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Gastroduodenal Arterial Reconstruction of thePancreaticoduodenal Allograft

J.Q. Li, Z.J. He, Z.Z. Si, W. Hu, Y.N. Li, and H.Z. Qi

ABSTRACT

Simultaneous procurement of the pancreas and liver necessitates division of vesselssupplying both organs. The integrity of the pancreatic arterial supply appears to be relatedto surgical complications after pancreas transplantation. We have described herein threecases of gastroduodenal artery (GDA) reconstruction during pancreas transplantation,and reviewed other options for GDA reconstruction. These techniques performed safelyduring bench reconstruction can be applied to various clinical situations.

PANCREAS TRANSPLANTATION (PTX) is an im-

portant treatment option for patients with all stages of

diabetes.1 The outcomes of PTX have also improved be-

cause of the use of novel immunosuppressants and ad-

vances in surgical techniques. However, complications after

pancreas transplantation remain the major cause (70%)

of early graft losses.24 Thrombosis is the most frequent

serious surgical complication with an incidence ranging

from 3% to 10%.5,6Anastomotic leaks and bleeding remain

the most frequent indications for relaparotomy.46 They

appear to be related to ischemia of the pancreaticoduode-

nal graft (PDG) and thus may be avoided by preservation ofthe integrity of the PDG arterial supply.4,79

The current procurement technique allows simultaneous

retrieval of the liver and the pancreas, necessitating division

of the vessels supplying both organs. Since the liver is a

lifesaving organ and pancreas transplantation, only a life-

enriching procedure, the liver team always obtains the

aortic patch carrying the celiac trunk, dividing the gastrodu-

odenal and the splenic arteries. In particular, when acces-

sory hepatic arteries are present, the celiac trunk and the

superior mesenteric artery (SMA) must be preserved for

the liver graft. In the worst scenario, the dorsal pancreatic

artery, the inferior pancreaticoduodenal artery, or their

branches are divided or injured, especially when the pan-

creaticoduodenal artery arcades are anatomically absent or

show variations.1012 According to the conventional arterial

reconstruction methods, the superior mesenteric and splenic

arteries are anastomosed to an iliac bifurcation graft to

perform the revascularization while the gastroduodenal

artery (GDA) is usually ligated.1315 However, this method

may ruin the integrity of the PDG arterial supply, causing

pancreatic graft loss. We have described herein three cases

of GDA reconstruction during pancreas transplantationand reviewed other approaches to GDA reconstruction.

MATERIALS AND METHODS

Patients and Donor and Recipient Operation

From February 2005 to May 2006, we performed two simultaneous

pancreas-kidney and one simultaneous liver-pancreas transplanta-tions (Table 1). No prisoners were used in the course of this studyeither as donors or as recipients. The pancreas as an en bloc

abdominal organ was procured with donor iliac artery and vein. Onthe back table we ligated the distal splenic artery and vein and

removed the spleen. The shortened duodenal segment was over-sewn to close its open proximal end. The portal vein was dissected

proximal to its junction with the splenic vein to obtain extra lengthfor an anastomosis to the recipient iliac vein. The whole pancreas

was transplanted into the right iliac fossa through an intraperito-

neal approach; the portal vein, anastomosed to the external iliacvein. Pancreatic exocrine secretions were managed by entericdrainage.

Pattern of GDA Reconstruction

To increase blood flow in the head of the grafted pancreas and

duodenum, the GDA was reconstructed according to the dissectionsite, as shown inFig 1.

From the Department of Organ Transplantation, Second

Xiangya Hospital, Central South University, Changsha, Hunan

province, China.

Financial support: This research was supported by a grant

(No. 81102241) from the National Basic Research Program of

China.

Address reprint requests to Hai-zhi Qi, Department of Organ

Transplantation, Second Xiangya Hospital, Central South Univer-

sity, 139 RenMin Road, Changsha, 410011, China. E-mail:

lijiequn2002@hotmail.com

2011 by Elsevier Inc. All rights reserved. 0041-1345/see front matter360 Park Avenue South, New York, NY 10010-1710 doi:10.1016/j.transproceed.2011.10.043

Transplantation Proceedings, 43, 39053907 (2011) 3905

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RESULTS

All pancreata reperfused well with subjects becoming insulin-independent andeuglycemic within 24 hours. No vascular throm-boses or duodenal leak was observed. All patients were followedbetween 10 and 66 months with well-functioning grafts (Table 1).Doppler ultrasonography showed good vascular flow within theinterposition graft. In case 1, we used a branch of the internal iliacartery to perform the revascularization of the GDA (Fig 1A). Incase 3, we interposed donor mesenteric artery between the stump

of the left gastric artery and the GDA Ishibashi et al25 alsoreported similar techniques using an interposed donor iliac arterybetween the stumps of the CHA and GDA. However, thediameter of CHA is greater than that of GDA. We think thatreconstruction between CHA and GDA should be less reason-able as their diameters are mismatched.

