Xu Y, Zhang JY, Yu XH, Xie Y, Cao Y, Zhao J. Vascular allocation between liver and pancreas allografts: A retrospective single-center study. World J Gastrointest Surg 2026; 18(4): 117684 [DOI: 10.4240/wjgs.v18.i4.117684]
Corresponding Author of This Article
Jie Zhao, Chief Physician, Department of Kidney Transplantation, Tianjin First Central Hospital, No. 24 Fukang Road, Nankai District, Tianjin 300192, China. zjsecond@aliyun.com
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Gastroenterology & Hepatology
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Case Control Study
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Apr 27, 2026 (publication date) through Apr 24, 2026
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World Journal of Gastrointestinal Surgery
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Xu Y, Zhang JY, Yu XH, Xie Y, Cao Y, Zhao J. Vascular allocation between liver and pancreas allografts: A retrospective single-center study. World J Gastrointest Surg 2026; 18(4): 117684 [DOI: 10.4240/wjgs.v18.i4.117684]
Author contributions: Xu Y was responsible for collected data, and wrote the paper; Zhang JY, Yu XH, and Xie Y were the main persons in charge of the surgery of orthotopic liver transplantation; Zhang JY, Xie Y, Cao Y, and Zhao J were the main persons in charge of the surgery of simultaneous pancreas-kidney; Cao Y was analyzed data, and assisted with the data interpretation; Zhao J designed the research and helped with manuscript revisions; all of the authors read and approved the final version of the manuscript to be published.
Supported by Beijing Medical Award Foundation, No. YXJL-2025-0483-0212; Tianjin Science and Technology Plan Project, No. 24JCZDJC01380; and the Tianjin Key Medical Discipline Construction Project, No. TJYXZDXK-3-006A.
Institutional review board statement: The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of Tianjin First Central Hospital, No. YC-BY-LC-2025-025.
Informed consent statement: All participants provided informed consent.
Conflict-of-interest statement: All authors declare no conflict of interest in publishing the manuscript.
STROBE statement: The authors have read the STROBE Statement – checklist of items, and the manuscript was prepared and revised according to the STROBE Statement – checklist of items.
Data sharing statement: The data that support the findings of this study are available from the authors upon request.
Corresponding author: Jie Zhao, Chief Physician, Department of Kidney Transplantation, Tianjin First Central Hospital, No. 24 Fukang Road, Nankai District, Tianjin 300192, China. zjsecond@aliyun.com
Received: December 15, 2025 Revised: January 10, 2026 Accepted: February 25, 2026 Published online: April 27, 2026 Processing time: 132 Days and 15.8 Hours
Abstract
BACKGROUND
The global shortage of organs from deceased donors has led transplant centers to maximize the utilization of each donation after brain death. Concomitant liver procurement and simultaneous pancreas-kidney (SPK) transplantation are increasingly performed; however, the celiac trunk and its branches are shared by both grafts. Effectively dividing these vessels without compromising arterial inflow presents a significant technical challenge, and no consensus exists regarding the optimal strategy for vessel allocation and reconstruction.
AIM
To analyze graft outcomes following arterial allocation between the liver and pancreas, with particular focus on the technique of gastroduodenal artery reconstruction.
METHODS
In this single-center, retrospective study, 395 adult liver transplantations were performed at our hospital from January 2018 to June 2019. Propensity score matching was used to balance covariates, resulting in a cohort of 102 patients. This group included 34 patients who underwent liver transplantation with concurrent pancreas procurement [pancreas-using group (PUG)] and 68 patients without pancreas procurement [non-PUG (NPUG)]. Clinical data and outcomes of both groups, as well as 34 patients who underwent SPK transplantation during the same period, were analyzed.
