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1
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Machado MC, Machado MA. How I do it. Pancreatojejunostomy: surgical tips to mitigate the severity of postoperative pancreatic fistulas after open or minimally invasive pancreatoduodenectomy. Updates Surg 2024; 76:1265-1270. [PMID: 38724873 DOI: 10.1007/s13304-024-01867-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 05/03/2024] [Indexed: 08/24/2024]
Abstract
Pancreatoduodenectomy is the most appropriate technique for the treatment of periampullary tumors. In the past, this procedure was associated with high mortality and morbidity, but with improvements in patient selection, anesthesia, and surgical technique, mortality has decreased to less than 5%. However, morbidity remains increased due to various complications such as delayed gastric emptying, bleeding, abdominal collections, and abscesses, most of which are related to the pancreatojejunostomy leak. Clinically relevant postoperative pancreatic fistula is the most dangerous and is related to other complications including mortality. The incidence of postoperative pancreatic fistula ranges from 5-30%. Various techniques have been developed to reduce the severity of pancreatic fistulas, from the use of an isolated jejunal loop for pancreatojejunostomy to binding and invagination anastomoses. Even total pancreatectomy has been considered to avoid pancreatic fistula, but the late effects of this procedure are unacceptable, especially in relatively young patients. Recent studies on the main techniques of pancreatojejunostomy concluded that duct-to-mucosa anastomosis is advisable, but no technique eliminates the risk of pancreatic fistula. The purpose of this study is to highlight technical details and tips that may reduce the severity of pancreatic fistula after pancreatojejunostomy during open or minimally invasive pancreatoduodenectomy.
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2
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Ward EP, Vincent-Sheldon S, Tolat P, Kulkarni N, Aldakkak M, Budithi R, Clarke CN, Tsai S, Evans DB, Christians KK. Median arcuate ligament release at the time of pancreaticoduodenectomy or total pancreatectomy. Surgery 2024; 175:1386-1393. [PMID: 38413302 DOI: 10.1016/j.surg.2024.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/27/2023] [Accepted: 01/08/2024] [Indexed: 02/29/2024]
Abstract
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.
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Affiliation(s)
- Erin P Ward
- Huntsman Cancer Institute, University of Utah Health, Salt Lake City, UT.
| | | | | | | | | | | | | | - Susan Tsai
- Medical College of Wisconsin, Milwaukee, WI
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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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Doita S, Aoki H, Kajioka H, Tanakaya K, Kawamoto K. The combination of preoperative celiac axis stenting and neoadjuvant chemotherapy in an elderly patient with pancreatic cancer: a case report. Surg Case Rep 2024; 10:59. [PMID: 38467960 PMCID: PMC10928057 DOI: 10.1186/s40792-024-01857-2] [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: 01/23/2024] [Accepted: 03/03/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Celiac axis stenosis (CAS) is frequently observed in patients undergoing pancreaticoduodenectomy (PD). This poses challenges because of the potential disruption of the hepatic arterial blood flow. CASE PRESENTATION We present the case of an 81-year-old woman diagnosed with pancreatic head cancer and severe CAS caused by calcification. The patient received neoadjuvant chemotherapy (NAC) and underwent preoperative endovascular stenting of the celiac axis to restore blood flow. After two cycles of NAC, subtotal stomach-preserving PD was performed. An intraoperative assessment of the hepatic arterial blood flow determined that it was well maintained. PD was performed using the standard technique; specialized techniques were not necessary. Importantly, no ischemic complications were encountered. CONCLUSION This case report describes the successful combination of preoperative celiac axis stenting, NAC, and surgical intervention for the management of CAS in an elderly patient with pancreatic cancer. This approach offers a potential solution for maintaining the hepatic arterial blood flow in the presence of CAS without vascular reconstruction, particularly in elderly individuals.
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Affiliation(s)
- Susumu Doita
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, 1-1-1 Atago-Machi, Iwakuni-City, Yamaguchi, 740-8510, Japan.
| | - Hideki Aoki
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, 1-1-1 Atago-Machi, Iwakuni-City, Yamaguchi, 740-8510, Japan
| | - Hiroki Kajioka
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, 1-1-1 Atago-Machi, Iwakuni-City, Yamaguchi, 740-8510, Japan
| | - Kohji Tanakaya
- Department of Surgery, National Hospital Organization Iwakuni Clinical Center, 1-1-1 Atago-Machi, Iwakuni-City, Yamaguchi, 740-8510, Japan
| | - Kenji Kawamoto
- Department of Cardiovascular Medicine, National Hospital Organization Iwakuni Clinical Center, 1-1-1 Atago-Machi, Iwakuni-City, Yamaguchi, 740-8510, Japan
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5
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Lazzarotto-da-Silva G, Santos LM, Lucena IRS, Rabolini BB, Hallal CP, Feier FH, Grezzana-Filho TJM, Chedid MF, Leipnitz I, Chedid AD, de Araujo A, Alvares-da-Silva MR, Kruel CRP. Celiac trunk stenosis by median arcuate ligament in orthotopic liver transplantation: a potential hidden foe to the biliary tree. HPB (Oxford) 2024; 26:137-144. [PMID: 37722997 DOI: 10.1016/j.hpb.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 08/16/2023] [Accepted: 09/04/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Celiac trunk compression by the median arcuate ligament (MAL) increases the risk of ischemic complications following gastrointestinal surgical procedures. Previous studies suggest increased risk of hepatic artery thrombosis (HAT) in orthotopic liver transplant (OLT) recipients. The aim of this study is to investigate the impact of untreated MAL compression (MAL-C) on biliary complications in OLT. METHODS Contrast-enhanced imaging was used to classify celiac trunk stenosis by MAL-C. Medical records were reviewed to extract pre-transplant, transplant and post-transplant data. Patients were divided into two groups: no MAL compression (nMAL-C) and MAL-C. The primary endpoint was biliary complications. Secondary endpoints were HAT and graft survival. RESULTS 305 OLT were performed from 2010 to 2021, of which 219 were included for analysis: 185 (84.5%) patients without and 34 (15.5%) with MAL-C. The incidence of HAT was 5.9% in both groups. Biliary complications were more common in the MAL-C group (35.3% vs. 17.8%, p = 0.035). Graft survival was decreased in patients with MAL-C (p = 0.035). CONCLUSIONS MAL-C of the celiac trunk was associated with increased risk of biliary complications and inferior graft survival in OLT patients. These findings highlight the importance of preoperative screening and treatment of MAL in this population.
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Affiliation(s)
| | | | - Iara R S Lucena
- Radiology Unit, Hospital de Clínicas de Porto Alegre, Brazil
| | - Bruno B Rabolini
- Post-Graduate Program in Surgical Sciences, Medical School of UFRGS, Brazil
| | - Celina P Hallal
- Post-Graduate Program in Surgical Sciences, Medical School of UFRGS, Brazil
| | - Flavia H Feier
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Brazil
| | | | - Marcio F Chedid
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Brazil
| | - Ian Leipnitz
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Brazil
| | - Aljamir D Chedid
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Brazil
| | - Alexandre de Araujo
- Gastroenterology and Hepatology Unit, Hospital de Clínicas de Porto Alegre, Brazil
| | | | - Cleber R P Kruel
- Liver Transplant and Hepatobiliary Surgery Unit, Hospital de Clínicas de Porto Alegre, Brazil
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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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7
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Usta S, Karabulut K, Artaş H. Median arcuate ligament syndrome noticed during pancreaticoduodenectomy. Turk J Surg 2022; 38:95-97. [DOI: 10.47717/turkjsurg.2022.3989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 01/03/2018] [Indexed: 11/23/2022]
Abstract
Median arcuate ligament syndrome (MALS) occurs as a result of compression of the celiac artery by a fibrous band called the median ligament, which originates from the diaphragmatic crus. The prevalence of MALS has been reported as 10-24% among patients. The etiology is not clear. The components of the clinical triad are a chronic post-prandial pain, epigastric murmur and weight loss. Diagnosis is based on clinical and radiological findings. MALS has been reported in a small portion of patients undergoing pancreaticoduodenectomy. Most of the patients have been diagnosed prior to surgery.
