Clinical significance of aberrant left hepatic artery during gastrectomy: A systematic review

Table 1 The search strategy of the review

Search strategy
Search Databases: PubMed, Embase, Cochrane Library
Date: Up to June 3, 2021
Strategy: #1 AND #2
#1 Left hepatic artery [Title/Abstract] or LHA[Title/Abstract]
#2 (((((stomach tumor [Title/Abstract]) OR (stomach neoplasm [Title/Abstract])) OR (stomach cancer [Title/Abstract])) OR (cancer of the stomach [Title/Abstract])) OR (gastric neoplasm [Title/Abstract])) OR (gastric cancer [Title/Abstract]) AND gastrectomy [Title/Abstract]

Table 2 Characteristics of the studies included in the review

Ref.	Country	Study design	Study date	Surgical procedure	Simple size	Vascular variation rate	Main results	NOS
Waki et al[25], 2020	Japan	RS	2012-2018	LDG	106	20.70%	Preserve. Surgeons should confirm the RLHA preoperatively and preserve it, because the preservation of RLHA could reduced postoperative transaminase elevation and hepatic infraction	8
Okano et al[26], 1993	Japan	RS	1985-1991	LG	28	19.90%	Possible preserve. For patients with preoperative liver dysfunction or a large LHLG, the LHLG diameter should be estimated, as it can help with the decision of whether to preserve it	7
Ang et al[29], 2020	Korea	RS	2012-2016	LG	204	8.20%	Possible preserve. When ligating ALHA > 1.5 mm in diameter regardless of subtype, a transient rise would be seen in postoperative SGOT and SGPT levels, and liver enzymes should be monitored postoperatively	8
Shinohara et al[17], 2007	Japan	RS	1997-2001	Gastrectomy	50	7.00%	Preserve. Routine division of the ALHA does not be required as long as it is not directly involved by the tumour	7
Huang et al[24], 2013	China	RS	2007-2012	LG	135	11.50%	Possible preserve. ALHA is a common anomaly that was found in 11.5% of patients. It can be safely severed during radical gastrectomy in patients without CLD, but should be left intact in patients with CLD to prevent liver dysfunction	7
Jeong et al[10], 2011	Korea	RS	2006-2007	Gastrectomy	215	N/A	Preserve. Patients who underwent a gastrectomy showed significantly increased hepatic enzyme levels on POD1, regardless of the surgical technique, which returned to normal on POD5. This study concludes that the liver function alteration after LAG may have been caused by direct liver manipulation or aberrant hepatic artery ligation rather than the CO2 pneumoperitoneum	8
Kim et al[30], 2016	Korea	RS	2009-2014	LDG	150	12.50%	Preserve. Preservation of an ALHA during laparoscopic gastrectomy is feasible. This study suggests preserving ALHA which arises from a large LGA, diameter larger than 5 mm, during laparoscopic gastrectomy to prevent immediate postoperative hepatic dysfunction	8
Sano et al[27], 2021	Japan	RS	2013-2019	LG	54	35.30%	Preserve. Liver retraction using the NLR and ligation of an ALHA were recognized as independent risk factors for PLEE after LG for gastric cancer. ALHA preservation may contribute to avoiding postoperative liver dysfunction	7
Lee et al[28], 2021	Korea	RS	2015-2019	Gastrectomy	160	17.60%	Possible preserve. 8.6% patients with a ligated ALHA presented with MS liver enzyme elevation. These patients showed poorer short-term postoperative outcomes, in terms of the length of hospital stay and the incidence and severity of postoperative complications, than patients with NM liver enzyme elevation	8

LDG: Laparoscopic distal gastrectomy; LG: Laparoscopic gastrectomy; RS: Retrospective study; ALHA: Aberrant left hepatic arteries; NOS: Newcastle-Ottawa Scale. CLD: Chronic liver disease.

Table 3 The characteristic of four studies compared ALHA ligation and ALHA preservation group

	ALHAWaki et al[25], ALHA			Ang et al[29], RLHA			AcLHA			Shinohara et al[17], ALHA			Kim et al[30], ALHA
	Divided (n = 18)	Preserved (n = 37)	P value	Divided (n = 17)	Preserved (n = 114)	P value	Divided (n = 52)	Preserved (n = 21)	P value	Divided (n = 23)	Preserved (n = 27)	P value	Divided (n = 116)	Preserved (n = 34)	P value
Operation time (min)	285 (171-490)	301 (173-476)	0.36	222 ± 55	243 ± 73	0.158	216 ± 49	221 ± 59	0.727	293 ± 19	223 ± 18	0.0141	151.5 (84-315)	177.5 (118-329)	0.084
EBL (mL)	10 (0-155)	18 (0-308)	0.427	102 ± 93	134 ± 126	0.316	108 ± 93	129 ± 126	0.429	450 ± 44	269 ± 43	0.0051	100 (20-1000)	100 (30-200)	0.791
RLS (n)	59 (34-64)	36.5 (21-53)	0.152							54 ± 5.7	38 ± 3.5	0.0181	37 (16-87)	33 (16-66)	0.207
PHS (d)	10 (7-38)	9 (7-21)	0.113	11.8 ± 8.0	9.7 ± 7.5	0.295	10.9 ± 16.7	11.9 ± 9.2	0.804	-	-	-	-	-	-
Complications, n (%)	6 (33.3%)	6 (16.2%)	0.177	3 (17.6%)	16 (14%)	0.713	8 (15.4%)	6 (28.6%)	0.207	-	-	-	-	-	-
PLECT	POD1, POD3		< 0.0011	AST POD2, ALT (POD2, POD5)		< 0.0011, (< 0.0011, 0.0461)	-		-	POD1, POD3		< 0.011	AST POD1; ALT (POD1, POD5)		0.0091; (0.0031, 0.0071)

¹P < 0.05. Values are presented as mean ± SE or median (range).

EBL: Estimated blood loss; RLS: Retrieved lymph nodes; PHS: Postoperative hospital stay; PLECT: Postoperative liver enzyme changed time; ALT: alanine aminotransferase; AST: aspartate aminotransferase; POD: postoperative day.