DISCUSSION

Simultaneous procurement of the pancreas and liver necessi-tates division of the vessels supplying both organs. The mostcommon technique for arterial reconstruction of pancreastransplantations involves a donor Y-graft of common iliacartery with its external and internal iliac branches1315 or of

innominate artery with subclavian and common carotid artery

branches16 to be anastomosed to the donor superior mesen-teric and splenic arteries. The GDA is usually ligated. How-ever, the anterior-superior pancreaticoduodenal artery arisingfrom GDA is the main artery to the pancreas head, especiallythe anterior part of pancreas head, which less frequently

communicates with the anterior-inferior pancreaticoduodenalartery.17 Employing this arterial reconstruction 7.2% to 14.2%of pancreas transplants have been shown to be deprived of a

blood supply to the head and the neck of the pancreasallograft using indigocarmine-renograffin table angiograms.7,8

Thus, artery reconstruction without the GDA is not a safeprocedure. In our cases, the integrity of the pancreatic arterialsupply was reconstituted by performing a triple arterial recon-struction including the gastroduodenal, superior mesenteric,and splenic arteries. To date, all patients have functioninggrafts with no requirement for exogenous insulin or dialysis.There have been no vascular complications in terms of arterial

thrombosis or anastomotic bleeding.There have not been many reports to reconstruct GDA

during PTX surgery. One attempt to revascularize the GDAwas reported by Han.18 He performed a GDA reconstruc-

Fig 1. Pattern of GDA reconstruction.(A) The donor EIA was anastomosed end-to-end with the SMA. The donor internal iliac artery

was anastomosed end-to-end with the splenic artery and its branch with GDA. (B) The liver allograft was abandoned as severe

steatosis and an aortic patch containing the celiac and SMA was anastomosed end-to-side with common iliac artery. (C)The common

hepatic artery transected at the level of the splenic artery, leaving the left gastric artery with CT for the pancreas. A donor mesentery

artery was interposed between stump of left gastric artery and GDA. GDA, gastroduodenal artery; CIA, common iliac artery; EIA,

external iliac artery; SA, splenic artery; LGA, left gastric artery; CHA, common hepatic artery; CT, celiac trunk; SMA, superior

mesenteric artery.

Table 1. Patient Demographics and Pancreas Allograft Function

Patient Sex Age

Duration of

DM ( y) Transpla ntati on

GDA

Reconstruction

Follow-up

(mo)

Glu

(mmol/L)

C-pep

(ng/mL)

HbA1c

(%)

1 M 54 12 SPK Fig 1A 10 5.6 1.8 5.7

2 M 42 8 SPK Fig 1B 66 5.7 2.5 6.1

3 M 44 11 SLPT Fig 1C 60 6.0 2.1 5.4

DM, diabetes mellitus; GDA, gastroduodenal artery; SPK, simultaneous pancreas-kidney transplantation; SLPT, simultaneous liver-pancreas transplantation; Glu,fasting blood sugar; C-pep, fasting C-peptide; HbA1c, glycosylated hemoglobin.

3906 LI, HE, SI ET AL

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tion using an external iliac artery interposition graft be-tween the end of the GDA and the side of the splenicartery. A more complicated, triple arterial reconstruction,including gastroduodenal, superior mesenteric, and splenicarteries, employed a side-to-end anastomosis between the

GDA and the donor external iliac artery with an iliac Ygraft anastomosed to the splenic artery and the SMAstumps.9 It would be difficult to use this procedure from atechnical standpoint when a large, thick vessel (eg, theexternal iliac artery) is anastomosed to a short, small,thin-walled gastroduodenal artery.8 Recently, Nghiem8 de-scribed the use of the gastroepiploic artery to provideretrograde flow into the GDA by an anastomosis to abranch of the SMA. However, dissecting the distal branchesof the SMA to provide inflow must be performed inmeticulous fashion to ensure that the inferior pancreati-coduodenal artery is spared. This dissection is tedious andtime-consuming, as there are multiple branches to be dealt

with; this can increase the operative time significantly.8,19

Replaced/accessory right hepatic arteries (R/A RHA) arereportedly observed in 12% series of angiograms. SomeR/A RHA share a common origin with the inferior pancre-aticoduodenal artery on the SMA.20 The R/A RHA istypically the first branch from the SMA on the right side. Itusually runs behind the portal vein and pancreas head;however, it sometimes courses through the parenchyma ofthe pancreatic head.21 The course of the replaced hepaticartery is important for pancreas and liver transplantations.Reconstruction of the R/A RHA must be performed onboth the liver and pancreatic sides.2224 Molmenti et al23

proposed a technique in which the R/A RHA was anasto-

mosed to the donor gastroduodenal or splenic arteries, thuspreserving the SMA and diminishing the potential of inju-ries to the liver or pancreatic allograft or their vascularstructures. However, the R/A RHA stump remaining withthe SMA is tied and kept with the pancreas withoutreconstructing the GDA for the pancreatic allograft.22,23

The GDA supply of a pancreatic allograft can be recon-structed using an end-to-end anastomosis between thedonor GDA distal stump and the R/A RHA stump of theSMA.22

In summary, we believe that the integrity of the pancre-atic arterial supply must be respected; neither of thesurgical techniques presented herein requires a complex

dissection during procurement, and both can be performedsafely during bench reconstruction.

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