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8
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Nakata K, Higuchi R, Ikenaga N, Sakuma L, Ban D, Nagakawa Y, Ohtsuka T, Asbun HJ, Boggi U, Tang CN, Wolfgang CL, Nishino H, Endo I, Tsuchida A, Nakamura M. Precision anatomy for safe approach to pancreatoduodenectomy for both open and minimally invasive procedure: A systematic review. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 29:99-113. [PMID: 33533158 DOI: 10.1002/jhbp.901] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/19/2020] [Accepted: 01/18/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Minimally invasive pancreatoduodenectomy (MIPD) has recently gained popularity. Several international meetings focusing on the existing literature on MIPD were held; however, the precise surgical anatomy of the pancreas for the safe use of MIPD has not yet been fully discussed. The aim of this study was to carry out a systematic review of available articles and to show the importance of identifying the anatomical variation in pancreatoduodenectomy. METHODS In this review, we described variations in surgical anatomy related to MIPD. A systematic search of PubMed (MEDLINE) was conducted, and the references were identified manually. RESULTS The search strategy yielded 272 articles, with 77 retained for analysis. The important anatomy to be considered during MIPD includes the aberrant right hepatic artery, first jejunal vein, first jejunal artery, and dorsal pancreatic artery. Celiac artery stenosis and a circumportal pancreas are also important to recognize. CONCLUSIONS We conclude that only certain anatomical variations are associated directly with perioperative outcomes and that identification of these particular variations is important for safe performance of MIPD.
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Affiliation(s)
- Kohei Nakata
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Naoki Ikenaga
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Leon Sakuma
- Professor with Special Assistant, Kawasaki Medical School, Okayama, Japan
| | - Daisuke Ban
- Department of Hepatobiliary and Pancreatic Surgery Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Takao Ohtsuka
- First Department of Surgery, Kagoshima University School of Medicine, Kagoshima, Japan
| | - Horacio J Asbun
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, FL, USA
| | - Ugo Boggi
- Division of General and Transplant Surgery, Pisa University Hospital, Pisa, Italy
| | - Chung-Ngai Tang
- Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China
| | | | - Hitoe Nishino
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Akihiko Tsuchida
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Shintakuya R, Kohashi T, Nakashima A, Oishi K, Honmyo N, Hihara J, Kagawa E, Mukaida H. How to do it: Endovascular stent and ligament resection during pancreaticoduodenectomy for coeliac axis stenosis in median arcuate ligament syndrome. ANZ J Surg 2021; 91:2824-2826. [PMID: 34180573 DOI: 10.1111/ans.17007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 06/03/2021] [Accepted: 06/03/2021] [Indexed: 11/29/2022]
Abstract
To decrease complications associated with the treatment of coeliac axis (CA) stenosis due to median arcuate ligament (MAL) syndrome in pancreaticoduodenectomy, we performed combined preoperative endovascular stenting and intraoperative MAL resection. This technique can secure the CA blood flow to the hepatic artery before surgery in one stage and prevent CA restenosis and stent dislocation because there is no extrinsic compression of the CA after MAL resection.
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Affiliation(s)
- Ryuta Shintakuya
- Department of Surgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Toshihiko Kohashi
- Department of Surgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan.,Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Akira Nakashima
- Department of Surgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Koichi Oishi
- Department of Surgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Naruhiko Honmyo
- Department of Surgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Jun Hihara
- Department of Surgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Eisuke Kagawa
- Department of Cardiology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Hidenori Mukaida
- Department of Surgery, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
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Balachandran G, Bharathy KGS, Sikora SS. Median Arcuate Ligament Syndrome: an Important Consideration in Pancreaticoduodenectomy. Indian J Surg Oncol 2021; 12:439-441. [PMID: 34295093 DOI: 10.1007/s13193-021-01308-6] [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: 09/01/2020] [Accepted: 03/02/2021] [Indexed: 11/26/2022] Open
Abstract
Pancreaticoduodenectomy (PD) is a common surgery performed with curative intent for periampullary and pancreatic head neoplasms. In the presence of intrinsic celiac artery narrowing due to atherosclerosis or extrinsic compression due to median arcuate ligament syndrome (MALS), division of the gastroduodenal artery during PD can result in liver ischemia. This report describes a patient who had MALS which was treated by intraoperative median arcuate ligament release during PD, resulting in restoration of hepatic artery pulsations. Preventive, management strategies for MALS and the communicating vascular arcades between the celiac and superior mesenteric arterial systems are discussed in the context of PD.
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Affiliation(s)
- Gayatri Balachandran
- Department of Surgical Gastroenterology & Liver Transplantation, Institute of Digestive & HPB Sciences, Sakra World Hospital, SY No.52/2 & 52/3, Devarabeesanahalli, Oppsite Intel, VarthurHobli, Bengaluru, Karnataka 560103 India
| | - Kishore G S Bharathy
- Department of Surgical Gastroenterology & Liver Transplantation, Institute of Digestive & HPB Sciences, Sakra World Hospital, SY No.52/2 & 52/3, Devarabeesanahalli, Oppsite Intel, VarthurHobli, Bengaluru, Karnataka 560103 India
| | - Sadiq S Sikora
- Department of Surgical Gastroenterology & Liver Transplantation, Institute of Digestive & HPB Sciences, Sakra World Hospital, SY No.52/2 & 52/3, Devarabeesanahalli, Oppsite Intel, VarthurHobli, Bengaluru, Karnataka 560103 India
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11
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Swami A, Yadav T, Varshney VK, Sreesanth KS, Dixit SG. Hepatic Arterial Variations and Its Implication During Pancreatic Cancer Surgeries. J Gastrointest Cancer 2021; 52:462-470. [PMID: 33616844 DOI: 10.1007/s12029-021-00598-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2021] [Indexed: 01/28/2023]
Abstract
PURPOSE Aberrant hepatic artery anatomy is a considerable challenge during pancreatic surgery as it warrants extreme caution for the preservation of vascular supply as well as achievement of R0 resection margin. METHOD We reviewed the literature about the aberrant anatomical variations of the hepatic artery and its relevance during pancreatoduodenectomy and distal pancreatectomy. RESULT Preoperative deliberation of peri-pancreatic vascular anatomy using advanced imaging methods is crucial for surgeons. At the same time, intra-operative suspicion and early identification of aberrant anatomy may help to prevent vascular injury and related complications. Yet, vascular reconstruction may be needed in many situations; several techniques like pre-operative embolization provide new options for management in specific situations. CONCLUSION We have provided here an overview of the anatomical variants of the hepatic artery and their implication during pancreatoduodenectomy and distal pancreatectomy.
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Affiliation(s)
- Ashish Swami
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Taruna Yadav
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Vaibhav Kumar Varshney
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India.
| | - Kelu S Sreesanth
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Shilpi Gupta Dixit
- Department of Anatomy, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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12
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Intraoperative evaluation of hepatic artery blood flow during pancreatoduodenectomy (HEPARFLOW): Protocol of an exploratory study. Int J Surg Protoc 2020; 21:21-26. [PMID: 32346665 PMCID: PMC7182758 DOI: 10.1016/j.isjp.2020.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/15/2020] [Accepted: 03/17/2020] [Indexed: 12/28/2022] Open
Abstract
Assessment of flow rates of the hepatic artery during pancreatoduodenectomy. Identification of pre- and intraoperative factors influencing liver blood flow. Relevance of a celiac axis stenosis by pancreatoduodenectomy. Introduction Pancreatoduodenectomy is the treatment of choice for a range of benign and malignant diseases. The pancreatic head must be separated from its supplying vessels, especially the gastroduodenal artery, during this operation. However, dissection of the gastroduodenal artery can disturb blood supply to the liver and result in liver ischemia. There is currently no well-established algorithm to evaluate and ensure sufficient blood flow in patients with altered hepatic artery blood flow. To address this important issue, this study aims to establish a basis for assessing liver blood supply during pancreatoduodenectomy. Furthermore, factors influencing arterial blood flow and related postoperative complications will be evaluated. Methods and analysis The HEPARFLOW study is a single institutional single-arm prospective exploratory observational clinical trial. All consecutive patients undergoing elective partial or total pancreatoduodenectomy will be screened for inclusion until 100 patients are enrolled. Blood flow in the proper hepatic artery, gastroduodenal artery, portal vein, and additional vessels supplying the liver will be measured during pancreatoduodenectomy using Doppler flowmetry. All patients will be followed up for 90 days after surgery. At each visit, standard clinical data, postoperative complications and mortality will be recorded. Discussion This will be the first study to prospectively assess intraoperative flow rates of the hepatic artery and portal vein to evaluate liver blood supply during pancreatoduodenectomy. The preoperative and intraoperative factors influencing blood flow in the hepatic arteries will be identified. This study may also reveal the hemodynamic and clinical relevance of a compression of the celiac axis during pancreatoduodenectomy. Ethics and dissemination This study was approved by the Ethics Committee of the University of Heidelberg (S-073/2018). The results will be published in a peer-reviewed journal and will be presented at medical meetings.
