Nonneoplastic celiac axis occlusion in patients undergoing pancreaticoduodenectomy

Pancreaticoduodenectomy after postoperative gastric tube reconstruction for esophageal cancer with median arcuate ligament syndrome: a case report

BACKGROUND

Pancreaticoduodenectomy (PD) is considered a challenging surgery for resecting the gastroduodenal artery (GDA), right gastric artery (RGA), and lymph node tumors. In cases of pancreatic head cancer surgery, vascular anastomosis or right gastroepiploic artery (RGEA)/GDA preservation is necessary after postoperative gastric tube reconstruction for esophageal cancer. Therefore, we report for the first time an extremely rare case of PD in a patient with pancreatic head cancer and median arcuate ligament syndrome (MALS) after gastric tube reconstruction following esophageal cancer surgery, in which the entire pancreatic head arcade was preserved.

CASE PRESENTATION

The patient was a 76-year-old man who had undergone esophageal cancer surgery after sternal gastric tube reconstruction 7 years ago. He was referred to our hospital because of the suspicion of intraductal papillary mucinous carcinoma (IPMC) owing to an enlarged cystic lesion and a substantial component in the uncinate process of the pancreas. Preoperative three-dimensional computed (3D-CT) tomography angiography showed celiac axis stenosis and pancreatic head arcade dilation. The diagnosis was IPMC without evidence of invasion; therefore, gastric tube blood flow was maintained by preserving the GDA and RGEA. Due to MALS, the GDA blood flow was supplied through the pancreatic head arcade, necessitating its preservation. The GDA-RGEA, right gastroepiploic vein, and anterior superior pancreaticoduodenal artery were taped over the entire pancreatic head for preservation. The inferior pancreaticoduodenal artery (IPDA) was also taped on the dorsal pancreas and the posterior or anterior IPDA, which further bifurcates were taped to preserve them. Subsequently, PD was performed.

CONCLUSION

We report a case of PD after gastric tube reconstruction for esophageal cancer with MALS, in which the pancreatic head arcade vessels were successfully preserved using 3D-CT to confirm the operation of the vessels.

Pancreaticoduodenectomy in Patients With Coeliac or Superior Mesenteric Artery Stenosis: A Review of the Literature

Pancreaticoduodenectomy (Whipple's procedure) is a technically demanding operation performed for malignant and premalignant conditions of the pancreatic head, duodenum and bile duct. Awareness of the vascular anatomy, variations, and pathology of this area is essential to achieve safe surgery and good outcomes. The operation involves division of the gastroduodenal artery (GDA) which provides communication between the foregut and midgut blood supply. In patients with coeliac or superior mesenteric artery (SMA) stenosis, this can lead to reduced blood supply to the foregut or midgut organs, with consequent severe ischaemic complications leading to significant morbidity and mortality. Coeliac artery stenosis is caused by median arcuate ligament syndrome (MALS) in the majority of patients with atherosclerosis being the second most common cause. SMA stenosis is much less common and is caused in the majority of cases by atherosclerosis. A review of preoperative imaging and intraoperative gastroduodenal artery clamp test is important to identify cases that may need additional procedures to preserve the blood supply. In this paper, we present a literature review for studies reporting patients undergoing Whipple's operation with concomitant coeliac axis stenosis (CAS) or SMA stenosis. Analysis of causes of stenosis or occlusion, prevalence, risk factors, different management strategies and outcomes was conducted.

Imaging of pancreatic ductal adenocarcinoma - An update for all stages of patient management

Background

Pancreatic ductal adenocarcinoma (PDAC) is a common and lethal cancer. From diagnosis to disease staging, response to neoadjuvant therapy assessment and patient surveillance after resection, imaging plays a central role, guiding the multidisciplinary team in decision-planning.

Review aims and findings

This review discusses the most up-to-date imaging recommendations, typical and atypical findings, and issues related to each step of patient management. Example cases for each relevant condition are presented, and a structured report for disease staging is suggested.

Conclusion

Despite current issues in PDAC imaging at different stages of patient management, the radiologist is essential in the multidisciplinary team, as the conveyor of relevant imaging findings crucial for patient care.

Successful treatment for pseudoaneurysm following distal pancreatectomy with celiac axis resection without postoperative pancreatic fistula: a case report

BACKGROUND

Distal pancreatectomy with celiac axis resection (DP-CAR) represents an innovative surgical approach for locally advanced pancreatic body cancer in cases involving celiac axis invasion. However, this procedure carries significant perioperative risks, including arterial aneurysms and organ ischemia. Understanding these risks is crucial for optimizing patient outcomes and guiding treatment decisions.

CASE PRESENTATION

This case report describes a unique case of a 74-year-old male patient who was diagnosed with locally advanced pancreatic body cancer with invasion of the celiac and splenic arteries. He underwent DP-CAR after six cycles of chemotherapy. His postoperative course was uneventful without any evidence of postoperative pancreatic fistula. However, at the 10-month postoperative follow-up, pseudoaneurysm was incidentally detected in the anterior superior pancreaticoduodenal artery by follow-up computed tomography. It was successfully treated with coil embolization. He had no signs of tumor recurrence or relapse of pseudoaneurysm formation 2 years postoperatively. This case report discusses the potential risks of pseudoaneurysm formation in patients undergoing DP-CAR due to hemodynamic changes. We emphasize the significance of close monitoring in such cases.

CONCLUSIONS

The case highlights the importance of recognizing and managing potential complications associated with DP-CAR in patients with pancreatic cancer. Despite its effectiveness in achieving complete resection, DP-CAR carries inherent risks, including the development of pseudoaneurysms. Vigilant surveillance and prompt intervention are crucial for optimizing patient outcomes and minimizing postoperative complications.

Median arcuate ligament release at the time of pancreaticoduodenectomy or total pancreatectomy

BACKGROUND

Celiac artery compression can complicate the performance of pancreaticoduodenectomy or total pancreatectomy due to the need for ligation of the gastroduodenal artery. Median arcuate ligament release restores normal arterial flow to the liver, spleen, and stomach and may avoid complications related to poor perfusion of the foregut.

METHODS

All patients who underwent median arcuate ligament release for celiac artery compression at the time of pancreatectomy between 2009 and 2023 were reviewed. Pre- and postoperative computed tomography was used to categorize celiac artery compression by the extent of compression (types A [<50%], B [50%-80%], and C [>80%]).

