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Lu LY, Eastment JG, Sivakumaran Y. Median Arcuate Ligament Syndrome (MALS) in Hepato-Pancreato-Biliary Surgery: A Narrative Review and Proposed Management Algorithm. J Clin Med 2024; 13:2598. [PMID: 38731126 PMCID: PMC11084382 DOI: 10.3390/jcm13092598] [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: 03/09/2024] [Revised: 04/04/2024] [Accepted: 04/22/2024] [Indexed: 05/13/2024] Open
Abstract
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?
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Affiliation(s)
- Lawrence Y. Lu
- Critical Care Research Group, The Prince Charles Hospital, Chermside, QLD 4032, Australia
- Faculty of Medicine, University of Queensland, Herston, QLD 4006, Australia
- Department of General Surgery, Princess Alexandra Hospital, Woolloongabba, QLD 4120, Australia
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
| | - Jacques G. Eastment
- Faculty of Medicine, University of Queensland, Herston, QLD 4006, Australia
- Department of General Surgery, Princess Alexandra Hospital, Woolloongabba, QLD 4120, Australia
| | - Yogeesan Sivakumaran
- Faculty of Medicine, University of Queensland, Herston, QLD 4006, Australia
- Department of Vascular Surgery, Princess Alexandra Hospital, Woolloongabba, QLD 4120, Australia
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Colella M, Mishima K, Wakabayashi T, Fujiyama Y, Al-Omari MA, Wakabayashi G. Preoperative blood circulation modification prior to pancreaticoduodenectomy in patients with celiac trunk occlusion: Two case reports. World J Gastrointest Surg 2022; 14:1310-1319. [PMID: 36504517 PMCID: PMC9727574 DOI: 10.4240/wjgs.v14.i11.1310] [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: 07/15/2022] [Revised: 09/24/2022] [Accepted: 10/19/2022] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Marco Colella
- Center for Advanced Treatment of HBP Diseases, Ageo Central General Hospital, Ageo 362-8588, Saitama, Japan
| | - Kohei Mishima
- Center for Advanced Treatment of HBP Diseases, Ageo Central General Hospital, Ageo 362-8588, Saitama, Japan
| | - Taiga Wakabayashi
- Center for Advanced Treatment of HBP Diseases, Ageo Central General Hospital, Ageo 362-8588, Saitama, Japan
| | - Yoshiki Fujiyama
- Center for Advanced Treatment of HBP Diseases, Ageo Central General Hospital, Ageo 362-8588, Saitama, Japan
| | - Malek A Al-Omari
- Center for Advanced Treatment of HBP Diseases, Ageo Central General Hospital, Ageo 362-8588, Saitama, Japan
| | - Go Wakabayashi
- Center for Advanced Treatment of HBP Diseases, Ageo Central General Hospital, Ageo 362-8588, Saitama, Japan
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Miyazaki K, Morine Y, Saito Y, Yamada S, Tokuda K, Ikemoto T, Imura S, Shimada M. Pancreatoduodenectomy co-morbid with celiac axis compression syndrome: a report of three cases. Surg Case Rep 2020; 6:113. [PMID: 32449014 PMCID: PMC7246236 DOI: 10.1186/s40792-020-00878-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 05/17/2020] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Katsuki Miyazaki
- The Department of Digestive and Transplant Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 770-8503, Japan
| | - Yuji Morine
- The Department of Digestive and Transplant Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 770-8503, Japan
| | - Yu Saito
- The Department of Digestive and Transplant Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 770-8503, Japan
| | - Shinichiro Yamada
- The Department of Digestive and Transplant Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 770-8503, Japan
| | - Kazunori Tokuda
- The Department of Digestive and Transplant Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 770-8503, Japan
| | - Tetsuya Ikemoto
- The Department of Digestive and Transplant Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 770-8503, Japan
| | - Satoru Imura
- The Department of Digestive and Transplant Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 770-8503, Japan
| | - Mitsuo Shimada
- The Department of Digestive and Transplant Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 770-8503, Japan.
