Pancreaticoduodenectomy and celiac occlusive disease

Pancreaticoduodenectomy is currently associated with an average perioperative mortality rate of 25%. Breakdown of the pancreaticojejunal anastomosis accounts for the greatest morbidity and usually results from technical complications. The potential contribution of unsuspected celiac occlusive disease to anastomotic dehiscence remains unclear. Two patients with biopsy-proven carcinoma of the head of the pancreas, in addition to arteriographic evidence of hemodynamically significant stenosis or occlusion of the celiac artery, recently underwent potentially curative pancreaticoduodenal resection and simultaneous celiac revascularization using a splenic to superior mesenteric artery reimplantation technique. Neither patient experienced postoperative complications. Inadvertent sacrifice during pancreaticoduodenectomy of celiacomesenteric collateral pathways which have developed in response to chronic celiac artery insufficiency may predispose to ischemia of the upper abdominal viscera and thus contribute to postoperative complications such as liver failure and anastomotic breakdown. Selective celiac and superior mesenteric arteriography is recommended prior to pancreaticoduodenectomy. If high grade ostial stenosis or occlusion of the celiac axis is demonstrated by preoperative arteriography, strong consideration should be given at the time of pancreaticoduodenal resection to simultaneous celiac revascularization.