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Ito K, Takemura N, Oikawa R, Inagaki F, Mihara F, Kokudo N. Detailed anatomy and procedure of celiac artery decompression in median arcuate ligament syndrome. Langenbecks Arch Surg 2021; 406:1717-1722. [PMID: 33987763 DOI: 10.1007/s00423-021-02195-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 05/10/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Median arcuate ligament (MAL) syndrome is a clinical syndrome caused by the compression of the celiac artery (CA) by the MAL. This study aimed to present the detailed anatomy and a step-by-step procedure of CA decompression for MAL syndrome. METHODS The CA decompression procedure involves exposing the diaphragmatic crura and aorta, taping the left gastric artery, and dividing the compressive tissues. The MAL and ganglionic tissue, which form a broad band with multiple layers overlying the CA, comprise the compressive tissues. Therefore, the compressive tissues overlying the CA are encircled and divided one by one until the CA stenosis is released. CA decompression is confirmed with intraoperative duplex ultrasonography of the CA, with a return to normal peak systolic velocities without variation between deep inspiration and expiration. CONCLUSION This report presents the detailed anatomy and procedural steps for CA decompression in MAL syndrome.
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Affiliation(s)
- Kyoji Ito
- Hepato-Biliary Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Nobuyuki Takemura
- Hepato-Biliary Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan.
| | - Ryo Oikawa
- Hepato-Biliary Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Fuyuki Inagaki
- Hepato-Biliary Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Fuminori Mihara
- Hepato-Biliary Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
| | - Norihiro Kokudo
- Hepato-Biliary Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan
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Ito K, Takemura N, Inagaki F, Mihara F, Shida Y, Tajima T, Kokudo N. Diagnosis of celiac artery stenosis using multidetector computed tomography and evaluation of the collateral arteries within the mesopancreas of patients undergoing pancreaticoduodenectomy. Clin Anat 2021; 34:1035-1042. [PMID: 33373084 DOI: 10.1002/ca.23716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 12/04/2020] [Accepted: 12/20/2020] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Celiac artery (CA) stenosis (CAS), caused by various factors, is often asymptomatic because collateral blood flow from the superior mesenteric artery supplies the CA outflow region. The purpose of this study was to investigate the usefulness of multidetector computed tomography (MDCT) for diagnosing CAS and associated collateral artery formation, and elucidating the effect of CAS on the numbers and diameters of the arteries within the mesopancreas. MATERIALS AND METHODS We investigated 106 patients who underwent contrast-enhanced MDCT, before pancreaticoduodenectomy, between January 2015 and September 2019. MDCT was used to determine the percentage stenosis of the CAs; patients were classified into CAS (-) (0-29% stenosis) and CAS (+) (30-100% stenosis) groups. The dissection lines of the mesopancreas were classed as Level I or II, and the numbers and diameters of the arteries along each dissection line were counted and measured. RESULTS There were 27 CAS (+) patients and 79 CAS (-) patients. In the CAS (+) group there were more arteries and they had larger diameters than those in the CAS (-) group, at both Levels I and II. There were significantly more arteries when the CA stenosis was ≥30% and they had larger diameters when the stenosis was ≥50%. CONCLUSIONS MDCT is useful for diagnosing CAS, and CAS is associated with larger numbers and diameters of the arteries within the mesopancreas.
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Affiliation(s)
- Kyoji Ito
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Nobuyuki Takemura
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Fuyuki Inagaki
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Fuminori Mihara
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yoshitaka Shida
- Department of Radiology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Tsuyoshi Tajima
- Department of Radiology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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Minagawa M, Ichida H, Yoshioka R, Gyoda Y, Mizuno T, Imamura H, Mise Y, Yoshimatsu H, Fukumura Y, Kato K, Kajiyama Y, Saiura A. Pancreaticoduodenectomy with reconstructing blood flow of the gastric conduit after esophagectomy with concomitant celiac axis stenosis: a case report. Surg Case Rep 2020; 6:267. [PMID: 33030640 PMCID: PMC7544791 DOI: 10.1186/s40792-020-01019-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/21/2020] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Masaaki Minagawa
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University, Graduate School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Hirofumi Ichida
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University, Graduate School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Ryuji Yoshioka
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University, Graduate School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Yu Gyoda
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University, Graduate School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Tomoya Mizuno
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University, Graduate School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Hiroshi Imamura
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University, Graduate School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Yoshihiro Mise
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University, Graduate School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Hidehiko Yoshimatsu
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yuki Fukumura
- Department of Human Pathology, Juntendo University, Graduate School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Kota Kato
- Department of Anatomy and Life Structure, Juntendo University, Graduate School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Yoshiaki Kajiyama
- Department of Esophageal and Gastroenterological Surgery, Juntendo University, Graduate School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Akio Saiura
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University, Graduate School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
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