Case Report
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Feb 7, 2017; 23(5): 919-925
Published online Feb 7, 2017. doi: 10.3748/wjg.v23.i5.919
Pancreaticoduodenectomy: Secondary stenting of the celiac trunk after inefficient median arcuate ligament release and reoperation as an alternative to simultaneous hepatic artery reconstruction
Théophile Guilbaud, Jacques Ewald, Olivier Turrini, Jean Robert Delpero
Théophile Guilbaud, Jacques Ewald, Olivier Turrini, Jean Robert Delpero, Department of Surgery, Institut Paoli Calmettes, 13009 Marseille, France
Author contributions: All authors made contributions to this manuscript.
Conflict-of-interest statement: The authors state that they have no conflict of interest regarding this case report.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Jean Robert Delpero, MD, PhD, Professor, Department of Surgery, Institut Paoli Calmettes, 232 Bd de Sainte Marguerite, 13009 Marseille, France. jrdelpero@numericable.fr
Telephone: +33-608719985
Received: September 25, 2016
Peer-review started: September 26, 2016
First decision: October 28, 2016
Revised: October 29, 2016
Accepted: November 16, 2016
Article in press: November 16, 2016
Published online: February 7, 2017
Processing time: 119 Days and 8.3 Hours
Abstract

In patients undergoing pancreaticoduodenectomy (PD), unrecognized hemodynamically significant celiac axis (CA) stenosis impairs hepatic arterial flow by suppressing the collateral pathways supplying arterial flow from the superior mesenteric artery and leads to serious hepatobiliary complications due to liver and biliary ischemia, with a high rate of mortality. CA stenosis is usually due to an extrinsic compression by a previously asymptomatic median arcuate ligament (MAL). MAL is diagnosed by computerized tomography in about 10% of the candidates for PD, but only half are found to be hemodynamically significant during the gastroduodenal artery clamping test with Doppler assessment, which is mandatory before any resection. MAL release is usually efficient to restore an adequate liver blood inflow and prevent ischemic complications. In cases of failure in MAL release, postponed PD with secondary stenting of the CA and reoperation for PD should be considered as an alternative to immediate hepatic artery reconstruction, which involves the risk of postoperative thrombosis of the arterial reconstruction. We recently used this two-stage strategy in a patient undergoing surgery for pancreatic adenocarcinoma.

Keywords: Pancreaticoduodenectomy; Celiac axis stenosis; Median arcuate ligament

Core tip: In patients undergoing pancreaticoduodenectomy (PD), hemodynamically significant celiac axis (CA) stenosis has the potential to cause vascular insufficiency leading to serious hepatobiliary complications with a high rate of mortality. CA stenosis is usually due to an extrinsic compression by a previously asymptomatic median arcuate ligament (MAL). MAL release is usually efficient to restore an adequate liver blood inflow and prevent ischemic complications. In cases of failure in MAL release, postponed PD with secondary stenting of the CA and reoperation for PD should be considered as an alternative to immediate hepatic artery reconstruction, which involves the risk of postoperative thrombosis.