Clinical impact of collateral circulation in patients with median arcuate ligament syndrome

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.

Sutton-Kadir Syndrome can be treated safely with endovascular embolisation alone

INTRODUCTION

Sutton-Kadir Syndrome (SKS) describes true inferior pancreaticoduodenal artery (IPDA) aneurysms in the setting of coeliac artery (CA) stenosis or occlusion. Although rare, SKS aneurysms can rupture and cause morbidity. Due to its rarity and lack of controlled treatment data, correct treatment for the CA lesion is currently unknown. Our aim was to assess if endovascular embolisation alone was safe and effective in treatment of SKS aneurysms, in emergent and elective settings. Secondary objectives were to describe presentation and imaging findings.

METHODS

A retrospective cohort study of patients treated at Sir Charles Gairdner Hospital between January 2014 and December 2021 was done. Data on presentation, diagnostics, aneurysm characteristics, CA lesion aetiology, treatment and outcomes were extracted from chart review.

RESULTS

Twenty-four aneurysms in 14 patients were identified. Rupture was seen in 7/15 patients. Most aneurysms (22/24) were in the IPDA or one of its anterior or posterior branches. Median arcuate ligament (MAL) compression was identified in all. There was no difference in median (IQR) maximal transverse diameter between ruptured and non-ruptured aneurysms (6 mm (9), 12 mm (6), P = 0.18). Of ruptures, 6/7 had successful endovascular embolisation and 1/7 open surgical ligation. Of non-ruptures, 6/7 had successful endovascular embolisation, 1/7 open MAL division then endovascular CA stenting and aneurysm embolisation. No recurrences or new aneurysms were detected with computed tomography or magnetic resonance angiography over a median (IQR) follow-up period of 30 (10) months in 12 patients.

CONCLUSION

Endovascular embolisation of SKS aneurysms without treatment of MAL compression is safe and effective in both the emergent and elective settings.

Pancreaticoduodenal Artery Aneurysm Complicated by Median Arcuate Ligament Syndrome

PURPOSE

To highlight median arcuate ligament syndrome as a potential cause for celiac artery stenosis and pancreaticoduodenal artery aneurysm, and describe treatment options in this setting.

CASE REPORT

A 63-year-old male presented with a pancreaticoduodenal artery aneurysm and concomitant celiac artery stenosis that was treated with celiac artery stenting and aneurysm coiling. He subsequently developed stent fracture and celiac artery occlusion secondary to previously unrecognized median arcuate ligament syndrome causing reperfusion of the aneurysm. This was treated with open median arcuate ligament release and aorta to common hepatic artery bypass with good clinical result and stable 20-month surveillance imaging.

CONCLUSION

It is critical to recognize median arcuate ligament syndrome as a cause of celiac artery stenosis in the setting of pancreaticoduodenal artery aneurysm given the high risk of failure of endovascular stenting. Open aorto-hepatic artery bypass and endovascular aneurysm coiling should be the preferred approach in these patients.

Median arcuate ligament syndrome (Dunbar syndrome): A diagnosis not to be underestimated

Medial arcuate ligament syndrome (MALS) is an anatomoclinical entity underestimated in most situations due to the lack of specific signs. However, the consequences can be disastrous if the diagnosis is not seriously considered and investigations are not fully undertaken to confirm this hypothesis. We report a case of Median Arcuate Ligament Syndrome in a young woman who presented to the Emergency Department with moderate postprandial pain. All investigations were carried out promptly, with no abnormalities, and the diagnosis was retained on the evidence of a well-performed and appropriately interpreted abdominal CT. This case illustrates a rare cause of epigastralgia simulating a surgical emergency. This condition should be considered when biological and often radiological investigations are inconclusive. The relative youth of the patient is often suggestive, but confirmation is based on a CT scan with injection of a well-technical contrast product, or angiography. Treatment is debatable between a conservative approach and surgery. Surgical approach is discussed depending on the degree of vascular stenosis and the impact on the digestive tract. However, the recurrence of symptoms may be a contributory factor in the therapeutic decision. The impact could be lethal depending on the degree of stenosis and consequently on the repercussions on the digestive tract. A multidisciplinary approach is required for its management.