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13
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Desai GS, Pande PM. Gastroduodenal artery: single key for many locks. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2019; 26:281-291. [PMID: 31099488 DOI: 10.1002/jhbp.636] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Gastroduodenal artery (GDA) commonly arises from common hepatic artery, a branch of celiac axis. It holds a unique anatomical position that connects the foregut and midgut due to its intimate communications with foregut and midgut arterial supply. Its numerous anatomical variations have a significant impact on planning and performance of hepatopancreaticobiliary (HPB) surgery. Its close relation to the first part of duodenum, common bile duct and head of pancreas makes it susceptible for inadvertent bleeding during or after surgery, or due to various HPB pathologies. Also, a large number of vascular interventions rely on GDA and its branches. Careful preoperative planning is the key and a detailed knowledge and awareness of its variant anatomy is of paramount importance, be it liver resections, liver transplant, biliary and pancreatic resections and pancreatic transplant or transarterial procedures involving these arteries. GDA can also be a cause of gastrointestinal hemorrhage due to true or pseudoaneurysms and anatomy has significant implications on its management. The article provides a succinct review on relevance of GDA anatomy and variations and highlights that preoperative planning and intraoperative awareness of variations is the key to performance of safe HPB surgery and interventions.
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Affiliation(s)
- Gunjan S Desai
- Department of Gastrointestinal Surgery, Lilavati Hospital and Research Center, Mumbai, Maharashtra, India
| | - Prasad M Pande
- Department of Gastrointestinal Surgery, Lilavati Hospital and Research Center, Mumbai, Maharashtra, India
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14
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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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15
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Yamamoto M, Itamoto T, Oshita A, Matsugu Y. Celiac axis stenosis due to median arcuate ligament compression in a patient who underwent pancreatoduodenectomy; intraoperative assessment of hepatic arterial flow using Doppler ultrasonography: a case report. J Med Case Rep 2018; 12:92. [PMID: 29642943 PMCID: PMC5896120 DOI: 10.1186/s13256-018-1614-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 02/12/2018] [Indexed: 12/13/2022] Open
Abstract
Background Celiac axis stenosis due to compression by the median arcuate ligament has been reported in patients undergoing pancreaticoduodenectomy; it leads to the development of major collateral pathways that feed the hepatic artery. Dividing these important collaterals during pancreaticoduodenectomy can cause ischemic complications which may lead to a high mortality rate. To prevent these complications, it is necessary to assess intrahepatic arterial flow. Case presentation A 71-year-old Japanese man with anorexia was referred to us for the treatment of alcoholic chronic pancreatitis. Computed tomography revealed a pancreatic head tumor with a calculus, associated with the dilatation of the main pancreatic duct and intrahepatic bile duct. Three-dimensional imaging demonstrated focal narrowing in the proximal celiac axis due to median arcuate ligament compression and a prominent gastroduodenal artery that fed the common hepatic artery. The preoperative diagnosis was alcoholic chronic pancreatitis with common bile duct obstruction and celiac axis stenosis due to median arcuate ligament compression. Pancreaticoduodenectomy with median arcuate ligament release was scheduled. Before the division of the median arcuate ligament, the peak flow velocity and resistive index of his intrahepatic artery measured with Doppler ultrasonography decreased from 37.7 cm/second and 0.510, respectively, to 20.6 cm/second and 0.508 respectively, when his gastroduodenal artery was clamped. However, these values returned to baseline levels after the division of the median arcuate ligament. These findings suggested that pancreaticoduodenectomy could be performed safely. Our patient was discharged on postoperative day 17 without significant complications. Conclusion The intraoperative quantitative evaluation of intrahepatic arterial blood flow using Doppler ultrasonography was useful in a patient who underwent pancreaticoduodenectomy, who had celiac axis stenosis due to compression by the median arcuate ligament.
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Affiliation(s)
- Masateru Yamamoto
- Department of Gastroenterological, Breast and Transplant Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Toshiyuki Itamoto
- Department of Gastroenterological, Breast and Transplant Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan. .,Department of Gastroenterological and Transplant Surgery, Applied Life Science, Institute of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan.
| | - Akihiko Oshita
- Department of Gastroenterological, Breast and Transplant Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan.,Department of Gastroenterological and Transplant Surgery, Applied Life Science, Institute of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Yasuhiro Matsugu
- Department of Gastroenterological, Breast and Transplant Surgery, Hiroshima Prefectural Hospital, Hiroshima, Japan
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16
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Sánchez AM, Tortorelli AP, Caprino P, Rosa F, Menghi R, Quero G, Doglietto GB, Alfieri S. Incidence and Impact of Variant Celiacomesenteric Vascularization and Vascular Stenosis on Pancreatic Surgery Outcomes: Personal Experience. Am Surg 2018. [DOI: 10.1177/000313481808400222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Ischemic complications after pancreatic surgery can raise postoperative mortality from 4 to 83 per cent. Variants in vascular anatomy play a major role in determining such complications, but they have been only occasionally reported in the literature. We retrospectively analyzed 100 records of patients consecutively treated between January 2011 and December 2013 for resectable malignant diseases who underwent pancreaticoduodenectomy (PD) or total pancreatectomy to state the statistical impact of anatomical vascular variations in surgical outcomes (mean surgical timing, mean blood loss during surgery, and postoperative major complications onset) and to state whether preoperatively undetected vascular anomalies (VA) can raise the risk of postoperative ischemic complications. PD was performed in 89 patients, requiring multiorgan resections in three cases and total pancreatectomy was performed in 11 cases, which was associated to splenectomy in four patients. Incidence of VA was 25/100 (25%), whereas in 18/25 cases (72%) they were detected by preoperative radiologic setting. Their presence in patients undergoing PD significantly raised mean surgical timing ( P = 0.003) and increased mean blood loss ( P < 0.0001). Preoperatively undetected VA resulted in a major risk of postoperative acute liver ischemia ( P = 0.008). Celiacomesenteric aberrant anatomy was proven to be related to an increased risk of intraoperative complications. If undetected preoperatively, they can be associated with anastomotic complications and liver failure. Maximal efforts must be done to detect and to preserve vascular anatomy of celiacomesenteric district.
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Affiliation(s)
- Alejandro M. Sánchez
- Digestive Surgery Unit, Department of Surgical Sciences, Catholic University School of Medicine, Rome, Italy
| | - Antonio P. Tortorelli
- Digestive Surgery Unit, Department of Surgical Sciences, Catholic University School of Medicine, Rome, Italy
| | - Paola Caprino
- Digestive Surgery Unit, Department of Surgical Sciences, Catholic University School of Medicine, Rome, Italy
| | - Fausto Rosa
- Digestive Surgery Unit, Department of Surgical Sciences, Catholic University School of Medicine, Rome, Italy
| | - Roberta Menghi
- Digestive Surgery Unit, Department of Surgical Sciences, Catholic University School of Medicine, Rome, Italy
| | - Giuseppe Quero
- Digestive Surgery Unit, Department of Surgical Sciences, Catholic University School of Medicine, Rome, Italy
| | - Giovanni B. Doglietto
- Digestive Surgery Unit, Department of Surgical Sciences, Catholic University School of Medicine, Rome, Italy
| | - Sergio Alfieri
- Digestive Surgery Unit, Department of Surgical Sciences, Catholic University School of Medicine, Rome, Italy
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17
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Impact of pancreaticoduodenal arcade dilation on postoperative outcomes after pancreaticoduodenectomy. HPB (Oxford) 2018; 20:49-56. [PMID: 28919282 DOI: 10.1016/j.hpb.2017.08.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 08/09/2017] [Accepted: 08/14/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this study was to investigate the impact of pancreaticoduodenal arcade (PDA) dilation on postoperative outcomes after pancreaticoduodenectomy. METHODS Consecutive patients submitted to pancreaticoduodenectomy between 2008 and 2016 underwent preoperative multi-detector computed tomography, the images of which were re-reviewed. The patients were categorized according to the grade of PDA dilation into 3 groups (remarkably-dilated, slightly-dilated, and non-dilated). RESULTS Among the 443 patients, 25 patients (5.6%) were categorized as remarkably-dilated PDA and 24 patients (5.4%) as having slightly-dilated PDA. The patients with remarkably-dilated PDA had undergone pancreaticoduodenectomy with additional surgical maneuvers to restore celiac arterial flow as needed, and had an uneventful postoperative recovery relative to those with non-dilated PDA. In contrast, patients with slightly-dilated PDA underwent only pancreaticoduodenectomy without additional surgical maneuvers, and developed clinically relevant postoperative pancreatic fistula (POPF) more frequently than those with non-dilated PDA (42% vs. 21%, P = 0.021). Moreover, slightly-dilated PDA was shown to be an independent risk factor for clinically relevant POPF (odds ratio = 2.719, P = 0.042). DISCUSSION For patients with PDA dilation requiring pancreaticoduodenectomy, a preoperative evaluation of the vascular anatomy, intraoperative assessment of the celiac arterial flow, and additional surgical maneuvers might be necessary to reduce the risk of postoperative complications.
