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Bieniek PA, Katou S, Kraehling H, Masthoff M, Morgul H, Pascher A, Struecker B. Clinical impact of a celiac axis stenosis in patients undergoing hepatobiliary surgery. Langenbecks Arch Surg 2023; 408:279. [PMID: 37454337 PMCID: PMC10350437 DOI: 10.1007/s00423-023-03003-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 06/26/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Celiac axis stenosis (CAS) often is an incidental finding in terms of diagnostic for hepatobiliary surgery since most cases remain asymptomatic. It remains unclear whether CAS is a risk factor for postoperative complications after hepatobiliary surgery. Therefore, the aim of this study was to evaluate the impact of an asymptomatic CAS on the postoperative morbidity and survival of patients undergoing hepatobiliary surgery. METHODS We retrospectively analyzed CT scans and clinicopathological data of 250 consecutive patients undergoing hepatobiliary surgery between 2011 and 2018 in our tertiary center. We compared the postoperative course between patients with and without an incidental CAS as well as their overall survival. RESULTS CAS was caused by atherosclerotic stenosis in 16 (64%) patients, by ligamentous stenosis in 4 (16%) and by combined conditions in 5 cases (20%). Mean age of patients in the CAS group was significantly higher in comparison to patients of the non-CAS group (71.0 vs. 59.1 years, p < 0.001). Major hepatectomy was conducted in 40% of the CAS patients and 19.6% of non-CAS patients, respectively (p = 0.036). Interestingly, no statistically significant differences in postoperative morbidity (40 vs. 46.2%, p = 0.673) or in overall survival between the groups (41.3 vs. 51.9 months, p = 0.611) were observed. CONCLUSION Our analysis found no correlation between an asymptomatic celiac axis stenosis and postoperative complications or overall survival after hepatobiliary surgery. Which impact the incidental CAS may have in highly complex cases remains unclear. Further studies are needed to identify patients who benefit from CAS treatment before hepatobiliary surgery.
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Affiliation(s)
- Pawel A Bieniek
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Waldeyerstrasse 1, 48149, Münster, Germany
| | - Shadi Katou
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Waldeyerstrasse 1, 48149, Münster, Germany
| | - Hermann Kraehling
- Clinic for Radiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Max Masthoff
- Clinic for Radiology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Haluk Morgul
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Waldeyerstrasse 1, 48149, Münster, Germany
| | - Andreas Pascher
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Waldeyerstrasse 1, 48149, Münster, Germany
| | - Benjamin Struecker
- Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Waldeyerstrasse 1, 48149, Münster, Germany.
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Giakoustidis A, Moschonas S, Christodoulidis G, Chourmouzi D, Diamantidou A, Masoura S, Louri E, Papadopoulos VN, Giakoustidis D. Median arcuate ligament syndrome often poses a diagnostic challenge: A literature review with a scope of our own experience. World J Gastrointest Surg 2023; 15:1048-1055. [PMID: 37405099 PMCID: PMC10315115 DOI: 10.4240/wjgs.v15.i6.1048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/05/2023] [Accepted: 04/18/2023] [Indexed: 06/15/2023] Open
Abstract
The median arcuate ligament syndrome (MALS) is recognized as a rare clinical entity, characterized by chronic post-prandial abdominal pain, nausea, vomiting, and unintentional weight loss. Due to its vague symptomatology, it is mainly regarded as a diagnosis of exclusion. Patients can often be misdiagnosed for several years before a correct diagnosis is established, also due to a medical team’s clinical suspicion. We present a case series of two patients who suffered from MALS and were treated successfully. The first patient is a 32-year-old woman, presenting with post-prandial abdominal pain and weight loss that have lasted for the past ten years. The second patient, a 50-year-old woman, presented with similar symptomatology, with the symptoms lasting for the last five years. Both cases were treated by laparoscopic division of the median arcuate ligament fibers, which alleviated extrinsic pressure from the celiac artery. Previous cases of MALS were retrieved from PubMed, to assemble a better diagnostic algorithm and propose a treatment method of choice. The literature review suggests an angiography with a respiratory variation protocol as the diagnostic modality of choice, along with the laparoscopic division of the median arcuate ligament fibers as the proposed treatment of choice.
