Experience with coeliac axis compression syndrome

Retroperitoneal endoscopic release in the management of celiac artery compression syndrome

INTRODUCTION

Celiac artery compression syndrome (CACS) can be treated successfully by division of the median arcuate ligament and celiac plexus fibers. The standard technique is the open approach by an upper midline or left subcostal incision. Only six single cases in which a laparoscopic transabdominal approach for CACS was used have been reported. We prospectively evaluated the feasibility of the endoscopic retroperitoneal approach for treatment of CACS.

METHODS

All patients with symptoms suggestive of CACS were evaluated using splanchnic duplex ultrasound scanning, gastric exercise tonometry (GET), and multiplane selective splanchnic angiography. The criteria for treatment were chronic abdominal symptoms, respiratory-dependent CA stenosis, and abnormal GET result. The release was performed by a retroperitoneal endoscopic approach. Anatomic success of the procedure was confirmed by angiography.

RESULTS

The endoscopic retroperitoneal approach was used to treat 46 patients with CACS. One patient (2%) required conversion to an open procedure due to suprarenal artery bleeding. Release was ended prematurely in one patient due to a pneumothorax resulting in loss of working space. A postoperative pneumothorax developed in two patients, of which one needed treatment. No other complications were observed. Postoperative angiography during inspiration and expiration showed normal vessel anatomy in 36 of 46 patients. Six of 10 patients with persisting intraluminal stenoses were treated endovascularly. Five of these were successful, which brings the primary-assisted anatomic patency for the total group to 89% (41 of 46 patients). Three patients are being observed, and endovascular treatment remains an option in case of insufficient improvement. On median follow-up of 20 months (range, 2-42 months) 41 patients were free of symptoms or showed significant improvement.

CONCLUSIONS

The endoscopic retroperitoneal approach for the release of the CA in CACS, with additional endovascular treatment of persistent stenosis, is feasible and effective. Short-term results were comparable with the open procedure.

Single vessel abdominal arterial disease

The long-standing discussion concerning the mere existence of single vessel abdominal artery disease can be closed: chronic gastrointestinal ischaemia (CGI) due to single vessel abdominal artery stenosis exists, can be treated successfully and in a safe manner. The most common causes of single vessel CGI are the coeliac artery compression syndrome (CACS) in younger patients, and atherosclerotic disease in elderly patients. The clinical symptoms of single vessel CGI patients are postprandial and exercise-related pain, weight loss, and an abdominal bruit. The current diagnostic approach in patients suspected of single vessel CGI is gastrointestinal tonometry combined with radiological visualisation of the abdominal arteries to define possible arterial stenosis. Especially in single vessel abdominal artery stenosis, gastrointestinal tonometry plays a pivotal role in establishing the diagnosis CGI. First-choice treatment of single vessel CGI remains surgical revascularisation, especially in CACS. In elderly or selected patients endovascular stent placement therapy is an acceptable option.

Gastric exercise tonometry: the key investigation in patients with suspected celiac artery compression syndrome

INTRODUCTION

Controversy continues about the mere existence of the celiac artery compression syndrome. Earlier results of treatment of unselected patients groups showed varying, mostly disappointing, results. The recently introduced gastric exercise tonometry test is able to identify patients with actual gastrointestinal ischemia. We prospectively studied the use of gastric exercise tonometry as a key criterion for revascularization treatment in patients with otherwise unexplained abdominal complaints and significant stenosis of the celiac artery by compression of the arcuate ligament.

METHODS

Patients were prospectively selected using abdominal artery angiography and gastric exercise tonometry. Patients with a significant compression of the celiac artery, typical abdominal complaints, and abnormal tonometry were considered for revascularization.

RESULTS

Over a 7-year period, 43 patients with significant celiac artery compression were included in this study, and 30 patients were diagnosed as ischemic. Twenty-nine patients had revascularization, 22 (76 %) had a trunk release only. After a median follow-up of 39 months, 83% of patients were free of symptoms. The repeated tonometry after treatment improved in 100% of patients free of symptoms, compared with 25% in patients with persistent complaints after revascularization.

CONCLUSIONS

The results of this study suggest that the celiac axis compression syndrome exists and that the actual ischemia can be detected by gastric exercise tonometry and treated safely, with success.

Arcuate ligament vascular compression syndrome in infants and children

BACKGROUND

Arcuate ligament vascular compression syndrome has not been described previously in the pediatric or pediatric surgical literature. However, it is mentioned in the literature of vascular and general surgery and in journals of radiology and orthopedics. In this review, the intraoperative pathological anatomy and the principles of treatment for 8 children will be presented.

METHODS

The chart records and the anatomical sketches that were documented by the surgeon immediately after each procedure were analyzed retrospectively. In addition, preoperative courses and long-term follow-up (range, 3-18 years) were evaluated by a defined program.

RESULTS

The diagnosis of celiac artery compression by an arcuate ligament was suspected in children presenting with a history of several years of recurrent acute abdominal pain associated with a typical arterial bruit in the midline of the epigastric region.

CONCLUSIONS

Other diseases with recurrent abdominal pain and an arterial bruit must be excluded before making the decision for an operative intervention. Duplex ultrasound and angiography are possibly helpful tools to establish the respective diagnosis, but in the patients of the present series, these techniques neither confirmed compression of the celiac axis nor demonstrated decreased perfusion of the superior mesenteric artery. However, as the clinical symptoms clearly announce the disease, these diagnostic measures are not mandatory.