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18
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Zhou Y, Wang W, Shi Y, Lu X, Zhan Q, Chen H, Deng X, Peng C, Shen B. Substantial atherosclerotic celiac axis stenosis is a new risk factor for biliary fistula after pancreaticoduodenectomy. Int J Surg 2017; 49:62-67. [PMID: 29258887 DOI: 10.1016/j.ijsu.2017.11.054] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 10/25/2017] [Accepted: 11/19/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Biliary fistula (BF) is a major surgical complication that can develop after pancreaticoduodenectomy (PD) whose risk factors remain unclear. Substantial atherosclerotic celiac axis stenosis (SACAS) has not been reported to be one of them. METHODS Data from 507 patients undergoing PD between Jan 1, 2013 and Dec 31, 2015 were retrospectively collected. Clinical data from patients with SACAS were studied, and the independent risk factors for BF underwent multivariate logistic regression analysis, including SACAS. RESULTS BF occurred in 22 (4.3%) patients, and the incidence of BF was significantly higher in patients with SACAS than in those without it (27.0% vs 2.6%, P < .001). In the univariate analysis, BF was significantly related to SACAS, older age, a higher ASA score, history of coronary disease, greater blood loss and RBC transfusion during surgery, smaller CBD diameter and higher POD 1 BUN level. The multivariate analysis showed that only SACAS (OR 8.91, 95% CI 2.36-33.69, P = .001), older age (OR 1.08, 95% CI 1.01-1.15, P = .028) and smaller preoperative CBD (OR 0.79, 95% CI 0.69-0.92, P = .002) were independent risk factors for postoperative BF. CONCLUSION Older age and a smaller preoperative CBD diameter are independent risk factors for BF after PD, which is consistent with the literature. In addition, SACAS is a new independent risk factor for BF. For patients with SACAS, postoperative drainage should be carefully managed to precisely observe the potential for BF.
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Affiliation(s)
- Yiran Zhou
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai 200025, China
| | - Wei Wang
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai 200025, China
| | - Yusheng Shi
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai 200025, China
| | - Xiongxiong Lu
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai 200025, China
| | - Qian Zhan
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai 200025, China
| | - Hao Chen
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai 200025, China
| | - Xiaxing Deng
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai 200025, China
| | - Chenghong Peng
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai 200025, China
| | - Baiyong Shen
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai 200025, China.
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19
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Beane JD, Schwarz RE. Vascular challenges from pancreatoduodenectomy in the setting of coeliac artery stenosis. BMJ Case Rep 2017; 2017:bcr-2016-217943. [PMID: 28302657 DOI: 10.1136/bcr-2016-217943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Coeliac artery stenosis due to median arcuate ligament compression or atherosclerotic disease is a frequently unrecognised challenge to recovery after pancreatoduodenectomy. The described case illustrates management with intraoperative superior mesenteric artery to hepatic artery bypass graft that led to haemorrhagic challenges postoperatively but ultimately a good recovery. Aspects of preoperative diagnosis, preoperative intervention and intraoperative management options are reviewed. Surgeons need to possess these tools to prevent complications from coeliac artery stenosis when pancreatoduodenectomy is required.
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Affiliation(s)
- Joal D Beane
- Department of Surgery Division of Surgical Oncology, Indiana University School of Medicine, South Bend, Goshen, Indiana, USA
| | - Roderich E Schwarz
- Department of Surgery Division of Surgical Oncology, Indiana University School of Medicine, South Bend, Goshen, Indiana, USA
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20
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Haquin A, Sigovan M, Si-Mohamed S, Mabrut JY, Manichon AF, Bakir M, Rode A, Boussel L. Phase-contrast MRI evaluation of haemodynamic changes induces by a coeliac axis stenosis in the gastroduodenal artery. Br J Radiol 2017; 90:20160802. [PMID: 28124567 DOI: 10.1259/bjr.20160802] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE To evaluate the correlation between the gastroduodenal artery (GDA) haemodynamic changes and the degree of coeliac axis (CA) stenosis using phase-contrast MRI. METHODS The study was institutional review board approved, and written informed consent was obtained from patients included prospectively. A two-dimensional phase-contrast MRI was performed in 23 patients scheduled for a potential complex supramesocolic surgery, in a plane perpendicular to the GDA, during inspiration and expiration. The peak and mean velocities (Vp and Vm), mean flow rate (Qm) and flow direction at inspiration and at expiration have been correlated with the degree of CA stenosis evaluated by CT. RESULTS 13 of 23 patients presented CA stenosis due to the median arcuate ligament (34-80% of stenosis), 4 of them had associated atheromatous calcifications. Vp, Vm and Qm of GDA presented a significant and linear relationship with the degree of CA stenosis, at inspiration as well as at expiration (r > 0.74, p < 0.001). Velocities and flow rates presented a different pattern depending on the degree of CA stenosis: <34% (n = 10), flow direction remained physiological with low velocities and flow rates; >60% of stenosis (n = 5), a reverse flow direction with increased velocities and flow rates were observed; variable patterns between 34% and 60%. CONCLUSION Phase-contrast MRI permits the evaluation of haemodynamic changes in GDA induced by CA stenosis, including median arcuate ligament compression, and could be of great interest in therapeutic decision making in supramesocolic surgery, such as liver transplantation or duodenopancreatectomy, by detecting haemodynamically significant stenoses. Advances in knowledge: Physiological phase-contrast MRI detects haemodynamically significant stenoses of the CA by evaluating haemodynamic parameters in the GDA. Physiological phase-contrast MRI demonstrates that flow in the GDA can be a direct marker of the real haemodynamic impact of a CA stenosis on the hepatic vascularization and could thus participate in the pre-surgical work-up of duodenopancreatectomy or hepatic graft, whereas existing pre-operative imaging are only morphological.
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Affiliation(s)
- Audrey Haquin
- 1 Department of Radiology, Hôpital de la Croix-Rousse, University of Lyon, Lyon, France
| | - Monica Sigovan
- 2 CREATIS, CNRS UMR 5220-INSERM U1206-University of Lyon, Lyon, France
| | - Salim Si-Mohamed
- 1 Department of Radiology, Hôpital de la Croix-Rousse, University of Lyon, Lyon, France.,2 CREATIS, CNRS UMR 5220-INSERM U1206-University of Lyon, Lyon, France
| | - Jean-Yves Mabrut
- 3 Department of Surgery, Hôpital de la Croix-Rousse, University of Lyon, Lyon, France
| | | | - Melisa Bakir
- 1 Department of Radiology, Hôpital de la Croix-Rousse, University of Lyon, Lyon, France
| | - Agnès Rode
- 1 Department of Radiology, Hôpital de la Croix-Rousse, University of Lyon, Lyon, France
| | - Loïc Boussel
- 1 Department of Radiology, Hôpital de la Croix-Rousse, University of Lyon, Lyon, France.,2 CREATIS, CNRS UMR 5220-INSERM U1206-University of Lyon, Lyon, France
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21
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Guilbaud T, Ewald J, Turrini O, Delpero JR. Pancreaticoduodenectomy: Secondary stenting of the celiac trunk after inefficient median arcuate ligament release and reoperation as an alternative to simultaneous hepatic artery reconstruction. World J Gastroenterol 2017; 23:919-925. [PMID: 28223737 PMCID: PMC5296209 DOI: 10.3748/wjg.v23.i5.919] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 10/29/2016] [Accepted: 11/16/2016] [Indexed: 02/06/2023] Open
Abstract
In patients undergoing pancreaticoduodenectomy (PD), unrecognized hemodynamically significant celiac axis (CA) stenosis impairs hepatic arterial flow by suppressing the collateral pathways supplying arterial flow from the superior mesenteric artery and leads to serious hepatobiliary complications due to liver and biliary ischemia, with a high rate of mortality. CA stenosis is usually due to an extrinsic compression by a previously asymptomatic median arcuate ligament (MAL). MAL is diagnosed by computerized tomography in about 10% of the candidates for PD, but only half are found to be hemodynamically significant during the gastroduodenal artery clamping test with Doppler assessment, which is mandatory before any resection. MAL release is usually efficient to restore an adequate liver blood inflow and prevent ischemic complications. In cases of failure in MAL release, postponed PD with secondary stenting of the CA and reoperation for PD should be considered as an alternative to immediate hepatic artery reconstruction, which involves the risk of postoperative thrombosis of the arterial reconstruction. We recently used this two-stage strategy in a patient undergoing surgery for pancreatic adenocarcinoma.