Staged treatment for pancreaticoduodenal artery aneurysm with coeliac artery revascularisation: Case report and systematic review

BACKGROUND

Despite being rare, pancreaticoduodenal artery aneurysms (PDAAs) carry a risk of rupture of up to 50% and are frequently associated with coeliac artery occlusion.

METHODS

PubMed and Embase databases were searched using appropriate terms. The systematic review was conducted according to PRISMA guidelines.

RESULTS

We present the case of a 2 cm pancreaticoduodenal artery aneurysm pre-operative angiography demonstrated that the coeliac artery was occluded and the pancreaticoduodenal artery was providing collateral blood supply to the liver. Treatment was a staged hybrid intervention inclusive of an aorto-hepatic bypass using a 6 mm graft, followed by coil embolisation of the aneurysm. We also present a systematic review of the management of PDAAs. Two hundred and ninety-two publications were identified initially with 81 publications included in the final review. Of the 258 peripancreatic aneurysms included, 175 (61%) were associated with coeliac artery disease either occlusion or stenosis. Abdominal pain was the main presentation in 158 cases. Rupture occurred in 111 (40%) of patients with only ten (3.8%) cases being unstable on presentation. Fifty (18%) cases were detected incidentally while investigating another pathology. Over half the cases (n=141/54.6%) were treated by trans arterial embolisation (TAE) alone, while 37 cases had open surgery only. Twenty-one cases needed TAE and a coeliac stent. Seventeen cases underwent hybrid treatment (open and endovascular). Sixteen cases were treated conservatively and in 26 cases, treatment was not specified.

CONCLUSION

PDAAs are commonly associated with coeliac artery disease. The most common presentation is pain followed by rupture. The scarcity of literature about true peripancreatic artery aneurysms associated with CA occlusive disease makes it difficult to assess the natural history or the appropriate treatment. Revascularisation of hepatic artery is better done with bypass in setting of median arcuate ligament compression and occluded celiac trunk.

Superior mesenteric aneurysm associated with median arcuate ligament syndrome and a single celiacomesenteric trunk

Median arcuate ligament syndrome (MALS) is known to promote arterial collateral circulation development from mesenteric vessel compression and can lead to the development of visceral aneurysms. These aneurysms are often diagnosed at the time of rupture and pose a significant morality risk without appropriate intervention. A celiacomesenteric trunk is a rare anatomic variant in which the celiac artery and superior mesenteric artery share a common origin and has been postulated as a risk factor for developing MALS. In this report, we present a novel case of MALS in a patient with a celiacomesenteric trunk and a superior mesenteric artery aneurysm.

Rapid Formation and Hybrid Treatment of a Large Superior Mesenteric Artery Aneurysm

BACKGROUND Superior mesenteric artery (SMA) aneurysms account for about 5.5% of all visceral aneurysms, and are most commonly secondary to infectious causes or dissection. They tend to expand and rupture. Here, we present our successful diagnosis and treatment of a 41-year-old man with asymptomatic coeliac trunk stenosis, in whom the large aneurysm of the branch of the SMA developed in a very short time after conservative treatment of plastron appendicitis. CASE REPORT A 41-year-old man was diagnosed with plastron appendicitis during abdomen ultrasound (US) examination. Following 2 weeks of conservative treatment with intravenous antibiotic therapy, complete resolution of symptoms was obtained and confirmed in the computed tomography (CT) scan, and no other pathologies were diagnosed. Three weeks later, during the US examination, a 33-mm aneurysm of the branch of the SMA was diagnosed. The patient was admitted to the Vascular Surgery Department, where a critical stenosis of the coeliac trunk secondary to the compression by median arcuate ligament and a 33-mm true visceral aneurysm of one of the branches of the SMA were diagnosed. Successful treatment of the aneurysm was performed. Surgical decompression of the coeliac trunk and subsequent elective endovascular embolization of the SMA aneurysm with angioplasty of the coeliac trunk were performed. The postoperative period was uneventful and the patient was released from the hospital and remains asymptomatic. CONCLUSIONS Visceral artery aneurysm can form very quickly. In some of the aneurysms, a combination of open surgical and endovascular methods should be performed.