RESULTS

Of 695 patients who underwent pancreatectomy, 22 (3%) had celiac artery compression, and a majority (17) were identified on preoperative imaging. Median celiac artery compression was 52% (interquartile range = 18); 8 (36%) patients had type A and 14 (64%) had type B compression with a median celiac artery compression of 39% (interquartile range = 18) and 59% (interquartile range = 14), respectively (P < .001). Postoperative imaging was available for 20 (90%) patients, and a reduction in the median celiac artery compression occurred in all patients: type A, 14%, and type B, 31%. Complications included 1 (5%) death after hospital discharge, 1 (5%) pancreatic fistula, 1 (5%) delayed gastric emptying, and 4 (18%) readmissions. No patient had evidence of a biliary leak or liver dysfunction.

CONCLUSION

Preoperative computed tomography allows accurate identification of celiac artery compression. Ligation of the gastroduodenal artery during pancreaticoduodenectomy or total pancreatectomy in the setting of celiac artery compression requires median arcuate ligament release to restore normal arterial flow to the foregut and avoid preventable complications.

Median Arcuate Ligament Syndrome (MALS) in Hepato-Pancreato-Biliary Surgery: A Narrative Review and Proposed Management Algorithm

Median arcuate ligament syndrome (MALS) is an uncommon condition characterized by the compression of the celiac trunk by the median arcuate ligament. Due to the anatomical proximity to the foregut, MALS has significant implications in hepato-pancreato-biliary (HPB) surgery. It can pose complications in pancreatoduodenectomy and orthotopic liver transplantation, where the collateral arterial supply from the superior mesenteric artery is often disrupted. The estimated prevalence of MALS in HPB surgery is approximately 10%. Overall, there is consensus for a cautious approach to MALS when embarking on complex foregut surgery, with a low threshold for intraoperative median arcuate ligament release or hepatic artery reconstruction. The role of endovascular intervention in the management of MALS prior to HPB surgery continues to evolve, but more evidence is required to establish its efficacy. Recognizing the existing literature gap concerning optimal management in this population, we describe our tertiary center experience as a clinical algorithm to facilitate decision-making. Research question: What is the significance and management of median arcuate ligament syndrome in patients undergoing hepato-pancreato-biliary surgery?

Pancreaticoduodenectomy combined gastroduodenal collateral reconstruction and preservation due to median arcuate ligament syndrome: technical notes with two surgical cases report (with video)

INTRODUCTION

Pancreaticoduodenectomy in patients with CA stenosis due to median arcuate ligament often required carefully collateral pathways management to avoid hepatic ischemic complications.

CASES PRESENTATION

Case 1: A 63-year-old man was referred to our department because of jaundice with distal common bile duct tumor. Pancreaticoduodenectomy with left posterior SMA first approach and circumferential lymphadenectomy was performed. Case 2: A 48-year-old man was referred to our department because of right-upper-quadrant abdominal pain with Vater tumor. Laparoscopic pancreaticoduodenectomy with left posterior SMA first approach and circumferential lymphadenectomy was performed. Postoperatively, in all two cases, three-dimensional reconstruction images showed developed collateral pathways around the pancreatic head, and the CA was stenosis in 75% and 70% due to MAL, respectively. Intraoperatively, in all two cases, we confirmed poor blood flow in the common hepatic artery (CHA) by palpation and observation. So that in the first case, we have decided to proceed a no-touch technique of GDA segmental resection en bloc with the tumor and reconstructed with an end-to-end GDA anastomosis; in the second cases, we have decided to proceed gastroduodenal collateral preservation. When preserving these collateral pathways, we confirmed that the PHA flow remained pulsatile as an indicator that the blood flow was adequate.

CONCLUSION

Celiac axis stenosis was a rare but difficult-to-managed condition associated with pancreaticoduodenectomy. Collateral pathways management depends on variety of collateral pathways.

Preoperative blood circulation modification prior to pancreaticoduodenectomy in patients with celiac trunk occlusion: Two case reports

BACKGROUND

Celiac trunk stenosis or occlusion is a common condition observed in patients undergoing pancreaticoduodenectomy (PD). The risk of upper abdominal organ ischemia or failure increases if the blood circulation in the celiac arterial system is not maintained after the surgery.

CASE SUMMARY

We present two cases of elderly patients with distal cholangiocarcinoma and celiac trunk occlusion who underwent PD. We performed blood circulation modification preoperatively with transcatheter coil embolization of the arterial arcades of the pancreatic head via the superior mesenteric artery to develop collateral communication between the superior mesenteric artery and the common hepatic or splenic arteries to ensure arterial blood flow to the upper abdominal organs. The postoperative course was marked by delayed gastric emptying, but no major surgical complications, such as biliary or pancreatic fistula, or clinical, biochemical, or radiological evidence of ischemic disease, was observed.

CONCLUSION

Preoperative blood circulation modification may be a valid alternative procedure for elderly patients with celiac trunk occlusion who are ineligible for interventional or surgical revascularization.

Treatment strategy for pancreatic head cancer with celiac axis stenosis in pancreaticoduodenectomy: A case report and review of literature

BACKGROUND

During pancreaticoduodenectomy in patients with celiac axis (CA) stenosis due to compression by the median arcuate ligament (MAL), the MAL has to be divided to maintain hepatic blood flow in many cases. However, MAL division often fails, and success can only be determined intraoperatively. To overcome this problem, we performed endovascular CA stenting preoperatively, and thereafter safely performed pancreaticoduodenectomy. We present this case as a new preoperative treatment strategy that was successful.

CASE SUMMARY

A 77-year-old man with a diagnosis of pancreatic head cancer presented to our department for surgery. Preoperative assessment revealed CA stenosis caused by MAL. We performed endovascular stenting in the CA preoperatively because we knew that going into the operation without a strategy could lead to ischemic complications. Double-antiplatelet therapy (DAPT) – which is needed when a stent is inserted – was then administered in parallel with neoadjuvant chemotherapy (NAC). This allowed us to administer DAPT for a sufficient period before the main pancreaticoduodenectomy procedure while obtaining therapeutic effects from NAC. Subtotal stomach-preserving pancreaticoduodenectomy was then performed. The operation did not require any unusual techniques and was performed safely. Postoperatively, the patient progressed well, without any ischemic complications. Histopathologically, curative resection was confirmed, and the patient had no recurrence or complications due to ischemia up to six months postoperatively.

