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Introduction: Cholelithiasis is the most common disease worldwide, and laparoscopic cholecystectomy is the standard treatment of choice. To perform laparoscopic cholecystectomy, it is essential to understand the critical view of safety, which primarily involves the dissection of Calot's triangle. Anatomical variations in Calot's triangle exist, and understanding them is crucial to avoid unintended situations during surgery. Mirizzi syndrome, a rare complication in Calot's triangle, can significantly increase mortality and morbidity rates. Aim: To evaluate the anatomical variations in the Calot’s triangle. Materials and Methods: A cross-sectional study was conducted at Mayo Institute of Medical Sciences, Department of General Surgery, from October 2021 to September 2022. The total sample size included 100 patients with gallstone disease who underwent surgical intervention. Intraoperative findings, such as variations in the cystic artery and cystic duct, as well as Mirizzi syndrome grading, were recorded in an Excel sheet and tabulated. The results were expressed in terms of frequency and percentage. Results: The average age of the patients was 39.42±12.11 years, with females outnumbering males. Among them, 28% had a cystic artery lying outside of Calot's triangle, and 96% had a cystic artery originating from the right hepatic artery. The remaining 2% originated from an aberrant right hepatic artery, 1% from the left hepatic artery, and 1% from the gastroduodenal artery. Cystic duct variations were found in 5% of cases. Of these, 2% had a short cystic duct (

Introduction: Cholelithiasis is the most common disease worldwide, and laparoscopic cholecystectomy is the standard treatment of choice. To perform laparoscopic cholecystectomy, it is essential to understand the critical view of safety, which primarily involves the dissection of Calot's triangle. Anatomical variations in Calot's triangle exist, and understanding them is crucial to avoid unintended situations during surgery. Mirizzi syndrome, a rare complication in Calot's triangle, can significantly increase mortality and morbidity rates. Aim: To evaluate the anatomical variations in the Calot's triangle. Materials and Methods: A cross-sectional study was conducted at Mayo Institute of Medical Sciences, Department of General Surgery, from October 2021 to September 2022. The total sample size included 100 patients with gallstone disease who underwent surgical intervention. Intraoperative findings, such as variations in the cystic artery and cystic duct, as well as Mirizzi syndrome grading, were recorded in an Excel sheet and tabulated. The results were expressed in terms of frequency and percentage. Results: The average age of the patients was 39.42±12.11 years, with females outnumbering males. Among them, 28% had a cystic artery lying outside of Calot's triangle, and 96% had a cystic artery originating from the right hepatic artery. The remaining 2% originated from an aberrant right hepatic artery, 1% from the left hepatic artery, and 1% from the gastroduodenal artery. Cystic duct variations were found in 5% of cases. Of these, 2% had a short cystic duct (<2 cm), 1% had a long cystic duct (approximately 5 cm), one patient had an absent cystic duct, and one had a low insertion into the common hepatic duct. Mirizzi syndrome Grade-I and Grade-II patients accounted for 4% and 2% respectively, while Grade-III, Grade-IV, and Grade-V each contributed to 1%. Conclusion: Knowledge of Calot's triangle variations is crucial, especially for aspiring surgeons, as it helps them make decisions promptly when encountering difficulties during surgery. Understanding the Calot's region ensures the safety not only of patients but also of surgeons. [ABSTRACT FROM AUTHOR]

Background: An aberrant vascular anatomy might present a technical pitfall for biliary atresia (BA) surgery. The purpose of this study was to report the rare cases and discuss the significance and management strategy for BA with an aberrant right hepatic artery (ARHA) by laparoscopic Kasai procedure in children. Methods: The subjects for this study were 10 consecutive type III BA patients with an ARHA who had laparoscopic Kasai procedure at our institute between January 2012 and August 2021. The common bile duct was mobilized between the right hepatic artery and the right branch of portal vein, and then lifted to the liver hilum. The fibrous cord was transected and then the laparoscopic Kasai was carried out. Results: All patients survived the laparoscopic Kasai without any intraoperative complications. The mean operative time was 235 minutes for each laparoscopic Kasai. The mean follow-up time was 32.6 months. The total and direct bilirubin dropped to normal within 4 months of surgery in 7 patients. One patient died of repeated cholangitis and liver failure 1 year after surgery. In the additional 2 patients the bilirubin levels dropped significantly after the surgery but elevated again because of repeated cholangitis and requiring ongoing observation and intermittent treatment. Conclusions: With the perfect laparoscopic skills, the common bile duct could be safely mobilized between the right hepatic artery and right branch of portal vein for the infants with type III BA associated with an ARHA, and laparoscopic Kasai could be carried out safely and successfully. [ABSTRACT FROM AUTHOR]

