Postpancreatectomy hemorrhage is an uncommon but highly morbid complication of pancreaticoduodenectomy. Clinical evidence often draws suspicion to the gastroduodenal artery stump, even without a clear source.To determine the frequency of gastroduodenal artery bleeding compared to other sites and the results of mitigation strategies.This cohort study involved a retrospective analysis of data for consecutive patients who had pancreaticoduodenectomy from 2011 to 2021 at Memorial Sloan Kettering Cancer Center (MSK) and Thomas Jefferson University Hospital (TJUH).Demographic, perioperative, and disease-related variables.The incidence, location, treatment, and outcomes of primary (initial) and secondary (recurrent) hemorrhage requiring invasive intervention were analyzed. Imaging studies were re-reviewed by interventional radiologists to confirm sites.Inclusion criteria were met by 3040 patients (n = 1761 MSK, n = 1279 TJUH). Patients from both institutions were similar in age (median [IQR] age at MSK, 67 [59-74] years, and at TJUH, 68 [60-75] years) and sex (at MSK, 814 female [46.5%] and 947 male [53.8%], and at TJUH, 623 [48.7%] and 623 male [51.3%]). Primary hemorrhage occurred in 90 patients (3.0%), of which the gastroduodenal artery was the source in 15 (16.7%), unidentified sites in 24 (26.7%), and non-gastroduodenal artery sites in 51 (56.7%). Secondary hemorrhage occurred in 23 patients; in 4 (17.4%), the gastroduodenal artery was the source. Of all hemorrhage events (n = 117), the gastroduodenal artery was the source in 19 (16.2%, 0.63% incidence in all pancreaticoduodenectomies). Gastroduodenal artery hemorrhage was more often associated with soft gland texture (14 [93.3%] vs 41 [62.1%]; P = .02) and later presentation (median [IQR], 21 [15-26] vs 10 days [5-18]; P = .002). Twenty-three patients underwent empirical gastroduodenal artery embolization or stent placement, 7 (30.4%) of whom subsequently experienced secondary hemorrhage. Twenty percent of all gastroduodenal artery embolizations/stents (8/40 patients), including 13% (3/13 patients) of empirical treatments, were associated with significant morbidity (7 hepatic infarction, 4 biliary stricture), with a 90-day mortality rate of 38.5% (n = 5) for patients with these complications vs 7.8% without (n = 6; P = .008). Ninety-day mortality was 12.2% (n = 11) for patients with hemorrhage (3 patients [20%] with primary gastroduodenal vs 8 [10.7%] for all others; P = .38) compared with 2% (n = 59) for patients without hemorrhage.In this study, postpancreatectomy hemorrhage was uncommon and the spectrum was broad, with the gastroduodenal artery responsible for a minority of bleeding events. Empirical gastroduodenal artery embolization/stent without obvious sequelae of recent hemorrhage was associated with significant morbidity and rebleeding and should not be routine practice. Successful treatment of postpancreatectomy hemorrhage requires careful assessment of all potential sources, even after gastroduodenal artery mitigation.

One of the critical steps during pancreatoduodenectomy (PD) procedure lies in identifying the complicated vascular anatomy of the resected area. The blood supply usually stems from branches of the celiac and the superior mesenteric arteries. However, only in 55-79% of surgeries, the anatomy of the blood vessels encountered by the surgeon is considered normal, while in the remaining cases, there are vascular variations that make these surgeries even more challenging. Any change or deviation from the known surgical course of PD makes surgery difficult and can result in an increase in intra/postoperative complications. In order to reduce difficulties encountered during PD, as well as reducing complication rates and improving surgical outcomes, a preliminary design, which includes preoperative identification of anatomical variations, is needed. The most accurate and accessible tool for identifying such variations is computed tomographic angiography (CTA). The aim of this retrospective study is to assess the prevalence of vascular anomalies encountered during PD, and examine whether there is an association between these anomalies and intra/postoperative morbidity and mortality.A retrospective study over 5 years was performed at the HPB and Surgical Oncology Unit, Rambam Health Care Campus, Haifa, Israel. The charts of all patients submitted to PD were reviewed, and all patients with vascular anomalies were included. The types of anatomical variant as well as other information were collected. For statistical purposes, the group of patients with vascular anomalies was compared to a control group with identical demographic characteristics. A statistical analysis on possible association between vascular anomalies and intra/postoperative complications (mainly bleeding) was performed.During the aforementioned period, 202 patients underwent PD, and in 41 (20.3%) vascular anomalies were identified. The majority of these patients (32/41) had single anatomical variant, where two and three anatomical variants were identified in seven and two patients, respectively. The most common vascular anomaly was replaced right hepatic artery, noticed in 34 patients (83%). The most common indication for PD for both groups (anatomical variant and control group) was pancreas adenocarcinoma (56%). Intraoperative complication, in the form of bleeding, developed in 6/41 patients (14.6%) of the anatomical variant group and none in the control group. Postoperative complication rates, including post- pancreatoduodenectomy hemorrhage (PPH), postoperative pancreatic fistula (POPF), intra-abdominal abscess and wound infection were almost identical for both groups. One case of death within 30 days occurred, and it was in the anatomical variant group.Anatomical vascular anomalies are a common variant encountered during PD, with RRHA being the most common. Although postoperative morbidity and mortality are not affected by the presence of these anomalies, intraoperative bleeding rate is higher in this specific group, thus; a preoperative diagnosis by means of CTA is mandatory.Copyright 2021, Mansour et al.

