Pancreaticoduodenectomy: Secondary stenting of the celiac trunk after inefficient median arcuate ligament release and reoperation as an alternative to simultaneous hepatic artery reconstruction

Celiac artery stenosis and its impact on postoperative outcomes following pancreaticoduodenectomy: An institutional analysis

BACKGROUND

The detection of a stenotic celiac artery (CA) typically mandates intraoperative revascularization during pancreaticoduodenectomy (PD) to preserve liver perfusion. The impact of CA stenosis on postoperative outcomes is unclear. This study evaluates whether CA stenosis (CAS) is associated with increased postoperative complications.

METHODS

We conducted a retrospective analysis of PD patients from February 2014 to February 2022. Preoperative imaging assessed the CA lumen, categorizing it as patent, <50%, or ≥50% stenosis. Patients with narrowed SMA were excluded. Complications were categorized using the Clavien-Dindo system, and statistical analyses identified outcome differences.

RESULTS

We included 427 patients in the study. Of these, 52 had CAS, and 311 had no-vessel stenosis (NVS). The median age of the CAS and NVS groups was 68 and 65 years, respectively. Postoperatively, 17.6% of patients with CAS exhibited delayed gastric emptying (DGE) versus 25.3% in the NVS group. Postoperative pancreatic fistula (POPF) was found in 13.5% of patients with CAS, compared with 23.7% without stenosis. The median length of hospital stay was shorter for patients with CAS (9 days) than for those with CAS (12 days). Severity-based classifications indicated higher complications in the no stenosis group and a 33.0% readmission rate within 30 days compared with 21.2% in CAS patients. However, none of these differences were statistically significant.

CONCLUSIONS

Critical stenosis of the CA does not significantly affect postoperative outcomes following PD, suggesting preoperative correction of the narrowed CA may not be necessary. Further research is needed to confirm these findings.

Pancreaticoduodenectomy in Patients With Coeliac or Superior Mesenteric Artery Stenosis: A Review of the Literature

Pancreaticoduodenectomy (Whipple's procedure) is a technically demanding operation performed for malignant and premalignant conditions of the pancreatic head, duodenum and bile duct. Awareness of the vascular anatomy, variations, and pathology of this area is essential to achieve safe surgery and good outcomes. The operation involves division of the gastroduodenal artery (GDA) which provides communication between the foregut and midgut blood supply. In patients with coeliac or superior mesenteric artery (SMA) stenosis, this can lead to reduced blood supply to the foregut or midgut organs, with consequent severe ischaemic complications leading to significant morbidity and mortality. Coeliac artery stenosis is caused by median arcuate ligament syndrome (MALS) in the majority of patients with atherosclerosis being the second most common cause. SMA stenosis is much less common and is caused in the majority of cases by atherosclerosis. A review of preoperative imaging and intraoperative gastroduodenal artery clamp test is important to identify cases that may need additional procedures to preserve the blood supply. In this paper, we present a literature review for studies reporting patients undergoing Whipple's operation with concomitant coeliac axis stenosis (CAS) or SMA stenosis. Analysis of causes of stenosis or occlusion, prevalence, risk factors, different management strategies and outcomes was conducted.

Outcomes of Vascular Surgery Performed Jointly With Other Departments

OBJECTIVE

The purpose of this study is to evaluate the results of vascular surgery performed at our hospital, a tertiary emergency general hospital, in patients undergoing surgery in other departments. The results of the study were reviewed.

METHODS

The study included cases in which cardiovascular surgery was performed at the request of other departments over a 15-year period from January 2006 to October 2022. Patient backgrounds, departments that requested surgery, surgical procedures, use of extracorporeal circulation, and surgical techniques were reviewed. Patients with femoral artery exposure or ECMO removal during transcatheter aortic valve implantation (TAVI) requested by cardiology were excluded.