Celiac artery compression syndromes

Compression of the visceral arteries can produce true mesenteric ischemia, but the syndrome is rare. The syndrome is caused by unfavorable anatomic relationships at the aortic hiatus among the CA, the SMA, and overlying structures, particularly the diaphragmatic crura. These anatomic relationships, in contrast to the syndrome they sometimes produce, are relatively common, which makes the detection of CA compression only a prerequisite to the diagnosis of the clinical entity. The diagnosis of CA compression syndrome ultimately depends on the relentless elimination of other possible causes for abdominal pain and on the knowledge that this curious syndrome does indeed exist. If properly diagnosed, the CA compression syndrome can be corrected with a safe, relatively simple surgical procedure. Past treatment series reflect too little appreciation for the extensiveness of a true, chronic CA injury. Revascularization of the CA, in addition to release of compression, should therefore be performed with greater frequency in the future. The young patients who are successfully diagnosed and treated for this unusual syndrome are frequently entirely relieved of long-standing, debilitating pain, and, like other patients with chronic mesenteric ischemia, they typically enjoy dramatic improvement in the quality of their lives. Thus, with the prospect of these patients in mind, a clinician should accept the opinion that the syndrome "does not exist" only after careful consideration of the entire literature.

Would you recognize celiac axis syndrome?

Since its original description, celiac axis syndrome has been a topic of debate. Clinical findings include postprandial abdominal pain, weight loss, and an epigastric bruit. Diagnosis is often made by exclusion and is confirmed by lateral aortography. The role of surgery in treating celiac axis syndrome is controversial.

Coeliac artery compression syndrome: the effect of decompression

The effects of operation to decompress the coeliac artery were evaluated in 11 consecutive patients with coeliac artery compression syndrome. Immediately after the operation all patients were free of symptoms. Three months later three of the 11 had recurrent abdominal pain. Long-term follow-up between 15 and 23 years, obtained by questionnaire, was available for eight patients. All eight had return of symptoms similar to those before surgery. These unsatisfactory results suggest that operation should not be undertaken in patients with vague upper abdominal complaints and compression of the coeliac artery by the median arcuate ligament, who do not otherwise have pathological conditions which might explain their symptoms.

Does 'intestinal angina' exist? A critical study of obstructed visceral arteries

A study of the mesenteric arteries was carried out in 203 unselected autopsies. Although mild degrees of stenosis were common, the incidence of a 'critical stenosis' was rare and no correlation between degrees of stenosis and previous gastrointestinal symptoms could be found. Radiological demonstration of stenosed or blocked visceral arteries remains therefore of doubtful clinical significance.

Diastolic bruit in chronic intestinal ischemia. Recognition by abdominal phonoangiography

Application of abdominal phonoanogiography in patients with suspected chronic intestinal ischemia may be diagnostic or highly suggestive of vascular compromise. The importance of a diastolic abdominal bruit is illustrated in two patients with intestinal ischemia.

Coeliac artery compression

Four women with abdominal pain and compression of the coeliac artery by the median arcuate ligament of the diaphragm are described. Pain was relieved in each case by decompression or reconstruction of the coeliac artery. A case in favour of the existence of the coeliac artery compression syndrome is presented.

The prevalence of epigastric bruit

A study was undertaken to determine the prevalence of an epigastric bruit in a family practice population.Auscultation of the abdomen in the supine position was carried out on 567 consecutive unselected patients. A systolic bruit, localized to the epigastrium, was heard in 80 patients, none of whom had symptoms of intra-abdominal vascular disorder.The results are tabulated by age and sex, and show statistically significant differences in prevalence between males and females of similar ages, and also between different age groups of the same sex. The highest prevalence is in females aged between 10 and 34 years and no significant difference is found between pregnant and non-pregnant females of comparable age.

Aneurysm formation on the small pancreatic arteries in assoication with coeliac axis compression

The coeliac axis compression syndrome has been recognized for 12 years. More recently an association between this syndrome and the occurrence of aneurysms on the collateral circulation has been described. A review of the coeliac axis compression syndrome is presented and the management of associated aneurysms discussed.

Coeliac artery compression syndrome: can we believe our ears?

Two patients with coeliac artery compression syndrome' are described.Symptoms were vague and nonspecific, and the diagnosis was made by finding an epigastric bruit on auscultation of the abdomen and confirming the presence of a vascular lesion by angiography. Both patients were cured by surgical decompression of the coeliac trunk. Auscultation of the abdomen can be a useful part of physical examination in general practice.

Surgical treatment of the celiac axis compression syndrome

Six patients with symptomatic celiac axis compression syndrome are reported on. Four were treated surgically with arterial reconstruction. None of these four patients was benefited more than temporarily by the corrective surgery. One patient had an abdominal exploration and highly selective vagotomy unrelated to the celiac axis and is symptom-free ten months after surgery. One patient had no surgery and remains symptomatic. Angiographic evaluation in all patients demonstrated that despite high grade stenosis of the celiac axis, there was no radiographically discernible reduction in constrast flow to the celiac axis because of well developed collaterals from the superior mesenteric artery. These results indicate that compression of the celiac axis may be merely an incidental angiographic finding, so this syndrome needs cautious evaluation.

Coeliac axis stenosis

Eleven cases of coeliac axis stenosis were operated on during 1966 to 1969. Each patient complained of persistent abdominal pain and loss of weight and investigation for carcinoma proved negative. Auscultation revealed the presence of an epigastric bruit and aortography demonstrated stenosis of the coeliac axis in each case with additional stenosis of the superior mesenteric artery in 3 patients. Operative findings showed that constriction was caused by the median arcuate ligament of the diaphragm in seven cases and by periarterial fibrosis in 4. Operative division of the constricting agent gave complete relief in 9 patients and improvement in 1, the other being unchanged.