RESULTS
No significant differences were observed in preoperative, intraoperative characteristics or postoperative surgical complications between the two groups (P > 0.05). On days 2, 3, and 4 post-surgery, PUG patients exhibited lower alanine aminotransferase (183.62 ± 103.91 U/L, 130.69 ± 65.19 U/L, 90.42 ± 34.01 U/L) and aspartate aminotransferase (97.33 ± 46.38 U/L, 47.55 ± 21.71 U/L, 34.03 ± 16.2 U/L) levels compared to NPUG patients (P < 0.05). The proportion of patients achieving normal total bilirubin levels within 7 days was significantly higher in the PUG group (73.5%) compared to the NPUG group (48.5%) (P < 0.05). Graft survival rates at 6 months, 12 months, and 18 months were 97.1%/95.5%, 97.1%/95.5%, and 97.1%/95.5% in the PUG/NPUG groups, respectively. Patient survival rates were identical in both groups (97.1% at all time points). For SPK transplantation patients, kidney/pancreas/patient survival rates were 96.2%/100%/100%, 96.2%/100%/100%, and 96.2%/90%/100% at 6 months, 12 months, and 18 months, respectively.
CONCLUSION
The allocation of donor blood vessels between the liver and pancreas does not adversely affect the prognosis of either graft when the pancreas is used. The described technique offers a novel approach to arterial reconstruction in SPK transplantation.
Core Tip: In donation-after-brain-death donors, the celiac axis was allocated to the pancreas graft, with the gastroduodenal artery reconstructed for the pancreas. This strategy enabled successful liver and pancreas-kidney transplantation without increasing the risk of hepatic artery thrombosis or graft loss. Additionally, it facilitated faster normalization of liver enzymes, providing a safe vascular sharing approach for multi-organ procurement.
Citation: Xu Y, Zhang JY, Yu XH, Xie Y, Cao Y, Zhao J. Vascular allocation between liver and pancreas allografts: A retrospective single-center study. World J Gastrointest Surg 2026; 18(4): 117684
Liver transplantation has become the preferred treatment for end-stage liver disease, while simultaneous pancreas-kidney (SPK) transplantation is the procedure of choice for diabetes mellitus patients with renal failure. Due to the scarcity of organs, many transplant centers adopt multi-organ harvesting from donors to optimize organ utilization. However, the shared vascular connections between organs, particularly between the liver and pancreas, present a challenge. Proper arterial allocation is critical for the success of both liver transplantation and SPK transplantation. This study analyzed the prognosis of grafts following arterial allocation of the liver and pancreas, along with the reconstruction of the gastroduodenal artery (GDA).
MATERIALS AND METHODS
Patient characteristic
A retrospective review was conducted of all patients who underwent orthotopic liver transplantation at our center between January 2018 and June 2019. A total of 395 liver transplant (LT) surgeries were performed, with all donation after brain death. Using propensity score matching to balance variables, 102 patients were enrolled in the study (Figure 1). Of these, 34 patients received LTs using the pancreas [pancreas-using group (PUG)], while 68 patients underwent liver transplantation without the pancreas [non-PUG (NPUG)].
Inclusion criteria: (1) Recipients aged ≥ 18 years; (2) Full liver grafts; (3) Donor age ≥ 18 years and ≤ 50 years; and (4) Postoperative immunosuppressive regimen: Calcineurin inhibitor + mycophenolate mofetil + prednisone.
Exclusion criteria: (1) Retransplantation and multi-organ transplantation; and (2) Patients unable to follow up regularly.
Surgery
Multi-organ procurement was performed for all donors. When the pancreas was not needed, 3000 mL of renal preservation solution [hypertonic citrate adenine (HCA)] at 4 °C was perfused into the abdominal aorta, and the portal vein (PV) was perfused through the superior mesenteric vein. The perfusion solution consisted of 1000 mL University of Wisconsin (UW) solution + 2000 mL histidine-tryptophan-ketoglutarate solution at 4 °C.
When the pancreas was used, 3000 mL of HCA + 1000 mL UW at 4 °C was perfused into the abdominal aorta, and the PV was perfused as described. The intestinal tract was flushed with 250 mL of saline, followed by 200 mL of metronidazole.
For vascular allocation, the arteries were divided at the bifurcation, 5 mm from the beginning of the GDA and the end of the common hepatic artery (CHA) (Figure 2). For arterial reconstruction in SPK transplantation, end-to-end anastomosis was performed between the GDA and CHA (Figure 3). A GDA-CHA patch was used from the donor liver. In cases where the donor hepatic artery was too short, the iliac or mesenteric arteries were used for bypass. When the pancreas was abandoned, all related vascular patches were allocated to the liver. Orthotopic liver transplantation was performed using the classic technique without veno-venous bypass.