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Giovanardi F, Lai Q, Garofalo M, Arroyo Murillo GA, Choppin de Janvry E, Hassan R, Larghi Laureiro Z, Consolo A, Melandro F, Berloco PB. Collaterals management during pancreatoduodenectomy in patients with celiac axis stenosis: A systematic review of the literature. Pancreatology 2018; 18:592-600. [PMID: 29776725 DOI: 10.1016/j.pan.2018.05.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 05/07/2018] [Accepted: 05/09/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Celiac axis stenosis (CAS) represents an uncommon and typically innocuous condition. However, when a pancreatic resection is required, a high risk for upper abdominal organs ischemia is observed. In presence of collaterals, such a risk is minimized if their preservation is realized. The aim of the present study is to systematically review the literature with the intent to address the routine management of collateral arteries in the case of CAS patients requiring pancreatoduodenectomy. METHODS A systematic search was done in accordance with the PRISMA guidelines, using "celiac axis stenosis" AND "pancreatoduodenectomy" as MeSH terms. Seventy-four articles were initially screened: eventually, 30 articles were identified (n = 87). RESULTS The main cause of CAS was median arcuate ligament (MAL) (n = 31; 35.6%), followed by atherosclerosis (n = 20; 23.0%). CAS was occasionally discovered during the Whipple procedure in 15 (17.2%) cases. Typically, MAL was divided during surgery (n = 24/31; 77.4%). In the great majority of cases (n = 83; 95.4%), vascular abnormalities involved the pancreatoduodenal arteries (i.e., dilatation, arcade, channels, aneurysms). Collateral arteries were typically preserved, being divided or reconstructed in only 14 (16.1%) cases, respectively. Severe ischemic complications were reported in six (6.9%) patients, 20.0% of whom were reported in patients with preoperatively unknown CAS (p-value 0.06). CONCLUSIONS A correct pre-operative evaluation of anatomical conditions as well as a correct surgical planning represent the paramount targets in CAS patients with arterial collaterals. Vascular flow must be always safeguarded preserving/reconstructing the collaterals or resolving the CAS, with the final intent to avoid dreadful intra- and post-operative complications.
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Affiliation(s)
- Francesco Giovanardi
- General Surgery and Organ Transplantation Unit, Department of Surgery, Sapienza University of Rome, Rome, Italy.
| | - Quirino Lai
- Hepato-bilio-pancreatic and Liver Transplant Unit, Department of Surgery, Sapienza University of Rome, Rome, Italy
| | - Manuela Garofalo
- General Surgery and Organ Transplantation Unit, Department of Surgery, Sapienza University of Rome, Rome, Italy
| | - Gabriela A Arroyo Murillo
- General Surgery and Organ Transplantation Unit, Department of Surgery, Sapienza University of Rome, Rome, Italy
| | - Eleonore Choppin de Janvry
- General Surgery and Organ Transplantation Unit, Department of Surgery, Sapienza University of Rome, Rome, Italy
| | - Redan Hassan
- Hepato-bilio-pancreatic and Liver Transplant Unit, Department of Surgery, Sapienza University of Rome, Rome, Italy
| | - Zoe Larghi Laureiro
- Hepato-bilio-pancreatic and Liver Transplant Unit, Department of Surgery, Sapienza University of Rome, Rome, Italy
| | - Adriano Consolo
- General Surgery and Organ Transplantation Unit, Department of Surgery, Sapienza University of Rome, Rome, Italy
| | - Fabio Melandro
- General Surgery and Organ Transplantation Unit, Department of Surgery, Sapienza University of Rome, Rome, Italy
| | - Pasquale B Berloco
- General Surgery and Organ Transplantation Unit, Department of Surgery, Sapienza University of Rome, Rome, Italy
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Shibuya K, Kamachi H, Orimo T, Nagatsu A, Shimada S, Wakayama K, Yokoo H, Kamiyama T, Taketomi A. Pancreaticoduodenectomy with Preservation of Collateral Circulation or Revascularization for Biliary Pancreatic Cancer with Celiac Axis Occlusion: A Report of 2 Cases. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:413-420. [PMID: 29628495 PMCID: PMC5912007 DOI: 10.12659/ajcr.908516] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 02/05/2018] [Indexed: 02/05/2023]
Abstract
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.