Variations in graft arterial anatomy can increase the risk of postoperative hepatic arterial thrombosis (HAT), especially in presence of a replaced or accessory right hepatic artery (RHA). We retrospectively analyzed 223 cases of liver transplantations with the presence of an RHA on the graft. Patient outcomes were compared according to the four different reconstruction methods used: (i) the re‐implantation of the RHA into the splenic or gastroduodenal artery (n = 106); (ii) the interposition of the superior mesenteric artery (SMA) (n = 83); (iii) dual anastomosis (n = 24); (iv) use of an aortic patch including the origins of both the SMA and the coeliac trunk (n = 10). A competing risk analysis and Inverse Probability Weighting (IPW) were used. We found that the interposition of the SMA method was associated with a significantly lower incidence of HAT, at 4.8% compared to the re‐implantation method at 17.9%, dual anastomosis at 12.5%, and aortic patch at 20%, p =.03. In the competing risk analysis with IPW, the only risk factor for RHA thrombosis was the type of reconstruction. Taking the SMA interposition group as the reference, the sub‐hazard ratio (sHR) was 5.05 (CI 95 [1.72; 14.78], p <.01) for the re‐implantation group, sHR = 2.37 (CI 95 [0.51; 11.09], p =.27) for the dual anastomosis group and sHR = 2.24 (CI 95 [0.35; 14.33], p =.40) for the aortic patch group. There were no differences for intraoperative transfusion, hospitalization duration (p =.37) or incidence of severe complications (p =.1). The long‐term graft (p =.69) and patient (p =.52) survival was not different. In conclusion, the SMA interposition method was associated with a lower incidence of RHA thrombosis. [ABSTRACT FROM AUTHOR]

Background: Combined resection of the right hepatic artery (RHA) is sometimes required to achieve complete resection of hilar cholangiocarcinoma. The present study aimed to evaluate the feasibility of combined resection and subsequent reconstruction by continuous suture of the RHA during left hepatectomy for cholangiocarcinoma. Materials and methods: We retrospectively compared the outcomes after left hepatectomy with biliary reconstruction for cholangiocarcinoma between patients with and without RHA resection and reconstruction. Results: Of the 25 patients who underwent left hepatectomy combined with biliary reconstruction, eight patients (32%) underwent combined resection and reconstruction of the RHA (AR group). The demographic characteristics were not different between the AR and non-AR groups. The amount of intraoperative bleeding was significantly greater in patients with AR (2350 mL vs. 900 mL, p = 0.017). The prevalence of early complications above grade III in Clavien–Dindo classification and late complications were not significantly different between the AR and non-AR groups. In the AR group, complications directly associated with AR, such as thrombosis or reanastomosis, were not observed. On Kaplan–Meier analysis, recurrence-free survival (p = 0.618) and overall survival (p = 0.803) were comparable between the two groups despite the advanced T stages in the AR group. Conclusions: Combined resection and subsequent reconstruction of the RHA during left-sided hepatectomy is a feasible treatment alternative for cholangiocarcinoma.