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22
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Karabicak I, Satoi S, Yanagimoto H, Yamamoto T, Hirooka S, Yamaki S, Kosaka H, Kotsuka M, Inoue K, Matsui Y, Kon M. Acute median arcuate ligament syndrome after pancreaticoduodenectomy. Surg Case Rep 2016; 2:113. [PMID: 27744644 PMCID: PMC5065883 DOI: 10.1186/s40792-016-0242-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 10/11/2016] [Indexed: 12/14/2022] Open
Abstract
Median arcuate ligament syndrome (MALS) has been reported in 2–7.6 % of patients undergoing pancreaticoduodenectomy (PD). Most of the reported cases of MALS have been diagnosed perioperatively and treated radiologically or surgically before or during PD. MALS can have an acute postoperative onset after PD even if all preoperative and intraoperative evaluations are normal particularly in young patients. In this report, we present a second case of severe hepatic cytolysis secondary to MALS that developed acutely and the first patient who required acute division of the median arcuate ligament after PD.
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Affiliation(s)
- Ilhan Karabicak
- Department of Surgery, Kansai Medical University, 2-5-1, Shin-machi, Hirakata, Osaka, 573-1010, Japan
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, 2-5-1, Shin-machi, Hirakata, Osaka, 573-1010, Japan.
| | - Hiroaki Yanagimoto
- Department of Surgery, Kansai Medical University, 2-5-1, Shin-machi, Hirakata, Osaka, 573-1010, Japan
| | - Tomohisa Yamamoto
- Department of Surgery, Kansai Medical University, 2-5-1, Shin-machi, Hirakata, Osaka, 573-1010, Japan
| | - Satoshi Hirooka
- Department of Surgery, Kansai Medical University, 2-5-1, Shin-machi, Hirakata, Osaka, 573-1010, Japan
| | - So Yamaki
- Department of Surgery, Kansai Medical University, 2-5-1, Shin-machi, Hirakata, Osaka, 573-1010, Japan
| | - Hisashi Kosaka
- Department of Surgery, Kansai Medical University, 2-5-1, Shin-machi, Hirakata, Osaka, 573-1010, Japan
| | - Masaya Kotsuka
- Department of Surgery, Kansai Medical University, 2-5-1, Shin-machi, Hirakata, Osaka, 573-1010, Japan
| | - Kentoro Inoue
- Department of Surgery, Kansai Medical University, 2-5-1, Shin-machi, Hirakata, Osaka, 573-1010, Japan
| | - Yoichi Matsui
- Department of Surgery, Kansai Medical University, 2-5-1, Shin-machi, Hirakata, Osaka, 573-1010, Japan
| | - Masanori Kon
- Department of Surgery, Kansai Medical University, 2-5-1, Shin-machi, Hirakata, Osaka, 573-1010, Japan
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23
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Başkan Ö, Özdenkaya Y, Erol C, Dolay K. Problems with the Median Arcuate Ligament Should Be Recognized before Surgery; Its Importance in Pancreaticoduodenectomy. Balkan Med J 2015; 32:312-5. [PMID: 26185722 DOI: 10.5152/balkanmedj.2015.15082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 11/05/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Celiac artery stenosis (CAS) is a not a rare finding in the general population. The median arcuate ligament (MAL) is a fibrous arch that unites the diaphragmatic crura on either side of the aortic hiatus and, while it normally passes cranial to the origin of the celiac truncus, a low-lying ligament may lead to compression of the celiac artery and is the one of the major causes of CAS. CASE REPORT In this paper, we present a patient with a mass in the gastric bulbus who was diagnosed with celiac artery stenosis during the pancreaticoduodenectomy (PD). MAL was the cause of the celiac artery stenosis, determined based on the findings of preoperative computed tomography (CT). CONCLUSION Although CAS is usually asymptomatic due to the collateral blood supply, it may be associated with potentially disastrous results due to ischemia of the upper abdominal organs as a result of disruption of the collateral pathways. It is especially important to recognize the presence of CAS and its etiology before interventional procedures. With the increasing use of multidetector computed tomography (MDCT), it becomes essential for radiologists to be aware of this entity and the cross-sectional findings.
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Affiliation(s)
- Özdil Başkan
- Department of Radiology, İstanbul Medipol University, İstanbul, Turkey
| | - Yaşar Özdenkaya
- Department of Surgery, İstanbul Medipol University, İstanbul, Turkey
| | - Cengiz Erol
- Department of Radiology, İstanbul Medipol University, İstanbul, Turkey
| | - Kemal Dolay
- Department of Surgery, İstanbul Medipol University, İstanbul, Turkey
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24
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Del Hoyo Aretxabala I, Gómez García P, Cruz González MIC, Ruiz Carballo S, Iturburu Belmonte I. Celiac artery stenosis due to median arcuate ligament compression: A risk factor in cephalic duodenopancreatectomy? Cir Esp 2015; 93:541-3. [PMID: 26026908 DOI: 10.1016/j.ciresp.2015.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 03/28/2015] [Indexed: 11/26/2022]
Affiliation(s)
- Izaskun Del Hoyo Aretxabala
- Unidad de Cirugía Hepatobiliopancreática, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Basurto, Bilbao, Vizcaya, España.
| | - Pilar Gómez García
- Unidad de Cirugía Hepatobiliopancreática, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Basurto, Bilbao, Vizcaya, España
| | - M Inmaculada Concepción Cruz González
- Unidad de Cirugía Hepatobiliopancreática, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Basurto, Bilbao, Vizcaya, España
| | - Sandra Ruiz Carballo
- Unidad de Cirugía Hepatobiliopancreática, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Basurto, Bilbao, Vizcaya, España
| | - Iñaki Iturburu Belmonte
- Unidad de Cirugía Hepatobiliopancreática, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Basurto, Bilbao, Vizcaya, España
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25
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Emergency Pancreatoduodenectomy with Preservation of Gastroduodenal Artery for Massive Gastrointestinal Bleeding due to Duodenal Metastasis by Clear Cell Renal Cell Carcinoma in a Patient with Celiac Artery Stenosis. Case Rep Surg 2014; 2014:218953. [PMID: 25177508 PMCID: PMC4142743 DOI: 10.1155/2014/218953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2014] [Accepted: 07/29/2014] [Indexed: 11/18/2022] Open
Abstract
Duodenal metastasis from renal cell carcinoma is rare, and even rarer is a massive gastrointestinal bleeding from such tumours. Coeliac occlusive disease, although rarely symptomatic, can lead to ischaemic changes with anastomotic dehiscence and leaks when a patient undergoes pancreatoduodenectomy. A 41-year-old man with known metastasis to the adrenal glands and the second part of the duodenum close to the ampulla of Vater from clear cell renal cell carcinoma was admitted to our department due to massive gastrointestinal bleeding from the duodenal metastasis. Endoscopic control of the bleed was not possible, while the bleeding vessel embolization was able to control the haemorrhage only temporarily. An angiography during the embolization demonstrated the presence of stenosis of the coeliac artery and also hypertrophic inferior pancreaticoduodenal arteries supplying the proper hepatic artery via the gastroduodenal artery (GDA). The patient underwent emergency pancreatoduodenectomy with preservation of the gastroduodenal artery. The patient had an uneventful recovery and did not experience further bleeding. Also the blood flow to the liver was compromised as shown by the normal liver function tests (LFTs) postoperatively. To the best of our knowledge, this is the first report of a preservation of the GDA during an emergency pancreatoduodenectomy.
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Yi HT, Lee WL, Liu TJ, Ting CT, Su CS. Endovascular Angioplasty of Celiac Axis Obstruction Prior to Pancreaticoduodenectomy in a Patient with Pancreatic Neuroendocrine Carcinoma. ACTA CARDIOLOGICA SINICA 2014; 30:165-168. [PMID: 27122784 PMCID: PMC4805023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Accepted: 07/24/2013] [Indexed: 06/05/2023]
Abstract
UNLABELLED In patients with celiac axis stenosis or occlusion, a pancreaticoduodenectomy procedure can increase the risk of hepato-pancreato-biliary and other organ ischemia or failure unless a complete revascularization of the celiac axis is performed prior to or simultaneous with such surgery. Celiac axis occlusion does not appear to be an uncommon finding in cases of pancreaticoduodenectomy. Preoperative abdominal angiography can play an important role in diagnosing this high risk comorbid disease, and adequate intervention can lead to a successful operation and good postoperative outcome. Herein, we reported a patient with periampullary malignancy and metastatic liver cancer, whose preoperative diagnosis of severe celiac axis stenosis was proved by preoperative abdominal angiography. Preoperative angioplasty was subsequently performed. After angioplasty, pancreaticoduodenectomy with resection of segments 4, 6 and 7 of liver was done and the postoperative course was uneventful. KEY WORDS Celiac axis occlusion; Endovascular angioplasty; Pancreaticoduodenectomy.