CONCLUSION

Preoperative endovascular stenting, with NAC and DAPT, is effective and safe prior to pancreaticoduodenectomy in potentially resectable pancreatic cancer.

Pancreaticoduodenectomy with reconstructing blood flow of the gastric conduit after esophagectomy with concomitant celiac axis stenosis: a case report

Background

Pancreaticoduodenectomy after esophageal resection is technically difficult, because blood flow of the gastric conduit should be preserved. Celiac axis stenosis (CAS) is also a problem for pancreaticoduodenectomy, because arterial blood supply for the liver comes mainly through the collateral route from the superior mesenteric artery (SMA) via the gastroduodenal artery (GDA). Herein, we report the case of a patient with pancreatic head cancer who underwent a pancreaticoduodenectomy after esophagectomy with concomitant CAS.

Case presentation

A 76-year-old man with pancreatic head cancer was referred to our department. He had a history of esophagectomy with retrosternal gastric conduit reconstruction for esophageal cancer. Computed tomography showed severe CAS and a dilated collateral route between the SMA and the splenic artery (SPA). We prepared several surgical options depending on the intraoperative findings, and performed radical pancreaticoduodenectomy with concomitant resection of the distal gastric conduit. The right gastroepiploic artery (RGEA) of the remnant gastric conduit was fed from the left middle colic artery (MCA) with microvascular anastomosis. Despite CAS, when the GDA was dissected and clamped, good blood flow was confirmed, and the proper hepatic artery did not require reconstruction. The patient was discharged on postoperative day 90.

Conclusions

We successfully performed radical pancreaticoduodenectomy after esophagectomy with concomitant CAS, having prepared multiple surgical options depending upon the intraoperative findings.

Pancreatoduodenectomy co-morbid with celiac axis compression syndrome: a report of three cases

Background

Celiac axis compression syndrome (CACS) is a relatively rare disease. Because of the nature of the blood flow in the celiac region when a pancreatoduodenectomy (PD) is performed for CACS, the celiac region can become ischemic. The aim of this study is to report on the importance of pre-operative diagnosis of CACS in terms of the outcomes for patients post-operatively. In this study, three 3 cases of PD co-morbid with CACS are reported: one intra-operative diagnosis case and two pre-operative diagnosis cases.

Case presentation

The one case, not diagnosed with CACS prior to the operation, had a hard post-operative course because of complication caused by ischemia of the celiac region compared with the two cases diagnosed prior to the operation, who had a good post-operative course because of pre-operative or intra-operative intervention.

Conclusions

Post-operative complications due to CACS are preventable by pre-operative diagnosis and appropriate interventions.

Intraoperative evaluation of hepatic artery blood flow during pancreatoduodenectomy (HEPARFLOW): Protocol of an exploratory study

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Assessment of flow rates of the hepatic artery during pancreatoduodenectomy.

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Identification of pre- and intraoperative factors influencing liver blood flow.

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Relevance of a celiac axis stenosis by pancreatoduodenectomy.

Introduction

Pancreatoduodenectomy is the treatment of choice for a range of benign and malignant diseases. The pancreatic head must be separated from its supplying vessels, especially the gastroduodenal artery, during this operation. However, dissection of the gastroduodenal artery can disturb blood supply to the liver and result in liver ischemia. There is currently no well-established algorithm to evaluate and ensure sufficient blood flow in patients with altered hepatic artery blood flow. To address this important issue, this study aims to establish a basis for assessing liver blood supply during pancreatoduodenectomy. Furthermore, factors influencing arterial blood flow and related postoperative complications will be evaluated.

Methods and analysis

The HEPARFLOW study is a single institutional single-arm prospective exploratory observational clinical trial. All consecutive patients undergoing elective partial or total pancreatoduodenectomy will be screened for inclusion until 100 patients are enrolled. Blood flow in the proper hepatic artery, gastroduodenal artery, portal vein, and additional vessels supplying the liver will be measured during pancreatoduodenectomy using Doppler flowmetry. All patients will be followed up for 90 days after surgery. At each visit, standard clinical data, postoperative complications and mortality will be recorded.

Discussion

This will be the first study to prospectively assess intraoperative flow rates of the hepatic artery and portal vein to evaluate liver blood supply during pancreatoduodenectomy. The preoperative and intraoperative factors influencing blood flow in the hepatic arteries will be identified. This study may also reveal the hemodynamic and clinical relevance of a compression of the celiac axis during pancreatoduodenectomy.

Ethics and dissemination

This study was approved by the Ethics Committee of the University of Heidelberg (S-073/2018). The results will be published in a peer-reviewed journal and will be presented at medical meetings.

Leveraging Aberrant Vasculature in Celiac Artery Stenosis: The Arc of Buhler in Pancreaticoduodenectomy

Background: Celiac artery stenosis and occlusion have been described rarely in patients undergoing pancreaticoduodenectomy (PD), although it occurs relatively frequently in this group. An arterial connection between the celiac and superior mesenteric arteries, known as the Arc of Buhler, provides alternative flow to the celiac distribution once the gastroduodenal artery (GDA) is ligated in PD.

Case Presentation: A 69-year-old man, in whom pre- and intraoperative efforts to stent an occluded celiac artery failed, had sufficient retrograde flow from an unrecognized Arc of Buhler to maintain adequate hepatic arterial perfusion after ligation of the GDA during a PD.

Conclusions: Although there are several case reports and case series regarding the management of celiac stenosis in PD, the impact of an Arc of Buhler variant in this setting has been rarely reported. This case report demonstrates the ability of an intact Arc of Buhler to maintain adequate hepatic perfusion after ligation of the GDA and avoid the potential morbidity of a hepatic artery bypass procedure.

Acute median arcuate ligament syndrome after pancreaticoduodenectomy

Background

Median arcuate ligament syndrome (MALS) can cause severe complications after pancreaticoduodenectomy (PD). Most of the reported cases of MALS have been diagnosed perioperatively and can be treated efficiently by interventional radiology or division of the median acute ligament (MAL) fibers.

