Revascularization of the gastroduodenal artery in a pancreas allograft from a donor with a replaced right hepatic artery.

A 23-year-old donor undergoing multiorgan recovery, including the liver and pancreas, was discovered intraoperatively to have a replaced right hepatic artery (RHA) originating from the superior mesenteric artery (SMA). Upon separation of the liver from the pancreas on the back-table, dissection of the SMA revealed an aberrant artery, approximately 2 mm in diameter, proximal to the take-off of the RHA. This artery traversed into the head of the pancreas and was possibly an inferior pancreatoduodenal branch, had to be ligated to preserve vasculature to the liver, potentially compromising blood supply to the head of the pancreas and duodenum. Fortunately, this donor’s gastroduodenal artery (GDA) was relatively large in caliber (3–4 mm in diameter); therefore, it was preserved and reconstructed to provide supplemental perfusion to the head of the pancreas. On the back-table, a Y graft reconstruction was performed connecting the splenic artery and SMA as per usual (1). With flushing of preservation solution, there was a small amount of back flow into the GDA. A portion of the donor external iliac artery, left over from the Y graft reconstruction, was anastomosed to the GDA with interrupted 7– 0 prolene (Fig. 1). Connecting the GDA to splenic with a Y graft was considered as an alternative, but this reconstruction would have impinged on the portal vein during allograft implantation. A simultaneous kidney-pancreas transplant from this donor was performed on a 30-year-old male with Type 1 diabetes and end-stage nephropathy. Systemic venous drainage to the right external iliac vein and enteric drainage of the donor duodenum to the recipient jejunum was used. Two separate arterial anastomoses to the external iliac artery were performed approximately 3– 4 cm apart. No portal vein extension was required. Reperfusion was uneventful (CIT 12 hr) with excellent perfusion to the entire pancreas and duodenum; no congestion was apparent at the head of the pancreas allograft. Glucose clearance was seen within 1 hr. Induction therapy with Campath 1H (30 mg IV one time) and tacrolimus alone was used for maintenance immunosuppression. The patient had an unremarkable postoperative course. Amylase and lipase levels peaked at 123 IU/L and 432 IU/L, respectively, on day 1 postop and normalized within 2 days. Glucose levels normalized on day 1. An ultrasound on postoperative day 2 showed excellent visualization of the two arteries. Patient was taking soft foods on day 4 and was discharged on day 6 without any complications. This patient is now 1 month posttransplantation and is insulin-independent with normal glucose, amylase, and lipase levels. A C-peptide level posttransplant was 2.91 ng/mL. This case demonstrates an alternative arterial revascularization of the head of the pancreas allograft by a conduit via the GDA. This technique may be relevant for those pancreases of donor with aberrant, replaced right hepatic artery, as in this patient, or those cases where the small bowel is also harvested leaving the root of the mesentery and thus the inferior pancreatoduodenal vessels potentially vulnerable to injury.