A radio-anatomical study of median arcuate ligament syndrome: unveiling the morphology and morphometry of median arcuate ligament, celiac trunk, and superior mesenteric artery

PURPOSE

In the context of medical literature, a significant lacuna exists in understanding median arcuate ligament syndrome (MALS). While clinical aspects are well documented, literature lacks a robust exploration of the anatomical relationship between the celiac trunk and the median arcuate ligament (MAL).

METHODS

Morphometric parameters, including the vertebral level of MAL origin, MAL thickness, celiac trunk (CeT) origin level, diameter, and distances between CeT/Superior Mesenteric Artery (SMA) and the MAL center were observed on 250 CT angiograms. Cadavers (n = 11) were dissected to examine the same parameters and histo-morphological examination of MAL tissue was done.

RESULTS

Radiological findings established average MAL thickness of 7.79 ± 2.58 mm. The celiac trunk typically originated at T12. The average distance between the celiac trunk and the MAL center was 1.32 ± 2.04 mm. The angle of the celiac trunk to the abdominal aorta was primarily obtuse. The average celiac trunk diameter was 5.53 ± 1.33 mm. Histological examinations revealed a diverse MAL composition, indicating variable mechanical properties.

CONCLUSION

This study provides comprehensive morphometric data on the anatomical relationship between the MAL and the celiac trunk. In contrast to available literature which says the average MAL thickness of > 4 mm is an indicator of increased thickness, we observed much higher average thickness in the studied population. The findings contribute to a better understanding of normal anatomical variations which can serve as reference values for accurate radiological diagnosis of MALS. The histological examination revealed the heterogeneous nature of the MAL tissue composition, suggesting variable mechanical properties and functions in different regions.

Utility of Hook Sign in the Diagnosis of Median Arcuate Ligament Syndrome

OBJECTIVE

Median arcuate ligament syndrome (MALS) is a clinical syndrome caused by compression of the celiac artery by the median arcuate ligament (MAL) that often manifests with non-specific abdominal pain. Identification of this syndrome is often dependent on imaging of compression and upward bending of the celiac artery by lateral CTA, the so-called "hook sign." The purpose of this study was to assess the relationship of radiologic characteristicss of the celiac artery to clinically relevant MALS.

DESIGN

Single-center retrospective study METHODS: An IRB-approved retrospective chart review from 2000-2021 of 293 patients at a tertiary academic center diagnosed with celiac artery compression (CAC) was performed. Patient demographics and symptoms of 69 patients who were diagnosed with symptomatic MALS were compared to 224 patients without MALS (but with CAC) per electronic medical record review. CTA images were reviewed and the fold angle (FA) was measured. The presence of a hook sign (defined as a visual fold angle < 135 degrees) was recorded as well as stenosis (defined as >50% of luminal narrowing on imaging). Wilcoxon rank sum test and Chi-squared were utilized for comparative analysis. Logistic model was run to relate the presence of MALS with comorbidities and radiographic findings.

RESULTS

Imaging was available in 59 patients (25 males, 34 females) and 157 patients (60 males, 97 females) with and without MALS respectively. Patients with MALS were more likely to have a more severe FA (120.7 ± 33.6 vs. 134.8 ± 27.9, P = 0.002). Males with MALS were also more likely to have a more severe FA compared with males without MALS (111.1 ± 33.7 vs. 130.4 ± 30.4, P = 0.015). In patients with BMI > 25, MALS patients also had narrower FA compared with patients without MALS (112.6 ± 30.5 vs. 131.7 ± 30.3, P = 0.001). The FA was negatively correlated with BMI in patients with CAC . The hook sign and stenosis were associated with diagnosis of MALS (59.3% vs. 28.7%, P < 0.001, and 75.7% vs. 45.2%, P < 0.001, respectively). In logistic regression, pain, stenosis and a narrow FA were statistically significant predictors of the presence of MALS.

CONCLUSIONS

The upward deflection of the celiac artery in patients with MALS is more severe compared with patients without MALS. Consistent with prior literature, this bending of the celiac artery is negatively correlated with BMI in patients with and without MALS. When demographic variables and comorbidities are considered, a narrow FA is a statistically significant predictor of MALS. Regardless of MALS diagnosis, a hook sign was associated with narrower FA. While demographics and imaging findings may inform MALS diagnosis, clinicians should not rely on a visual assessment of a hook sign but should quantitatively measure the anatomic bending angle of the celiac artery to assist with the diagnosis and understand the outcomes.