The diagnostics and treatment management in conditions of massive sanitary losses with the use of staged treatment have their own specifics and require a multidisciplinary approach with the involvement of a wide range of specialists and the use of modern technologies. The number of sources covering the ultrasound diagnostics and clinical course of hepatic artery pseudoaneurysm as a complication of gunshot wounds is quite limited in world literature. We present the experience of the observation and management of the right hepatic artery pseudoaneurysm in case of the blast injury of liver in two patients: the example of successful resolution with spontaneous occlusion and the example with the occurrence of internal bleeding as a result of pseudoaneurysm rupture. Clinical cases presented here belong to the category of severe injuries caused by high-energy weapons, which are characterized by a syndrome of mutual aggravation and need for simultaneous treatment of several damaged organs. The use of contrast methods in severely injured patients requires instrumental justification, and results of daily ultrasound monitoring with the use of color Doppler program can be the one. Pseudoaneurysm of hepatic arteries is a dangerous complication of severe liver wounds and injuries, which occurs in 3·2 % of patients according to our data. The method of ultrasound examination with the use of color Doppler mapping program allows to visualize pseudoaneurysms and monitor their progress. When identifying patients with pseudoaneurysm of hepatic arteries at the level II–III medical care (Role II–III), their further evacuation should be carried out to medical institutions equipped with endovascular correction technologies. • Pseudoaneurysm of hepatic arteries is a dangerous complication of severe liver wounds and injuries • Cases of the spontaneous thrombosis and cases of pseudoaneurysm rupture with a massive bleeding are seen • Sonography method with the use of color Doppler mapping allows to visualize pseudoaneurysms and monitor their progress. • Patients with pseudoaneurysm of hepatic arteries should be evacuated to medical institutions with endovascular technologies. [ABSTRACT FROM AUTHOR]

Combined resection of the right hepatic artery (RHA) is sometimes required to achieve complete resection of hilar cholangiocarcinoma. The present study aimed to evaluate the feasibility of combined resection and subsequent reconstruction by continuous suture of the RHA during left hepatectomy for cholangiocarcinoma. We retrospectively compared the outcomes after left hepatectomy with biliary reconstruction for cholangiocarcinoma between patients with and without RHA resection and reconstruction. Of the 25 patients who underwent left hepatectomy combined with biliary reconstruction, eight patients (32%) underwent combined resection and reconstruction of the RHA (AR group). The demographic characteristics were not different between the AR and non-AR groups. The amount of intraoperative bleeding was significantly greater in patients with AR (2350 mL vs. 900 mL, p = 0.017). The prevalence of early complications above grade III in Clavien–Dindo classification and late complications were not significantly different between the AR and non-AR groups. In the AR group, complications directly associated with AR, such as thrombosis or reanastomosis, were not observed. On Kaplan–Meier analysis, recurrence-free survival (p = 0.618) and overall survival (p = 0.803) were comparable between the two groups despite the advanced T stages in the AR group. Combined resection and subsequent reconstruction of the RHA during left-sided hepatectomy is a feasible treatment alternative for cholangiocarcinoma. [ABSTRACT FROM AUTHOR]

Injuries to blood vessels occur in 0.8% of the cases following laparoscopic cholecystectomy. They may result from direct penetration while insertion of trocar or by thermal injury (electrocautery). Pseudoaneurysm of hepatic artery is a rare occurrence. It is a serious complication following acute or chronic injuries to hepatic artery, with only 0.06% to 0.6% of the cases being reported. Endovascular embolization is usually the first line treatment in the management of pseudoaneurysm of hepatic artery with high success rate. Surgical intervention should be considered if the embolization fails, pseudoaneurysm are infected or other vascular structures are compressed. Our case highlights a 48-year-old male presenting with complaints of pain abdomen and jaundice later diagnosed to be a case of pseudoaneurysm of right hepatic artery and was successfully managed with angiographic embolization, which is the first line of management., (© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

Background: In most cases, the right inferior phrenic artery originates as a posterolateral branch of the abdominal aorta at T12 and the superior mesenteric artery stems as a second ventral branch of the abdominal aorta at L1. The proper hepatic artery (a branch of the common hepatic artery) bifurcates into the right and the left hepatic arteries. The superior suprarenal artery arises from the inferior phrenic artery; the middle suprarenal artery from the abdominal aorta; and the inferior suprarenal artery from the renal artery. The brachial artery divides into its two terminal branches, i.e., the radial and ulnar arteries in the cubital fossa. Numerous variations have been reported deviating from these most common patterns however, variations in all these arteries have not been reported so far in a single cadaver. The left superior suprarenal artery originating from the left renal artery has not been documented yet. Methods: The vascular variations were noted at the time of dissection done on a formalin-fixed male cadaver. The measurements like length and diameter of arteries were done by Vernier caliper, and the height of the cadaver was taken by using a measuring tape. Acrylic paint was used to paint the arteries for a clear view. Then, the variations were photographed. Case description: The case in concern is that of a male cadaver documented to have five distinct vascular anatomical variations. The identified variations include: • the right inferior phrenic artery originating from the celiac trunk; • the superior mesenteric artery originating just distal to the celiac trunk with a gap of only 5mm; • the right hepatic artery originating from the superior mesenteric artery; • the right and the left middle suprarenal arteries branching from corresponding renal arteries, and the left superior suprarenal artery arising from the left renal artery; and • the right brachial artery dividing into radial and ulnar arteries very close to its origin. Conclusion: Taking note of the variation in origins of the right inferior phrenic artery and the right hepatic artery is important for conducting transcatheter arterial chemoembolization for hepatocellular carcinoma. Similarly, the celiac trunk at a higher position is more prone to compression by the median arcuate ligament. The higher termination of the right brachial artery affects blood pressure measurement and management in fracture of the humerus. Futher, all these variations are to be duly considered during angiography to avoid misinterpretation and surgery to avoid untoward bleeding.