Overview of Median Arcuate Ligament Syndrome: A Narrative Review

Median arcuate ligament syndrome (MALS) is a rare disorder caused primarily by compression of the celiac trunk by the median arcuate ligament (MAL). This disorder typically results in patients presenting with bloating, weight loss, nausea, vomiting, and abdominal pain. The MALS diagnosis is one of exclusion, as the disorder has no specific diagnostic criteria. Imaging modalities are often utilized to assist in making the diagnosis, such as ultrasound, computed tomography angiography (CTA), and magnetic resonance angiography (MRA). These imaging modalities typically reveal a stenosed celiac artery with post-stenotic dilation in patients. This disorder is usually treated by dividing the MAL, thus relieving the compression of the celiac artery. The surgery may be done through either an open approach or a minimally invasive approach, which can be either laparoscopic or robot-assisted. Most patients respond well to this treatment, though certain factors that predict a poorer response to treatment include elderly age, a history of alcohol abuse, and psychiatric illness.

Interventional Radiology for High-Flow Aneurysm of the Pancreaticoduodenal Arcades with Median Arcuate Ligament Syndrome: Review of 14 Patients

Transarterial embolization (TAE) for high-flow pancreaticoduodenal artery (PDA) aneurysms in patients with celiac-trunk stenosis by the median arcuate ligament (MAL) has been found effective both after rupturing and to prevent rupture. The objective was to describe the TAE techniques used and their effectiveness in excluding PDA aneurysms due to MAL syndrome. This single-center retrospective study done at the Dijon-Bourgogne University Hospital included all patients treated by TAE in 2010-2022 for ruptured or unruptured high-flow PDA aneurysms caused by MAL syndrome. We identified 14 patients (7 women and 7 men; mean age, 64 years). Packing and trapping techniques were used alone or together. Occlusion was with microcoils, co-polymer, or cyanoacrylate glue, used separately or combined. Technical success was achieved in 13 (93%) patients. Clinical success was achieved in 12 (86%) patients. One major and two minor complications were recorded within the first 30 days. No complications occurred after 30 days. Follow-up ranged from 1 to 84 months. No cases of aneurysm recanalization have been recorded to date. TAE had high technical and clinical success rates in our patients with unruptured or ruptured PDA aneurysms due to MAL syndrome.

Combination between Dunbar Syndrome and May-Thurner Syndrome: A Rare Case Report

Dunbar syndrome (DS) and May-Thurner syndrome (MTS) are part of a group of rare vascular disorders known as "vascular compression syndromes." Dunbar's syndrome is caused by the median arcuate ligament of diaphragm, which, due to an abnormal course, causes celiac artery compression. MTS is caused by the left common iliac vein compression pushed against the spine by the right common iliac artery causing progressive flow congestion and leading to thrombosis. Ultrasound is the first-level examination for the diagnosis of these rare pathologies and allows to recognize vascular compressions and to obtain an estimate of stenosis degree. We describe a very rare case of DS and MTS combination in a young man with postprandial pain and left lower limb thrombosis.

Collateral circulation develops in stenosis of the celiac trunk and superior mesenteric artery

PURPOSE

Mesenteric circulation is provided by the celiac trunk (CT), superior mesenteric artery (SMA), and inferior mesenteric artery (IMA). The collateral circulation between CT and SMA and between SMA and IMA plays a protective role against intestinal ischemia in case of narrowing or occlusion of the mesenteric vessels. In our study, it is aimed to determine the CT and SMA stenosis rates in patients with CT and SMA stenosis from angiography images, the occurrence of the collateral variations, and the frequency of these variations.

