Pancreaticoduodenectomy. The importance of preserving hepatic blood flow to prevent biliary fistula.

The arterial blood supply to the common bile duct must be preserved during pancreaticoduodenectomy to avoid ischemic breakdown of the biliary-enteric anastomosis. Interruption of this blood supply can occur during operation because of inadvertent division of the common hepatic artery or a hepatic artery variation. Approximately 17 per cent of patients have a hepatic artery variation that could contribute to devascularization of the common bile duct during surgical resection of the pancreatic head. This report discusses these hepatic artery variations and the value of angiography in defining hepatic arterial anatomy prior to surgery. Two cases are presented in which biliary-enteric anastomoses became ischemic and dehisced secondary to interruption of hepatic arterial blood flow.