Figure 2 The shared vessel allocation between liver and pancreas.
A: The dotted line means cut line; B: End-to-end anastomosised gastroduodenal artery and common hepatic artery using 7-0 suture for artery reconstruction in simultaneous pancreas-kidney patients. Liver team allocated gastroduodenal artery-common hepatic artery patch. Ligating the distal of splenic artery and vein, left gastric artery, the distal of superior mesenteric vein when trimming the pancreas in the back table. CA: Celiac artery; CHA: Common hepatic artery; GDA: Gastroduodenal artery; LGA: Left gastric artery; PV: Portal vein; RGA: Right gastric artery; SA: Splenic artery; SMA: Superior mesenteric artery.
Figure 3 The real object image of the shared vessel allocation between liver and pancreas.
A: The arteries were cut off at the bifurcation 5 mm from the beginning of the gastroduodenal artery and the end of common hepatic artery; B: End-to-end anastomosised the gastroduodenal artery and common hepatic artery for artery reconstruction. The celiac trunk-superior mesenteric artery patch allocate to pancreas for the graft blood supply. a: Gastroduodenal artery; b: Common hepatic artery; c: Proper hepatic artery.
In our center’s SPK transplantation method, a donor Y-graft of the common iliac artery, along with its external and internal iliac branches, was used for the reconstruction of the pancreas and kidney grafts. For arterial reconstruction of the pancreas, the GDA was routinely reconstructed. The internal iliac artery of the Y-graft was anastomosed end-to-end with the renal artery, while the external iliac artery of the Y-graft was anastomosed end-to-end with the patch of the celiac trunk-superior mesenteric artery (SMA). The common iliac artery of the Y-graft was anastomosed end-to-side with the recipient’s right external iliac artery. For venous reconstruction, the transplanted renal vein was anastomosed end-to-side with the recipient’s right external iliac vein. Using systemic circulation reflux, the PV and inferior vena cava were anastomosed, and external drainage of the pancreas was performed via intestinal drainage (Figure 4).
Figure 4 The surgery method of simultaneous pancreas-kidney in our center.
The arterial blood supply to the transplanted pancreas is provided by a common patch from the superior mesenteric artery and the celiac artery, with venous drainage via the portal vein into the inferior vena cava. In this reconstruction, the donor’s Y-shaped iliac vascular graft serves as a bridge, and a side-to-side enteroenterostomy is created for exocrine drainage. CHA: Common hepatic artery; GDA: Gastroduodenal artery; SMA: Superior mesenteric artery.
Observation
Preoperative, intraoperative, and postoperative clinical data, as well as alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL), and prothrombin time within 30 days after surgery, were collected. The postoperative survival rate and graft survival rate were compared between the two groups. Postoperative complications, as well as graft and patient survival rates in SPK transplantation patients, were also observed.
Statistical analysis
Data are presented as mean ± SD or medians with quartile values (25%-75%). Differences in continuous variables between the two groups were analyzed using unpaired t-tests or the Mann-Whitney test, depending on the data distribution (normal or not). Count data were compared using the χ² test. Kaplan-Meier survival analysis was performed to evaluate graft and patient survival, with survival rates compared using the Log-rank test. All statistical analyses were conducted using SPSS 22, and statistical significance was set at a P value of < 0.05.
RESULT
Patient characteristics
No significant differences were observed between the two groups in terms of age, sex, height, weight, creatinine levels, model for end-stage liver disease scores, alpha-fetoprotein levels, Child-Pugh scores, or primary disease (P > 0.05; Table 1).
Table 1 Patients characteristic of pancreas-using group and non-pancreas-using group, n (%)/median (interquartile range)/mean ± SD.
Intraoperative characteristic and postoperative prognosis
Intraoperative characteristics, including donor conditions, cold ischemia time (CIT), intraoperative bleeding, blood transfusion, and operation time, were also similar between the two groups (P > 0.05; Table 2).