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Affiliation(s)
- Alexandros Giakoustidis
- Department of Surgery, General Hospital Papageorgiou, Aristotle University of Thessaloniki, Thessaloniki 56429, Greece
- Fifth Department of Surgery, Interbalkan European Medical Centre, Thessaloniki 55535, Greece
| | - Stavros Moschonas
- Department of Surgery, General Hospital Papageorgiou, Aristotle University of Thessaloniki, Thessaloniki 56429, Greece
| | | | - Danae Chourmouzi
- Fifth Department of Surgery, Interbalkan European Medical Centre, Thessaloniki 55535, Greece
| | - Anna Diamantidou
- Fifth Department of Surgery, Interbalkan European Medical Centre, Thessaloniki 55535, Greece
| | - Sophia Masoura
- Fifth Department of Surgery, Interbalkan European Medical Centre, Thessaloniki 55535, Greece
| | - Eleni Louri
- Fifth Department of Surgery, Interbalkan European Medical Centre, Thessaloniki 55535, Greece
| | - Vasileios N Papadopoulos
- Department of Surgery, General Hospital Papageorgiou, Aristotle University of Thessaloniki, Thessaloniki 56429, Greece
| | - Dimitrios Giakoustidis
- Department of Surgery, General Hospital Papageorgiou, Aristotle University of Thessaloniki, Thessaloniki 56429, Greece
- Fifth Department of Surgery, Interbalkan European Medical Centre, Thessaloniki 55535, Greece
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Acute abdominal pain: a challenging diagnosis. Acta Gastroenterol Belg 2022; 85:646-647. [PMID: 35770291 DOI: 10.51821/85.4.9860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
We hereby describe a case of an acutely ill 41-year-old male without any medical history who presented with an acute abdomen in the emergency department. An abdominal CT showed a dissection of the coeliac trunk and infarction of the spleen. Because of a presumed diagnosis of vasculitis he was started on high dose IV steroids. However, after additional testing the diagnosis of segmental arteriolar Mediolysis (SAM) was made. In this case report we describe the presentation, diagnosis, treatment and follow-up of this patient and provide the readers with background about common differential diagnosis and criteria for diagnosing SAM.
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Skeik N, Smith J, Olson SL, Lohese OL, Mirza A, Manunga J. Mesenteric Artery Dissection and Wall-Thickening, Case Study and General Review. Angiology 2022:33197221100601. [PMID: 35921630 DOI: 10.1177/00033197221100601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Mesenteric artery dissection (D) and wall-thickening (WT) are rare vasculopathies that can lead to serious complications. This is a single center analysis of all patients evaluated for mesenteric arterial (celiac, superior (SMA) and/or inferior mesenteric (IMA)) D and/or WT from January 1, 2000, to January 31, 2020 at our hospital. Among the 101 included patients, the average age was 55.6 ± 13.6 years, mostly affecting men (62%). There were 20 celiac artery D, 8 WT, 15 D with WT, 15 SMA D, 7 WT, 8 D with WT, one IMA D, two WT, and 25 with multiple arterial involvement. Primary etiologies included segmental arterial mediolysis (SAM) (n = 17), isolated D (n = 17), localized vasculitis of the gastrointestinal tract (LVGT) (n = 16), fibromuscular dysplasia (FMD) (n = 13), extension of thoracoabdominal aortic D (n = 12), and trauma (n = 12). Most (71%) patients presented with abdominal pain. Hypertension (55%), hyperlipidemia (33%) and tobacco use (31%) were prevalent. Management included conservative (22%), medical (47%), endovascular (19%), and/or open repair (12%) with high in-hospital survival (98%) and symptom relief (73%). Our paper complements the scarce literature addressing the diagnosis and management of rare mesenteric vasculopathies. Most patients improved with conservative management, reserving endovascular or surgical interventions for symptomatic patients with more complicated presentations.