METHODS

A total of 408 non-selective or selective CT and SMA angiographic images were taken of 215 patients (130 males, 85 females) who were admitted to Akdeniz University Hospital with symptoms of chronic mesenteric ischemia (CMI) were included. The angiography images were analyzed in regards to CT and SMA stenosis rates, and the collateral variations between mesenteric vessels.

RESULTS

Stenosis of CT was observed in 14 patients, whereas the stenosis of the SMA was observed in 12 patients. The most common collateral vessel in these patients was the gastroduodenal artery. Both stenoses of CT and SMA were found in 9 patients. The Riolan arch was the most common type of collateral vessel in these patients.

CONCLUSION

It was observed that mesenteric circulation was mainly provided by gastroduodenal artery in patients with isolated CT or SMA stenosis or occlusion while in patients with stenosis or occlusion of both CT and SMA, mesenteric circulation was mainly provided by the Riolan arch. A significant increase was observed in the prominence of collateral vessels in patients with stenosis of more than 70%.

Prevalence of celiac artery compression by median arcuate ligament in patients with splanchnic artery aneurysms/pseudoaneurysms submitted to endovascular embolization

PURPOSE

To study the association between median arcuate ligament compression (MALC) of celiac artery (CA) and splanchnic artery aneurysms/pseudoaneurysms (SAAPs) submitted to endovascular embolization.

METHODS

Single center retrospective study of embolized SAAPs between 2010 and 2021, to evaluate the prevalence of MALC, and compare demographic data and clinical outcomes between patients with and without MALC. As a secondary objective, patient characteristics and outcomes were compared between patients with different causes of CA stenosis.

RESULTS

MALC was found in 12.3% of 57 patients. SAAPs were more prevalent in the pancreaticoduodenal arcades (PDAs) in patients with MALC, compared to those without MALC (57.1% vs. 10%, P = .009). Patients with MALC had a greater proportion of aneurysms (71.4% vs. 24%, P = .020), as opposed to pseudoaneurysms. Rupture was the main indication for embolization in both groups (71.4% and 54% of patients with and without MALC, respectively). Embolization was successful in most cases (85.7% and 90%), with 5 immediate (28.6% and 6%) and 14 non-immediate (28.6% and 24%) post-procedure complications. Thirty and 90-day mortality rate were 0% in patients with MALC, and 14% and 24% in patients without MALC. Atherosclerosis was the only other cause of CA stenosis, in 3 cases.

CONCLUSIONS

In patients with SAAPs submitted to endovascular embolization, the prevalence of CA compression by MAL is not uncommon. The most frequent location for aneurysms in patients with MALC is in the PDAs. Endovascular management of SAAPs is very effective in patients with MALC, with low complications, even in ruptured aneurysms.

A Case Series of Median Arcuate Ligament Syndrome With Varied Presentations

Median arcuate ligament syndrome (MALS) is characterized by the constriction of the celiac trunk caused by fibrous connections originating from the median arcuate ligament (MAL) and diaphragmatic crura. It presents with symptoms often leading to misdiagnosis. In this study, we present three cases of MALS, with distinct manifestations. These cases were diagnosed through comprehensive investigations and managed successfully using laparoscopic decompression. The diagnosis of MALS poses challenges due to its variable presentations and overlap with other conditions. Diagnostic imaging techniques such as Doppler ultrasound, computed tomography (CT) scans and angiography play a role in confirming the diagnosis. Laparoscopic decompression has proven to be a treatment option that relieves symptoms and restores blood flow. This series highlights the importance of considering MALS as a cause for abdominal pain cases. Early detection and the use of diagnostic techniques can result in favorable outcomes.