Table 2 Intraoperative characteristic of pancreas-using group and non-pancreas-using group, n (%)/median (interquartile range)/mean ± SD.
Regarding complications, five patients required surgical re-exploration for hemoperitoneum (four in the NPUG and one in the PUG). Arterial complications occurred in five recipients from the NPUG, including four cases of hepatic artery occlusion [three treated with balloon dilation and stent implantation for hepatic artery stenosis, one with hepatic artery thrombosis (HAT) managed by anticoagulant therapy] and one case of splenic artery steal syndrome (treated with splenic artery embolism). Additionally, two recipients from the NPUG experienced PV complications, both involving PV stenosis, which were treated with balloon dilation and stent implantation.
Bile leaks occurred in 11 recipients (10 from NPUG and 1 from PUG) during follow-up. Ten cases were successfully managed with non-surgical interventions, while one recipient in the NPUG underwent suturing to repair the leak. Bile duct strictures were observed in four and three recipients from NPUG and PUG, respectively. Balloon dilation was performed in two recipients from each group (Table 3).
Table 3 Postoperative characteristic and complications of pancreas-using group and non-pancreas-using group, n (%)/median (interquartile range).
AST, ALT, TBIL, and prothrombin time levels were significantly elevated in both groups on the first day postoperatively, but decreased substantially over time (Figures 5 and 6). At days 2, 3, and 4 after surgery, the ALT and AST levels in the PUG were significantly lower than those in the NPUG (P < 0.05), with PUG values of ALT (183.62 ± 103.91 U/L, 130.69 ± 65.19 U/L, 90.42 ± 34.01 U/L) and AST (97.33 ± 46.38 U/L, 47.55 ± 21.71 U/L, 34.03 ± 16.2 U/L) compared to NPUG values of ALT (276.74 ± 257.71 U/L, 204.33 ± 217.37 U/L, 146.44 ± 138.64 U/L) and AST (202.02 ± 264.23 U/L, 95.32 ± 117.66 U/L, 47.58 ± 36.18 U/L) (P < 0.05). There were no significant differences in the rate of decline of AST, ALT, and TBIL at 24 hours, 48 hours, and 72 hours postoperatively (P > 0.05; Table 4). Within 7 days, 73.5% of PUG recipients had a TBIL level that returned to normal, compared to 48.5% of NPUG recipients (P < 0.05; Table 5).
Figure 5 Aspartate aminotransferase, alanine aminotransferase, total bilirubin changes within 30 days of pancreas-using group and non-pancreas-using group after orthotopic liver transplantation.
Levels of aspartate aminotransferase, alanine aminotransferase, and total bilirubin rose significantly on postoperative day 1 before declining gradually in both groups. Significantly lower alanine aminotransferase and aspartate aminotransferase values were observed in the pancreas-using group (PUG) group compared to the non-PUG group on days 2, 3, and 4 post-surgery, and the differences were statistically significant. ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; NPUG: Non-pancreas-using group; PUG: Pancreas-using group; TBIL: Total bilirubin. aP < 0.05.
Figure 6 Changes in prothrombin time within 30 days post- orthotopic liver transplantation in the pancreas-using group and non-pancreas-using group groups.
NPUG: Non-pancreas-using group; PT: Prothrombin time; PUG: Pancreas-using group.
Table 4 The 24 hours, 48 hours, 72 hours rate of descent of alanine aminotransferase, aspartate aminotransferase, total bilirubin in pancreas-using group and non-pancreas-using group, mean ± SD.
Table 5 Alanine aminotransferase, aspartate aminotransferase, total bilirubin decreased to normal within 7 days in pancreas-using group and non-pancreas-using group, n (%).
Non-PUG (n = 68)
PUG (n = 34)
P value
Alanine aminotransferase decreased to normal within 7 days
23 (33.8)
14 (41.2)
0.467
Aspartate aminotransferase decreased to normal within 7 days
The follow-up deadline was December 31, 2019. The liver graft survival rates in the PUG and NPUG were 97.1%/95.5%, 97.1%/95.5%, and 97.1%/95.5% at 6 months, 12 months, and 18 months, respectively. The patient survival rates were 97.1%/97.1%, 97.1%/97.1%, and 97.1%/97.1% at the same intervals (Figure 7). Three recipients died during follow-up: (1) One in the PUG due to sepsis; (2) One in the NPUG due to respiratory failure from invasive pulmonary aspergillosis; and (3) One in the NPUG due to multiple organ failure.
