DOI: 10.1097/SLA.0b013e3181c76c0e
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Issn Print: 0003-4932
Publication Date: 2010/01/01
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Excerpt
Even if mortality due to ischemic complication is only 10%, this is to our opinion, sufficient enough to justify a careful prevention. They rightfully point out that multiple collateral pathways do exist between the celiac axis and superior mesenteric artery, nevertheless those are inconstant, their functional value is questionable, and most of them can be damaged during PD. Regarding intraoperative diagnosis of an intrinsic celiac axis or superior mesenteric artery stenosis by a gastroduodenal artery clamping test, this is in our opinion, a very hazardous situation that can lead to immediate indication for concomitant arterial by-pass or postoperative stenting. Thus, when this situation is suspected on preoperative multidetector-CT scan, analysis of preoperative arteriography with a high degree of suspicion to plan the most appropriate therapeutic sequence seems preferable to intraoperative diagnosis. Dr. Sujith raised an important point concerning the delay between stenting and surgery in patients with malignant disease. Since those patients would not have been operated otherwise, we accept delaying surgery some weeks after stenting, considering in some cases adjuvant chemotherapy.
This answer gives us the opportunity again to state ischemic complications after PD as a specific complication carrying a high mortality, justifying appropriate preventive measures. Careful dissection of the hepatic artery and a gastroduodenal clamping test are important but are inadequate in case of intrinsic stenosis. To decrease postoperative mortality, multidetector-CT scan associated with routine arterial reconstructions should be added to the preoperative work-up of patients requiring PD.