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Affiliation(s)
- Hung Taoe Yi
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung
| | - Wen-Lieng Lee
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung
- Institute of Clinical Medicine, Cardiovascular Research Center, Department of Medicine, National Yang Ming University School of Medicine, Taipei, Taiwan
| | - Tsun-Jui Liu
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung
- Institute of Clinical Medicine, Cardiovascular Research Center, Department of Medicine, National Yang Ming University School of Medicine, Taipei, Taiwan
| | - Chih-Tai Ting
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung
- Institute of Clinical Medicine, Cardiovascular Research Center, Department of Medicine, National Yang Ming University School of Medicine, Taipei, Taiwan
| | - Chieh-Shou Su
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung
- Institute of Clinical Medicine, Cardiovascular Research Center, Department of Medicine, National Yang Ming University School of Medicine, Taipei, Taiwan
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Gupta V, Chandra A. A case of chronic pancreatitis with celiac axis stenosis complicated by hepatic artery pseudoaneurysm: a therapeutic challenge. Clin Res Hepatol Gastroenterol 2013; 37:e37-e39. [PMID: 22633644 DOI: 10.1016/j.clinre.2012.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 04/11/2012] [Indexed: 02/04/2023]
Abstract
BACKGROUND While hepatic artery pseudoaneurysm is an uncommon complication of the chronic pancreatitis, celiac axis stenosis has rarely been reported in chronic pancreatitis. Although both of these entities have been reported in isolation, simultaneous occurrence of these two problems in one patient of chronic pancreatitis has not been reported so far. METHODS A 32-year-old nonalcoholic male presented with hematemesis and melena for one month. He had undergone longitudinal pancreatico-jejunostomy for the idiopathic chronic pancreatitis one year back. Esophagogastroduodenoscopy could not find any source, but CT angiography revealed a 1.5 × 1.5 cm common hepatic artery pseudoaneurysm along with the complete stenosis of the celiac axis. RESULTS As the endovascular approach was not found to be feasible, surgical ligation of the pseudoaneurysm was performed. Intraoperatively, peripancreatic adhesions with multiple arterial collaterals were found. Patient had an uneventful postoperative recovery, and has been well during the last six months of follow up with no recurrence of bleeding. CONCLUSIONS As the presence of celiac axis stenosis may alter the management plan of bleeding visceral artery pseudoaneurysm, this abnormality should always be looked for in CT angiography performed for suspected bleeding visceral artery pseudoaneurysm.
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Affiliation(s)
- Vishal Gupta
- Department of Surgical Gastroenterology, Chhatrapati Shahuji Maharaj Medical University (Erstwhile King George Medical University), Lucknow, 226003 Uttar Pradesh, India
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Whistance RN, Shah V, Grist ER, Shearman CP, Pearce NW, Odurny A, Stedman B, Johnson CD. Management of median arcuate ligament syndrome in patients who require pancreaticoduodenectomy. Ann R Coll Surg Engl 2011; 93:e11-4. [PMID: 21944786 DOI: 10.1308/003588411x13008915740787] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Pancreaticoduodenectomy is the standard treatment for localised neoplasms of the pancreatic head. The operation can be performed safely in specialist units but good outcome is compromised if postoperative blood flow to the liver and biliary tree is inadequate. Coeliac artery occlusion with blood supply to the liver arising from the superior mesenteric artery via the gastroduodenal artery is difficult to recognise, especially intraoperatively. Recognition of absent hepatic artery pulsation after occlusion of the gastroduodenal artery opens a dilemma: should the resection be abandoned or should vascular reconstruction be undertaken, adding risk to an already complex procedure? We describe two cases with a resectable pancreatic endocrine tumour in which coeliac artery occlusion caused by median arcuate ligament compression was identified from cross-sectional imaging and reconstructions. We highlight two different strategies to correct the vascular insufficiency and allow safe pancreatic resection.
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Affiliation(s)
- Robert N Whistance
- Department of Hepatobiliary and Pancreatic Surgery, Southampton General Hospital, UK.
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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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Berselli M, Sperti C, Ballotta E, Beltrame V, Pedrazzoli S. Pancreaticoduodenectomy with unusual artery reconstruction in a patient with celiac axis occlusion: report of a case. Updates Surg 2010; 62:117-120. [PMID: 20845012 DOI: 10.1007/s13304-010-0015-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Accepted: 07/30/2010] [Indexed: 02/05/2023]
Abstract
Celiac axis stenosis is a relatively common finding that may require major revascularization during pancreaticoduodenectomy. We present a patient that underwent pancreaticoduodenectomy for intraductal papillary mucinous neoplasm of the pancreatic head associated with celiac axis obstruction. To secure arterial blood flow to the upper abdominal organs, the superior posterior pancreaticoduodenal artery and the posterior-inferior pancreatic-duodenal artery were carefully preserved, and anastomosed. The postoperative course was complicated by a pseudoaneurysm of the splenic artery that was successfully treated with angiographic embolization through the vascular bypass. This may be a valid alternative procedure for revascularization of the common hepatic artery during pancreaticoduodenectomy in a patient with celiac axis stenosis.
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Affiliation(s)
- Mattia Berselli
- Department of Medical and Surgical Sciences, Clinica Chirurgica IV, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
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Shukla PJ, Barreto SG, Kulkarni A, Nagarajan G, Fingerhut A. Vascular anomalies encountered during pancreatoduodenectomy: do they influence outcomes? Ann Surg Oncol 2010; 17:186-193. [PMID: 19838756 DOI: 10.1245/s10434-009-0757-1] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2009] [Indexed: 12/14/2022]
Abstract
BACKGROUND Because of the potential risk of hemorrhage or ischemia, the presence of vascular anomalies adds to the surgical challenge in pancreatoduodenectomy (PD). OBJECTIVE To analyze the literature concerning the influence of aberrant peripancreatic arterial anatomy on outcomes of PD. MATERIALS AND METHODS A systematic search using Medline and Embase for the years 1950-2008. RESULTS The most common aberration in hepatic arterial anatomy is the replaced right hepatic artery. Other vascular abnormalities such as replaced common hepatic artery with a hepatomesenteric trunk and celiomesenteric trunk and arcuate ligament syndrome leading to celiac artery stenosis are also associated with post-PD complications. Damage to the biliary branches of the hepatic arteries increases the risk of postoperative biliary anastomotic leak. CONCLUSION The most common abnormalities of the hepatic vasculature include a replaced RHA, replaced LHA, and accessory RHA or LHA. Celiac artery stenosis secondary to median arcuate ligament compression may also be encountered. Every attempt should be made to preserve the aberrant vessel unless their resection is oncologically indicated. Routine preoperative computerized tomography angiography helps to identify the hepatic vascular anatomy and thereby prepares the surgeon to better deal with the vascular anomalies intraoperatively. Increased awareness of the vascular anatomy would decrease the chances of intraoperative vascular injury and consequent postoperative complications such as biliary anastomotic leaks as well as the chances of postoperative hemorrhage.
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Affiliation(s)
- Parul J Shukla
- Department of Gastrointestinal Surgical Oncology, Tata Memorial Hospital, Mumbai, India.
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Laparoscopic treatment of celiac artery compression syndrome: case series and review of current treatment modalities. J Gastrointest Surg 2009; 13:293-8. [PMID: 18818978 DOI: 10.1007/s11605-008-0702-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2008] [Accepted: 09/08/2008] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Compression of the celiac artery by the diaphragmatic crura, the median arcuate ligament, or the fibrous periaortic ganglionic tissue results in a rare constellation of symptoms known as celiac artery compression syndrome (CACS). ANATOMY First described in 1963 by Harjola in a patient with symptoms of mesenteric ischemia, it remains an elusive diagnosis. CLINICAL PRESENTATION Patients commonly present with a wide variety of symptoms resulting in multiple diagnostic tests. DIAGNOSIS A firm diagnosis is difficult to establish, and treatment is equally challenging. These challenges are illustrated by the following case series, and evidence supporting current treatment modalities is reviewed. TREATMENT We describe a laparoscopic approach to decompression of the celiac artery facilitated by intraoperative ultrasound.