Modern medicine is developing towards application of endovascular techniques such as trans-arterial hepatic chemoembolisation. They displace classic open procedures. However, their correct planning and performance depend on the knowledge pre-operative detection of hepatic arterial anatomical variations. The main abnormality that may generate complications during radiological and surgical procedures is occurrence of an accessory hepatic artery. In the present study we propose our own classification of the variability observed in the vessels based on cases reported in the literature. It analyses more types of variations as compared to previous trials. A great advantage of this study is also a description of different pathological and frequently life-threatening conditions associated with hepatic arteries. This study is of value to medical practitioners, e.g. surgeons. [ABSTRACT FROM AUTHOR]

Purpose: To describe a previously unreported anatomical variant of the hepatic arterial supply: a conjoined right hepatic artery, formed by branches of the common hepatic artery and gastroduodenal artery. Method: A 54-year-old female with oligometastatic colorectal cancer with metastases to the liver presented for planning stage arteriography in preparation for Y90 radioembolization. Results: Arteriography of the common hepatic artery demonstrated bifurcation into a right hepatic artery and gastroduodenal artery. The gastroduodenal artery gave rise to a proximal branch, from which the left hepatic artery originated and then continued to anastomose in the hilum of the liver to the right hepatic artery originating from the common hepatic artery. It was initially identified on visceral artery arteriography and then retrospectively recognized on pre-procedural CT scan. Conclusion: Anatomical variants of the hepatic arterial supply are important to recognize during planning stage arteriography in preparation for Y90 radioembolization. Knowledge of these variants is also important for pre-operative planning. [ABSTRACT FROM AUTHOR]

Pseudoaneurysms of the right hepatic artery following cholecystectomy are caused by either vascular damage or erosion after a biliary leak. Symptoms often include haemobilia, melena, vomiting, jaundice, and hemodynamic failure due to aneurysm rupture. The ideal treatment is arterial embolization or, in rare cases, stenting. We present a case of pseudoaneurysm of the right hepatic artery post-laparoscopic cholecystectomy. The patient presented with abdominal pain, vomiting, and hemodynamic failure on postoperative day 45. Magnetic resonance imaging (MRI) showed a large hematoma and a pseudoaneurysm of the right hepatic artery. A laparotomy was performed, and a large hematoma was found and evacuated. After the pringle maneuver, the pseudoaneurysm was resected. The right hepatic artery was ligated with clips, and a sub-hepatic drain was placed. The non-availability of emergency embolization forced surgical closure of the right hepatic artery, which is still the first-line treatment for such cases. Injury of the right hepatic artery is a rare complication, often overlooked by surgeons, and requires early diagnosis. Surgical treatment is reserved for cases of embolization failure or hemodynamic instability., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Nouri et al.)

