Does Moderate Celiac Axis Stenosis Identified on Preoperative Multidetector Computed Tomographic Angiography Predict an Increased Risk of Complications After Pancreaticoduodenectomy for Malignant Pancreatic Tumors?

Smith, Simon; Rae, David; Sinclair, Martin; Satyadas, Thomas

doi:10.1097/01.mpa.0000240607.49183.7e

Cited by 24 publications

(17 citation statements)

References 13 publications

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“…This was consistent with significant interindividual variations of the duct system in the pancreatic head 11,12. However, surgeons might expect a clear frontal plane even based on PP immunohistochemistry of adult materials 4,7,8.…”

Section: Discussionsupporting

confidence: 76%

“…Identification of the dorsal and ventral primordia of the pancreas, using adult as well as fetal materials, had been conducted with the aid of pancreatic polypeptide (PP) immunohistochemistry4-8 and the results provided a concept of segmentectomy for benign tumors in the pancreatic head 9,10. However, in contrast to the detailed studies of the pancreatic duct system,11,12 the arterial configuration was not investigated in the context of the pancreatic primordia or segments except for Sakamoto, et al4 possibly because of no basic embryologic study on arterial development of the pancreatic head. Consequently, in combination with studies using PP immunohistochemistry, the present study was aimed to describe development of the vascular topographical anatomy at and around the pancreatic head in order to provide a better understanding of the "segmental" treatment in pancreatic surgery.…”

Section: Introductionmentioning

confidence: 99%

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Fetal Topographical Anatomy of the Pancreatic Head and Duodenum with Special Reference to Courses of the Pancreaticoduodenal Arteries

Jin

Cho

et al. 2010

Yonsei Med J

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PurposeThe purpose of this study is to provide better understanding as to how the "double" vascular arcades, in contrast to other intestinal marginal vessels, develop along the right margin of the pancreatic head.Materials and MethodsIn human fetuses between 8-30 weeks, we described the topographical anatomy of the vessels, bile duct, duodenum as well as the ventral and dorsal primordia of the pancreatic head with an aid of pancreatic polypeptide immunohisto-chemistry.ResultsThe contents of the hepatoduodenal ligament crossed the superior side of the pylorus. Moreover, the right hepatic artery originating from the superior mesenteric artery ran along the superior aspect of the pancreatic head. An arterial arcade, corresponding to the posterior pancreaticoduodenal arteries, encircled the superior part of the pancreatic head, whereas another arcade, corresponding to the anterior pancreaticoduodenal arteries, surrounded the inferior part. The dorsal promordium of the pancreas surrounded and/or mixed the ventral primordium at 13-16 weeks. Thus, both arterial arcades were likely to attach to the dorsal primordium.ConclusionThe fetal anatomy of the pancreaticoduodenal vascular arcades as well as that of the hepatoduodenal ligament were quite different from adults in topographical relations. Thus, in the stage later than 30 weeks, further rotation of the duodenum along a horizontal axis seemed to be required to move the pylorus posterosuperiorly and to reflect the superior surface of the pancreatic head posteriorly. However, to change the topographical anatomy of the superior and inferior arterial arcades into the final position, re-arrangement of the pancreatic parenchyma might be necessary in the head.

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Section: Discussionsupporting

confidence: 76%

Section: Introductionmentioning

confidence: 99%

Fetal Topographical Anatomy of the Pancreatic Head and Duodenum with Special Reference to Courses of the Pancreaticoduodenal Arteries

Jin

Cho

et al. 2010

Yonsei Med J

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“…The role of interventional vascular techniques for coeliac axis obstruction prior to PD in reducing postoperative complications is controversial for low-grade lesions, but have clear indications for lesions with >60% stenosis 16. Endovascular stents are used preoperatively to avoid technical challenges and potential morbidity associated with performing a vascular bypass at the time of PD 4 14 15.…”

Section: Discussionmentioning

confidence: 99%

“…However, predicting which patients will develop clinically relevant ischaemia following PD is challenging due to the highly variable nature of the collaterals that develop; this is an ongoing area of research 7. Smith et al 16 found no association between coeliac occlusion and increased postoperative morbidity when they analysed patients with <60% stenosis. Yet, in at-risk patients with radiographic evidence of high-grade coeliac stenosis with development of retrograde flow through the CHA, preoperative endovascular approach is a necessary intervention 4…”