Case report

A 69-year-old woman underwent PD with resection of the SMV for pancreatic head cancer. Intraoperative exploration showed normal anatomy of the celiac trunk. Intraoperative digital palpation revealed normal pulsation of the common hepatic artery after resection of the gastroduodenal artery. On postoperative day (POD) 3, her liver function tests were abnormal, and bloody fluids were found in the drain. Abdominal CT showed necrosis of the pancreatic body and ischemia in the liver secondary to MALS which was not detected in the preoperative CT. Interventional radiology was tried first but failed. Division of the MAL fibers markedly increased the blood flow in the hepatic artery. Resection of the remnant pancreas and spleen was also performed simultaneously. Abdominal CT on POD 20 showed re-occlusion of the celiac artery. She experienced rupture of the gastrojejunostomy site, severe hepatic cytolysis, and choledochojejunostomy stricture thereafter.

Conclusions

This is the third case of MALS that has developed acutely after PD. MALS can cause refractory complications even after MAL release.

Celiac axis stenosis due to median arcuate ligament compression in a patient who underwent pancreatoduodenectomy; intraoperative assessment of hepatic arterial flow using Doppler ultrasonography: a case report

Background

Celiac axis stenosis due to compression by the median arcuate ligament has been reported in patients undergoing pancreaticoduodenectomy; it leads to the development of major collateral pathways that feed the hepatic artery. Dividing these important collaterals during pancreaticoduodenectomy can cause ischemic complications which may lead to a high mortality rate. To prevent these complications, it is necessary to assess intrahepatic arterial flow.

Case presentation

A 71-year-old Japanese man with anorexia was referred to us for the treatment of alcoholic chronic pancreatitis. Computed tomography revealed a pancreatic head tumor with a calculus, associated with the dilatation of the main pancreatic duct and intrahepatic bile duct. Three-dimensional imaging demonstrated focal narrowing in the proximal celiac axis due to median arcuate ligament compression and a prominent gastroduodenal artery that fed the common hepatic artery. The preoperative diagnosis was alcoholic chronic pancreatitis with common bile duct obstruction and celiac axis stenosis due to median arcuate ligament compression. Pancreaticoduodenectomy with median arcuate ligament release was scheduled. Before the division of the median arcuate ligament, the peak flow velocity and resistive index of his intrahepatic artery measured with Doppler ultrasonography decreased from 37.7 cm/second and 0.510, respectively, to 20.6 cm/second and 0.508 respectively, when his gastroduodenal artery was clamped. However, these values returned to baseline levels after the division of the median arcuate ligament. These findings suggested that pancreaticoduodenectomy could be performed safely. Our patient was discharged on postoperative day 17 without significant complications.

Conclusion

The intraoperative quantitative evaluation of intrahepatic arterial blood flow using Doppler ultrasonography was useful in a patient who underwent pancreaticoduodenectomy, who had celiac axis stenosis due to compression by the median arcuate ligament.

Pancreaticoduodenectomy with Preservation of Collateral Circulation or Revascularization for Biliary Pancreatic Cancer with Celiac Axis Occlusion: A Report of 2 Cases

BACKGROUND In cases of celiac axis occlusion requiring pancreaticoduodenectomy for malignancy, both oncologic curability and control of hepatic arterial flow must be considered, but the operative strategy is undeveloped. CASE REPORT Case 1: A 74-year-old man was diagnosed with hilar cholangiocarcinoma with celiac axis stenosis. The collateral from the superior mesenteric artery ran through the pancreas head but no invasion was observed in preoperative imaging. Hepatopancreatoduodenectomy with preservation of a collateral was performed. Case 2: A 69-year-old woman was diagnosed with pancreas head cancer with celiac axis occlusion. The collateral from the superior mesenteric artery ran through pancreas head and tumor invasion was observed. Pancreaticoduodenectomy with bypass revascularization using a vein graft was performed. Both operations were performed safely oncologically under preoperative planning that was based on computed tomographic angiography. The operative procedure was ultimately determined by evaluation of perioperative blood flow under Doppler ultrasonography after clamping the gastroduodenal artery. CONCLUSIONS Preoperative simulations of arterial revascularization and perioperative evaluation of blood flow are necessary for the success of this procedure.

Celiac Artery Compression Syndrome Evaluated with 3-D Contrast-Enhanced Ultrasonography: a New Approach

This study was performed to estimate the value of 3-D contrast-enhanced ultrasonography (3-D-CEUS) in the diagnosis of celiac artery compression syndrome (CACS). Patients suspected of having CACS were assessed with 3-D-CEUS and contrasted with computed tomography angiography. Diagnostic accuracy was evaluated with a receiver operating characteristic curve. Three-dimensional CEUS revealed 19 positive and 9 negative cases. In the negative group, the contrast agent did not change with respiration. In the positive group, the contrast agent exhibited a hook-shaped stenosis on expiration and returned to normal on inspiration. Computed tomography angiography indicated 1 false-positive case and 1 false-negative case. The sensitivity and specificity of 3-D-CEUS were 95% and 89%, respectively. The area under the receiver operating characteristic curve was 0.982 (p <0.01). In conclusion, 3-D-CEUS can accurately reveal the characteristic hooked appearance and dynamic nature of CACS with respiration, and thus, it represents a new, non-invasive approach to CACS diagnosis.

Impact of pancreaticoduodenal arcade dilation on postoperative outcomes after pancreaticoduodenectomy

BACKGROUND

The aim of this study was to investigate the impact of pancreaticoduodenal arcade (PDA) dilation on postoperative outcomes after pancreaticoduodenectomy.

METHODS

Consecutive patients submitted to pancreaticoduodenectomy between 2008 and 2016 underwent preoperative multi-detector computed tomography, the images of which were re-reviewed. The patients were categorized according to the grade of PDA dilation into 3 groups (remarkably-dilated, slightly-dilated, and non-dilated).

RESULTS

Among the 443 patients, 25 patients (5.6%) were categorized as remarkably-dilated PDA and 24 patients (5.4%) as having slightly-dilated PDA. The patients with remarkably-dilated PDA had undergone pancreaticoduodenectomy with additional surgical maneuvers to restore celiac arterial flow as needed, and had an uneventful postoperative recovery relative to those with non-dilated PDA. In contrast, patients with slightly-dilated PDA underwent only pancreaticoduodenectomy without additional surgical maneuvers, and developed clinically relevant postoperative pancreatic fistula (POPF) more frequently than those with non-dilated PDA (42% vs. 21%, P = 0.021). Moreover, slightly-dilated PDA was shown to be an independent risk factor for clinically relevant POPF (odds ratio = 2.719, P = 0.042).