Rare variation: the absence of both the celiac trunk artery and the common hepatic artery

BACKGROUND

Knowledge of celiac trunk anatomy is important in gastrointestinal surgery, hepatopancreatobiliary surgery, transplantation and interventional radiology. Variations in the celiac trunk are common and should be predicted prior to these interventions.

METHODS

A 58-year-old woman was admitted to our department for surgical treatment of gastric cancer (GC) confirmed by gastroduodenoscopy and gastric antrum biopsy. In the contrast-enhanced computed tomography (CT), we found an absence of both the celiac trunk artery (CA) and the common hepatic artery (CHA). Therefore, we used computerized three-dimensional (3D) vascular reconstruction technology to reconstruct the abdominal trunk and its branch vessels before operation.

RESULTS

Computerized 3D vascular reconstruction confirmed an extremely rare vascular anomaly: the absence of both CA and CHA. The splenic artery (SA) and gastroduodenal artery (GDA) originated from the abdominal aorta (AA). The left gastric artery (LGA) originated from the AA directly above the junction of SA and the GDA. The left hepatic artery (LHA) originated from the left gastric artery (LGA). The right hepatic artery (RHA) originated from the superior mesenteric artery (SMA). Laparoscopic radical resection of GC was performed. This anomaly was also confirmed intraoperatively. This patient was discharged on the 10th day after surgery without any postoperative complication. There were no signs of tumor recurrence during the 6-month follow-up.

CONCLUSION

Correct identification of abnormal abdominal large blood vessels and their relationship with tumors before surgery is of great significance to avoid intraoperative blood vessel damage, major postoperative complications and the missing of lymph node dissection.

Evaluation of Celiac Trunk, Hepatic Artery Variations, and Their Collateral Arteries by Multi-Slice Computed Tomography

Objectives:

Celiac Trunk (CT) is a vital artery and the first unmatched branch of the abdominal aorta, providing blood to upper abdominal structures, particularly the liver, stomach, and spleen. It is essential to know its anatomy in terms of pancreas, spleen, gallbladder, liver surgeries, and interventional radiological procedures such as chemoembolization. The aim of our study is to contribute to the literature with the measurements of distances between the diaphragmatic crus and vascular structures with their diameters, which have been studied insufficiently, and to detect the possible relationships between vascular variations and collateral branches.

Methods:

Imaging findings of 200 patients (114 males and 86 females), who underwent Multi-Section Computed Tomography examination with various indications in our center between June 2016 and July 2020, were retrospectively analyzed. The statistical relations between CT and Hepatic Artery variations, collateral formations, age, and gender were evaluated with the Spearman’s Rho Correlation Coefficient Test.

Results:

The distance between the crus of diaphragm and CT was 4–60 mm (mean 24.3 mm), the distance between CT and superior mesenteric artery (SMA) was 2.5–35 mm (mean 8.6 mm), CT diameter was 4.6–9.4 mm (mean 7.3 mm), and the main hepatic artery diameter was 2.4–5.8 mm (mean 4.1 mm). There was no correlation in our study between CT, Hepatic Artery variations, and their collaterals (r in range of −20,124–0.116, p>0.05). It can be said that in cases of the single accessory left hepatic artery originating from the left gastric artery, such as Michel’s Type V and Type VIII, collaterals between common hepatic artery and SMA were relatively more frequent (p=0.1).

Conclusion:

Our study contributed to the literature by measuring the distance between diaphragmatic crus-vascular structures, which has been little studied in the past. Frequencies of CT and Hepatic Artery variations that have been detected in our study are similar to the results of the previous studies with non-malignancy patient groups.

