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

Abstract

BACKGROUND During pancreaticoduodenectomy in patients with celiac axis (CA) stenosis due to compression by the median arcuate ligament (MAL), the MAL has to be divided to maintain hepatic blood flow in many cases. However, MAL division often fails, and success can only be determined intraoperatively. To overcome this problem, we performed endovascular CA stenting preoperatively, and thereafter safely performed pancreaticoduodenectomy. We present this case as a new preoperative treatment strategy that was successful. CASE SUMMARY A 77-year-old man with a diagnosis of pancreatic head cancer presented to our department for surgery. Preoperative assessment revealed CA stenosis caused by MAL. We performed endovascular stenting in the CA preoperatively because we knew that going into the operation without a strategy could lead to ischemic complications. Double-antiplatelet therapy (DAPT) – which is needed when a stent is inserted – was then administered in parallel with neoadjuvant chemotherapy (NAC). This allowed us to administer DAPT for a sufficient period before the main pancreaticoduodenectomy procedure while obtaining therapeutic effects from NAC. Subtotal stomach-preserving pancreaticoduodenectomy was then performed. The operation did not require any unusual techniques and was performed safely. Postoperatively, the patient progressed well, without any ischemic complications. Histopathologically, curative resection was confirmed, and the patient had no recurrence or complications due to ischemia up to six months postoperatively. CONCLUSION Preoperative endovascular stenting, with NAC and DAPT, is effective and safe prior to pancreaticoduodenectomy in potentially resectable pancreatic cancer.

The combination of preoperative celiac axis stenting and neoadjuvant chemotherapy in an elderly patient with pancreatic cancer: a case report

“…Combined therapy comprising stent placement and NAC for CAS caused by MAL has been previously reported [ 14 ]. For this case, a similar procedure was followed: stent placement was performed during chemotherapy, which was followed by surgery.…”

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

“…MALS is typically diagnosed after an extensive workup for non-specific gastrointestinal symptoms and is often considered a diagnosis of exclusion. In patients with biliary or pancreatic pathology, it is frequently diagnosed incidentally during radiological investigations [10]. MALS can be detected using computed tomography MALS is typically diagnosed after an extensive workup for non-specific gastrointestinal symptoms and is often considered a diagnosis of exclusion.…”

“…MALS can be detected using computed tomography MALS is typically diagnosed after an extensive workup for non-specific gastrointestinal symptoms and is often considered a diagnosis of exclusion. In patients with biliary or pancreatic pathology, it is frequently diagnosed incidentally during radiological investigations [10]. MALS can be detected using computed tomography angiography, magnetic resonance angiography, or digital subtraction angiography.…”

“…In the context of radical HPB surgeries, which often necessitate an open surgical approach, the management of MALS can be approached in two ways: concurrently with the HPB procedure or as a two-stage procedure, wherein celiac trunk decompression is performed before the HPB surgery [10]. Concurrent MAL release offers certain advantages, such as cost-effectiveness and avoiding the need for a second-stage procedure, which can reduce waiting time and minimize the risk associated with general anesthesia, particularly in those patients with elevated anesthetic risk profiles.…”

“…Secondly, laparoscopy permits the evaluation of intraperitoneal or hepatic metastases in patients with cancer, thus avoiding laparotomy and its associated mortality and morbidity. Thirdly, MAL release alone may not suffice in restoring hepatic blood flow in more than 20% of patients undergoing PD, mainly due to a combination of atherosclerotic changes, chronicity of MALS, or scarring of the arterial wall [10,47]. Thus, the two-stage procedure allows an opportunity to confirm the restoration of adequate arterial blood flow to the celiac trunk and its branches after MAL release.…”