An innovative way of managing coeliac artery stenosis during pancreaticoduodenectomy

Abstract

Coeliac artery stenosis (CAS) is rarely of consequence owing to rich collateral supply from the superior mesenteric artery via the pancreatic head. Pancreaticoduodenectomy (PD) in CAS disrupts these collaterals, and places the liver, stomach and spleen at risk of ischaemia. A 56-year-old man presented with a 3-week history of obstructive jaundice. Computed tomography revealed an operable periampullary tumour with CAS due to compression by the median arcuate ligament with multiple collaterals in the pancreatic head and a prominent gastroduodenal artery (GDA). Following unsuccessful coeliac axis endovascular stenting, a PD was performed. Intraoperative median arcuate ligament release failed to restore good flow in the common hepatic artery (CHA) and splenic artery (SpA) A decision was made to use the left gastric artery (LGA) for arterial reconstruction, disconnect it from the stomach with its origin intact and anastomose it to the supracoeliac aorta. Doppler ultrasonography with a GDA clamp confirmed good filling of the CHA and SpA via the LGA. The GDA was ligated and the PD completed. The patient had an uneventful recovery except for a biochemical pancreatic leak and was discharged on day 10. CAS during PD (confirmed by a decrease in CHA flow with a GDA clamp) requires an additional procedure to restore blood flow to the liver, stomach and spleen. Anastomosing the LGA to the supracoeliac aorta is a simple reconstruction technique for achieving this.

Treatment strategy for pancreatic head cancer with celiac axis stenosis in pancreaticoduodenectomy: A case report and review of literature

“…First, it requires a high level of skill for stenting in the case of MAL compression. There are previous reports of failure in cases of stenting[ 21 - 23 ]. It is hoped that IVR techniques will become more widespread and improve in the future.…”

Median Arcuate Ligament Syndrome (MALS) in Hepato-Pancreato-Biliary Surgery: A Narrative Review and Proposed Management Algorithm

“…Two groups chose to perform stenting prior to PD to ensure adequate flow of the celiac trunk without dividing MAL [53,54]. Balakrishnan et al reported an unsuccessful attempt at upfront endovascular stenting of the celiac trunk prior to PD, leading the patient to undergo subsequent MAL release and arterial reconstruction [55]. Endovascular intervention during neoadjuvant chemotherapy has been described in another case study [10].…”

Hyperspectral Imaging (HSI)—A New Tool to Estimate the Perfusion of Upper Abdominal Organs during Pancreatoduodenectomy

“…Resection of pancreatic head cancer routinely involves the sacrifice of these communications, which may lead to insufficient perfusion of the upper abdominal organs and sometimes (e.g.,in the case of significant CAS) to their ischemic complications. To prevent these dramatic complications, the GDA clamping test has already been described as a mandatory test to evaluate the hepatic blood flow by ascertaining the satisfactory pulsation of the proper hepatic artery, as well as via Doppler ultrasonography [ 10 , 11 , 12 , 13 ]. To the best of our knowledge, there are no quantitative data or well-established algorithms to assess the perfusion of upper abdominal organs and hepatic blood flow during pancreatic surgery before and after GDA clamping.…”