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Affiliation(s)
- Nedaa Skeik
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA.,51432Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Jenna Smith
- 51432Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Sydney L Olson
- 12244Northwestern University Feiberg School of Medicine, Chicago, IL, USA
| | - Opema L Lohese
- 51432Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Aleem Mirza
- Department of Cardiovascular and Vascular Surgery, 12340University of Texas Health Science, Houston, TX, USA
| | - Jesse Manunga
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA.,51432Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
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Alabousi M, Junek M, Garner S, Khalidi N, Rebello R. Value of second opinion subspecialty radiology consultation in suspected abdominal medium vessel vasculitis. Abdom Radiol (NY) 2021; 46:5763-5771. [PMID: 34550415 DOI: 10.1007/s00261-021-03277-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/06/2021] [Accepted: 09/07/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To perform a descriptive analysis of individuals with suspected Polyarteritis nodosa (PAN) referred for second opinion imaging consultation. METHODS A retrospective observational cohort study was performed at a single institution. A consecutive sample was performed of individuals who underwent a second opinion CT or MR angiography subspecialty radiologist consultation between January 2008 and September 2019 for suspected abdominal medium vessel vasculitis. Demographic, clinical, and imaging data were collected. Clinical and imaging findings were reported for PAN, small vessel vasculitis, and "non-vasculitis" groups. Agreement and diagnostic accuracy between final clinical and second opinion imaging diagnoses for PAN were determined. Two-tailed t-tests with a significant p-value < 0.05 were utilized. RESULTS Of the 58 participants, 9 were clinically diagnosed with PAN, 11 with small vessel vasculitis (including lupus, IgA, and ANCA-associated vasculitis), and 38 with non-vasculitis diagnoses. The non-vasculitis group included 15 SAM, 3 FMD, and 1 SAM-FMD spectrum diagnoses. Higher C-reactive protein level (51 vs 17, p = 0.04) and superior mesenteric artery involvement (56% vs 21%, p = 0.04) were more common in PAN than non-vasculitis diagnoses, while arterial dissection (40% vs 0%, p = 0.02) and celiac vasculature involvement (53% vs 0%, p = 0.003) were more common in the non-vasculitis group. There was 88% agreement (51/58; Cohen's kappa 0.56); sensitivity was 67% [95%-confidence interval (CI) 30-93%] and specificity was 92% (95%-CI 80-98%). CONCLUSION Isolated celiac artery involvement and arterial dissection were more common in non-inflammatory vasculopathies than PAN. Our findings highlight the need for multidisciplinary collaboration and awareness of the diverse findings of abdominal vasculopathies.
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Ota I, Ono M, Fukuda R, Aoki Y, Nagai K, Hiraide A, Takahashi H. A case of black esophagus with duodenal involvement. Clin J Gastroenterol 2021; 14:975-979. [PMID: 33835417 DOI: 10.1007/s12328-021-01410-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 04/01/2021] [Indexed: 11/28/2022]
Abstract
Black esophagus is a rare condition referred from acute necrosis of the esophagus, with characteristic endoscopic finings of circumferential black appearance of the mucosa. Black esophagus is associated with systemic dysfunction, such as massive bleeding, or severe dehydration. Although the duodenal mucosa is also susceptible to ischemia, reports of black esophagus with duodenal involvement, such as bleeding or perforation, are limited. Here, we present the case of a 61-year-old male who developed the typical black esophagus with duodenal involvement following severe dehydration. The patient was treated conservatively and recovered from the acute phase. In the chronic stage, transthoracic esophagectomy was performed because of esophageal stricture, and the patient then returned to his daily life. Although the etiological mechanism of acute esophageal necrosis is unknown, it is thought to be associated with the presence of an underlying severe systemic condition. Our case is not exceptional for these systemic conditions demonstrating extreme dehydration. However, it remains unclear why our case showed duodenal involvement. Although the reason is unknown, the presence of a celiac aneurysm located near the bifurcation to duodenal blood flow might explain the impaired blood flow to the duodenum.
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Affiliation(s)
- Ikuo Ota
- Department of Emergency Medicine, Nagayama Hospital, 1-1-10 Okubohigashi, Kumatori, Osaka, 590-0406, Japan
| | - Mugumi Ono
- Department of Emergency Medicine, Nagayama Hospital, 1-1-10 Okubohigashi, Kumatori, Osaka, 590-0406, Japan
| | - Ryuto Fukuda
- Department of Emergency Medicine, Nagayama Hospital, 1-1-10 Okubohigashi, Kumatori, Osaka, 590-0406, Japan
| | - Yoshiro Aoki
- Department of Surgery, Hiroshima City Asa Citizens Hospital, 2-1-1 Kabeminami, Asakita, Hiroshima, 731-0293, Japan
| | - Kenta Nagai
- Department of Surgery, Hiroshima City Asa Citizens Hospital, 2-1-1 Kabeminami, Asakita, Hiroshima, 731-0293, Japan
| | - Atsushi Hiraide
- Department of Emergency Medicine, Nagayama Hospital, 1-1-10 Okubohigashi, Kumatori, Osaka, 590-0406, Japan. .,Department of Emergency Medical Science, Kyoto Tachibana University, 34 Oyakeyamada, Yamashina, Kyoto, 607-8175, Japan.
