipo de anastomose como variável, foi observado que a sutura contínua tem maior risco de trombose quando comparada com aquela em pontos separados. Conclusão: Tempo de isquemia quente prolongado, MELD calculado e idade do recipiente foram fatores de risco independentes para trombose de artéria hepática após transplante de fígado em adultos. Pacientes submetidos à anastomose com sutura contínua apresentaram mais trombose quando comparados com a em pontos separados. Retransplante por trombose está associado com maior mortalidade.

Anatomical variations of the superior mesenteric artery and its clinical and surgical implications in humans / Variações anatômicas da artéria mesentérica superior e suas implicações clínicas e cirúrgicas em humanos

ABSTRACT Introduction: Superior mesenteric artery (SMA) usually arises from the abdominal aorta, just below the celiac trunk and it supplies the midgut-derived embryonic structures. Anatomical variations in this vessel contribute to problems in the formation and/or absorption of this part of the intestine and its absence has been recognized as the cause of congenital duodenojejunal atresia. Objective: To analyze SMA anatomical variations in humans and the possible associated clinical and surgical implications. Methods: This is a systematic review of papers indexed in PubMed, SciELO, Springerlink, Science Direct, Lilacs, and Latindex databases. The search was performed by two independent reviewers between September and December 2018. Original studies involving SMA variations in humans were included. SMA presence/absence, level, place of origin and its terminal branches were considered. Results: At the end of the search, 18 studies were selected, characterized as for the sample, method to evaluate the anatomical structure and main results. The most common type of variation was when SMA originated from the right hepatic artery (6.13%). Two studies (11.11%) evidenced the inferior mesenteric artery originating from the SMA, whereas other two (11.11%) found the SMA sharing the same origin of the celiac trunk. Conclusion: SMA variations are not uncommon findings and their reports evidenced through the scientific literature demonstrate a great role for the development of important clinical conditions, making knowledge about this subject relevant to surgeons and professionals working in this area.

RESUMO Introdução: A artéria mesentérica superior (AMS), normalmente, tem sua origem a partir da aorta abdominal, um pouco abaixo do tronco celíaco e é responsável pela irrigação das estruturas derivadas, embrionariamente, do intestino médio. Variações anatômicas nesse vaso contribui para defeitos na formação e/ou absorção dessa parte do intestino e a sua ausência tem sido reconhecida como a causa da atresia duodenojejunal congênita. Objetivo: Analisar as variações anatômicas dela em humanos e as possíveis implicações clínicas e cirúrgicas associadas. Métodos: Trata-se de uma revisão sistemática de artigos indexados nas bases de dados PubMed, SciELO, Springerlink, Scienc Direct, Lilacs e Latindex. A busca ocorreu por dois revisores independentes entre setembro e dezembro de 2018. Foram incluídos artigos originais envolvendo as variações da AMS em humanos. Considerou-se para este estudo a presença/ausência da AMS, o nível, local de origem e seus ramos terminais. Resultados: Ao final da busca foram selecionados 18 artigos, caracterizados quanto à amostra, método para avaliar a estrutura anatômica e principais resultados. O tipo de variação mais comum foi aquele cuja AMS se originou da artéria hepática direita (6,13%). Dois estudos (11,11%) evidenciaram a artéria mesentérica inferior originando-se a partir da AMS, enquanto outros dois (11,11%) constataram ser ela compartilhada na mesma origem do tronco celíaco. Conclusão: Variações na AMS não são achados incomuns e seus relatos evidenciados através da literatura científica demonstram grande importância para o desenvolvimento de condições clínicas importantes, tornando o conhecimento sobre esse assunto relevante para os cirurgiões e profissionais atuantes nesta área.

Artéria hepática direita originada da artéria mesentérica superior: Qual seu real trajeto anatômico? / Right hepatic artery originated from the superior mesenteric artery: What is the standard anatomic position?

RESUMO Objetivos: A irrigação arterial hepática tem como característica a elevada frequência de variações da anatomia. O objetivo do estudo foi descrever o trajeto anatômico da artéria hepática direita quando originada da artéria mesentérica superior. Métodos: Foram analisadas 5147 tomografias computadorizadas com contraste endovenoso de pacientes atendidos no Serviço de Radiologia do Hospital de Clínicas de Passo Fundo - RS, no período outubro de 2016 a dezembro de 2017. Foram selecionados 125 pacientes portadores de variação anatômica da artéria hepática direita na origem. Os achados foram categorizados pela variação do trajeto vascular, emergência da artéria mesentérica superior e a relação com demais estruturas. Resultados: Obtivemos o trajeto mais frequente desta variação como retropancreático (88,8%), retroportal (76,8%) e pós-coledociano (75,2%), emergindo cerca de 2,33 cm da origem da artéria mesentérica superior. Conclusão: Demonstramos que na maioria das vezes, a artéria hepática direita variante, apresenta trajeto posterior ao pâncreas e ao pedículo hepático e emerge próxima da origem da artéria mesentérica superior.