Figure 7 Patient and liver graft survival rates in the pancreas-using group and non-pancreas-using group.
NPUG: Non-pancreas-using group; PUG: Pancreas-using group.
Complications and survival rate of SPK patients
The kidney, pancreas, and patient survival rates for SPK transplantation recipients were 96.2%/100%/100%, 96.2%/100%/100%, and 96.2%/90%/100% at 6 months, 12 months, and 18 months, respectively (Figure 8). Complications are summarized in Table 6. One recipient underwent graft pancreatectomy due to pancreas thrombosis, and another required graft nephrectomy for renal artery thrombosis. One recipient had a duodenal leak, and four recipients experienced gastrointestinal bleeding, all of which were managed with conservative therapy.
The abdominal organ procurement techniques, originally developed by the University of Pittsburgh, can be categorized into two approaches: (1) Organ harvest in situ; and (2) Multi-organ harvest[1,2]. Yersiz et al[3] suggested that organ harvest in situ reduces total CIT and potential injury from prolonged ex vivo manipulations, while facilitating organ sharing between centers through direct shipment from the donor facility. The ability to harvest the liver and kidneys without dissection eliminates unintended and often unrecognized ischemic periods, which may occur if individual vessels are isolated using traditional meticulous techniques. A distinct advantage of multi-organ harvest is its suitability for unstable donors who were previously deemed unsuitable for transplantation[2]. Our center employs a multi-organ procurement technique, with allocation performed on the back table, which helps preserve variant arterial anatomy[4]. Cold HCA solution (3000 mL)[5] and UW solution (1000 mL) are infused via the abdominal aorta to ensure optimal perfusion of the kidney, pancreas, and liver[6]. When the pancreas is used for SPK transplantation, an additional 1000 mL of UW solution is infused due to the pancreas’ limited blood supply. In this study, all donors were procured from our hospital, so the CIT was minimal. The PUG showed faster liver function recovery than the NPUG, which may be attributed to the extra 1000 mL of UW solution used when the pancreas was included.
Since the liver is a life-saving organ and pancreas transplantation is a life-enriching procedure, the liver team typically allocates the aortic patch carrying the celiac trunk, while the pancreatic vessels require reconstruction[7]. Conventional arterial reconstruction involves anastomosing the SMA and splenic arteries to an iliac bifurcation graft (internal iliac artery to splenic artery, external iliac artery to SMA), while the GDA is either ligated or connected to the splenic artery and SMA via an end-to-side anastomosis, extending the vessels if necessary, a method known as T-type anastomosis[8]. Alternatively, an iliac Y-graft can be used to reconstruct the blood vessels, with the extra branch of the internal iliac artery anastomosed to the GDA[9]. Socci et al[10] performed an end-to-side anastomosis between the GDA and external iliac artery, followed by a side-to-side anastomosis with the SMA, and anastomosed the internal iliac artery to the splenic artery. If the bilateral donor iliac arteries are unavailable, the donor’s brachiocephalic trunk can be used as a Y-graft[11].
The arterial supply to the pancreatic head primarily originates from the anterior and posterior pancreaticoduodenal arches; however, these arches are not always intact[12,13], necessitating routine reconstruction of the GDA. Additionally, increasing blood perfusion helps reduce the risk of pancreatic thrombosis[14]. Our SPK transplantation technique ensures adequate blood supply to the transplanted pancreas, while the blood shunt from the transplanted kidney prevents high perfusion injury to the pancreas. However, due to the shorter hepatic artery and smaller vessel caliber, hepatic artery anastomosis becomes more challenging. To address this, longer vascular patches, such as the right hepatic artery-gallbladder artery patch, left and middle hepatic artery patches, or left and right hepatic artery patches, are reserved during dissection of the recipient’s hepatoduodenal ligament. If these patches are still too short for anastomosis, iliac or mesenteric vessels can be used for vascular bypass.
