Revascularization of the gastroepiploic artery in pancreas transplant

Abstract

Summary Thrombosis accounted for 52.0% of all transplant failures in one recent large series and is felt to result from devascularization of the pancreas during organ procurement. A technique to revascularize the pancreas is described. The operative notes and angiograms of 110 consecutive pancreas transplants were reviewed. Eight pancreata were found deprived of blood supply to the head and the neck of the pancreas on indigocarmine‐renograffin table angiograms. During back table reconstruction a distal branch of the superior mesenteric artery (SMA) was dissected and anastomosed end to end to the gastroepiploic artery using 8–0 monofilament suture. Repeated table angiogram showed excellent blood supply to the head of the pancreas, the duodenum and the body and tail of the pancreas. The pancreas transplantation proceeded with iliac artery graft inflow, portal venous outflow and enteric drainage. Simultaneous quadruple therapy with thymoglobulin, CNI, MMF and a 4‐day course of steroids was used. All patients became insulin independent and euglycemic. No duodenal leak was observed in the entire series. In summary, 1‐ligation of the gastroduodenal artery (GDA) is not a safe procedure, especially when arterial blood supply from the inferior pancreaticoduodenal artery is poor or inexistent, 2‐table angiogram helps delineate the high risk hypo‐perfused pancreas, 3‐preservation of the right gastroepiploic artery and the branches of the SMA allows an easy revascularization of the pancreatic graft.

Gastroduodenal Artery Reconstruction as Salvage Procedure for Pancreas Head Ischemia during Transplantation: A Case Report

“…Revascularization through the stump of the GDA was performed to improve flow and avoid the consequences of an ischemic anastomosis. Revascularization of the gastroepiploic artery [3] or the gastroduodenal artery [4,5], have been proposed by some groups, to increase blood flow to the head of the pancreas, thus increasing venous return to avoid venous thrombosis. This is done during the bench preparation and considerations are also taken into account during the retrieval process.…”

Expanding the Pancreas Donor Pool

“…All of these variations are compatible with safe procurement of both the pancreas and the liver, given that there is careful attention to detail, as long as the SA and SMA are preserved with the pancreas allograft. Reconstruction of the GDA or gastro-epiploic artery may be performed to improve perfusion to the head of the pancreas and duodenum, in the case of an extremely short SMA stump [60][61][62], particularly in the absence of cross-circulation between the SA and SMA (which may be assessed by flushing the SA and looking for back-flushing through the SMA or vice versa).…”

Contribution of Contrast-Enhanced Ultrasonography to Nonoperative Management of Segmental Ischemia of the Head of a Pancreas Graft

“…Nghiem recently showed that hypoperfusion of the HPG and DD can be identified at the back table in 7% of pancreas planned for PTx and suggested to selectively revascularize these graft segments by anastomozing a distal branch of the SMA to the right gastroepiploic artery (19). Although there is no final proof that 7% of pancreas grafts actually need additional back-table revascularization, it is clear that ischemia involving HPG and DD should be avoided whenever possible.…”