Successful coil embolization of a ruptured aneurysm of the arc of Riolan artery

The arc of Riolan (AOR) is an anastomosis between the middle and left colic arteries. Aneurysms of the AOR are very rare visceral artery aneurysms. A 44-year-old man presented with abdominal pain and loss of consciousness. Computed tomography and angiography showed hemorrhagic ascites around the liver and spleen. An irregularly dilated artery was visible within a hematoma in the upper left region of the abdomen, consistent with a ruptured pseudoaneurysm of the AOR. Transcatheter arterial embolization was performed with microcoils. The patient's abdominal pain disappeared after embolization, and no symptoms of intestinal ischemia were observed. To our knowledge, this is the first case of an AOR aneurysm with AOR dilation due to dissection of the celiac artery that was successfully treated by coil embolization.

Median arcuate ligament syndrome with retroperitoneal haemorrhage: A case report

BACKGROUND

Median arcuate ligament syndrome (MALS) is relatively rare and is due to extraluminal compression of the coeliac artery by the median arcuate ligament of the diaphragm. Here, we report a case of MALS found in a patient with abdominal pain and retroperitoneal haemorrhage for education and dissemination.

CASE SUMMARY

This article describes a 46-year-old female patient who was admitted to our hospital with abdominal pain as her chief complaint. She had experienced no obvious symptoms but had retroperitoneal bleeding during the course of the disease. Contrast-enhanced computed tomography (CT) and noninvasive CT angiography (CTA) led to an initial misdiagnosis of pancreaticoduodenal artery aneurysm (PDAA) causing retroperitoneal hemorrhage. After intraoperative exploration and detailed analysis of enhanced CT and CTA images, a final diagnosis of MALS was made. The cause of the haemorrhage was bleeding from a branch of the gastroduodenal artery, not rupture of a PDAA. The prognosis of MALS combined with PDAA treated by laparoscopy and interventional therapy is still acceptable. The patient was temporarily treated by gastroduodenal suture haemostasis and was referred for further treatment.

CONCLUSION

MALS is very rare and usually has postprandial abdominal pain, upper abdominal murmur, and weight loss. It is diagnosed by imaging or due to complications. When a patient has abdominal bleeding or PDAA, we should consider whether the patient has celiac trunk stenosis (MALS or other etiology). When abdominal bleeding is combined with an aneurysm, we generally think of aneurysm rupture and hemorrhage first, but it may also be collateral artery rupture and hemorrhage.

Median arcuate ligamentum syndrome: Four case reports

BACKGROUND

Median arcuate ligamentum syndrome (MALS) is a disease entity with unclear pathogenesis. If it is not considered in advance, the clinical diagnosis of the disease is very difficult because patients complain of digestive discomfort including pain. However, this characteristic is not specific to MALS. There have been no studies to assist in making a quick diagnosis. The aim of this case series was to recognize that MALS must be considered as a differential factor in the cause of abdominal pain.

CASE SUMMARY

We described cases in which four patients complained of abdominal pain over a long period but in whom a diagnosis of MALS could not be made. If the gastroenterologist does not take into account abdominal pain in advance, the patient is considered an asymptomatic gallstone patient and has their gallbladder removed despite imaging evaluation. The patient may also be considered a psychiatric patient and may be administered psychiatric drugs over a long period. In all four cases in this report, the patients experienced abdominal pain. In three cases, the diagnosis was possible by the clinician’s judgment considering both clinical symptoms and imaging techniques shortly after the onset of symptoms. However, in one case that lasted over 20 years, a clear diagnosis was not possible. Even after complaining of colicky pain and performing a cholecystectomy, the diagnosis was made only after the symptoms persisted. In all four cases, the symptoms were relieved by neuromodulators.

CONCLUSION

MALS is a rare disease and it is easy to miss because it is not malignant, but patients can suffer from pain over a long period. For the accurate diagnosis of a patient complaining of abdominal pain, the diagnosis must be differentiated. In addition, as there are asymptomatic patients, patients who need treatment should be carefully selected, and improvement with medical treatment can be expected. Large-scale studies are also needed.

