Ischemic Complications After Pancreaticoduodenectomy

Abstract

Ischemic complications are an underestimated cause of death after PD and are due to preexisting stenoses of CA and SMA, or intraoperative hepatic artery injury. Preexisting arterial stenoses are detected by routine multidetector CT. Preoperative endovascular stenting for intrinsic stenosis, division of median arcuate ligament for extrinsic compression, and meticulous dissection of the hepatic artery can contribute to minimize ischemic complications.

Tricks and tips in pancreatoduodenectomy

“…CAS has been reported in 2%-7.6% of patients undergoing PD [23] . In these patients, upper abdominal organs are at risk of necrosis from ischemia because PD resection involves the collateral vessels (the gastroduodenal and pancreaticoduodenal arteries) [19,24,[26][27][28] . The cause of CAS may be vascular (mainly arteriosclerosis) or non-vascular: compression of the median arcuate ligament (MAL) or invasion by tumor or lymph nodes [23,26,27] .…”

“…After division, blood flow should be restored by Doppler or palpation [23,26,27] . Gaujoux et al [24] only consider MAL division when the intraoperative clamping test of the gastroduodenal artery is positive. Revascularization should be performed (arterial anastomoses or bypass grafting) if MAL division does not improve perfusion, or in other selected cases [24,27] .…”

“…The treatment options are tailored to stenosis grade and etiology of CAS, but preserving collateral pathways during PD is essential [26,27] . Placing arterial preoperative stenting before PD is a valid therapeutic option especially in severe cases of CAS unrelated to MAL compression [24,26,27] . When CAS is caused by MAL compression, surgical division of the MAL is performed during PD.…”

“…The best method for defining CAS and its etiology is multidetector CT [24,27] . The treatment options are tailored to stenosis grade and etiology of CAS, but preserving collateral pathways during PD is essential [26,27] .…”

“…A thorough knowledge of HA anatomy is essential; in the presence of HA anatomical variations (HAAV), accidental ligation may occur during PD, provoking hepatic necrosis, ischemic biliary injury or an anastomotic fistula [6,[20][21][22][23][24] . Preoperative assessment of peripancreatic vascular patterns using imaging methods is crucial for surgeons [22] .…”