Hepatic Ischemia, Caused by Celiac Axis Compression, Complicating Pancreaticoduodenectomy

Bull, David A.; Hunter, Glenn C.; Crabtree, Thomas G.; Bernhard, Victor M.; Putnam, Charles W.

doi:10.1097/00000658-199303000-00005

Cited by 68 publications

(45 citation statements)

References 2 publications

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“…Therefore we recommend performing the resection as in any other case if the celiac axis stenosis is diagnosed preoperatively. According to our results, an initial test occlusion of the gastroduodenal artery prior to its division as described by Bull et al [5] does not seem necessary. In the case of no pulse in the common hepatic artery we recommend the local administration of a vasodilatory drug because of a possible vasospasm of the common hepatic artery (first step, see below).…”

Section: Resultssupporting

confidence: 60%

“…Fortner and Watson [8] describe two cases of pancreatic resections for carcinoma in which division of the median arcuate ligament was necessary to avoid ischemia of the upper abdominal organs. Other patients are reported by Kohler et al [6] and Bull et al [5]. In these cases decompression of the impinging diaphragmatic fibers released the celiac artery after pancreatic resection.…”

Section: Introductionmentioning

confidence: 85%

“…During pancreatic head resection some of these important collaterals must be divided. A diminished blood flow may lead to ischemia of the upper abdominal organs and results in liver failure and insufficiency of the pancreatico-jejunal anastomosis [1,5,6]. Traverso and Freeny [7] have also pointed out the importance of preserving hepatic artery blood flow to prevent biliary fistula from the biliodigestive anastomosis.…”

Section: Introductionmentioning

confidence: 99%

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Celiac axis stenosis in pancreatic head resection for chronic pancreatitis

Pfeiffenberger

Adam

Drognitz

et al. 2002

Langenbeck's Archives of Surgery

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Section: Resultssupporting

confidence: 60%

Section: Introductionmentioning

confidence: 85%

Section: Introductionmentioning

confidence: 99%

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Celiac axis stenosis in pancreatic head resection for chronic pancreatitis

Pfeiffenberger

Adam

Drognitz

et al. 2002

Langenbeck's Archives of Surgery

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“…Currently, this is performed mainly by anatomical measurement (X-ray angiography, CT or MRI 10 ) of the degree of CA stenosis and the diameter of the GDA, the main collateral pathway that can compensate for the decrease of flow due to the CA with retrograde flow from the superior mesenteric artery. 11 Nevertheless, these measurements only indirectly reflect the complex haemodynamics in the coeliac area: Doppler hepatic artery flow monitoring 12,13 or clamping trial of the GDA [14][15][16] are often necessary during the surgical procedure. 17 Thus, a simple and robust non-invasive tool would be of great interest to directly assess the effect of CA stenosis on the haemodynamics before surgery.…”

Section: Introductionmentioning

confidence: 99%

Phase-contrast MRI evaluation of haemodynamic changes induces by a coeliac axis stenosis in the gastroduodenal artery

Haquin

Sigovan

Mabrut

et al. 2017

BJR

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Objective: To evaluate the correlation between the gastroduodenal artery (GDA) haemodynamic changes and the degree of coeliac axis (CA) stenosis using phasecontrast 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 (V p and V m ), mean flow rate (Q m ) 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. V p , V m and Q m 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 5 10), flow direction remained physiological with low velocities and flow rates; .60% of stenosis (n 5 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 presurgical work-up of duodenopancreatectomy or hepatic graft, whereas existing pre-operative imaging are only morphological.

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“…However, in patients requiring pancreaticoduodenectomy, coeliac trunk patency is essential because of the requirement for intraoperative division of the GDA and the potential for postoperative hepatic and biliary ischaemia as a result of interruption of the collateral blood supply. 8 Coeliac axis stenosis due to MALS has traditionally been identified intraoperatively when the GDA is temporarily clamped. The absence of pulsatile flow in the common hepatic artery suggests coeliac occlusion and proximal dissection towards the aorta and diaphragm may then reveal a tight median arcuate ligament in close proximity to the coeliac trunk.…”

mentioning

confidence: 99%

Management of median arcuate ligament syndrome in patients who require pancreaticoduodenectomy

Whistance

Shah

Grist

et al. 2011

annals

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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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Hepatic Ischemia, Caused by Celiac Axis Compression, Complicating Pancreaticoduodenectomy

Cited by 68 publications

References 2 publications

Celiac axis stenosis in pancreatic head resection for chronic pancreatitis

Celiac axis stenosis in pancreatic head resection for chronic pancreatitis

Phase-contrast MRI evaluation of haemodynamic changes induces by a coeliac axis stenosis in the gastroduodenal artery

Management of median arcuate ligament syndrome in patients who require pancreaticoduodenectomy

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