title: Ischemic complications after pancreaticoduodenectomy: incidence, prevention, and management.
abstract: OBJECTIVE
  To assess prevalence, prevention, and management strategy of visceral ischemic complications after pancreaticoduodenectomy (PD).
  
  
  BACKGROUND
  Ischemic complications after PD resulting from preexisting celiac axis (CA), superior mesenteric artery (SMA), stenosis, or intraoperative arterial trauma appear as an underestimated cause of death. Their prevention and adequate management are challenging.
  
  
  METHODS
  From 1995 to 2006, 545 PD were performed in our institution. All patients were evaluated by thin section multidetector computed tomography (CT) with arterial reconstruction to detect and class SMA or CA stenosis. Hemodynamical significance of stenosis was assessed preoperatively by arteriography for atherosclerotic stenosis and intraoperatively by gastroduodenal artery clamping test for CA compression by median arcuate ligament. Significant atherosclerotic stenosis was stented or bypassed, whereas CA compression was treated by median arcuate ligament division during PD. Multidetector-CT accuracy to detect arterial stenosis, results of revascularization procedures, and both prevalence and prognosis of ischemic complications after PD were analyzed.
  
  
  RESULTS
  Among 62 (11%) stenoses detected by multidetector-CT, 27 (5%) were hemodynamically significant, including 23 CA compressions by median arcuate ligament, 2 CA, and 2 SMA atherosclerotic stenoses, respectively. All atherosclerotic stenoses were successfully treated by preoperative stenting (n = 3) or bypass (n = 1). Among the 23 cases who underwent median arcuate ligament division, 3 (13%) failed due to 1 CA injury and 2 misdiagnosed intrinsic CA stenoses. Overall, 6 patients developed ischemic complications, due to intraoperative hepatic artery injury (n = 4), unrecognized SMA atherosclerotic stenosis (n = 1), or CA fibromuscular dysplasia (n = 1). Five (83%) of them died, representing 36% of the 14 deaths of the whole series (overall mortality = 2.6%). Overall, CT detected significant arterial stenosis with a 96% sensitivity and determined etiology of CA stenosis with a 92% accuracy.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Hepatic and Pancreatic Surgery, AP-HP, Beaujon Hospital, University Paris 7 Denis Diderot, Clichy, France.
authors.forename: Sébastien
authors.initials: S
authors.lastname: Gaujoux
authors.forename: Alain
authors.initials: A
authors.lastname: Sauvanet
authors.forename: Marie-Pierre
authors.initials: MP
authors.lastname: Vullierme
authors.forename: Alexandre
authors.initials: A
authors.lastname: Cortes
authors.forename: Safi
authors.initials: S
authors.lastname: Dokmak
authors.forename: Annie
authors.initials: A
authors.lastname: Sibert
authors.forename: Valérie
authors.initials: V
authors.lastname: Vilgrain
authors.forename: Jacques
authors.initials: J
authors.lastname: Belghiti
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001157:Arterial Occlusive Diseases / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000209:etiology* / Q000517:prevention & control / Q000628:therapy; D002445:Celiac Artery; D005260:Female; D006801:Humans; D015994:Incidence; D007511:Ischemia / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000209:etiology* / Q000517:prevention & control / Q000628:therapy; D008297:Male; D017538:Mesenteric Artery, Superior; D008875:Middle Aged; D016577:Pancreaticoduodenectomy / Q000009:adverse effects*; D014057:Tomography, X-Ray Computed; D014781:Viscera / Q000098:blood supply*; D055815:Young Adult