Vascular compression syndromes: a pictorial review

Vascular compression syndromes include a group of rare vascular changes due to extrinsic compression of veins or arteries by surrounding structures. These pathologies are often underestimated due to their rarity, clinicians’ poor level of knowledge, and the non-specificity of their symptoms. The best known are Eagle syndrome, thoracic outlet syndrome, nutcracker syndrome, May-Thurner syndrome, Dunbar syndrome, and popliteal entrapment syndrome. This work summarizes the main ultrasonographic characteristics, symptoms, and treatments of choice for these syndromes. Knowledge of these conditions’ characteristic signs is essential for the differential diagnosis. Failure to diagnose these rare diseases can expose patients to serious complications and risks to their health.

Median Arcuate Ligament Syndrome

Median arcuate ligament syndrome (MALS) is uncommon and often difficult to diagnose due to the vague presenting symptoms of abdominal pain, weight loss, and early satiety. Here, we report the case of a 63-year-old man who was successfully treated with laparoscopic median arcuate ligament release. Computed tomography (CT) of the abdomen and pelvis performed preoperatively demonstrated compression of the celiac artery with post-stenotic dilatation consistent with MALS. Subsequently, laparoscopic median arcuate ligament release was performed without any complications. Postoperatively, the patient reported resolution of abdominal pain with increased appetite and weight gain. Nonspecific abdominal pain and weight loss may raise concern for malignancy, but MALS should also be considered in the differential diagnoses. Diagnosis can be confirmed with CT and/or angiography. Median arcuate ligament release results in partial if not complete resolution of symptoms due to decompression of the celiac artery as well as division of the overlying celiac plexus.

Median arcuate ligament syndrome diagnosis on Computed Tomography: what a radiologist needs to know

Median arcuate ligament syndrome or celiac artery compression syndrome is one of the abdominal vascular compression syndromes due to compression of proximal celiac artery by the median arcuate ligament. The median arcuate ligament unites diaphragmatic crura on either side at the level of aortic hiatus. The ligament has a low insertion causing compression of the celiac artery resulting in clinical symptoms of postprandial pain and weight loss. It is a rare syndrome, detected incidentally on routine Computed Tomography abdomen and pelvis studies. We present a rare case of a 35-year-old female who presented with abdominal pain. She was evaluated by Computed Tomography scan of the abdomen and pelvis. Ultrasound Doppler of mesenteric vasculature helped detect celiac artery stenosis. A referral to the vascular surgery department was made; however, the patient was managed conservatively.

Laparoscopic treatment of median arcuate ligament syndrome without ganglionectomy of the celiac plexus in the hybrid operating room: Report of a case

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The treatment of median arcuate ligament syndrome is the surgical release of the ligament.

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Symptomatic patients need the ligament release with wide excision of the celiac plexus.

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However, the majority of the patients with celiac artery compression remains asymptomatic.

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It might be enough to just release the ligament without ganglionectomy for asymptomatic patients.

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Hybrid operating room could allow for adequate ligament release without ganglionectomy.

Introduction

Median arcuate ligament syndrome (MALS) is a rare condition in which the median arcuate ligament (MAL) causes compression of the celiac artery (CA) and plexus. Although 13–50 % of healthy population exhibit radiologic evidence of the CA compression, the majority remains asymptomatic. With or without symptoms, MALS have a risk of developing collateral circulation that leads to pancreaticoduodenal artery (PDA) aneurysms that have high risk of rupture. The treatment of MALS is the surgical release of the MAL. However, the necessity of ganglionectomy of the celiac plexus is still unclear.