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Abstract
OBJECTIVE To assess prevalence, prevention, and management strategy of visceral ischemic complications after pancreaticoduodenectomy (PD). BACKGROUND Ischemic complications after PD resulting from preexisting celiac axis (CA), superior mesenteric artery (SMA), stenosis, or intraoperative arterial trauma appear as an underestimated cause of death. Their prevention and adequate management are challenging. METHODS From 1995 to 2006, 545 PD were performed in our institution. All patients were evaluated by thin section multidetector computed tomography (CT) with arterial reconstruction to detect and class SMA or CA stenosis. Hemodynamical significance of stenosis was assessed preoperatively by arteriography for atherosclerotic stenosis and intraoperatively by gastroduodenal artery clamping test for CA compression by median arcuate ligament. Significant atherosclerotic stenosis was stented or bypassed, whereas CA compression was treated by median arcuate ligament division during PD. Multidetector-CT accuracy to detect arterial stenosis, results of revascularization procedures, and both prevalence and prognosis of ischemic complications after PD were analyzed. RESULTS Among 62 (11%) stenoses detected by multidetector-CT, 27 (5%) were hemodynamically significant, including 23 CA compressions by median arcuate ligament, 2 CA, and 2 SMA atherosclerotic stenoses, respectively. All atherosclerotic stenoses were successfully treated by preoperative stenting (n = 3) or bypass (n = 1). Among the 23 cases who underwent median arcuate ligament division, 3 (13%) failed due to 1 CA injury and 2 misdiagnosed intrinsic CA stenoses. Overall, 6 patients developed ischemic complications, due to intraoperative hepatic artery injury (n = 4), unrecognized SMA atherosclerotic stenosis (n = 1), or CA fibromuscular dysplasia (n = 1). Five (83%) of them died, representing 36% of the 14 deaths of the whole series (overall mortality = 2.6%). Overall, CT detected significant arterial stenosis with a 96% sensitivity and determined etiology of CA stenosis with a 92% accuracy. CONCLUSIONS Ischemic complications are an underestimated cause of death after PD and are due to preexisting stenoses of CA and SMA, or intraoperative hepatic artery injury. Preexisting arterial stenoses are detected by routine multidetector CT. Preoperative endovascular stenting for intrinsic stenosis, division of median arcuate ligament for extrinsic compression, and meticulous dissection of the hepatic artery can contribute to minimize ischemic complications.
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Sakorafas GH, Sarr MG, Peros G. Celiac artery stenosis: an underappreciated and unpleasant surprise in patients undergoing pancreaticoduodenectomy. J Am Coll Surg 2007; 206:349-56. [PMID: 18222391 DOI: 10.1016/j.jamcollsurg.2007.09.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2007] [Revised: 08/16/2007] [Accepted: 09/04/2007] [Indexed: 12/11/2022]
Affiliation(s)
- George H Sakorafas
- 4th Department of Surgery, Athens University, Medical School, Attikon University Hospital, Athens, Greece.
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Hashimoto M, Beck Y, Mise Y, Kokudo N, Makuuchi M. Celiac axis compression during the expiratory phase as a cause of hepatic ischemia during pancreaticoduodenectomy. Surgery 2007; 142:429-30. [PMID: 17723903 DOI: 10.1016/j.surg.2007.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2007] [Revised: 05/10/2007] [Accepted: 05/16/2007] [Indexed: 10/22/2022]
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Soonawalla Z, Ganeshan A, Friend P. Celiac artery occlusion encountered during pancreatic resection: a case report. Ann R Coll Surg Engl 2007; 89:W15-7. [PMID: 17316515 PMCID: PMC1963528 DOI: 10.1308/147870807x160344] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Pancreatic surgeons need to be aware of, and have the expertise available to deal with, unexpected vascular anomalies encountered during pancreatic resections. We present a patient with celiac artery occlusion that was encountered unexpectedly during pancreaticoduodenectomy. As a result of this anomaly, the celiac territory is dependent on retrograde flow via collaterals from the superior mesenteric artery. We discuss the method of identifying this situation, and of revascularising the celiac trunk to prevent ischaemia of upper abdominal viscera. We highlight the implications for surgical training.
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Affiliation(s)
- Zahir Soonawalla
- Nuffield Department of Surgery, John Radcliffe Hospital, Oxford, UK.
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Farma JM, Hoffman JP. Nonneoplastic celiac axis occlusion in patients undergoing pancreaticoduodenectomy. Am J Surg 2007; 193:341-4; discussion 344. [PMID: 17320531 DOI: 10.1016/j.amjsurg.2006.09.027] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2006] [Revised: 09/20/2006] [Accepted: 09/20/2006] [Indexed: 12/12/2022]
Abstract
BACKGROUND Celiac artery occlusion occurs in a small percentage of the population. Identifying this is critical in planning for pancreaticoduodenectomy. We reviewed 332 patients treated with pancreaticoduodenectomy, and identified 14 patients with celiac artery occlusion. METHODS Between 1988 and 2006, 14 (4%) of 332 patients treated with pancreaticoduodenectomy had median arcuate ligament syndrome with celiac artery occlusion (6 men, 8 women; mean age, 70 y; range, 38-80 y). Patients underwent preoperative imaging with computed tomography (n = 14) and angiography (n = 13). RESULTS Patients were diagnosed preoperatively (n = 13) and intraoperatively (n = 1) with celiac artery occlusion. Surgeries included classic pancreaticoduodenectomy (n = 12), pylorus-preserving pancreaticoduodenectomy (n = 1), median arcuate ligament release (n = 10), and vascular reconstructions (n = 4), with no surgical mortalities and postoperative complications in 6 patients (46%). CONCLUSIONS We report our experience of median arcuate ligament syndrome with celiac artery occlusion in 4% of our patients treated with pancreaticoduodenectomy. Patients underwent median arcuate ligament release, vascular reconstruction, and/or stenting. Angiography diagnosed celiac artery occlusion and allowed preoperative planning. Pancreatic surgeons must understand the importance of identifying celiac artery occlusion before resection to prevent severe complications.
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Affiliation(s)
- Jeffrey M Farma
- Department of Surgery, Temple University Hospital, Philadelphia, PA, USA
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Kamisawa T, Egawa N, Tu Y, Tsuruta K, Okamoto A. Does moderate celiac axis stenosis identified on preoperative multidetector computed tomographic angiography predict an increased risk of complications after pancreaticoduodenectomy for malignant pancreatic tumors? Pancreas 2007; 34:96-102. [PMID: 17198190 DOI: 10.1097/01.mpa.0000240607.49183.7e] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To identify any association between celiac artery compromise found on computed tomographic angiography and the incidence of postoperative and perioperative complications. METHODS The computed tomographic angiograms of 36 patients who underwent the Whipple procedure for pancreatic adenocarcinoma were examined retrospectively. The association between the results and surgical course was investigated. RESULTS Twelve patients (33%) had significant postoperative complications. Ten (28%) had evidence of celiac artery stenosis. Stenosis ranged from 20% to 60%. There was no evidence of a difference between the 2 groups. CONCLUSION There seems to be no evidence of an increased risk of postoperative or perioperative complication in patients undergoing the Whipple procedure, with a celiac stenosis of up to 60%.
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Affiliation(s)
- Terumi Kamisawa
- Department of Internal Medicine, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan.
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Halazun KJ, Kotru A, Menon KV, Patel J, Prasad KR. Stenting of coeliac axis stenosis facilitates pancreatectomy. Eur J Surg Oncol 2006; 32:811-2. [PMID: 16784835 DOI: 10.1016/j.ejso.2006.04.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2005] [Accepted: 04/21/2006] [Indexed: 12/21/2022] Open
Affiliation(s)
- K J Halazun
- Hepatobiliary and Transplant Unit, St James's University Hospital, Beckett Street, Leeds LS9 7TF, UK
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Takamatsu S, Ban D, Irie T, Noguchi N, Kudoh A, Nakamura N, Kawamura T, Igari T, Teramoto K, Arii S. Resection of a cancer developing in the remnant pancreas after a pancreaticoduodenectomy for pancreas head cancer. J Gastrointest Surg 2005; 9:263-9. [PMID: 15694823 DOI: 10.1016/j.gassur.2004.05.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We report a rare case of a curative resection performed on a carcinoma developing in the remnant pancreas at 3 years 7 months after a pancreaticoduodenectomy for pancreatic cancer. A 63-year-old man underwent a pancreaticoduodenectomy for pancreatic cancer on November 1999. Because the celiac trunk was occluded by atherosclerosis, an aortohepatic bypass with a saphenous vein graft was performed simultaneously. In May 2003, tumor marker levels increased, and a tumor was detected in the remnant pancreas on computed tomography. There were no findings such as invasion into the surrounding tissue or distant metastasis, and therefore we removed the remnant pancreas in July 2003. Histopathologically, the tumor consisted of a well-differentiated tubular adenocarcinoma and was limited to the pancreas. Moreover, the anastomotic site of the pancreaticojejunostomy was negative for cancer, and some foci of papillary hyperplasia and goblet cell metaplasia of the pancreatic ductal epithelium, which was thought to be the precursor of the pancreatic cancer, were seen. These findings suggested that the tumor was a second primary cancer developing in the remnant pancreas. This case provided suggestive evidence for the development of pancreatic cancer, and the surgical procedure for a pancreaticoduodenectomy with occlusion of the celiac trunk is discussed.