Purpose: It has been reported that there are left and right hepatic arterial arcades via the blood vessels around the hilar bile duct; therefore, when the hilar bile duct is preserved, hepatic artery reconstruction may not be necessary. We compared the short-term and long-term outcomes in patients with distal cholangiocarcinoma who underwent pancreatoduodenectomy (PD) with right hepatic artery resection without right hepatic artery reconstruction (RHAR group) with those patients who underwent conventional PD. Methods: All data were retrospectively collected from patient records. A 1:4-propensity score-matched case-control study was conducted in patients with distal cholangiocarcinoma who received treatment at Tokyo Women's Medical University from February 1985 to April 2015. Results: There was no statistical difference in the overall morbidity rate between the two groups. No patient in the RHAR group (10 patients) had liver failure, liver abscess, or cholangitis in the postoperative period; one patient died postoperatively because of a bleeding pseudoaneurysm in the gastroduodenal artery. The PD group (40 patients) had a significantly better median time regarding the recurrence (34 vs. 11 months, p=0.027) and 5-year disease-free survival (35% vs. 10%, p=0.027) rates than the RHAR group, which may be attributed to the presence of a more severe disease in patients in the RHAR group. Conclusion: We concluded that pancreaticoduodenectomy with right hepatic artery resection without reconstruction has a comparable overall morbidity rate with that of a conventional pancreaticoduodenectomy surgery and may be performed as an alternative procedure when tumor invasion of the right hepatic artery is suspected. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic Cholecystectomy is widely accepted as the gold standard in the treatment of cholelithiasis and this new technique was initially associated with a significant increase in morbidity, and in particular, in iatrogenic biliary injury and arterial haemorrhage, perhaps due to a lack of knowledge of the laparoscopic anatomy of the gallbladder pedicle.The arterial system of human body is often subjected to a good number of variations. Therefore, trying to find out variations in origin of right and left hepatic arteries and also cystic artery will surely be a useful endeavor for an Anatomist and Autopsy Surgeon, moreover such an effort will help the surgeons in planning and operating upon the hepatobiliary system. Method:The present work was carried out in the Department of FMT, NRSMCH, Kolkata in collaboration with the Department of Anatomy, Medical College, Kolkata over a period of one year to find out variations ion origin of right and left hepatic arteries and cystic artery. Fifty cadavers of both sexes were subjected to detail dissection method based on inclusion and exclusion criteria. The study was prospective, cross sectional, observational, autopsy based study. Conclusion:In 92% cases total number of branches from the HAP were three, four branches were arising from it in 6% cases, whereas >four branches from the HAP in remaining 2% cases.The branching pattern of the HAP at the porta hepatis showed bifurcation in 96 % cases, whereas HAP showed trifurcation pattern at porta hepatis in 4% cases.Any source of origin of the RHA and LHA other than the HAP was recorded as 0%. The percentage of occurrence of accessory or replaced RHA was 0%.This was also the case with LHA. The present study revealed the RHA (92%) being the commonest source of origin of cystic artery. In 8% cases cystic artery represented variant origin. Variant origins of CA were represented by the HAP (6%) and GDA (2%). In 96% of cases, the cystic artery was single. Remaining 4% of cadavers showed presence of more than one cystic artery, the number being two. Most significant finding in this present study according to the researcher is the presence of double cystic arteries. [ABSTRACT FROM AUTHOR]

Background: The present study aimed to evaluate anatomical variations of the right hepatic artery (RHA) in patients with congenital biliary dilatation (CBD) and the appropriate approach in laparoscopic surgery for CBD. Methods: The medical records of 36 patients who underwent laparoscopic or open surgery for CBD from 1996 to 2018 were retrospectively reviewed. Radiological evaluation of the origin and course of the RHA in these 36 patients were compared with 195 control patients without CBD. Results: The incidence of the RHA crossing anterior to the common hepatic duct (CHD) was significantly higher in patients with CBD than in those without CBD (33% versus 10%, P =.0001). There was no intraoperative injury of the RHA, irrespective of the course of the RHA. The CHD was divided at the caudal side of the RHA in 11 of 12 patients (92%) with the anterior type of RHA, and in 13 of 24 patients (54%) with the posterior type of RHA (P =.03). Conclusions: Patients with CBD had a higher incidence of the RHA crossing anterior to the CHD than patients without CBD. Preservation of the RHA in each situation is necessary during surgery for CBD in the era of laparoscopic surgery. [ABSTRACT FROM AUTHOR]