Presentation of case

A 60-year-old man with a ruptured PDA aneurysm caused by MALS was admitted to our hospital for an emergency. After treatment for the ruptured PDA aneurysm by transcatheter arterial coil embolization, he underwent elective laparoscopic MAL release in the hybrid operation room to check blood flow of the CA intraoperatively. The angiography of the CA immediately after MAL release without ganglionectomy of the celiac plexus showed the antegrade blood flow to the proper hepatic artery instead of the retrograde flow via the pancreaticoduodenal arcade. The postoperative course was uneventful and the follow-up computed tomography revealed no residual CA stenosis.

Discussion

Unlike symptomatic MALS, it might be enough to just release the MAL without ganglionectomy of the celiac plexus for asymptomatic MALS, especially that with the treated PDA aneurysm.

Conclusion

Laparoscopic treatment of MALS in hybrid operating room could allow for adequate MAL release without ganglionectomy of the celiac plexus using the intraoperative angiography of the CA.

Clinico-pathologic findings in patients with median arcuate ligament syndrome (celiac artery compression syndrome)

Median Arcuate Ligament Syndrome (MALS) is a rare entity characterized by severe post-prandial epigastric pain, nausea, vomiting, and/or weight loss. Symptoms have been attributed to vascular compression (celiac artery compression syndrome, CACS), but it remains controversial whether they could be secondary to neural compression. Literature review identified rare description of pathologic findings in surgery journals. The clinico-pathologic findings of four MALS patients who underwent robotic or laparoscopic surgery in our hospital are described. All our patients were female with a median age of 32.5 (range 25-55 years), and a median BMI of 23.5 kg/m². They presented with chronic often post-prandial abdominal pain (4/4), nausea (3/4), emesis (2/4), anorexia (1/4), and weight loss (1/4). Two patients had a history of Crohn's disease. At intraoperative exploration, the celiac artery and adjacent nerves and ganglia were encased and partially compressed by fibrotic tissue in each patient. In each case laparoscopic excision of fibrotic tissue, celiac plexus and ligament division and was performed; celiac plexus nerve block was also performed in one patient. After surgical intervention, symptoms improved in three of the patients whose specimens show periganglionic and perineural fibrosis with proliferation of small nerve fibers. Our findings support neurogenic compression as a contributing factor in the development of pain and other MALS symptoms, and favor the use of MALS rather than CACS as diagnostic terminology. To further study the pathogenesis of this unusual syndrome, surgeons should submit all tissues excised during MALS procedures for histopathologic examination.

Diagnosis of celiac artery stenosis using multidetector computed tomography and evaluation of the collateral arteries within the mesopancreas of patients undergoing pancreaticoduodenectomy

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.

Celiac axis stenosis and digestive disease: Diagnosis, consequences and management

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.

The Role of Ultrasound in Dunbar Syndrome: Lessons Based on a Case Report

Patient: Male, 55-year-old

Final Diagnosis: Dunbar syndrome

Symptoms: Epigastric pain • weight loss

Medication: —

Clinical Procedure: None

Specialty: Gastroenterology and Hepatology • Radiology

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.

Interprofessional Management of Median Arcuate Ligament Syndrome (Dunbar Syndrome) Related to Lumbar Lordosis and Hip Dysplasia: A Patient's Perspective

We present a 53-year-old female patient with median arcuate ligament syndrome (MALS), also known as Dunbar syndrome or celiac artery compression syndrome, related to lumbar lordosis and hip dysplasia. She utilized interprofessional management strategies, which were beneficial in reducing lumbar lordosis and MALS-related symptoms. This finding is important because there are no other reports in the literature describing interprofessional strategies to manage symptoms for patients who are waiting for surgery or are not candidates for surgery.