Section: Discussionmentioning

confidence: 99%

Vascular challenges from pancreatoduodenectomy in the setting of coeliac artery stenosis

Beane

Schwarz

2017

BMJ Case Reports

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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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“…Smith et al reported that stenosis of <60%, as seen on CT, was not associated with an increased risk of postoperative or perioperative complications in patients undergoing PD. 4) The extreme variability of pancreatic and peripancreatic collateral vascularization and the common existence of collateral pathways from the dorsal pancreatic artery or from a replaced right hepatic artery may explain why hepatic blood flow can be maintained even after divisions of the GDA in cases of CA stenosis or occlusion. Ouaissi et al mentioned that decompression procedures were not necessary for patients with arterial stenosis of <50% before or during PD, while stenosis >50% needed treatment by revascularization surgery and/or endovascular stenting.…”

mentioning

confidence: 99%

Endovascular Stenting for Non-Traumatic Celiac Artery Stenosis Following Pancreatoduodenectomy

Yao

Yagi

Ueda

2016

Annals of Vascular Diseases

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Postoperative celiac artery stenosis (CAS) rarely occurs in the absence of vascular injury or pseudoaneurysm after pancreatoduodenectomy (PD). Because of its low incidence, the optimal treatment for non-traumatic postoperative CAS is unknown. Here, we show a case of CAS possibly due to exacerbated median arcuate ligament compression after PD. The purpose of this report is to describe this rare complication and its successful endovascular treatment with review of literatures.Keywords: pancreatoduodenectomy, celiac artery stenosis, stent incidence and few reported cases, the optimal treatment for non-traumatic postoperative celiac artery stenosis (CAS) is unknown. Here, we present a case of CAS possibly caused by exacerbated MAL compression after PD. The purpose of this report is to describe this rare complication and its successful treatment. Case ReportA 51-year-old Asian woman with abnormally elevated tumor markers (serum CA19-9 of 371 U/ml, SPAN-1 of 63 U/ml) was referred to our outpatient department for further evaluation. She had no significant past medical history and her physical examination was unremarkable. Abdominal ultrasound and contrast enhanced abdominal computed tomography (CT) scan revealed a 25-mm solid neoplasm in the body of the pancreas. Although there were no signs of distant metastasis, direct invasion to the portal vein was suspected. Subtotal stomach-preserving PD, including portal vein reconstruction and D2 lymphadenectomy, was performed based on the preliminary diagnosis of pancreatic cancer. No anatomical variations of the celiac trunk or mesenteric vessels and relative branches were detected during preoperative radiological imaging or during surgery. The result of preoperative CT is shown (Fig. 1). The operation was successfully performed without any vascular injury. A clamp test of the gastroduodenal artery (GDA) did not show ischemic alterations of the liver, stomach or spleen. The operative time was 449 minutes and blood loss totaled 515 ml. At definitive histological examination, a ductal pancreatic adenocarcinoma was confirmed (pT4 N1 M0).During the postoperative course, laboratory tests showed abnormally elevated hepatic enzymes on postoperative day (POD) 2, including aspartate aminotransferase of 1160 U/L and alanine aminotransferase of 1534 U/L. Contrast enhanced abdominal CT revealed multiple liver and spleen infarctions (Figs. 2a and 2b). The reconstructed portal vein, proper hepatic artery, and splenic artery were patent. However, a stenotic celiac arterial root was evident on CT angiography, without pseudoaneurysm (Fig. 2c). Emergency celiac arteriography was performed and the stenotic celiac arterial root was confirmed (Fig. 2d). To maintain hepatic and splenic arterial flow, percutaneous

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Does Moderate Celiac Axis Stenosis Identified on Preoperative Multidetector Computed Tomographic Angiography Predict an Increased Risk of Complications After Pancreaticoduodenectomy for Malignant Pancreatic Tumors?

Abstract: 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%.

Cited by 24 publications

References 13 publications

Fetal Topographical Anatomy of the Pancreatic Head and Duodenum with Special Reference to Courses of the Pancreaticoduodenal Arteries

Fetal Topographical Anatomy of the Pancreatic Head and Duodenum with Special Reference to Courses of the Pancreaticoduodenal Arteries

Vascular challenges from pancreatoduodenectomy in the setting of coeliac artery stenosis

Endovascular Stenting for Non-Traumatic Celiac Artery Stenosis Following Pancreatoduodenectomy

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