The present article is the fifth part of a comprehensive review on the arterial blood supply of the pancreas and deals with the dorsal pancreatic artery. The aim of this review is to summarise the anatomic studies, starting from Haller's reports, and to supply, as far as possible with original material, angiographic evidence for the classic anatomic notions. For this purpose, the overall research was carried out by studying 1015 selective angiographies (celiac trunk and its branches, superior mesenteric artery) taken from the angiographic archives of the Institutes of Radiology of Siena, Rome (Catholic University), and Perugia. Angiographically, the authors could demonstrate the dorsal pancreatic artery, present in most instances, as arising from the splenic artery, common hepatic artery, superior mesenteric artery or celiac trunk and accessory right hepatic artery as coming from the superior mesenteric artery. Variations in the course and length of the dorsal pancreatic artery were demonstrated as well as some collateral branches. The authors underline the discordant opinions still existing regarding the incidence of the different ways the dorsal pancreatic artery arises, and discuss its uncertain embryologic development and surgical relevance.

Organ procurement errors account for almost 20% of discarded pancreatic allografts. For this reason, the anatomical significance of the dorsal pancreatic artery (DPA) was reviewed.A strategy on dealing with an often overlooked DPA is evaluated.The DPA provides together with the splenic artery the main blood supply to the pancreatic tail. Three different arterial variations have been described. In the rare instances when the DPA arises from the common hepatic artery or the celiac trunk, instead of the splenic origin, the DPA can easily be overlooked by surgeons not familiar with this artery. This may result in an unintentional damage to the pancreatic tail blood supply. If unrecognized during the back-table inspection, it could potentially jeopardize the pancreatic graft after reperfusion. When a cut DPA is encountered during inspection, efforts should be attempted to revascularize the graft, especially if there is no backflow from the splenic artery as sign of absent collateral circulation.The DPA may play a more prominent role in the vascularization of pancreas transplants than currently assumed. Better understanding of the vascular anatomy may lead to improved results in pancreas transplantation.© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

The dorsal pancreatic artery is the main artery of the body and tail of the pancreas. Its origin and branching is highly variable. The aim of this study was to perform a meta-analysis to generate pooled prevalence data on the presence and origin of the dorsal pancreatic artery. Clinically important aspects of the dorsal pancreatic artery were summarised during the literature review.Major medical databases were searched. Data on the presence and point of origin of the dorsal pancreatic artery were extracted and quantitatively synthesised. The obtained data of anatomical based studies and computed tomography based studies were statistically analysed.In total, 30 studies, comprising 2322 anatomical and computed tomography based cases were included. The dorsal pancreatic artery was present in 95.8% of cases. It originated from the splenic artery in 37.6% of cases, common hepatic artery in 18.3% of cases, coeliac trunk in 11.9% of cases and the superior mesenteric artery in 23.9% of cases. Other rare origins were present in 2.77% of cases. Multiple dorsal pancreatic arteries were found in 1,7% of cases. There was no significant difference in the presence or origin of the dorsal pancreatic artery between anatomical and computed tomography based studies.The dorsal pancreatic artery is present in the vast majority of cases. Its origin and branching are highly variable. Multiplicity of the dorsal pancreatic artery is infrequent.Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.

The dorsal pancreatic artery (DP), characterized by a course that crosses behind the proximal part of the splenic vein. It is regarded as clinically important, providing essential distribution to the pancreas. However, the origin of the DP is extremely variable and therefore cannot provide a sufficient basis for identifying it. The DPs of 11 cadavers were investigated in terms of origin, course and distribution. A total of 45 branches of the DP are classified into seven types on the basis of course and distribution. One of these seven types was consistently observed among the specimens: it ran to the right, passed behind the superior mesenteric vein and anterior surface of the posterior part of the head of the pancreas, and then distributed to the uncinate process and the posterior part of the head of the pancreas. Variations in the branching pattern of the DP can be explained from the following perspective: the consistent branch (#5) is the stem of the DP, and other branches originate from it. It is advisable for surgeons to pay attention to this consistent branch of the dorsal pancreatic artery when performing a pancreaticoduodenectomy.Copyright © 2013 Wiley Periodicals, Inc.

The variability of pancreatic vasculature, especially the dorsal pancreatic artery (DPA), increase surgical difficulty and may elevate the risk of intra- and postoperative bleeding. This study aimed to establish a precise preoperative vascular assessment protocol for pancreatic surgery, summarize DPA variant patterns, and evaluate their impact on pancreatic surgery-related bleeding.