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Miyata T, Yamamoto Y, Sugiura T, Okamura Y, Ito T, Ashida R, Uemura S, Kato Y, Ohgi K, Kohga A, Uchida T, Sano S, Nakagawa M, Uesaka K. Pancreaticoduodenectomy with hepatic arterial revascularization for pancreatic head cancer with stenosis of the celiac axis due to compression by the median arcuate ligament: a case report. J Surg Case Rep 2018; 2018:rjy002. [PMID: 29383246 PMCID: PMC5786235 DOI: 10.1093/jscr/rjy002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 12/24/2017] [Accepted: 01/14/2018] [Indexed: 12/17/2022] Open
Abstract
A 71-year-old woman presented to our hospital because pancreatic head cancer was suspected on a medical checkup. Computed tomography showed a 30 mm low-density lesion in the pancreatic head, and the stenosis of the celiac axis (CA) due to the median arcuate ligament (MAL) compression. We made a preoperative diagnosis of pancreatic head cancer and performed laparotomy. Transection of the MAL failed to restore adequate hepatic arterial flow, necessitating arterial revascularization, which was achieved by end-to-end anastomosis between the gastroduodenal artery and the middle colic artery. After reconstruction, Doppler ultrasonography showed improved hepatic arterial signal. The patient was discharged 16 days after surgery with no complications. When planning pancreaticoduodenectomy (PD) for such patients with CA stenosis due to MAL compression, surgeons should simulate a situation of insufficient hepatic arterial flow after division of the MAL, and prepare for reconstruction of the hepatic artery during PD.
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Affiliation(s)
- Takashi Miyata
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yusuke Yamamoto
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Teiichi Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yukiyasu Okamura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Takaaki Ito
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Ryo Ashida
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Sunao Uemura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yoshiyasu Kato
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Katsuhisa Ohgi
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Atsushi Kohga
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Tsuneyuki Uchida
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Shusei Sano
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Masahiro Nakagawa
- Division of Plastic and Reconstructive Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
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Sugae T, Fujii T, Kodera Y, Kanzaki A, Yamamura K, Yamada S, Sugimoto H, Nomoto S, Takeda S, Nakao A. 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. Surgery 2011; 151:543-9. [PMID: 22001637 DOI: 10.1016/j.surg.2011.08.012] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Accepted: 08/16/2011] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Takashi Sugae
- Department of Surgery II, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Loukas M, Pinyard J, Vaid S, Kinsella C, Tariq A, Tubbs RS. Clinical anatomy of celiac artery compression syndrome: a review. Clin Anat 2007; 20:612-7. [PMID: 17309066 DOI: 10.1002/ca.20473] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Anatomic variations are often responsible for a variety of clinical conditions. In this review we investigate compression of the celiac artery and the superior mesenteric artery by the median arcuate ligament (MAL), diaphragmatic crura, or the celiac nerve plexus. This clinical condition known as celiac artery compression syndrome (CACS) has proven controversial in definition and relevance. This condition was first described as chronic abdominal pain because of the mesenteric ischemia caused by extrinsic compression of the celiac artery. Dunbar and others presented surgical approaches to decompress the celiac artery by releasing the MAL. Definitive answers have been sought to classify and relieve the clinical symptoms patients experience postprandially. Persistent symptoms following surgical treatment for CACS have led investigators to question the existence of this disease. Advances in technology such as angiographic MRI and color duplex ultrasonography have refreshed the importance of considering compression of the celiac artery during differential diagnoses. Because of the varying anatomic etiologies of disease, it is not possible to pinpoint a single cause for CACS. Potential etiologies for compression of the celiac artery include a "high take off" origin of the celiac artery compressed by normal diaphragmatic crura and MAL, a normal origin of the celiac artery with long diaphragmatic crura and MAL, large bilaterally fused celiac ganglia (with or without the involvement of the superior mesenteric ganglia) compressing the celiac trunk, celiacomesenteric trunk compression by diaphragmatic crura and MAL, or combinations of the above mentioned entities. In this review we describe potential sources of compression of the celiac artery by regional structures and treatments of CACS in an effort to justify the relevance of CACS in modern medicine.
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Affiliation(s)
- Marios Loukas
- Department of Anatomical Sciences, St. George's University, Grenada, West Indies.
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