Management for traumatic hepatic injury diagnosed by contrast-enhanced ultrasonography in a patient with an occluded coeliac axis: a case report

Transcatheter arterial embolization (TAE) is the standard of care for haemodynamically-stable patients with blunt hepatic injury but it is sometimes impossible due to unfavourable vascular anatomies. This case report describes a 43-year-old male patient with abdominal pain following a motorcycle accident. Based on computed tomography (CT) findings, he was diagnosed with high-grade hepatic injury with coeliac axis stenosis (CAS) due to compression by the median arcuate ligament, and an aberrant right hepatic artery. Contrast-enhanced ultrasonography (CEUS) demonstrated multiple high echogenic tubular and ovoid structures suggestive of active bleeding within the injured liver area. Angiography revealed unique interlobar and intrahepatic collateral vessels between the right and left hepatic arteries. Liver haemorrhages were also identified. Catheterization of the feeding arteries through the collateral pathway was unsuccessful, so a decision was made to cannulate the stenotic portion of the coeliac trunk with a 5-Fr Yashiro catheter. After several attempts, the microcatheter was successfully advanced coaxially into the common hepatic artery. Embolization was performed with a 1:2 mixture of N-butyl cyanoacrylate and iodized oil. Successful haemostasis was confirmed following TAE. CEUS helped clinicians identify active bleeding following traumatic solid organ injury. TAE was a safe and effective treatment strategy. Before performing TAE, attention should be given to the presence of CAS associated with compression by the median arcuate ligament.

Curing pancreatic cancer

The distinct biology of pancreatic cancer with aggressive and early invasive tumor cells, a tumor promoting microenvironment, late diagnosis, and high therapy resistance poses major challenges on clinicians, researchers, and patients. In current clinical practice, a curative approach for pancreatic cancer can only be offered to a minority of patients and even for those patients, the long-term outcome is grim. This bitter combination will eventually let pancreatic cancer rise to the second leading cause of cancer-related mortalities. With surgery being the only curative option, complete tumor resection still remains the center of pancreatic cancer treatment. In recent years, new developments in neoadjuvant and adjuvant treatment have emerged. Together with improved perioperative care including complication management, an increasing number of patients have become eligible for tumor resection. Basic research aims to further increase these numbers by new methods of early detection, better tumor modelling and personalized treatment options. This review aims to summarize the current knowledge on clinical and biologic features, surgical and non-surgical treatment options, and the improved collaboration of clinicians and basic researchers in pancreatic cancer that will hopefully result in more successful ways of curing pancreatic cancer.

Splenic Artery Embolization for Patients with High-Grade Splenic Trauma: Indications, Techniques, and Clinical Outcomes

The spleen is the most commonly injured organ in blunt abdominal trauma. Patients who are hemodynamically unstable due to splenic trauma undergo definitive operative management. Interventional radiology plays an important role in the multidisciplinary management of the hemodynamically stable trauma patient with splenic injury. Hemodynamically stable patients selected for nonoperative management have improved clinical outcomes when splenic artery embolization is utilized. The purpose of this article is to review the indications, technical aspects, and clinical outcomes of splenic artery embolization for patients with high-grade splenic injuries.

Branching form of celiac artery to be aware of in laparoscopic surgery: A case report using MDCT angiography

The anomalies of the celiac artery have been reported and reviewed in literature. Hence, it is not uncommon to clinically encounter its various types. This report presents the case of a 76-year-old male who underwent laparoscopic distal gastrectomy. Preoperative abdominal contrast-enhanced computed tomography showed an anomaly of the celiac artery, which was extremely rare, with various other anomalies of the artery.

Celiac axis stenosis and digestive disease: Diagnosis, consequences and management

Arterial blood flow to the organs of the upper abdomen is provided by the celiac axis (CA) and the superior mesenteric artery (SMA) that communicate between each other via the gastro-duodenal artery, the anterior and posterior pancreatico-duodenal arcades, the branches of the dorsal pancreatic artery and inconsistently, though a supplementary arcade that connects the CA and the SMA (arcade of Bühler). Celiac axis stenosis may or may not have a hemodynamic impact on the splanchnic circulation. Hemodynamically significant CA stenosis can be asymptomatic, or symptomatic with variables clinical consequences. Management depends on whether the mechanism of stenosis is extrinsic or intrinsic. When upper gastrointestinal interventional radiology or surgery is indicated, stenosis can pose technical difficulties or create severe ischemia requiring good understanding of this entity in the planning of operative steps and adapted management. Management of CA stenosis is therefore multidisciplinary and may involve interventional radiologists, gastrointestinal surgeons, vascular surgeons as well as medical physicians. Even though the prevalence of CA stenosis is relatively low (between 5 and 10%) and irrespective of its etiology, surgeons, radiologists and physicians must be aware of it because it can intervene in the management of upper gastrointestinal disease. It must be sought, and treatment must be adapted to each particular situation to avoid potentially severe complications.

