Fatal arterial hemorrhage after pancreaticoduodenectomy: How do we simultaneously accomplish complete hemostasis and hepatic arterial flow?

Figure 1 Arterial flow before and after pancreaticoduodenectomy. During pancreaticoduodenectomy (PD), the gastroduodenal artery (GDA) from the celiac artery and inferior pancreaticoduodenal artery (IPDA) from the superior mesenteric artery are ligated and then cut. Additionally, the pancreaticoduodenal arcade is resected. Hence, arterial flow to the liver is modified after PD. A hepatopetal blood supply from the GDA and IPDA via the pancreaticoduodenal arcade can no longer be expected. The hepatic artery flow depends on the celiac artery. Lymphadenectomy and nerve dissection for treatment of malignancies might render visceral arteries vulnerable to postoperative wall injuries. Arterial arcades still remain in the pancreatic remnant. ASPDA: Anterior superior pancreaticoduodenal artery; CA: Celiac artery; CHA: Common hepatic artery; DPA: Dorsal pancreatic artery; FJA: First jejunal artery; GDA: Gastroduodenal artery; HA: Hepatic artery; IPDA: Inferior pancreaticoduodenal artery; LGA: Left gastric artery; LHA: Left hepatic artery; PHA: Proper hepatic artery; RGA: Right gastric artery; RGEA: Right gastroepiploic artery; RHA: Right hepatic artery; PSPDA: Posterior superior pancreaticoduodenal artery; SA: Splenic artery; SJA: Second jejunal artery; SMA: Superior mesenteric artery.