Introduction: Vasculobiliary and vascular injuries following cholecystectomy are the most serious complications requiring complex surgical management resulting in greater patient morbidity and mortality.Methodology: The study was performed at a tertiary teaching hospital of North India. Records of patients referred for biliary or vascular injury sustained during cholecystectomy were reviewed retrospectively to identify patients with vascular injury between January 2009 and March 2018. Clinical profile, hospital course and outcome of these patients were analysed.Results: Over nine years, 117 patients were referred for cholecystectomy related complications. Total incidence of vascular injury was 5.1% (6/117). Combined vasculobiliary injury (VBI) occurred in 3.4% (4/117) while isolated vascular injury was present in 1.7% patients (2/117). Most (5/6) patients were operated for uncomplicated gall stone disease. Incidences of portal vein (PV) and right hepatic artery (RHA) injuries were equal (3/6). PV injuries were repaired either during cholecystectomy (1/3) or during re-exploration after damage control packing (2/3). RHA injuries presented as pseudoaneurysm and were managed surgically (2/3) or by coil embolization (1/3). All VBI referrals (4/117) were following open cholecystectomy. In VBI patients, vascular injury was diagnosed intra-operatively in two while it was diagnosed several weeks after cholecystectomy in two others. Biliary injury manifested as bile leak post-operatively in all four of them. Nature of biliary injury could be characterized in only 50% (2/4) patients. Definitive repair of biliary injury was performed in one patient only. There was one mortality in our series.Conclusion: Vascular injury is an uncommon complication of cholecystectomy with catastrophic outcome if not managed timely and properly. Adequate surgeon training, keeping the possibility of aberrant vasculobiliary anatomy in all cases, and proper surgical technique is crucial for prevention of such injuries. However in such an event, proper documentation and referral to tertiary centre will help in decreasing morbidity and further litigation. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Laparoscopic cholecystectomy has been started to be applied in the field of surgery in the 1990s and became the gold standard in treatment in a short time period. The generally applied method in laparoscopic cholecystectomy is the infundibular technique and calot dissection is of great importance for a safe cholecystectomy. In this presentation, we presented a rare hepatic artery variation that we noticed after calot dissection during laparoscopic cholecystectomy in the light of the literature. [ABSTRACT FROM AUTHOR]

We describe the case of an 84-year-old woman who presented with right lower chest pain, anaemia and newly deranged liver function which was followed by massive upper gastrointestinal (GI) bleeding with no source of bleeding found on upper GI endoscopy. CT angiography of the GI tract confirmed rupture of a pseudoaneurysm of the right hepatic artery (RHA) that was treated successfully with trans-arterial embolization of the RHA.

Laparoscopic cholecystectomy complications include rare and fatal complication named hepatic artery pseudoaneurysm (HAPA). It is always iatrogenic. Mortality rates of about 50% of patients have been reported if rupture occurs. This report presents a case of a 42-year-old woman with history of laparoscopic cholecystectomy 6 months before. She has had few attacks of hematemesis; the last was one week prior to imaging. Multislice CT angiography (MSCTA) for the celiac trunk and CT portography (MSCTP) for portal venous system was requested aiming to locate the site of the bleeding.

Background: Lower gastrointestinal (GI) bleeding is predominantly caused by hemorrhoids, angiodysplasias, diverticular disease, inflammatory bowel disease, or polyps. However, on rare occasions, it occurs from another etiology. Right hepatic artery (RHA) pseudoaneurysm is a rare entity, attributed to infections, trauma, and upper abdominal surgery. Most cases occur after biliary and pancreatic surgery. We present a case of a 60-year-old male with lower GI bleeding caused by RHA pseudoaneurysm tear. Case Report: The patient with a history of chronic alcoholic pancreatitis and obstructive icterus was admitted to the hospital in March 2020 on account of experiencing syncope and the presence of bright red blood in his stool. His biliary obstruction was primarily treated by ERCP in 2019 but due to the persistence of symptoms he had undergone biliary surgery (cholecystectomy and choledochojejunostomy) in January 2020. Physical examination revealed signs of hemodynamic instability and lab results showed signs of anemia. Esophagogastroduodenoscopy (EGD) was done to exclude upper GI bleeding and it was followed by a colonoscopy which showed fresh blood in the colon and terminal ileum. Computed tomography (CT) angiography showed no abnormalities. The patient was hospitalized and put on symptomatic therapy. In the following days, his BP dropped and he developed tachycardia as a sign of recurrent bleeding. EGD and colonoscopy were performed again and showed the same findings. Digital subtraction angiography (DSA) of abdominal arteries subsequently showed a pseudoaneurysm of the right hepatic artery, which was immediately treated by “sandwich” coil embolization. After the procedure, the patient became stable and was discharged from the hospital without experiencing a relapse of gastrointestinal bleeding. Conclusion: RHA pseudoaneurysm is a serious potential complication of abdominal surgery. Early recognition and emergency management of RHA pseudoaneurysm are crucial for a favorable patient outcome. [ABSTRACT FROM AUTHOR]