| | - Hitoshi Takahashi
- Department of Emergency Medicine, Nagayama Hospital, 1-1-10 Okubohigashi, Kumatori, Osaka, 590-0406, Japan
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Dembinski J, Robert B, Sevestre MA, Freyermuth M, Yzet T, Dokmak S, Regimbeau JM. Celiac axis stenosis and digestive disease: Diagnosis, consequences and management. J Visc Surg 2020; 158:133-144. [PMID: 33191149 DOI: 10.1016/j.jviscsurg.2020.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Arterial blood flow to the organs of the upper abdomen is provided by the celiac axis (CA) and the superior mesenteric artery (SMA) that communicate between each other via the gastro-duodenal artery, the anterior and posterior pancreatico-duodenal arcades, the branches of the dorsal pancreatic artery and inconsistently, though a supplementary arcade that connects the CA and the SMA (arcade of Bühler). Celiac axis stenosis may or may not have a hemodynamic impact on the splanchnic circulation. Hemodynamically significant CA stenosis can be asymptomatic, or symptomatic with variables clinical consequences. Management depends on whether the mechanism of stenosis is extrinsic or intrinsic. When upper gastrointestinal interventional radiology or surgery is indicated, stenosis can pose technical difficulties or create severe ischemia requiring good understanding of this entity in the planning of operative steps and adapted management. Management of CA stenosis is therefore multidisciplinary and may involve interventional radiologists, gastrointestinal surgeons, vascular surgeons as well as medical physicians. Even though the prevalence of CA stenosis is relatively low (between 5 and 10%) and irrespective of its etiology, surgeons, radiologists and physicians must be aware of it because it can intervene in the management of upper gastrointestinal disease. It must be sought, and treatment must be adapted to each particular situation to avoid potentially severe complications.
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Affiliation(s)
- J Dembinski
- Department of Digestive Surgery, University Hospital of Amiens Picardie et Université de Picardie Jules Verne, 1, rue du Professeur Christian Cabrol, 80054 Amiens, France; Clinical research unit SSPC (Simplifications des Soins des Patients Complexes) UR UPJV 7518, University of Picardie Jules Verne, Amiens, France
| | - B Robert
- Radiology Department, University Hospital of Amiens Picardie and Picardie Jules Verne University, Amiens, France
| | - M-A Sevestre
- Vascular Medicine Department, University Hospital of Amiens Picardie and Picardie Jules Verne University, Amiens, France
| | - M Freyermuth
- Vascular Surgery Department, University Hospital of Amiens Picardie and Picardie Jules Verne University, Amiens, France
| | - T Yzet
- Radiology Department, University Hospital of Amiens Picardie and Picardie Jules Verne University, Amiens, France
| | - S Dokmak
- Department of Hepatobiliary Surgery and Liver Transplantation, Assistance Publique-Hôpitaux de Paris and Paris University, Clichy, France
| | - J-M Regimbeau
- Department of Digestive Surgery, University Hospital of Amiens Picardie et Université de Picardie Jules Verne, 1, rue du Professeur Christian Cabrol, 80054 Amiens, France; Clinical research unit SSPC (Simplifications des Soins des Patients Complexes) UR UPJV 7518, University of Picardie Jules Verne, Amiens, France.
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Sharmeen S, Arcomano M, Langenberg J, Kato H, Allam F. Clinicopathologic Conference: A 70-Year-Old Male With Hypertensive Emergency. Arthritis Care Res (Hoboken) 2020; 73:1701-1707. [PMID: 32058666 DOI: 10.1002/acr.24164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 01/28/2020] [Indexed: 11/12/2022]
Affiliation(s)
| | | | | | - Hiroshi Kato
- SUNY Upstate Medical University, Syracuse, New York
| | - Fatme Allam
- Syracuse VA Medical Center, Syracuse, New York
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