RESULTS

There were 58 vascular surgery cases requested by other departments during the study period. The age was 63±14 years, 43 (74%) were male and 15 (26%) were female. The departments of the patients were urology in 29 (50%), gastroenterology in 18 (31%), orthopedics in seven (12%), emergency department in three (5%), and obstetrics and gynecology in one (2%). The following surgical procedures were performed: tumor resection and reconstruction due to tumor invasion of the inferior vena cava in 27 cases (47%), bypass to secure intraperitoneal arterial blood flow in 15 cases (26%), bypass during resection of the femoral tumor in four cases (7%), hemostasis due to trauma in three cases (5%), intraperitoneal hemostasis in three cases (5%), thrombectomy in two cases (3%), and others in four cases (7%). Extracorporeal circulation was used in six (10%) of the patients.

CONCLUSION

A 15-year case study of vascular surgery supports operations requested by other departments at our hospital. All reconstructed sites were open at the time of discharge.

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

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.

Precision anatomy for safe approach to pancreatoduodenectomy for both open and minimally invasive procedure: A systematic review

BACKGROUND

Minimally invasive pancreatoduodenectomy (MIPD) has recently gained popularity. Several international meetings focusing on the existing literature on MIPD were held; however, the precise surgical anatomy of the pancreas for the safe use of MIPD has not yet been fully discussed. The aim of this study was to carry out a systematic review of available articles and to show the importance of identifying the anatomical variation in pancreatoduodenectomy.

METHODS

In this review, we described variations in surgical anatomy related to MIPD. A systematic search of PubMed (MEDLINE) was conducted, and the references were identified manually.

RESULTS

The search strategy yielded 272 articles, with 77 retained for analysis. The important anatomy to be considered during MIPD includes the aberrant right hepatic artery, first jejunal vein, first jejunal artery, and dorsal pancreatic artery. Celiac artery stenosis and a circumportal pancreas are also important to recognize.

CONCLUSIONS

We conclude that only certain anatomical variations are associated directly with perioperative outcomes and that identification of these particular variations is important for safe performance of MIPD.

Clinico-pathologic findings in patients with median arcuate ligament syndrome (celiac artery compression syndrome)

Median Arcuate Ligament Syndrome (MALS) is a rare entity characterized by severe post-prandial epigastric pain, nausea, vomiting, and/or weight loss. Symptoms have been attributed to vascular compression (celiac artery compression syndrome, CACS), but it remains controversial whether they could be secondary to neural compression. Literature review identified rare description of pathologic findings in surgery journals. The clinico-pathologic findings of four MALS patients who underwent robotic or laparoscopic surgery in our hospital are described. All our patients were female with a median age of 32.5 (range 25-55 years), and a median BMI of 23.5 kg/m². They presented with chronic often post-prandial abdominal pain (4/4), nausea (3/4), emesis (2/4), anorexia (1/4), and weight loss (1/4). Two patients had a history of Crohn's disease. At intraoperative exploration, the celiac artery and adjacent nerves and ganglia were encased and partially compressed by fibrotic tissue in each patient. In each case laparoscopic excision of fibrotic tissue, celiac plexus and ligament division and was performed; celiac plexus nerve block was also performed in one patient. After surgical intervention, symptoms improved in three of the patients whose specimens show periganglionic and perineural fibrosis with proliferation of small nerve fibers. Our findings support neurogenic compression as a contributing factor in the development of pain and other MALS symptoms, and favor the use of MALS rather than CACS as diagnostic terminology. To further study the pathogenesis of this unusual syndrome, surgeons should submit all tissues excised during MALS procedures for histopathologic examination.

Outcomes After Open and Endovascular Repair of Non-Ruptured True Pancreaticoduodenal and Gastroduodenal Artery Aneurysms Associated with Coeliac Artery Compression: A Multicentre Retrospective Study

OBJECTIVE

True aneurysms of the peri-pancreatic arcade (PDAA) have been attributed to increased collateral flow related to coeliac axis (CA) occlusion by a median arcuate ligament (MAL). Although PDAA exclusion is currently recommended, simultaneous CA release and the technique to be used are debated. The aim of this retrospective multicentre study was to compare the results of open surgical repair of true non-ruptured PDAA with release or CA bypass (group A) vs. coil embolisation of PDAA and CA stenting or laparoscopic release (group B).