DISCUSSION

For patients with PDA dilation requiring pancreaticoduodenectomy, a preoperative evaluation of the vascular anatomy, intraoperative assessment of the celiac arterial flow, and additional surgical maneuvers might be necessary to reduce the risk of postoperative complications.

Substantial atherosclerotic celiac axis stenosis is a new risk factor for biliary fistula after pancreaticoduodenectomy

BACKGROUND

Biliary fistula (BF) is a major surgical complication that can develop after pancreaticoduodenectomy (PD) whose risk factors remain unclear. Substantial atherosclerotic celiac axis stenosis (SACAS) has not been reported to be one of them.

METHODS

Data from 507 patients undergoing PD between Jan 1, 2013 and Dec 31, 2015 were retrospectively collected. Clinical data from patients with SACAS were studied, and the independent risk factors for BF underwent multivariate logistic regression analysis, including SACAS.

RESULTS

BF occurred in 22 (4.3%) patients, and the incidence of BF was significantly higher in patients with SACAS than in those without it (27.0% vs 2.6%, P < .001). In the univariate analysis, BF was significantly related to SACAS, older age, a higher ASA score, history of coronary disease, greater blood loss and RBC transfusion during surgery, smaller CBD diameter and higher POD 1 BUN level. The multivariate analysis showed that only SACAS (OR 8.91, 95% CI 2.36-33.69, P = .001), older age (OR 1.08, 95% CI 1.01-1.15, P = .028) and smaller preoperative CBD (OR 0.79, 95% CI 0.69-0.92, P = .002) were independent risk factors for postoperative BF.

CONCLUSION

Older age and a smaller preoperative CBD diameter are independent risk factors for BF after PD, which is consistent with the literature. In addition, SACAS is a new independent risk factor for BF. For patients with SACAS, postoperative drainage should be carefully managed to precisely observe the potential for BF.

Preoperative imaging and prediction of oesophageal conduit necrosis after oesophagectomy for cancer

BACKGROUND

Oesophageal conduit necrosis following oesophagectomy is a rare but life-threatening complication. The present study aimed to assess the impact of coeliac axis stenosis on outcomes after oesophagectomy for cancer.

METHODS

The study included consecutive patients who had an Ivor Lewis procedure with curative intent for middle- and lower-third oesophageal cancer at two tertiary referral centres. All patients underwent preoperative multidetector CT with arterial phase to detect coeliac axis stenosis. The coeliac artery was classified as normal, with extrinsic stenosis due to a median arcuate ligament or with intrinsic stenosis caused by atherosclerosis.

RESULTS

Some 481 patients underwent an Ivor Lewis procedure. Of these, ten (2·1 per cent) developed oesophageal conduit necrosis after surgery. Coeliac artery evaluation revealed a completely normal artery in 431 patients (91·5 per cent) in the group without conduit necrosis and in one (10 per cent) with necrosis (P < 0·001). Extrinsic stenosis of the coeliac artery due to a median arcuate ligament was found in two patients (0·4 per cent) without conduit necrosis and five (50 per cent) with necrosis (P < 0·001). Intrinsic stenosis of the coeliac artery was found in 11 (2·3 per cent) and eight (80 per cent) patients respectively (P < 0·001). Eight patients without (1·7 per cent) and five (50 per cent) with conduit necrosis had a single and thin left gastric artery (P < 0·001).

CONCLUSION

This study suggests that oesophageal conduit necrosis after oesophagectomy for cancer may be due to pre-existing coeliac axis stenosis.

Clinics in diagnostic imaging (176). Acute embolic occlusion of the coeliac artery

A 52-year-old man, who had a background of chronic heart disease and atrial fibrillation, as well as non-compliance with warfarin therapy, presented with a two-week history of worsening upper abdominal pain. Computed tomography mesenteric angiography showed complete embolic occlusion of the coeliac artery with resultant segmental splenic infarction, and thrombus within the left ventricle. A decision was made to proceed with catheter-directed thrombolysis. Subsequent follow-up angiogram at 12 hours showed successful treatment with complete dissolution of the coeliac embolus. The patient's symptoms resolved during his hospitalisation and he was subsequently discharged well on long-term oral anticoagulation therapy. Isolated acute embolic occlusion of the coeliac axis is a rare occurrence that may result in end-organ infarction. Treatment options include systemic anti-coagulation, mechanical thrombectomy, catheter thrombolysis or open surgery. Catheter-directed thrombolysis therapy is a feasible and effective option for treating acute thromboembolic occlusion of the coeliac artery.

Vascular challenges from pancreatoduodenectomy in the setting of coeliac artery stenosis

Coeliac artery stenosis due to median arcuate ligament compression or atherosclerotic disease is a frequently unrecognised challenge to recovery after pancreatoduodenectomy. The described case illustrates management with intraoperative superior mesenteric artery to hepatic artery bypass graft that led to haemorrhagic challenges postoperatively but ultimately a good recovery. Aspects of preoperative diagnosis, preoperative intervention and intraoperative management options are reviewed. Surgeons need to possess these tools to prevent complications from coeliac artery stenosis when pancreatoduodenectomy is required.

Phase-contrast MRI evaluation of haemodynamic changes induces by a coeliac axis stenosis in the gastroduodenal artery

OBJECTIVE

To evaluate the correlation between the gastroduodenal artery (GDA) haemodynamic changes and the degree of coeliac axis (CA) stenosis using phase-contrast MRI.

METHODS

The study was institutional review board approved, and written informed consent was obtained from patients included prospectively. A two-dimensional phase-contrast MRI was performed in 23 patients scheduled for a potential complex supramesocolic surgery, in a plane perpendicular to the GDA, during inspiration and expiration. The peak and mean velocities (V_p and V_m), mean flow rate (Q_m) and flow direction at inspiration and at expiration have been correlated with the degree of CA stenosis evaluated by CT.

RESULTS

13 of 23 patients presented CA stenosis due to the median arcuate ligament (34-80% of stenosis), 4 of them had associated atheromatous calcifications. V_p, V_m and Q_m of GDA presented a significant and linear relationship with the degree of CA stenosis, at inspiration as well as at expiration (r > 0.74, p < 0.001). Velocities and flow rates presented a different pattern depending on the degree of CA stenosis: <34% (n = 10), flow direction remained physiological with low velocities and flow rates; >60% of stenosis (n = 5), a reverse flow direction with increased velocities and flow rates were observed; variable patterns between 34% and 60%.