Role of imaging in visceral vascular emergencies

Differential diagnosis in non-traumatic acute abdomen is broad and unrelated diseases may simulate each other from a clinical perspective. Despite the fact that they are not as common, acute abdominal pain due to diseases related to visceral vessels may be life-threating if not detected and treated promptly. Thrombosis, dissection, and aneurysm in the abdominal visceral arteries or thrombosis in visceral veins may cause acute abdominal pain. Imaging with appropriate protocoling plays a fundamental role in both early diagnosis and determination of the treatment approach in these cases where early treatment can be life-saving. Computed tomography (CT) appears to be the most effective modality for the diagnosis as it provides high detail images in a very short time. Patient cooperation is also a less concern as compared to magnetic resonance imaging (MRI). As the imaging findings may sometimes be really subtle, diagnosis may be difficult especially to inexperienced imagers. Correct protocoling is also very critical to detect arterial abnormalities as visceral arterial abnormalities may not be detectable in portal phase only abdominal CT scans. In this article, we aimed to increase awareness among imaging specialists to these not very common causes of acute abdomen.

Interprofessional Management of Median Arcuate Ligament Syndrome (Dunbar Syndrome) Related to Lumbar Lordosis and Hip Dysplasia: A Patient's Perspective

We present a 53-year-old female patient with median arcuate ligament syndrome (MALS), also known as Dunbar syndrome or celiac artery compression syndrome, related to lumbar lordosis and hip dysplasia. She utilized interprofessional management strategies, which were beneficial in reducing lumbar lordosis and MALS-related symptoms. This finding is important because there are no other reports in the literature describing interprofessional strategies to manage symptoms for patients who are waiting for surgery or are not candidates for surgery.

Variations of the celiac trunk investigated by multidetector computed tomography: Systematic review and meta-analysis with clinical correlations

In recent years multidetector computed tomography (MDCT) has been used to investigate vascular anatomy for scientific and diagnostic purposes. These studies allow for much larger sample sizes than traditional cadaveric studies. The aim of this research was to perform a systematic review and meta-analysis on studies investigating the variations of the celiac trunk using MDCT. Major medical databases were used to find studies investigating celiac trunk anatomy using MDCT. Extracted information included demographic details, number of normal celiac trunks, and number of each variant celiac trunk. Using a random effects meta-analysis the pooled prevalence of each variation was calculated. A total of 36 studies from 14 countries and four continents were included in the meta-analysis. The total number of subjects included was 17,391. The total prevalence of variant celiac trunks was 10.85%. The different types of celiac trunk variations with their prevalences were: gastrosplenic trunk (3.46%), hepatosplenic trunk (3.88%), hepatogastric trunk (0.24%), absent celiac trunk (0.28%), celiacomesenteric trunk (0.46%), hepatosplenomesenteric trunk (0.26%), gastrosplenomesenteric trunk (0.07%), and celiacomesenteric anastomosis (0.09%). A total of 61 cases (0.19%) were either not described or not described adequately to be included in our classification. Major variations of the celiac trunk are not uncommon and should be anticipated before radiological and surgical interventions. Knowledge of celiac trunk anatomy is important in hepatopancreatobiliary surgery, transplantology, and interventional radiology.

The Roles of Celiac Trunk Angle and Vertebral Origin in Median Arcuate Ligament Syndrome

Median arcuate ligament syndrome (MALS) is a rarely diagnosed condition resulting from compression of the celiac trunk (CT) by the median arcuate ligament (MAL) of the diaphragm. Ischemia due to reduced blood flow through the CT and/or neuropathic pain resulting from celiac ganglion compression may result in a range of gastrointestinal symptoms, including nausea, postprandial discomfort, and weight loss. However, the mechanism of compression and its anatomical correlates have been incompletely delineated. It has been hypothesized that CT angle of origination may be more acute in individuals with MALS. Here, frequency of anatomical variation in the MAL and CT were assessed in 35 cadaveric subjects (17M/18F), including the vertebral level of origin of CT and superior mesenteric artery (SMA), the distance between CT and MAL and SMA, the angles of origination of CT and SMA, the diameter at the CT base, and MAL/CT overlap. Females exhibited significantly higher rates of inferred MAL/CT overlap than males. Significant correlations were revealed between MAL/CT overlap and angles of origination of the CT and SMA. Vertebral level of origin of the CT in individuals with MAL/CT overlap was not significantly more superior than in those without. This study also revealed a significant relationship between MAL/CT overlap and angle of origination of the CT, which has clinical implications for understanding the anatomy associated with MALS.