ABSTRACT Objective: Liver arterial irrigation is characterized by a high frequency of variations in its anatomy. The aim of the study was to describe the anatomic position of the right hepatic artery as a brunch of the superior mesenteric artery. Methods: A total of 5147 intravenous contrast-enhanced computed tomography scans of patients seen at the Radiology Service of the Passo Fundo Clinical Hospital (RS), from October 2016 to December 2017, were selected. 125 patients with anatomic variation of the right hepatic artery were selected. The findings were categorized by the variation of the vascular position, emergence from the superior mesenteric artery and the relationship with other structures. Results: The most frequent position was retropancreatic (88.8%), retroportal (76.8%) and post-choledocian (75.2%), emerging about 2.33 cm from the superior mesenteric artery. Conclusion: We have shown that most common variant of the right hepatic artery presents its posterior origin from the pancreatic and hepatic pedicle, and arises close to the origin of the superior mesenteric artery.

Angiotomografía de las variantes anatómicas de la arteria cística: estudio en el preoperatorio de colelitiasis / Angiotomography of the anatomical variants of the cystic artery: pre-operative study of cholelithiasis

La colecistectomía laparoscópica es el tratamiento indicado en la colelitiasis, sin embargo el procedimiento no está exento de complicaciones o morbilidad concomitante. Es posible que, debido a lesiones ductales colaterales, ocurra sangrado con posibilidad de conversión de la cirugía e indeseables resultados. Para un correcto abordaje de la región se hace fundamental la identificación del trígono cistohepático (TCH) y sus componentes, a su vez de la ligadura y sección de la arteria cística (AC). Conociendo la elevada variabilidad de la AC, el objetivo de este trabajo consistió en identificar el número, origen, trayecto y relación de la AC con el TCH y sus variaciones, utilizando angiotomografía por medio de un tomógrafo detector de 64 cortes, en el preoperatorio de 30 pacientes de sexo femenino, entre 24 y 54 años de edad, con colelitiasis diagnosticadas clínicamente y por ecosonografía. La AC en el 76,67 % era única y se encontraba dentro del TCH, en el 16,67 % era única y se observó fuera del TCH. En el 6,67 % se observaron dos AC, una dentro y otra fuera del TCH. En el 66,67 % de los casos la AC se originaba de manera normal de la arteria hepática derecha. La trazabilidad de la AC fue en el 53,3 % medianamente visible y en el 46,7 % de trazabilidad excelente. En conclusión, la identificación de la AC y sus variaciones anatómicas se puede determinar en el preoperatorio y puede ser útil para mejorar el plan quirúrgico en pacientes con colelitiasis, brindando información al procedimiento, optimizarlo y disminuir los riesgos de eventuales complicaciones relacionados con sangrado.

Laparoscopic cholecystectomy is the treatment indicated for cholelithiasis, however the procedure is not free of complications or concomitant morbidity. It is possible that, due to collateral ductal lesions, bleeding occurs with the possibility of surgery conversion and undesirable results. For a correct approach to the region it is essential to identify the cystohepatic trigone (CHT) and its components, as well as the ligation and section of the cystic artery (AC). Knowing the high variability of CA, the aim of this work was to identify the number, origin, path and relationship of CA with the CHT and its variations using angiotomography by means of a 64-slice detector tomograph in the preoperative period of 30 female patients, between 24 and 54 years old, with clinically diagnosed cholelithiasis and by echo sonography. The AC in 76.67 % was unique and was within the CHT, in 16.67 % it was unique and was observed outside the CHT. In 6.67 %, two ACs were observed, one inside and one outside the TCH. In 66.67 % of cases, CA originated normally from the right hepatic artery. The traceability of AC was 53.3 % moderately visible and 46.7 % excellent traceability. In conclusion, the identification of AC and its anatomical variations can be determined in the preoperative period and can be useful to improve the surgical plan in patients with cholelithiasis, providing information on the procedure, optimizing it and reducing the risks of possible bleeding related complications.

Assessment of remnant liver function and volume after selective ligation of portal vein and hepatic artery in a rat model

Abstract Purpose: To evaluate liver regeneration after selective ligation of portal vein and hepatic artery by 3D Computed Tomography in an experimental model. Methods: Sixteen Wistar rats were randomized into four equal groups: Group I- control (sham), Group II- isolated selective ligation of the hepatic artery, Group III- isolated selective ligation of the portal vein and Group IV- combined ligation of portal vein and hepatic artery. Before procedure and five days after a 3D CT Scan was performed to analyze the hypertrophy, weight and function of the remnant liver. Results: The largest regeneration rate and increase of weight in the hypertrophied lobe was detected in group IV, the first with an average of 3.99 (p=0.006) and the last varying from 6.10g to 9.64g (p=0.01). However, total liver weight and the R1 ratio (Hypertrophied Lobe Weight/Total Liver Weight) was higher in group III (P<0.001) when compared with groups I, II and IV and showed no difference between them. The immunohistochemical examination with PCNA also found higher percentages with statistical significance differences in rats of groups III and IV. It was possible to confirm a strong correlation between hypertrophied lobe weight and its imaging volumetric study. Liver function tests only showed a significant difference in serum gamma-glutamyltransferase and phosphorous. Conclusion: There is a largest liver regeneration after combined ligation of portal vein and hepatic artery and this evidence may improve the knowledge of surgical treatment of liver injuries, with a translational impact in anima nobile.