CONCLUSION

Phase-contrast MRI permits the evaluation of haemodynamic changes in GDA induced by CA stenosis, including median arcuate ligament compression, and could be of great interest in therapeutic decision making in supramesocolic surgery, such as liver transplantation or duodenopancreatectomy, by detecting haemodynamically significant stenoses. Advances in knowledge: Physiological phase-contrast MRI detects haemodynamically significant stenoses of the CA by evaluating haemodynamic parameters in the GDA. Physiological phase-contrast MRI demonstrates that flow in the GDA can be a direct marker of the real haemodynamic impact of a CA stenosis on the hepatic vascularization and could thus participate in the pre-surgical work-up of duodenopancreatectomy or hepatic graft, whereas existing pre-operative imaging are only morphological.

Pancreaticoduodenectomy: Secondary stenting of the celiac trunk after inefficient median arcuate ligament release and reoperation as an alternative to simultaneous hepatic artery reconstruction

In patients undergoing pancreaticoduodenectomy (PD), unrecognized hemodynamically significant celiac axis (CA) stenosis impairs hepatic arterial flow by suppressing the collateral pathways supplying arterial flow from the superior mesenteric artery and leads to serious hepatobiliary complications due to liver and biliary ischemia, with a high rate of mortality. CA stenosis is usually due to an extrinsic compression by a previously asymptomatic median arcuate ligament (MAL). MAL is diagnosed by computerized tomography in about 10% of the candidates for PD, but only half are found to be hemodynamically significant during the gastroduodenal artery clamping test with Doppler assessment, which is mandatory before any resection. MAL release is usually efficient to restore an adequate liver blood inflow and prevent ischemic complications. In cases of failure in MAL release, postponed PD with secondary stenting of the CA and reoperation for PD should be considered as an alternative to immediate hepatic artery reconstruction, which involves the risk of postoperative thrombosis of the arterial reconstruction. We recently used this two-stage strategy in a patient undergoing surgery for pancreatic adenocarcinoma.

Acute median arcuate ligament syndrome after pancreaticoduodenectomy

Median arcuate ligament syndrome (MALS) has been reported in 2–7.6 % of patients undergoing pancreaticoduodenectomy (PD). Most of the reported cases of MALS have been diagnosed perioperatively and treated radiologically or surgically before or during PD. MALS can have an acute postoperative onset after PD even if all preoperative and intraoperative evaluations are normal particularly in young patients.

In this report, we present a second case of severe hepatic cytolysis secondary to MALS that developed acutely and the first patient who required acute division of the median arcuate ligament after PD.

Celiac axis stenosis as a rare but critical condition treated with pancreatoduodenectomy: report of 2 cases

We describe 2 cases of patients with loss of hepatic arterial flow during surgery for pancreatic head cancer due to celiac stenosis caused by median arcuate ligament compression. The first case underwent pylorus-resecting pancreatoduodenectomy for pancreatic head cancer. After resection of the gastroduodenal artery, flow in the common hepatic artery disappeared, and celiac axis stenosis was identified. Interventional stent insertion was attempted, however, it failed due to the acute angle of the celiac orifice (os). This problem was resolved by arterial reconstruction. The second case underwent pylorus-preserving pancreatoduodenectomy for pancreatic head cancer and the same phenomenon occurred during the procedure. Interventional stent insertion was also tried; in this patient, however, it failed due to the acute angle of the celiac os. The problem was resolved by changing a femoral approach to a brachial approach, and the stent was inserted into the celiac os successfully.

Endovascular Stenting for Non-Traumatic Celiac Artery Stenosis Following Pancreatoduodenectomy

Postoperative celiac artery stenosis (CAS) rarely occurs in the absence of vascular injury or pseudoaneurysm after pancreatoduodenectomy (PD). Because of its low incidence, the optimal treatment for non-traumatic postoperative CAS is unknown. Here, we show a case of CAS possibly due to exacerbated median arcuate ligament compression after PD. The purpose of this report is to describe this rare complication and its successful endovascular treatment with review of literatures.

Advances in the Surgical Management of Resectable and Borderline Resectable Pancreas Cancer

Successful surgical resection offers the only chance for cure in patients with pancreatic cancer. However, pancreatic resection is feasible in less than 20% of the patients. In this review, the current state of surgical management of pancreatic cancer is discussed. The definition of resectability based on cross-sectional imaging and the technical aspects of surgery, including vascular resection and/or reconstruction, management of aberrant vascular anatomy and extent of lymphadenectomy, are appraised. Furthermore, common pancreatic resection-specific postoperative complications and their management are reviewed.

A case of pancreatic cancer with concomitant median arcuate ligament syndrome treated successfully using an allograft arterial transposition

An association of pancreatic cancer and median arcuate ligament syndrome (MALS) is a rare and challenging situation in terms of treatment. A 60-year-old man diagnosed with pancreatic cancer underwent laparotomy. A pancreaticoduodenectomy was planned, but during the resection part of the operation, a celiac artery stenosis was noticed. The patient was diagnosed with MALS causing almost total celiac artery occlusion, with no radiological solution. The patient was re-operated the next day, and an iliac artery allograft was used for aorta-proper hepatic artery reconstruction, concomitant with the total pancreaticoduodenectomy. Preoperative meticulous evaluation of vascular structures of the celiac trunk and its branches is important, especially in pancreatic surgery. A vascular allograft may be a lifesaving alternative when vascular reconstruction is necessary.

Bypass grafting between the supraceliac aorta and the common hepatic artery during pancreaticoduodenectomy

Patients with celiac artery stenosis often remain asymptomatic due to formation of extensive collateral pathways. Hepatic or anastomotic ischemia may occur when the gastroduodenal artery and these collaterals are ligated during pancreaticoduodenectomy. Here, we present a patient with severe atherosclerotic disease of the celiac axis who successfully underwent pancreaticoduodenectomy with aorto-hepatic bypass.

Problems with the Median Arcuate Ligament Should Be Recognized before Surgery; Its Importance in Pancreaticoduodenectomy

BACKGROUND

Celiac artery stenosis (CAS) is a not a rare finding in the general population. The median arcuate ligament (MAL) is a fibrous arch that unites the diaphragmatic crura on either side of the aortic hiatus and, while it normally passes cranial to the origin of the celiac truncus, a low-lying ligament may lead to compression of the celiac artery and is the one of the major causes of CAS.