CT imaging findings of abdominopelvic vascular compression syndromes: what the radiologist needs to know

Abdominopelvic vascular compression syndromes include a variety of uncommon conditions characterized by either extrinsic compression of blood vessels by adjacent anatomical structures (i.e., median arcuate ligament syndrome, nutcracker syndrome, May-Thurner syndrome) or compression of hollow viscera by adjacent vessels (i.e., superior mesenteric artery syndrome, ureteropelvic junction obstruction, ureteral vascular compression syndromes, portal biliopathy). These syndromes can be unexpectedly diagnosed even in asymptomatic patients and the predisposing anatomic conditions can be incidentally discovered on imaging examinations performed for other indications, or they can manifest with atypical abdominal symptoms and acute complications, which may lead to significant morbidity if unrecognized. Although computed tomography (CT) is an accurate noninvasive technique for their detection, the diagnosis remains challenging due to the uncommon clinical presentation and often overlooked imaging features. Dynamic imaging may be performed in order to evaluate patients with inconstant symptoms manifesting in a specific position. The purposes of this paper are to review the CT imaging findings of abdominopelvic vascular compression syndromes, correlating with anatomical variants and to provide key features for the noninvasive imaging diagnosis.

Arterial communication around the pancreatic tail enabled division of the gastroduodenal artery during pancreaticoduodenectomy in patient with complete celiac artery occlusion: a case report

Background

Stenosis or obstruction of the celiac artery (CA) is known as celiac artery stenosis (CAS) and is usually accompanied by the formation of arterial anastomosis between the superior mesenteric artery (SMA) system and the CA system. Arterial bypass is mainly achieved through the gastroduodenal artery (GDA); therefore, the division of the GDA during pancreaticoduodenectomy (PD) could pose a problem in patients with CAS.

Case presentation

We reported a case of PD presenting complete occlusion of the CA, in which perfusion to organs in the CA system was maintained via peri-pancreatic arterial communication. There were complicated arterial anastomoses around the pancreas, which were clearly visualized on a three-dimensional reconstruction of the arterial system using multi-detector computed tomography. Among these complicated anastomoses, one well-developed anastomosis between the SMA and the splenic artery through the dorsal pancreatic artery (DPA) was identified. The DPA was considered to work as a potential collateral pathway from the SMA to organs in the CA system after division of the GDA. During surgery, Doppler ultrasonography detected hepatopetal arterial flow even after the GDA clamping; therefore, we performed typical PD with division of the GDA. The postoperative course of the patient was uneventful, and there was no sign of ischemic complications in the CA system organs including the liver, stomach or spleen.

Conclusions

Three-dimensional reconstruction of the arterial system using multi-detector computed tomography and the intraoperative GDA clamping test were useful to determine whether it was possible to divide the GDA in PD, in the case of CAS.

Laparoscopic treatment in a patient with median arcuate ligament syndrome identified at the onset of superior mesenteric artery dissection: a case report

Background

Median arcuate ligament syndrome (MALS) is a rare clinical entity caused mainly by extrinsic compression of the celiac axis by the median arcuate ligament (MAL). Severe celiac artery stenosis can lead to the development of collateral circulation, aneurysms, and, rarely, superior mesenteric artery (SMA) dissection. The treatment of MALS involves the surgical release of the MAL. However, a standard procedure with the use of laparoscopy has not been established, and intraoperative complications can lead to severe vascular injury.

Case presentation

The patient was a 43-year-old man with MALS identified at the onset of SMA dissection. After treatment for the SMA dissection, he underwent laparoscopic MAL release. Using the technique of laparoscopic gastrectomy within the surgical field, we performed laparoscopic MAL release and ganglionectomy safely with a good view. Immediate symptomatic improvement was acquired, and no recurrence was observed at the 20-month follow-up.

Conclusion

We reported a rare case of MALS and SMA dissection. A horizontal 3D laparoscopic approach of the celiac axis allows for safe, meticulous, and radical MAL release and ganglionectomy.

An unusual association: median arcuate ligament syndrome and nutcracker syndrome

We present a case of arcuate ligament syndrome diagnosed in a 23-year-old patient with epigastric pain, vomiting and weight loss, using Doppler ultrasound and CT-angiography, treated by surgical resection of the ligament with complete resolution of symptoms. In addition, incidentally the patient was diagnosed with a nutcracker syndrome, without clinical repercussions.