Incidence and appropriate management of intraoperative arterial injuries during pancreatoduodenectomy

Intraoperative arterial injury during pancreatoduodenectomy (PD) can cause severe ischemic complications. This study examined the perioperative factors affecting these injuries and their management.

Of the 1620 PDs performed between 2002 and 2023, 17 patients (1.0%) underwent concomitant reconstruction due to intraoperative arterial injury. The perioperative findings, including details of the injury, reconstruction, and complications, were reviewed. To identify the risk factors for injury, 11 of the 17 patients were compared with a control group of 384 PDs performed by board-certified surgeons.

The frequency of repeated preoperative biliary drainage was higher in patients with intraoperative arterial injury (odds ratio, 9.12; 95% confidence interval, 0.84-54.7; P = 0.034). The injured arteries included the right hepatic artery (RHA, n = 4), replaced RHA (n = 3), origin of the gastroduodenal artery (n = 2), proper hepatic artery (n = 2), bifurcation of the right anterior and posterior hepatic arteries (n = 2), and superior mesenteric artery (n = 1). All patients underwent immediate reconstructions. Injury-related complications occurred in two patients: one with a liver abscess and the other with a pseudoaneurysm followed by a liver abscess.

Concomitant arterial reconstruction may reduce the risk of severe complications. Patients who have undergone repeated preoperative biliary drainage may require more vigilance in identifying the arterial anatomy.