Revascularization of the hepatic artery by reimplantation of the gastroduodenal artery during a pancreatoduodenectomy (with video)

The celiac axis and the superior mesenteric artery are the primary sources of blood supply for the abdominal viscera. In the event of a celiac axis stenosis or occlusion, the gastroduodenal artery and pancreaticoduodenal arcades are responsible for the perfusion of the hepatic artery and splenic artery. In this setting, pancreatoduodenectomy can be particularly challenging due to the risk of potentially serious ischemic complications. The incidence of celiac axis stenosis is estimated to range between 10% and 25%. In these patients, three techniques of revascularization of the celiac axis can be proposed: • bypass graft of occlusal segment with autogenous saphenous vein; • bypass graft with prosthetic material; • arterial reimplantation. There is a lack of data regarding the most effective revascularization procedure for celiac axis occlusion in patients undergoing pancreatoduodenectomy. To date, few experiences on revascularization during pancreatoduodenectomy have been reported. This video aims to show the case of a gastroduodenal artery reimplantation to the superior mesenteric artery for hepatic artery revascularization during pancreatoduodenectomy for ampullary adenocarcinoma associated with a celiac axis complete occlusion. This video shows a 60-year-old woman with a history of cholangitis who was referred for the diagnosis of ampullary adenocarcinoma. The CT scan and MRI showed a 2 cm tumor of the ampullary region associated with a celiac axis complete occlusion. After a multidisciplinary discussion, a pancreatoduodenectomy was performed with arterial reconstruction using a side-to-end anastomosis between the superior mesenteric artery and gastroduodenal artery using a Cooley running suture of Prolene 7-0 on the posterior aspect and a running suture on the anterior aspect. After declamping, the intrahepatic arteries were found to be well perfused, as confirmed by excellent signal detection on Doppler ultrasound. The operative time was 462 minutes. Blood loss was about 300 ml, without the need for perioperative blood transfusion. The duration of superior mesenteric artery clamping was 25 min. The postoperative course was uneventful, and the patient was discharged home 12 days after surgery. Histological examination confirmed the diagnosis of infiltrating ampullary adenocarcinoma with 5 metastatic lymph nodes of 22 retrieved. This video shows the different steps necessary to perform a gastroduodenal artery reimplantation to the superior mesenteric artery for hepatic artery revascularization during pancreatoduodenectomy. Celiac axis stenosis or occlusion in patients undergoing pancreatoduodenectomy represents a risk for life-threatening ischemic complications in the liver. In this patient with a complete celiac axis occlusion, the preferred approach was the direct arterial reimplantation into the superior mesenteric artery, allowing for immediate revascularization and avoiding the use of bypass vascular grafting. This video will be useful for all residents in visceral and digestive surgery, as well as for teams performing pancreatic surgery (Figs. 1—4).