To investigate the diagnostic performance of 64-section CTA in the detection of dorsal pancreatic artery before interventional therapy for patients with diabetes.The study was approved by the institutional ethics committee; written informed consent was obtained. Forty-two consecutive patients with diabetes received an experimental treatment of autologous bone marrow-derived stem cell transplantation by means of infusion into the dorsal pancreatic artery. All cases underwent abdominal CTA before angiography of pancreatic arteries in order to locate the origin and course of dorsal pancreatic artery. Angiography of coeliac artery, splenic artery, common hepatic artery and superior mesenteric artery were performed both in CTA and DSA. Superselective catheterization of dorsal pancreatic artery was carried out for the infusion of stem cell. Sensitivity, specificity and accuracy for the detection of dorsal pancreatic artery with CTA were calculated using DSA images as the reference standard.Thirty-five and thirty-six dorsal pancreatic arteries were detected by CTA and DSA respectively. Dorsal pancreatic artery was not visualized in either CTA or DSA in 5 patients. The sensitivity, specificity and accuracy for CTA were 94.4%, 83.3% and 92.9%.64-section CTA is accurate for the detection of dorsal pancreatic artery. It may be useful for the facilitation of superselective arterial infusion of stem cells to pancreas.Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

The purpose of this study was to define the learning curves for laparoscopic pancreaticoduodenectomy (LPD) with and without laparoscopic reconstruction, using paired surgical teams consisting of advanced laparoscopic-trained surgeons and advanced oncologic-trained surgeons.All patients undergoing PD without vein resection at a single institution were retrospectively analyzed. LPD was introduced by initially focusing on laparoscopic resection followed by open reconstruction (hybrid) for 18 months prior to attempting a totally LPD (TLPD) approach. Cases were compared with Chi square, Fisher's exact test, and Kruskal-Wallis analysis of variance (ANOVA).Between March 2010 and June 2013, 140 PDs were completed at our institution, of which 56 (40 %) were attempted laparoscopically. In 31/56 procedures we planned to perform only the resection laparoscopically (hybrid), of which 7 (23 %) required premature conversion before completion of resection. Following the first 23 of these hybrid cases, a total of 25 TLPDs have been performed, of which there were no conversions to open. For all LPD, a significant reduction in operative times was identified following the first 10 patients (median 478.5 vs. 430.5 min; p = 0.01), approaching open PD levels. After approximately 50 cases, operative times and estimated blood loss were consistently lower than those for open PD.In our experience of building an LPD program, the initial ten cases represent the biggest hurdle with respect to operative times. For an experienced teaching center using a staged and team-based approach, LPD appears to offer meaningful reductions in operative time and blood loss within the first 50 cases.

The technique of pancreatoduodenectomy (PD) has evolved. Previously, non-resectability was determined by involvement of the portal vein-superior mesenteric vein. Because venous resection can be achieved safely and with greater awareness of the prognostic significance of the status of the posteromedial resection margin, non-resectability is now determined by involvement of the superior mesenteric artery (SMA). This change, with a need for early determination of resectability before an irreversible step, has promoted the development of an 'artery-first' approach. The aim of this study was to review, and illustrate, this approach.An electronic search was performed on MEDLINE, Embase and PubMed databases from 1960 to 2011 using both medical subject headings and truncated word searches to identify all published articles that related to this topic.The search revealed six different surgical approaches that can be considered as 'artery first'. These involved approaching the SMA from the retroperitoneum (posterior approach), the uncinate process (medial uncinate approach), the infracolic region medial to the duodenojejunal flexure (inferior infracolic or mesenteric approach), the infracolic retroperitoneum lateral to the duodenojenunal flexure (left posterior approach), the supracolic region (inferior supracolic approach) and through the lesser sac (superior approach).The six approaches described provide a range of options for the early determination of arterial involvement, depending on the location and size of the tumour, and before the 'point of no return'. Whether these approaches will achieve an increase in the proportion of patients with negative margins, improve locoregional control and increase long-term survival has yet to be determined.Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

In pancreaticoduodenectomy (PD), the approach to superior mesenteric artery (SMA) is a critical process that supports adequate surgical margins and radicality for pancreatic tumors. In most of the reports on laparoscopic PD, the right-sided approach in which the jejunum is pulled out to the right side for peri-SMA dissection is used, since the left side of the SMA is difficult to dissect, and the only way to do this is to dissect the vein first.We devised a method to simplify and safely perform peri-SMA dissection by reversing the process, starting from the left side of the SMA. The first step involves the mobilization of the pancreatic head, which allows for rotation around the SMA. The second step involves the dissection of the left side of the SMA and transection of the jejunum. The key point is to change the incision line between the anterior and posterior mesojejunum. The third process includes the inferior pancreatoduodenal artery (IPDA) and first jejunal artery (J1A) dissection, which can be easily performed from the left side because the SMA rotates by simply continuing the dissection along the previously exposed SMA, and the IPDA/J1A are safely dissected at the root because they are drawn to the left side. The remaining processes are performed on the right side.This method was performed in 16 cases, and in most cases IPDA/J1A were divided from the left side.The technique for SMA dissection from the left posterior side was described with illustrations and video. Our method allows safe oncologic dissection around SMA avoiding anatomical misorientation during laparoscopic PD.© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.