Figure 159

Preparation of the pancreaticoduodenal allograft and arterial reconstruction. The donor pancreas, duodenum, and spleen are perfused in situ with cold University of Wisconsin solution and harvested en bloc with the liver. The pancreaticoduodenal graft is separated from the liver graft and prepared on the surgical back table at 4oC. The spleen is first removed by ligating the splenic artery and vein. The duodenal segment is shortened to approximately 10 cm, and the suture lines are reinforced. The common bile duct (CBD) and the superior mesenteric artery and vein (SMA and SMV) have been ligated previously in the donor. A variety of techniques exist to reconstruct the dual arterial blood supply to the pancreas. In our experience, the most favorable approach entails using an iliac artery bifurcation graft harvested from the same donor. As shown, the external iliac arterial limb of the graft is anastomosed to the SMA, and the hypogastric arterial limb is anastomosed to the splenic artery. This technique is reliable and associated with a very low thrombosis rate. The venous anastomosis (portal vein to iliac vein or inferior vena cava) can be performed without tension by complete mobilization of both the donor portal vein and the recipient iliac vein. A venous extension graft is rarely necessary and probably increases the risk of thrombosis.

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