CASE REPORT

In this paper, we present a patient with a mass in the gastric bulbus who was diagnosed with celiac artery stenosis during the pancreaticoduodenectomy (PD). MAL was the cause of the celiac artery stenosis, determined based on the findings of preoperative computed tomography (CT).

CONCLUSION

Although CAS is usually asymptomatic due to the collateral blood supply, it may be associated with potentially disastrous results due to ischemia of the upper abdominal organs as a result of disruption of the collateral pathways. It is especially important to recognize the presence of CAS and its etiology before interventional procedures. With the increasing use of multidetector computed tomography (MDCT), it becomes essential for radiologists to be aware of this entity and the cross-sectional findings.

Technique and outcomes of robot-assisted median arcuate ligament release for celiac artery compression syndrome

OBJECTIVE

Celiac artery compression by the median arcuate ligament (MAL) is a potential cause of postprandial abdominal pain and weight loss that overlaps with other common syndromes. Robotic technology may alter the current paradigm for surgical intervention. Open MAL release is often performed with concurrent bypass for celiac stenosis due to the morbidity of reintervention, whereas the laparoscopic approach is associated with high rates of conversion to open due to bleeding. We hypothesized that a robot-assisted technique might minimize conversion events to open, decrease perioperative morbidity, and defer consideration of vascular bypass at the initial operative setting.

METHODS

We retrospectively analyzed patients treated for MAL syndrome by a multidisciplinary team at a tertiary medical center between September 2012 and December 2013. Diagnosis was based on symptom profile and peak systolic velocity (PSV) >200 cm/s during celiac artery duplex ultrasound imaging. All patients underwent robot-assisted MAL release with simultaneous circumferential neurolysis of the celiac plexus. Postoperative celiac duplex and symptom profiles were reassessed longitudinally to monitor outcomes.

RESULTS

Nine patients (67% women) were evaluated for postprandial pain (100%) and weight loss (100%). All patients had celiac stenosis by mesenteric duplex ultrasound imaging (median PSV, 342; range, 238-637 cm/s), and cross-sectional imaging indicated a fishhook deformity in five (56%). Robot-assisted MAL release was completed successfully in all nine patients (100%) using a standardized surgical technique. Estimated blood loss was <50 mL, with a median hospital stay of 2 days (range, 2-3 days). No postoperative complications of grade ≥3, readmissions or reoperations were observed. All patients (100%) improved symptomatically at the 25-week median follow-up. Three patients experienced complete resolution on postoperative celiac duplex ultrasound imaging, and six patients showed an improved but persistent stenosis (PSV >200 cm/s) compared with preoperative velocities (P < .05 by Wilcoxon signed rank). No patients required additional treatment.

CONCLUSIONS

Robot-assisted MAL release can be performed safely and effectively with avoidance of conversion events and minimal morbidity. Potential factors contributing to success are patient selection by a multidisciplinary team and replication of the open surgical technique by means of robot-assisted dexterity and visualization. The need for delayed reintervention for persistently symptomatic celiac stenosis is uncertain.

Tricks and tips in pancreatoduodenectomy

Pancreaticoduodenectomy (PD) is the standard surgical treatment for tumors of the pancreatic head, proximal bile duct, duodenum and ampulla, and represents the only hope of cure in cases of malignancy. Since its initial description in 1935 by Whipple et al, this complex surgical technique has evolved and undergone several modifications. We review three key issues in PD: (1) the initial approach to the superior mesenteric artery, known as the artery-first approach; (2) arterial complications caused by anatomic variants of the hepatic artery or celiac artery stenosis; and (3) the extent of lymphadenectomy.

Image findings in celiac artery stenosis due to median arcuate ligament compression: a crucial diagnosis when planning for pancreaticoduodenectomy

Celiac axis stenosis caused by extrinsic compression by the median arcuate ligament (MAL) is present in up to 5% of patients undergoing pancreaticoduodenectomy. Failure to identify and manage MAL compression can lead to potentially devastating postoperative consequences that include frank liver necrosis and death. We report an incidental discovery of celiac axis stenosis by MAL in a patient prepared for pancreaticoduodenectomy. Image findings and operative management are discussed.

Management of median arcuate ligament syndrome in patients who require pancreaticoduodenectomy

Pancreaticoduodenectomy is the standard treatment for localised neoplasms of the pancreatic head. The operation can be performed safely in specialist units but good outcome is compromised if postoperative blood flow to the liver and biliary tree is inadequate. Coeliac artery occlusion with blood supply to the liver arising from the superior mesenteric artery via the gastroduodenal artery is difficult to recognise, especially intraoperatively. Recognition of absent hepatic artery pulsation after occlusion of the gastroduodenal artery opens a dilemma: should the resection be abandoned or should vascular reconstruction be undertaken, adding risk to an already complex procedure? We describe two cases with a resectable pancreatic endocrine tumour in which coeliac artery occlusion caused by median arcuate ligament compression was identified from cross-sectional imaging and reconstructions. We highlight two different strategies to correct the vascular insufficiency and allow safe pancreatic resection.

Classification of the celiac axis stenosis owing to median arcuate ligament compression, based on severity of the stenosis with subsequent proposals for management during pancreatoduodenectomy

BACKGROUND

After pancreatoduodenectomy in patients with celiac axis stenosis or obstruction, it becomes problematic to maintain the upper abdominal organ blood flow, especially to the liver. The aim of this study was to investigate the celiac axis stenosis caused by median arcuate ligament (MAL) compression and to classify it according to preoperative image findings.

METHODS

From January 1989 to November 2010, 562 patients underwent operations for diseases of the pancreatic head region in our department. To diagnose celiac artery compression by the MAL, angiography was used in the early period and 3-dimensional image reconstruction of multidetector-row computed tomography was used from 2004. The morphologic characteristics of the celiac axis stenosis were analyzed during intraoperative treatment.

RESULTS

Twelve (2.1%) patients were diagnosed with MAL compression, and 8 of these patients only underwent MAL division to restore the celiac artery blood flow. One patient required conservation of the collateral circulation, and 2 patients needed arterial reconstruction. In the analysis of the level of origin of the celiac axis, there were no remarkable differences between nonstenotic and stenotic cases, or between mild and severe stenotic cases. Morphologic grades were defined based on the preoperative image findings and consequent intraoperative treatments.

