Abdominal pain secondary to celiac axis compression

Treatment Options and Outcomes for Celiac Artery Compression Syndrome

Background. Abdominal pain attributed to compression of the celiac artery at the level of the median arcuate ligament (MAL) of the diaphragm is an uncommon disorder. Although ultrasound investigation and arteriography can be suggestive of the diagnosis, no definitive criteria exist with only cases reports in the literature. This study presents the only known reported case series in which a combination of open and laparoscopic access techniques of MAL decompression are reported. Methods. A retrospective review of prospectively collected electronic databases of the University of North Carolina at Chapel Hill was performed for the period February 1999 until February 2009. Patients having undergone operation for celiac artery compression syndrome were identified and participated in a telephone interview. Questions were asked about the success of the operation, the recovery period, and patient satisfaction. Results. Six patients were identified, 3 were male; mean age was 37.7 years. Four underwent open MAL division and celiac ganglion neurolysis, and 2 underwent a laparoscopic approach. Mean follow-up was 48.6 months. All patients experienced symptomatic improvement and were satisfied with their outcome. No patient had symptoms recurrence. Conclusion. In this limited experience, MAL division with celiac ganglion neurolysis appears to be an effective treatment for celiac artery compression syndrome in appropriately selected patients. Both the open and laparoscopic approaches are safe with durable midterm follow-up results.

Retroperitoneal endoscopic release in the management of celiac artery compression syndrome

INTRODUCTION

Celiac artery compression syndrome (CACS) can be treated successfully by division of the median arcuate ligament and celiac plexus fibers. The standard technique is the open approach by an upper midline or left subcostal incision. Only six single cases in which a laparoscopic transabdominal approach for CACS was used have been reported. We prospectively evaluated the feasibility of the endoscopic retroperitoneal approach for treatment of CACS.

METHODS

All patients with symptoms suggestive of CACS were evaluated using splanchnic duplex ultrasound scanning, gastric exercise tonometry (GET), and multiplane selective splanchnic angiography. The criteria for treatment were chronic abdominal symptoms, respiratory-dependent CA stenosis, and abnormal GET result. The release was performed by a retroperitoneal endoscopic approach. Anatomic success of the procedure was confirmed by angiography.

RESULTS

The endoscopic retroperitoneal approach was used to treat 46 patients with CACS. One patient (2%) required conversion to an open procedure due to suprarenal artery bleeding. Release was ended prematurely in one patient due to a pneumothorax resulting in loss of working space. A postoperative pneumothorax developed in two patients, of which one needed treatment. No other complications were observed. Postoperative angiography during inspiration and expiration showed normal vessel anatomy in 36 of 46 patients. Six of 10 patients with persisting intraluminal stenoses were treated endovascularly. Five of these were successful, which brings the primary-assisted anatomic patency for the total group to 89% (41 of 46 patients). Three patients are being observed, and endovascular treatment remains an option in case of insufficient improvement. On median follow-up of 20 months (range, 2-42 months) 41 patients were free of symptoms or showed significant improvement.

CONCLUSIONS

The endoscopic retroperitoneal approach for the release of the CA in CACS, with additional endovascular treatment of persistent stenosis, is feasible and effective. Short-term results were comparable with the open procedure.

Celiac Artery Compression Syndrome Due to Acute Type B Aortic Dissection

Acute distal aortic dissection sometimes causes one or more visceral vessels to be stenosed by the thrombosed false lumen. Although stenosis of the only celiac artery (CA) usually does not cause ischemic symptoms because of the extensive collateral pathways of the mesenteric circulation, we experienced a rare case of CA compression syndrome which was caused by acute type B aortic dissection. The principal symptom was severe epigastric pain that was refractory to medicinal treatment. The angiogram showed absence of the anatomically well-developed collateral pathways between the CA and the superior mesenteric artery. We treated the patient with percutaneous transluminal angioplasty in the CA. This report indicates that attention should be given to the possibility of CA compression syndrome in the case of acute distal aortic dissection and that endovascular management can be successfully applied to control symptoms caused by the syndrome, which is otherwise extremely difficult to repair directly by surgery.

Surgical treatment of the celiac axis compression syndrome

Six patients with symptomatic celiac axis compression syndrome are reported on. Four were treated surgically with arterial reconstruction. None of these four patients was benefited more than temporarily by the corrective surgery. One patient had an abdominal exploration and highly selective vagotomy unrelated to the celiac axis and is symptom-free ten months after surgery. One patient had no surgery and remains symptomatic. Angiographic evaluation in all patients demonstrated that despite high grade stenosis of the celiac axis, there was no radiographically discernible reduction in constrast flow to the celiac axis because of well developed collaterals from the superior mesenteric artery. These results indicate that compression of the celiac axis may be merely an incidental angiographic finding, so this syndrome needs cautious evaluation.

Coeliac axis stenosis

Eleven cases of coeliac axis stenosis were operated on during 1966 to 1969. Each patient complained of persistent abdominal pain and loss of weight and investigation for carcinoma proved negative. Auscultation revealed the presence of an epigastric bruit and aortography demonstrated stenosis of the coeliac axis in each case with additional stenosis of the superior mesenteric artery in 3 patients. Operative findings showed that constriction was caused by the median arcuate ligament of the diaphragm in seven cases and by periarterial fibrosis in 4. Operative division of the constricting agent gave complete relief in 9 patients and improvement in 1, the other being unchanged.

Experience with coeliac axis compression syndrome

Seven patients with "coeliac axis compression syndrome" are reported. Five were treated surgically, but only two did well. A survey of 200 healthy adults showed epigastric bruits in 6.5%; only one of these had dyspepsia, though dyspepsia was present in 12.5% overall.Caution is urged in attributing a causal relationship between coeliac axis compression and pain and in proceeding to arteriography when compression is suspected on clinical grounds.

Chronic intestinal ischaemia

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