HAT is the most serious vascular complication following liver transplantation, with an incidence ranging from 2% to 9%. Hepatic artery stricture (HAS) occurs in 2%-13% of transplants, and it has been suggested that HAS may progress to HAT, indicating that HAS and HAT are two interrelated components of the broader ischemic spectrum in allotransplantation[15-18]. Technical issues are the primary risk factors for HAT and HAS, with other contributing factors including infection, endothelial injury, caliber mismatch, acute cellular rejection, and graft ischemia time[19]. Furthermore, a retrospective analysis showed that the use of a long graft artery, regardless of the recipient’s anastomosis site, is an independent risk factor for HAT, suggesting that shorter graft arteries could reduce the occurrence of HAT after liver transplantation[20]. In our center, three recipients from the NPUG group with HAS underwent interventional treatment, and one recipient with HAT was treated with anticoagulation due to good liver function. The incidence of splenic artery steal syndrome in our center was consistent with reports from other studies[21,22]. By the time of follow-up, all grafts had recovered. There were no arterial complications in the PUG, supporting the feasibility of this vascular allocation method.
Thrombosis and/or stenosis of the PV have been reported in 1%-16% of LT cases, with common causes including the length and tortuosity of the PV, mismatched donor-recipient vein diameters, prolonged CIT, previous vascular thrombosis, and acute rejection[23-27]. In our center, when allocating the hepatopancreatic PV, the PV is typically cut 0.5-1 cm from the upper edge of the pancreas graft. This approach prevents excessive tortuosity of the donor-pancreatic PV, reducing the risk of outflow tract obstruction and thrombosis. While reserving too short a length could complicate anastomosis, our method ensures that the donor liver’s PV length is sufficient for proper vascular anastomosis. Notably, there were no PV complications in the PUG group.
Biliary complications have a prevalence ranging from 11% to 13%, and they are categorized into bile leakage and biliary obstruction (including bile duct stenosis, stones, casts, and papillary muscle dysfunction)[28,29]. Special attention should be given to the donor’s hepatic artery variants, particularly the reconstruction of the accessory right hepatic artery or replaced right hepatic artery, as these may affect the vascular branches supplying the biliary tract. Protecting the small arteries supplying the bile duct is also critical[30]. In this study, all organs were harvested from our center, where the shorter CIT and warm ischemia time[31], along with heparinization before harvesting, reduced the risk of arterial thrombosis[32] and ischemic biliary complications.
Surgical complications following pancreas transplantation are a major cause of graft loss. The rate of relaparotomy in current practices is about 35%, with over 70% of transplanted pancreas losses attributed to surgical complications[33,34]. Vascular thrombosis, occurring in approximately 3%-10% of cases, is the leading cause of pancreas loss and typically requires reoperation[35]. In addition to surgical technique, other risk factors for graft loss include donor age, type of preservation solution, rejection, body mass index of donor and recipient, and graft pancreatitis[36-38]. The University of Minnesota, the pioneer in pancreatic transplantation, reported a technical failure rate of 13.1% for SPK transplantation, with causes including thrombosis (6.8%), intra-abdominal infection (2.5%), pancreatitis (2.7%), pancreatic leakage (0.9%), and bleeding (2.4%)[37]. The Edouard Herriot Hospital reported a 44.3% complication rate in pancreatic transplantation surgery, with bleeding (26.2%), thrombosis (9.8%), and abdominal infection (6.6%) as the most common complications[38]. In our center, two SPK transplantation recipients lost both kidney and pancreas grafts due to thrombosis, but there were no instances of pancreatic or duodenal leakage.
CONCLUSION
The use of a multi-organ harvest technique for blood vessel allocation between the liver and pancreas does increase the complexity of hepatic artery reconstruction when the pancreas is used. However, our vascular allocation strategy, which includes GDA reconstruction, did not adversely affect the outcomes for either liver or SPK transplantation recipients.
ACKNOWLEDGEMENTS
The author wants to thank all staff members of Department of Kidney Transplantation and Department of Liver Transplantation of Tianjin First Central Hospital for their clinical contribution
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