Back-table surgery pancreas allograft for transplantation: Implications in complications

Abstract

To describe the main aspects of back-table surgery in pancreatic graft and the problems arising from poor technique. Back-table surgery for pancreatic graft is a complex, meticulous and laborious technique on which the success of implant surgery and perioperative results depends. The technique can be described in the following steps: Preparation of the sterile table, ex-situ inspection of the pancreas-spleen block, management of the duodenum, identification of the bile duct, preparation of the portal vein, preparation of the own graft arteries and anastomosis to the arterial graft, spleen management and graft preservation prior to implantation in the recipient. A careful inspection of the pancreas-spleen block should be performed. It is important to identify the stump of the main bile duct, the portal vein cuff, and the arrangement of the superior mesenteric artery and splenic artery. The redundant duodenum must be removed. The availability of a good venous cuff facilitates the portal vein anastomosis and the positioning of the graft, two key points to prevent thrombosis. The section line of the arteries must be clean, without atherosclerosis, to prevent arterial thrombosis. The superior and splenic mesenteric arteries are generally separated by dense fibrolymphatic tissue. The artery can be reconstructed by interposing a "Y" graft from the donor iliac artery; or with an end-to-end anastomosis between the splenic artery and the superior mesenteric artery. An exquisite technique of bench work helps to prevent the most feared complications of pancreas transplantation: Thrombosis and graft pancreatitis.

Keywords: Pancreas transplantation, Back-bench work, Pancreas thrombosis, Graft pancreatitis, Arterial reconstruction, Pancreas allograft

Core Tip: Back-table work in pancreas transplantation is a delicate and complex technique. It consists of numerous steps, all of them aimed at avoiding serious complications in the postoperative period of the transplant. It requires exquisite management of the duodenal remnant, the portal vein of the graft, and the arteries that ensure oxygenation of the gland. It is important to perform a methodical technique by an expert surgical team. A large part of pancreatic transplant failures is due to faulty back-table work.