Background: Pancreatoduodenectomy (PD) is a complex surgical procedure known for its significant morbidity rates, and the presence of an aberrant hepatic artery (AHA) introduces additional challenges. The impact of AHA on post-PD outcomes has been a subject of conflicting findings in the medical literature. This study aimed to investigate how variations in hepatic arterial anatomy influence intra-operative variables and postoperative morbidity., Methods: A retrospective analysis was conducted on 113 PD cases. Patients with variant hepatic arterial anatomy (n=38) were categorized as Group 1, while those without vascular abnormalities comprised Group 2. Perioperative and postoperative outcomes were examined., Results: Patients in Groups 1 and 2 exhibited similar characteristics, and no notable differences in surgical complications were observed. There was, however, a noticeable trend towards a higher incidence of postpancreatectomy hemorrhage (PPH) in Group 1 (31.6% vs. 20.0%; P=0.17). Furthermore, a statistically significant increase in the rate of arterial resections was noted in patients with vascular anomalies (10.5% vs. 1.33%; P=0.02)., Conclusions: The prevalence of vascular abnormalities in the hepatic arterial circulation is more frequent than initially anticipated. These anomalies present additional complexities to the already intricate PD procedure, leading to a heightened necessity for arterial resection, albeit without any discernible impact on postoperative complications., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jgo.amegroups.com/article/view/10.21037/jgo-23-191/coif). The authors have no conflicts of interest to declare., (2023 Journal of Gastrointestinal Oncology. All rights reserved.)

Common hepatic artery, normally is one of the three branches of coeliac trunk, gives off gastroduedonal artery and proper hepatic artery at the upper face of the first part of the duedonum. Renal arteries are two thick arteries which are located just below the mesenteric superior artery and separated by a right angle to the sides of the aorta. 64 year-old male patient with suspected adenocarcinoma of the fundus of the stomach was taken spiral computed upper abdominal CT. Right hepatic artery as a variational is originated from the superior mesenteric artery proximally and left hepatic artery is originated from coeliac trunk. In our case double left renal arteries were observed. Due to growing interventional radiological procedures, transplantation and vascular surgical procedures, variations of the renal arteries and the hepatic arteries are becoming more and more important. This is why patients who undergoing gastrectomy and lymphadenectomy in gastric carcinoma like our patient, a good knowledge of the anatomy and variations of the arteries leaving the abdominal aorta is required.

Anatomical variations of the hepatic arteries are not uncommon. The anomalous hepatic arterial supply is of paramount importance in hepatobiliary, pancreatic or liver transplantation and in laparoscopic surgery. We describe an unusual case of a 66-year-old Greek male cadaver, where a rare anastomosis (in the form of an enlarged arterial loop, 4.84 mm in diameter) between the common hepatic artery (6.42 mm) and the gastroduodenal artery (GDA) (4.82 mm) coexisted with an aberrant right hepatic artery (ARHA) (6.38 mm) originating from the superior mesenteric artery. The proper hepatic artery was absent. The ARHA followed a route posterior to the portal vein and the common hepatic duct, entering the liver and supplying the right hepatic segment. A hypoplastic right gastric artery emanated from the GDA. Our case report highlights the combined variations of hepatic arteries and possible anastomoses emphasizing that a thorough knowledge of the classic and variable hepatic arterial anatomy are mandatory for surgeons and radiologists performing hepatic surgery and arteriography to avoid potential iatrogenic injuries in hepatobiliary and pancreas area and further medico-legal implications. [ABSTRACT FROM AUTHOR]

The anatomical variations of superior mesenteric artery branches are common. In this study we reported an extraordinary morphology and branching of superior mesenteric artery, during our routine dissection of a 38-year-old Sudanese male cadaver, where the superior mesenteric artery forms an arch over the confluence of inferior vena cava and left renal vein. Other variations observed were: 1) The superior mesenteric artery shares the same origin of coeliac trunk; 2) The unusual origin of right hepatic artery. We think that the knowledge of these variations plays an important role in conducting and planning of radiological and surgical procedures especially in hepatobiliary and pancreatic surgery. Morphology and branching patterns of this artery is anecdotic, which makes this case the most unique. [ABSTRACT FROM AUTHOR]