METHODS

From January 1994 to February 2019, 57 consecutive patients (group A: 31 patients; group B: 26 patients), including 35 (61%) men (mean age 56 ± 11 years), were treated at three centres. Twenty-six patients (46%) presented with non-specific abdominal pain: 15 (48%) in group A and 11 (42%) in group B (p = .80).

RESULTS

No patient died during the post-operative period. At 30 days, all PDAAs following open repair and embolisation had been treated successfully. In group A, all CAs treated by MAL release or bypass were patent. In group B, 2/12 CA stentings failed at < 48 hours, and all MAL released by laparoscopy were successful. Median length of hospital stay was significantly greater in group A than in group B (5 vs. 3 days; p = .001). In group A, all PDAAs remained excluded. In group B, three PDAA recanalisations following embolisation were treated successfully (two redo embolisations and one open surgical resection). At six years, Kaplan-Meier estimates of freedom for PDAA recanalisation were 100% in group A, and 88% ± 6% in group B (p = .082). No PDAA ruptured during follow up. In group A, all 37 CAs treated by MAL release were patent, and one aortohepatic bypass occluded. In group B, five CAs occluded: four after stenting and the other after laparoscopic MAL release with two redo stenting and three aortohepatic bypasses. Estimates of freedom from CA restenosis/occlusion were 95% ± 3% for MAL release or visceral bypass, and 60% ± 9% for CA stenting (p = .001). Two late restenoses following CA stenting were associated with PDAA recanalisation.

CONCLUSION

Current data suggest that open and endovascular treatment of PDAA can be performed with excellent post-operative results in both groups. However, PDAA embolisation was associated with few midterm recanalisations and CA stenting with a significant number of early and midterm failures.

Two-way Revascularization to Manage Celiac Artery Stenosis during Pancreaticoduodenectomy: A Case Report

Celiac artery (CA) occlusion, or stenosis, is not uncommon, and most cases are asymptomatic. If the CA is occluded, collateral circulation from the superior mesenteric artery (SMA) is maintained through the pancreaticoduodenal arcade. However, the pancreaticoduodenal arcade is removed if pancreaticoduodenectomy (PD) is performed, which results in ischemia of the liver, stomach, and residual pancreas. Thus, these patients require CA revascularization, which can include antegrade endovascular reconstruction and retrograde reconstruction using vascular anastomosis from the SMA system to the CA system. Both methods carry risks of restenosis or anastomotic thrombosis. We report a technique that involves a combination of both revascularization methods in an 89-year-old man who underwent PD for lower bile duct cancer. Preoperative endovascular stent placement in the CA preserved antegrade blood flow to the liver, and intraoperative vascular anastomosis of the jejunal artery and right gastroepiploic artery achieved retrograde blood flow. Although we confirmed both stent and anastomosis patency and blood circulation in our case, obstruction of 1 of these revascularization pathways would not likely lead to ischemia of the liver. Thus, our 2-way revascularization technique for managing celiac artery stenosis during PD may reduce the risk of organ ischemia.

Aneurysms of Pancreaticoduodenal Artery due to Median Arcuate Ligament Syndrome, Treated by Open Surgery and Laparoscopic Surgery

Introduction

There are many possible causes of an abdominal visceral aneurysm, including the obstruction of the celiac artery by the median arcuate ligament (MAL). We report two cases of an aneurysm of the pancreaticoduodenal artery due to MAL syndrome that we treated surgically.

Case Presentation

Case 1: a 66-year-old Japanese woman was diagnosed with a rupture of an aneurysm of the inferior pancreaticoduodenal artery. Because of the difficulty of endovascular therapy, we performed an emergency operation. We chose an abdominal operation, and the postoperative course was uneventful. Case 2: a 75-year-old Japanese man presented at our hospital with acute abdominal pain, nausea, and cold sweat. Our experience of treating MAL syndrome in case 1 enabled us to diagnose the disease accurately. We chose laparoscopic surgery, and the postoperative course was uneventful.

Discussion

There are several treatment choices for an aneurysm of the pancreaticoduodenal artery due to MAL syndrome. We have performed only a release of the MAL for treatment, but it is difficult to conclude whether only releasing the MAL is enough to ensure a positive long-term prognosis. Regular follow-up is needed in such cases.