CONCLUSION

Preoperative grading of celiac axis stenosis could make pancreatoduodenectomy safer with maintenance of the upper abdominal organ blood flow in patients with MAL compression.

Reconstruction of the common hepatic artery at the time of total pancreatectomy using a splenohepatic bypass

Arterial involvement by a periampullary adenocarcinoma is often a contraindication for resection, since an R0 resection cannot be achieved. This is usually observed in cases with involvement of the superior mesenteric artery. Involvement of the common hepatic artery, however, requires a bypass procedure if the gastroduodenal artery was divided during the resection. In such cases, the splenic artery can be used as an inflow-source provided that there is no stenosis of the celiac trunk and the splenic blood flow is preserved via the short gastric arteries. We describe a technique used in four cases for the reconstruction of the common hepatic artery following a segmental resection of this vessel en bloc with a periampullary tumor during pancreatectomy. The inflow is maintained by a splenohepatic bypass using the splenic artery.

Vascular anomalies encountered during pancreatoduodenectomy: do they influence outcomes?

BACKGROUND

Because of the potential risk of hemorrhage or ischemia, the presence of vascular anomalies adds to the surgical challenge in pancreatoduodenectomy (PD).

OBJECTIVE

To analyze the literature concerning the influence of aberrant peripancreatic arterial anatomy on outcomes of PD.

MATERIALS AND METHODS

A systematic search using Medline and Embase for the years 1950-2008.

RESULTS

The most common aberration in hepatic arterial anatomy is the replaced right hepatic artery. Other vascular abnormalities such as replaced common hepatic artery with a hepatomesenteric trunk and celiomesenteric trunk and arcuate ligament syndrome leading to celiac artery stenosis are also associated with post-PD complications. Damage to the biliary branches of the hepatic arteries increases the risk of postoperative biliary anastomotic leak.

CONCLUSION

The most common abnormalities of the hepatic vasculature include a replaced RHA, replaced LHA, and accessory RHA or LHA. Celiac artery stenosis secondary to median arcuate ligament compression may also be encountered. Every attempt should be made to preserve the aberrant vessel unless their resection is oncologically indicated. Routine preoperative computerized tomography angiography helps to identify the hepatic vascular anatomy and thereby prepares the surgeon to better deal with the vascular anomalies intraoperatively. Increased awareness of the vascular anatomy would decrease the chances of intraoperative vascular injury and consequent postoperative complications such as biliary anastomotic leaks as well as the chances of postoperative hemorrhage.

Ischemic complications after pancreaticoduodenectomy: incidence, prevention, and management

OBJECTIVE

To assess prevalence, prevention, and management strategy of visceral ischemic complications after pancreaticoduodenectomy (PD).

BACKGROUND

Ischemic complications after PD resulting from preexisting celiac axis (CA), superior mesenteric artery (SMA), stenosis, or intraoperative arterial trauma appear as an underestimated cause of death. Their prevention and adequate management are challenging.

METHODS

From 1995 to 2006, 545 PD were performed in our institution. All patients were evaluated by thin section multidetector computed tomography (CT) with arterial reconstruction to detect and class SMA or CA stenosis. Hemodynamical significance of stenosis was assessed preoperatively by arteriography for atherosclerotic stenosis and intraoperatively by gastroduodenal artery clamping test for CA compression by median arcuate ligament. Significant atherosclerotic stenosis was stented or bypassed, whereas CA compression was treated by median arcuate ligament division during PD. Multidetector-CT accuracy to detect arterial stenosis, results of revascularization procedures, and both prevalence and prognosis of ischemic complications after PD were analyzed.

RESULTS

Among 62 (11%) stenoses detected by multidetector-CT, 27 (5%) were hemodynamically significant, including 23 CA compressions by median arcuate ligament, 2 CA, and 2 SMA atherosclerotic stenoses, respectively. All atherosclerotic stenoses were successfully treated by preoperative stenting (n = 3) or bypass (n = 1). Among the 23 cases who underwent median arcuate ligament division, 3 (13%) failed due to 1 CA injury and 2 misdiagnosed intrinsic CA stenoses. Overall, 6 patients developed ischemic complications, due to intraoperative hepatic artery injury (n = 4), unrecognized SMA atherosclerotic stenosis (n = 1), or CA fibromuscular dysplasia (n = 1). Five (83%) of them died, representing 36% of the 14 deaths of the whole series (overall mortality = 2.6%). Overall, CT detected significant arterial stenosis with a 96% sensitivity and determined etiology of CA stenosis with a 92% accuracy.

CONCLUSIONS

Ischemic complications are an underestimated cause of death after PD and are due to preexisting stenoses of CA and SMA, or intraoperative hepatic artery injury. Preexisting arterial stenoses are detected by routine multidetector CT. Preoperative endovascular stenting for intrinsic stenosis, division of median arcuate ligament for extrinsic compression, and meticulous dissection of the hepatic artery can contribute to minimize ischemic complications.

Celiac artery embolism due to thrombophilia - a case report

A case of celiac artery embolism in a patient with factor V Leiden thrombophilia is reported. The embolism was likely due to an undetected cardiac thrombus, causing an abdominal aortic embolism. The patient underwent emergency surgery for the abdominal embolism. The celiac artery embolism was treated nonsurgically due to the presence of collateral circulation through the gastroduodenal artery from the superior mesenteric artery. The patient fully recovered and was discharged from the hospital one month after his first referral.

Total gastric necrosis due to aberrant arterial anatomy and retrograde blood flow in the gastroduodenal artery: a complication following pancreaticoduodenectomy

Patients with coeliac artery occlusion often remain asymptomatic due to the rich collateral blood supply (pancreaticoduodenal arcades) from the superior mesenteric artery. However, division of the gastroduodenal artery (GDA) during pancreaticoduodenectomy may result in compromised blood supply to the liver, stomach and spleen. Postoperative complications associated with this condition are rarely reported in the literature. We report two cases of coeliac artery occlusion encountered during pancreaticoduodenectomy, one of which was complicated by hepatic ischaemia and total gastric infarction postoperatively. Based on our experience and review of the literature, a management algorithm for coeliac artery stenosis encountered during pancreaticoduodenectomy is proposed.