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Affiliation(s)
- Susumu Takamatsu
- Department of Hepato-Biliary-Pancreatic Surgery, Tokyo Medical and Dental University, Graduate School of Medicine, Tokyo 113-8519, Japan.
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Murakami Y, Uemura K, Yokoyama Y, Sasaki M, Morifuji M, Hayashidani Y, Sudo T, Sueda T. Celiac axis occlusion with replaced common hepatic artery and pancreatoduodenectomy. J Gastrointest Surg 2004; 8:520-2. [PMID: 15120379 DOI: 10.1016/j.gassur.2004.01.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
A rare case of intraductal papillary mucinous tumor of the pancreas associated with a replaced common hepatic artery and celiac axis occlusion, which was treated by pancreatoduodenectomy, is reported. In this patient, the celiac trunk was occluded at its root and the splenic and left gastric artery could be visualized serially via the enlarged collateral artery on superior mesenteric arteriography. At surgery, the collateral artery was carefully preserved and pancreatoduodenectomy was successfully performed without ischemia of the stomach, spleen, and remnant pancreas. Although celiac axis occlusion is an uncommon finding for patients undergoing pancreatoduodenectomy, we recommend performing celio-mesenteric angiography before pancreatoduodenectomy, and, at surgery, clamping of the gastroduodenal artery is required for patients with celiac axis occlusion.
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Affiliation(s)
- Yoshiaki Murakami
- Department of Surgery, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan.
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Francque S, Condat B, Asselah T, Vilgrain V, Durand F, Moreau R, Valla D. Multifactorial aetiology of hepatic infarction: a case report with literature review. Eur J Gastroenterol Hepatol 2004; 16:411-5. [PMID: 15028975 DOI: 10.1097/00042737-200404000-00008] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The rarity of hepatic infarction has been explained by the protection from ischaemia provided by the double arterial and portal inflow. Hepatic infarction hence should require the association of multiple factors jeopardizing compensatory mechanisms. We report on a case of hepatic infarction related to combined hepatic arterial and portal venous thrombosis after a blunt abdominal trauma, a previously unreported cause of hepatic infarction. Several causes of vascular impairment were present: shear stress injury due to the trauma, protein C deficiency, type II diabetes and administration of glibenclamide, a splanchnic vasoconstrictor agent. There was repermeation of the portal vein and hepatic artery following anticoagulation therapy. Because hepatic infarction is usually explained by the concurrence of several factors impairing the hepatic blood supply, an extensive search for associated conditions is necessary even when a conspicuous cause is present.
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Affiliation(s)
- Sven Francque
- Service d'Hépatologie and INSERM U481, Hôpital Beaujon, Clichy, France
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Hasegawa K, Imamura H, Akahane M, Miura Y, Takayama T, Ohtomo K, Makuuchi M. Endovascular stenting for celiac axis stenosis before pancreaticoduodenectomy. Surgery 2003; 133:440-2. [PMID: 12717363 DOI: 10.1067/msy.2003.103] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Kiyoshi Hasegawa
- Division of Hepato-Biliary-Pancreatic and Transplantation Surgery, Department of Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
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Kim AW, McCarthy WJ, Maxhimer JB, Quiros RM, Hollinger EF, Doolas A, Millikan KW, Deziel DJ, Godellas CV, Prinz RA. Vascular complications associated with pancreaticoduodenectomy adversely affect clinical outcome. Surgery 2002; 132:738-44; discussion 744-7. [PMID: 12407360 DOI: 10.1067/msy.2002.127688] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Early survival after pancreaticoduodenectomy has improved, but its morbidity remains high. The purpose of this study is to determine how the intra-operative (OR) occurrence of major vascular complications affects the outcome of pancreaticoduodenectomy. METHODS The medical records of 180 consecutive patients having pancreaticoduodenectomy from 1991 to 2001 were reviewed. Vascular complications were defined as "an unanticipated injury or thrombosis of a major vessel necessitating intervention." Age, sex, type of pancreaticoduodenectomy, tumor size, estimated blood loss, OR time, time in intensive care, post-OR hospitalization, and survival were compared. RESULTS Eighteen vascular complications were identified. Differences in age, sex, and type of resection between patients with or without vascular complications were not significant. OR time, estimated blood loss, blood transfusions, tumor size, time in intensive care, and post-OR hospitalization were all significantly greater in patients with vascular complications. Median survival for patients with vascular complications was significantly shorter than for patients without vascular complications. Thirty-day mortality was greater in patients with vascular complications. CONCLUSION Vascular complications significantly affect the outcome of pancreaticoduodenectomy increasing OR time, estimated blood loss, blood transfusion requirements, time in intensive care, post-OR hospitalization, and mortality.
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Affiliation(s)
- Anthony W Kim
- Departments of General and Cardiovascular Thoracic Surgery, Rush Presbyterian-St. Luke's Medical Center, Chicago, Ill 60612, USA
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Pelloni A, Gertsch P. [Cephalic duodenopancreatectomy with preservation of pancreaticoduodenal arcades in coeliac trunk occlusion]. ANNALES DE CHIRURGIE 2000; 125:660-4. [PMID: 11051696 DOI: 10.1016/s0003-3944(00)00259-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
In the case of complete occlusion of the coeliac trunk, the hepatic and splenic arterial blood supply is ensured by the superior mesenteric artery. Interruption of this collateral circulation by pancreaticoduodenectomy carries a risk of hepatic ischaemia and anastomotic leaks. In addition to the various techniques of coeliac trunk revascularization, preservation of the gastroduodenal artery and pancreaticoduodenal arcades may help to preserve the arterial blood supply. The authors report the case of a 58-year-old female with a benign tumour of the pancreatic head and partially corrected coeliac trunk occlusion. Pancreaticoduodenectomy was performed with preservation of the pancreaticoduodenal arcades and gastroduodenal artery.
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Affiliation(s)
- A Pelloni
- Service de chirurgie, Ospedale San Giovanni, Bellinzona, Suisse
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Vellar ID, Banting SW, Mossop P. Stenting of the severely stenotic coeliac axis in the management of pancreatic and biliary fistulas following pancreaticoduodenectomy. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1999; 69:823-5. [PMID: 10553975 DOI: 10.1046/j.1440-1622.1999.01705.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- I D Vellar
- Department of Surgery, University of Melbourne, Fitzroy, Victoria, Australia
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Berney T, Pretre R, Chassot G, Morel P. The role of revascularization in celiac occlusion and pancreatoduodenectomy. Am J Surg 1998; 176:352-6. [PMID: 9817254 DOI: 10.1016/s0002-9610(98)00195-0] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Performance of pancreatoduodenectomy involves sacrifice of the gastroduodenal artery (GDA), which poses an ischemic threat to the liver, stomach, pancreas, and various anastomoses in patients with celiac trunk occlusion. METHODS A survey was conducted in surgical centers with expertise in the field of pancreatic surgery. Detailed information was collected from 17 institutions worldwide. Fifteen patients with celiac trunk obstruction were identified. The indication for resection was periampullary tumor in 10 cases and chronic pancreatitis in 5. RESULTS The cause of occlusion was atheromatous disease in 13 cases and arcuate ligament in 2. Trial clamping of the GDA was done in 11 patients, and provoked obvious ischemia in 4. Six patients underwent vascular procedures: the arcuate ligament was severed in 2 cases, the GDA was preserved in 2 cases of chronic pancreatitis, an aorto-hepatic bypass was performed in 1 case, and the celiac trunk was reimplanted in 1 case. Complications occurred in 5 patients, with 2 fatalities. CONCLUSIONS Occlusion of the celiac trunk in patients undergoing pancreatoduodenectomy rarely leads to significant problems. Trial clamping of the GDA is required to assess the need for revascularization.
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Affiliation(s)
- T Berney
- Clinic of Digestive Surgery, Geneva University Hospital, Switzerland
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Abstract
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.
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Affiliation(s)
- F R Bech
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Woods MS. Preoperative visceral angiography for mapping the midgut arterial anatomy. Ann Surg 1995; 221:206-7. [PMID: 7857152 PMCID: PMC1234962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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