Implications of Arterial Variations in Pancreatoduodenectomy for Cancer

Pancreatoduodenectomy for cancer is a complex surgical procedure with significant morbidity and mortality. Technical aspects of this procedure typically comprise dissection of celiac trunk, the common and the proper hepatic arteries. The presence of hepatic arterial anomalies is not uncommon and influences surgical technique. An aberrant right hepatic artery (replaced or accessory) or a common hepatic artery originating from the superior mesenteric artery are present in nearly 13% of cases and usually run in contact with the posterior aspect of the head of the pancreas. These anomalous arteries are at risk of iatrogenic injury and tumor involvement. Iatrogenic vascular lesions can lead to bleeding and/or ischemic complications, such as anastomotic stenosis, hepatic abscess and liver failure. Also, vascular tumor involvement might require arterial resection and reconstruction. The presence of arterial variations should not affect the radicalness of pancreatic resection as the involvement of aberrant arteries does not seem to affect postoperative outcomes or overall survival. These vascular variations should be, preferably, recognized pre-operatively in order to define possible surgical strategies. Preoperative contrast enhanced computed tomography provides accurate arterial anatomy evaluation. Lastly, aberrant hepatic arteries require proper dissection and/or occasionally resection and reconstruction during pancreatoduodenectomy to achieve a safe resection with proper radicalness. Knowledge of arterial variations is crucial for pancreatic cancer surgery.