Conclusion

Laparoscopic surgery can be considered one of the options for MAL syndrome.

Pancreaticoduodenectomy complicated by Budd-Chiari syndrome: A case report and review of literature

BACKGROUND

Pancreaticoduodenectomy (PD)-induced morbidity, consisting mainly of the pancreatic fistula and its hemorrhagic and infectious consequences, is well described in the literature, in terms of its definition, risk factors, preventive measures, and standardized management of complications. However, some life-threatening complications remain atypical and undescribed.

CASE SUMMARY

We report here the case of a 69-year-old patient with Budd-Chiari syndrome that occurred after arterial embolization of postpancreatectomy hemorrhage. Diagnosis was established with biological findings (i.e., acute liver failure) and radiological findings (i.e., compressive hematoma of the retrohepatic vena cava). Emergency surgical revision was performed to evacuate the hematoma. The postoperative course was uneventful, with rapid recovery of liver function. To our knowledge, post-PD Budd-Chiari syndrome has never been described in the literature.

CONCLUSION

Acute liver failure in early post-PD should prompt investigation to rule out Budd-Chiari syndrome.

Acute median arcuate ligament syndrome after pancreaticoduodenectomy

Background

Median arcuate ligament syndrome (MALS) can cause severe complications after pancreaticoduodenectomy (PD). Most of the reported cases of MALS have been diagnosed perioperatively and can be treated efficiently by interventional radiology or division of the median acute ligament (MAL) fibers.

Case report

A 69-year-old woman underwent PD with resection of the SMV for pancreatic head cancer. Intraoperative exploration showed normal anatomy of the celiac trunk. Intraoperative digital palpation revealed normal pulsation of the common hepatic artery after resection of the gastroduodenal artery. On postoperative day (POD) 3, her liver function tests were abnormal, and bloody fluids were found in the drain. Abdominal CT showed necrosis of the pancreatic body and ischemia in the liver secondary to MALS which was not detected in the preoperative CT. Interventional radiology was tried first but failed. Division of the MAL fibers markedly increased the blood flow in the hepatic artery. Resection of the remnant pancreas and spleen was also performed simultaneously. Abdominal CT on POD 20 showed re-occlusion of the celiac artery. She experienced rupture of the gastrojejunostomy site, severe hepatic cytolysis, and choledochojejunostomy stricture thereafter.

Conclusions

This is the third case of MALS that has developed acutely after PD. MALS can cause refractory complications even after MAL release.

Substantial atherosclerotic celiac axis stenosis is a new risk factor for biliary fistula after pancreaticoduodenectomy

BACKGROUND

Biliary fistula (BF) is a major surgical complication that can develop after pancreaticoduodenectomy (PD) whose risk factors remain unclear. Substantial atherosclerotic celiac axis stenosis (SACAS) has not been reported to be one of them.

METHODS

Data from 507 patients undergoing PD between Jan 1, 2013 and Dec 31, 2015 were retrospectively collected. Clinical data from patients with SACAS were studied, and the independent risk factors for BF underwent multivariate logistic regression analysis, including SACAS.

RESULTS

BF occurred in 22 (4.3%) patients, and the incidence of BF was significantly higher in patients with SACAS than in those without it (27.0% vs 2.6%, P < .001). In the univariate analysis, BF was significantly related to SACAS, older age, a higher ASA score, history of coronary disease, greater blood loss and RBC transfusion during surgery, smaller CBD diameter and higher POD 1 BUN level. The multivariate analysis showed that only SACAS (OR 8.91, 95% CI 2.36-33.69, P = .001), older age (OR 1.08, 95% CI 1.01-1.15, P = .028) and smaller preoperative CBD (OR 0.79, 95% CI 0.69-0.92, P = .002) were independent risk factors for postoperative BF.

CONCLUSION

Older age and a smaller preoperative CBD diameter are independent risk factors for BF after PD, which is consistent with the literature. In addition, SACAS is a new independent risk factor for BF. For patients with SACAS, postoperative drainage should be carefully managed to precisely observe the potential for BF.