Retrospective Analysis and Systematic Review of Isolated Traumatic Dissections of the Celiac Artery

BACKGROUND

Isolated dissections of the celiac artery (CA) after blunt trauma are rarely described. This retrospective analysis and systematic review analyzes epidemiology, radiologic examinations, patterns of injuries, therapeutic measures, clinical courses, and outcomes.

METHODS

Retrospective analysis of polytraumatized patients admitted between 1997 and 2012 to a trauma center level I. Systematic literature search was carried out on pubmed.gov, eurorad.org, and google.com.

RESULTS

Isolated traumatic dissections of the CA had an incidence of 0.17% in a retrospective collective (n = 9). Mean age was 31.7 years in 6 male (66.7%) and 3 female (33.3%) patients. Systematic literature search identified 12 primary sources describing 13 males (100%) with a mean age of 41.3 years. Traffic accidents and falls were the most common causes of injury. An intimal flap (77.7%) and a thrombosed false lumen (59.1%) were the most common computed tomographic findings. Twenty-two patients were analyzed, and 16 patients were treated conservatively. The CA was bypassed in 2 symptomatic patients. One patient was treated with a stent. Two patients died because of massive bleeding, and 1 patient died because of liver failure. About 19 discharged patients were asymptomatic on follow-up. Long-term follow-up with magnetic resonance angiography showed stable dissections (n = 1), medium stenosis (n = 1), resolution of the dissection (n = 2), high-grade stenosis of the CA combined with a small pseudoaneurysm (n = 1), or occlusion of the CA with sufficient collateralization (n = 3). Pharmaceutical treatment was individualized with low-molecular-weight heparin, heparin, or warfarin, and acetylicsalicylic acid.

CONCLUSIONS

Traumatic CA dissections are mostly caused by traffic accidents and falls. Visceral perfusion should be monitored clinically and radiologically. Beginning visceral ischemia requires early invasive treatment. Endovascular and open surgery are possible options. Benefits of specific pharmaceuticals are still up for debate. Follow-up via magnetic resonance imaging or computed tomography angiography is essential to rule out vascular complications.

LEVEL OF EVIDENCE

III (Retrospective therapeutic study and systematic literature review).

Basic Arterial Anatomy and Interpretation of CT Angiography for Intra-Abdominal or Gastrointestinal Bleeding: Correlation with Conventional Angiographic Findings for Beginners

복강 내 혹은 소화기계의 활동성 출혈이 있는 경우, 원인이 되는 동맥 혈관을 파악하는 것이 중요하다. 조영증강 컴퓨터단층촬영술을 이용한 혈관조영술과 고식적인 카테터 혈관조영술에서 원인이 되는 동맥을 파악하기 위해서는 기본적인 혈관 해부학을 숙지하고 있어야 한다. 기본 해부학을 숙지하고 있다면 혈관의 기원과 주행에 다양한 변이가 있다고 하더라도 이에 대한 접근이 한결 쉬워질 것이다. 영상의학에 갓 입문한 초심자들을 대상으로 하여, 복강 내 혹은 소화기계 활동성 출혈의 원인이 될 수 있는 혈관들을 파악하는 데 도움이 될만한 기본 해부학을 설명하고자 한다.

Reappraisal of the classical abdominal anatomical landmarks using in vivo computerized tomography imaging

INTRODUCTION

With expanding scope of interventions it becomes mandatory to have correct and evidence-based knowledge of surface anatomy of internal abdominal structures. Information available in text books is derived from work done on cadaveric studies. Current study was designed to provide data of key abdominal surface anatomical landmarks and their variations in living subjects using CT imaging of adult population.

MATERIALS AND METHODS

Cross-sectional study was conducted using 100 abdominopelvic CT scans of patients of Indian origin.

