Pancreaticoduodenectomy: Secondary stenting of the celiac trunk after inefficient median arcuate ligament release and reoperation as an alternative to simultaneous hepatic artery reconstruction

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.

Aneurysms of Pancreaticoduodenal Artery due to Median Arcuate Ligament Syndrome, Treated by Open Surgery and Laparoscopic Surgery

“…MAL is found in approx. 10% of preoperative CT examinations of patients for whom a PD is planned [7].…”

Acute median arcuate ligament syndrome after pancreaticoduodenectomy

“…Gaujoux et al reported that multidetector CT, especially its lateral views, can detect significant arterial stenosis with 96% sensitivity and determine the etiology of celiac axis stenosis with 92% accuracy [ 11 ]. If MALS is diagnosed before PD, various methods are available for revascularization before or during the procedure; these include open or laparoscopic MAL division, vascular bypass procedure, or endovascular stenting [ 7 , 8 , 12 , 13 ]. Sharafuddin et al reported 25 cases treated with stent-assisted angioplasty for stenosis of the celiac artery or the superior mesenteric artery with a 96% success rate [ 7 ].…”

“…When MALS is diagnosed preoperatively, it can be treated by interventional radiology, MAL division, or bypass grafting [ 5 , 6 ]. These strategies have been reported to be usually effective in restoring an adequate blood flow and preventing ischemic complications [ 7 , 8 ].…”

Pancreaticoduodenectomy complicated by Budd-Chiari syndrome: A case report and review of literature

“…The complication of liver failure in the postoperative period after PD occurs only seldomly, and is reported in the literature to the same low extent. Most of the reported cases are only described in cases reports; these include an underestimated or undiagnosed liver disease before surgery[3,4], a nutritional origin related to exocrine pancreatic insufficiency[5,6], an asymptomatic median arcuate ligament not detected before and during surgery, or inefficiently treated[7,8], a hepatic artery injury during the PD[9,10], as secondary to adjuvant chemotherapy (mainly with gemcitabine)[11], a proximal or selective hepatic arterial embolization or intrastent thrombosis[12-17], and a portal vein occlusion[18,19].…”