# A Case of Focal Liver Necrosis Following Whipple’s Procedure: Presentation, Workup, and Management

## TL;DR

A patient developed focal liver necrosis after a Whipple’s procedure, but recovered due to an unusual collateral artery connection.

## Contribution

Highlights a rare case of focal liver necrosis managed successfully due to an aberrant arterial connection.

## Key findings

- Hepatic arterial flow disruption led to focal liver necrosis and abscess formation.
- Collateral arterial pathways from the left gastric artery minimized liver injury.
- Medical treatment and drainage successfully managed the complications.

## Abstract

Liver necrosis, liver abscess, and mesenteric ischemia are uncommon but serious complications of Whipple’s procedure. Hepatic arterial tree assessment before surgery and meticulous surgical technique may prevent liver injury. We present a case of focal liver necrosis of the left lobe following Whipple’s procedure due to hepatic arterial cut off, with minimal clinical effects due to an aberrant arterial connection of the left gastric artery to the left hepatic artery. A 53-year-old female underwent Whipple’s procedure for a neuroendocrine tumor of the head of the pancreas. Forty-eight hours later, liver enzyme levels were high, and direct bilirubin levels were elevated. The duplex ultrasound scan showed a normal portal venous flow. Hepatic arterial flow was not visualized. She was managed with a liver failure regimen and recovered within a week. The patient was re-admitted with a purulent discharge from the surgical incision on postoperative day 30, which tested negative for amylase and microbial growth. CT of the abdomen showed a necrotic segment of the left lobe of the liver with an abscess tracking into the skin. However, the liver biochemistry was normal. Mesenteric angiography showed an abrupt cut-off of the hepatic artery at the common hepatic artery origin. However, right and left hepatic artery flow was intact distally to the bifurcation, due to a communicating collateral artery from the left gastric artery to the left hepatic artery. She underwent a laparotomy. Necrotic material was washed out, and a drain was inserted. Outpatient care with monthly ultrasound scans was performed. Drain output gradually reduced. The patient resumed her daily activities and preoperative body weight. A follow-up CT at eight months showed minimal hepatic collection. Subsequently, the drain was removed. Hepatic arterial flow disruption can present as transient liver failure, focal liver necrosis, and abscess formation. Liver necrosis and abscess can be managed by initial medical treatment and percutaneous surgical drainage. Collateral arterial pathways to the hepatic artery may minimize the extent of liver injury.