RESULTS

Vertebral levels of origin of celiac trunk varied from T11 to L1/2 intervertebral disc, superior mesenteric artery from T12 to L2, inferior mesenteric artery from L2 to L4 and aortic bifurcation from L3 to L5. Origin of both renal arteries varied between T12 and L2 and the formation of inferior vena cava varied from L3 to L5. Vertebral levels of upper pole of both kidneys ranged from T11 to upper L3. Spleen was related to 9th to 11th ribs in 36% and 10th to 12th ribs in 34% scans. Most common vertebral levels of subcostal plane, planum supracristale and planum intertuberculare noticed were lower L2, L4 and lower L5, respectively.

CONCLUSIONS

Data derived from imaging investigations of living subjects and variations from the conventional descriptions observed in the current study might be helpful for clinicians.

Vascular anomalies of the celiac trunk and implications in treatment of HCC with TACE. Description of a case and review of the literature

Knowledge of the vascular anatomy of the upper abdomen is important in the daily practice of surgeons specialized in the hepatobiliary and pancreatic area, and for general surgeons and radiologists, mainly those involved in interventional radiology. Since anatomical variants of the celiac axis and hepatic arteries are common, an accurate description of vascularization is required before procedures to avoid iatrogenic vascular changes.

We reported a case of a young male patient with HBV related cirrhosis, who came to our institution for the treatment of 2 HCC nodules. The preprocedural contrast-enhanced CT examination showed combined variations of celiac trunk, hepatic arteries, gastroduodenal artery, and right inferior phrenic artery. The careful pre- and intraprocedural evaluation of vascularization allowed us to perform transarterial chemoembolization of the 2 nodules without complications.

The incidence and developmental and clinical significance of this variation is discussed with a detailed review of the literature. Knowledge of such a case has important clinical significance in abdominal operations or invasive arterial procedures.

Assessment of Congenital Vascular and Organ Anomalies in Subjects With Thalidomide Embryopathy Using Non-Contrast Magnetic Resonance Angiography

BACKGROUND

To determine the type and frequency of vascular and organ malformations in adults with thalidomide embryopathy (TE) using non-contrast magnetic resonance angiography (MRA) and to assess the effect of the observed malformations on renal function. Methods and Results: The institutional ethics committee approved this prospective study and written informed consent was given by all 78 subjects (50 females) with TE (mean age: 55±1.1 years), who were examined by non-contrast MRA at 3T. ECG-triggered balanced turbo field echo images of the chest, abdomen and pelvis were obtained in coronal and sagittal orientations. Two observers assessed the frequency of vascular and organ malformations. Serum creatinine and estimated glomerular filtration rate (eGFR) were obtained to assess renal function. In 58 subjects, 99 vascular anomalies were observed, including 68 arterial (69%) and 31 venous anomalies (31%); 15 patients had 16 abdominal organ malformations including 12 kidney anomalies and 4 cases of gallbladder agenesis. Most vascular anomalies affected the renal vessels (n=66, 67%) or supraaortic arteries (n=28, 28%). Serum creatinine and eGFR revealed normal renal function in all subjects.

CONCLUSIONS

Vascular and organ anomalies occurred in a high number of subjects with TE without evidence of renal dysfunction. Information about the presence of malformations may be important for future surgical interventions in subjects with TE.

Symptomatic Celiomesenteric Trunk: Variable Presentations and Outcomes in 2 Patients

Mesenteric ischemia can be difficult to diagnose without a high degree of suspicion because it presents in a variety of ways. Visceral vascular collaterals between the fore- and midgut often provide protection against ischemia; however, the presence of anatomic variations, such as celiomesenteric trunk, can undermine the expected redundancy. Misdiagnosis can result in prolonged suffering or death, as evidenced in 2 of our patients with celiomesenteric trunk. The first patient with chronic mesenteric ischemia was diagnosed in the clinic and underwent successful surgical correction; the other had overwhelming, acute mesenteric ischemia, which resulted in death. Our cases show that successful diagnosis and management of mesenteric ischemia require astute interpretation of radiologic images.

Modified Appleby procedure for locally advanced pancreatic cancer

Locally advanced pancreas cancer (LAPC) involving the celiac axis is typically considered unresectable and carries a poor prognosis. We present a case of a patient with LAPC who underwent a modified Appleby procedure for tumor clearance following neoadjuvant therapy. Technical aspects include diagnostic laparoscopy to exclude occult metastatic disease followed by complete mobilization of the pancreas and spleen, preservation of the left gastric artery, and resection and reconstruction of the common hepatic artery. With proper patient selection and preparation, LAPC with celiac axis involvement can be safely resected with favorable outcomes.