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Yoshida E, Kimura Y, Kyuno T, Kawagishi R, Sato K, Kono T, Chiba T, Kimura T, Yonezawa H, Funato O, Kobayashi M, Murakami K, Takagane A, Takemasa I. Treatment strategy for pancreatic head cancer with celiac axis stenosis in pancreaticoduodenectomy: A case report and review of literature. World J Gastroenterol 2022; 28:868-877. [PMID: 35317096 PMCID: PMC8900579 DOI: 10.3748/wjg.v28.i8.868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 10/07/2021] [Accepted: 01/22/2022] [Indexed: 02/06/2023] Open
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.
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Affiliation(s)
- Eiji Yoshida
- Department of Surgery, Hakodate Goryoukaku Hospital, Hakodate City 040-8611, Japan
| | - Yasutoshi Kimura
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo City 060-8543, Hokkaido, Japan
| | - Takuro Kyuno
- Department of Surgery, Hakodate Goryoukaku Hospital, Hakodate City 040-8611, Japan
| | - Ryoko Kawagishi
- Department of Surgery, Hakodate Goryoukaku Hospital, Hakodate City 040-8611, Japan
| | - Kei Sato
- Department of Surgery, Hakodate Goryoukaku Hospital, Hakodate City 040-8611, Japan
| | - Tsuyoshi Kono
- Department of Surgery, Hakodate Goryoukaku Hospital, Hakodate City 040-8611, Japan
| | - Takehiro Chiba
- Department of Surgery, Hakodate Goryoukaku Hospital, Hakodate City 040-8611, Japan
| | - Toshimoto Kimura
- Department of Surgery, Hakodate Goryoukaku Hospital, Hakodate City 040-8611, Japan
| | - Hitoshi Yonezawa
- Department of Surgery, Hakodate Goryoukaku Hospital, Hakodate City 040-8611, Japan
| | - Osamu Funato
- Department of Surgery, Hakodate Goryoukaku Hospital, Hakodate City 040-8611, Japan
| | - Makoto Kobayashi
- Department of Surgery, Hakodate Goryoukaku Hospital, Hakodate City 040-8611, Japan
| | - Kenji Murakami
- Department of Diagnostic Radiology, Hakodate Goryoukaku Hospital, Hakodate City 040-8611, Japan
| | - Akinori Takagane
- Department of Surgery, Hakodate Goryoukaku Hospital, Hakodate City 040-8611, Japan
| | - Ichiro Takemasa
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo City 060-8543, Hokkaido, Japan
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Miyazaki K, Morine Y, Saito Y, Yamada S, Tokuda K, Ikemoto T, Imura S, Shimada M. Pancreatoduodenectomy co-morbid with celiac axis compression syndrome: a report of three cases. Surg Case Rep 2020; 6:113. [PMID: 32449014 PMCID: PMC7246236 DOI: 10.1186/s40792-020-00878-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 05/17/2020] [Indexed: 02/06/2023] Open
Abstract
Background Celiac axis compression syndrome (CACS) is a relatively rare disease. Because of the nature of the blood flow in the celiac region when a pancreatoduodenectomy (PD) is performed for CACS, the celiac region can become ischemic. The aim of this study is to report on the importance of pre-operative diagnosis of CACS in terms of the outcomes for patients post-operatively. In this study, three 3 cases of PD co-morbid with CACS are reported: one intra-operative diagnosis case and two pre-operative diagnosis cases. Case presentation The one case, not diagnosed with CACS prior to the operation, had a hard post-operative course because of complication caused by ischemia of the celiac region compared with the two cases diagnosed prior to the operation, who had a good post-operative course because of pre-operative or intra-operative intervention. Conclusions Post-operative complications due to CACS are preventable by pre-operative diagnosis and appropriate interventions.
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Affiliation(s)
- Katsuki Miyazaki
- The Department of Digestive and Transplant Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 770-8503, Japan
| | - Yuji Morine
- The Department of Digestive and Transplant Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 770-8503, Japan
| | - Yu Saito
- The Department of Digestive and Transplant Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 770-8503, Japan
| | - Shinichiro Yamada
- The Department of Digestive and Transplant Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 770-8503, Japan
| | - Kazunori Tokuda
- The Department of Digestive and Transplant Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 770-8503, Japan
| | - Tetsuya Ikemoto
- The Department of Digestive and Transplant Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 770-8503, Japan
| | - Satoru Imura
- The Department of Digestive and Transplant Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 770-8503, Japan
| | - Mitsuo Shimada
- The Department of Digestive and Transplant Surgery, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 770-8503, Japan.
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Beane JD, Schwarz RE. Vascular challenges from pancreatoduodenectomy in the setting of coeliac artery stenosis. BMJ Case Rep 2017; 2017:bcr-2016-217943. [PMID: 28302657 DOI: 10.1136/bcr-2016-217943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
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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Affiliation(s)
- Joal D Beane
- Department of Surgery Division of Surgical Oncology, Indiana University School of Medicine, South Bend, Goshen, Indiana, USA
| | - Roderich E Schwarz
- Department of Surgery Division of Surgical Oncology, Indiana University School of Medicine, South Bend, Goshen, Indiana, USA
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Sugae T, Fujii T, Kodera Y, Kanzaki A, Yamamura K, Yamada S, Sugimoto H, Nomoto S, Takeda S, Nakao A. Classification of the celiac axis stenosis owing to median arcuate ligament compression, based on severity of the stenosis with subsequent proposals for management during pancreatoduodenectomy. Surgery 2011; 151:543-9. [PMID: 22001637 DOI: 10.1016/j.surg.2011.08.012] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Accepted: 08/16/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND After pancreatoduodenectomy in patients with celiac axis stenosis or obstruction, it becomes problematic to maintain the upper abdominal organ blood flow, especially to the liver. The aim of this study was to investigate the celiac axis stenosis caused by median arcuate ligament (MAL) compression and to classify it according to preoperative image findings. METHODS From January 1989 to November 2010, 562 patients underwent operations for diseases of the pancreatic head region in our department. To diagnose celiac artery compression by the MAL, angiography was used in the early period and 3-dimensional image reconstruction of multidetector-row computed tomography was used from 2004. The morphologic characteristics of the celiac axis stenosis were analyzed during intraoperative treatment. RESULTS Twelve (2.1%) patients were diagnosed with MAL compression, and 8 of these patients only underwent MAL division to restore the celiac artery blood flow. One patient required conservation of the collateral circulation, and 2 patients needed arterial reconstruction. In the analysis of the level of origin of the celiac axis, there were no remarkable differences between nonstenotic and stenotic cases, or between mild and severe stenotic cases. Morphologic grades were defined based on the preoperative image findings and consequent intraoperative treatments. CONCLUSION Preoperative grading of celiac axis stenosis could make pancreatoduodenectomy safer with maintenance of the upper abdominal organ blood flow in patients with MAL compression.
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Affiliation(s)
- Takashi Sugae
- Department of Surgery II, Nagoya University Graduate School of Medicine, Nagoya, Japan
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