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Celiac axis stenosis as a rare but critical condition treated with pancreatoduodenectomy: report of 2 cases

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ABSTRACT

We describe 2 cases of patients with loss of hepatic arterial flow during surgery for pancreatic head cancer due to celiac stenosis caused by median arcuate ligament compression. The first case underwent pylorus-resecting pancreatoduodenectomy for pancreatic head cancer. After resection of the gastroduodenal artery, flow in the common hepatic artery disappeared, and celiac axis stenosis was identified. Interventional stent insertion was attempted, however, it failed due to the acute angle of the celiac orifice (os). This problem was resolved by arterial reconstruction. The second case underwent pylorus-preserving pancreatoduodenectomy for pancreatic head cancer and the same phenomenon occurred during the procedure. Interventional stent insertion was also tried; in this patient, however, it failed due to the acute angle of the celiac os. The problem was resolved by changing a femoral approach to a brachial approach, and the stent was inserted into the celiac os successfully.

No MeSH data available.


Related in: MedlinePlus

A 57-year-old female who received pylorus-resecting PD for pancreatic head cancer, after the resection of gastroduodenal artery (GDA); the flow of common hepatic artery was not detected and celiac axis stenosis was identified intraoperatively. (A) Intervention failed due to acute angulation (full line, arrow) of the celiac orifice. (B) The patient was sent back to operating room, and stent insertion (circle) was performed through GDA stump intraoperatively.
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Figure 1: A 57-year-old female who received pylorus-resecting PD for pancreatic head cancer, after the resection of gastroduodenal artery (GDA); the flow of common hepatic artery was not detected and celiac axis stenosis was identified intraoperatively. (A) Intervention failed due to acute angulation (full line, arrow) of the celiac orifice. (B) The patient was sent back to operating room, and stent insertion (circle) was performed through GDA stump intraoperatively.

Mentions: A 57-year-old woman was referred to our institution with a 2-month history of painless jaundice. Other than that, she was healthy. Her serum total bilirubin level was 6.5 mg/dL, her CA 19-9 concentration was 3,243 U/mL, and her CEA level was 6.9 ng/mL. Preoperative abdominal CT revealed a mass in the pancreatic head with the double duct sign. The patient underwent a pylorus-resecting PD (PrPD). Intraoperatively, after the gastroduodenal artery (GDA) was resected, a significant decrease in blood flow through the hepatic artery proper was detected. MAL was incidentally observed to be compressing the celiac axis. Therefore, we released the MAL and subsequently finished the PD. However, the celiac trunk was found to be hypotrophic and failed to fully expand, and the patient's arterial flow did not recover. The patient was transferred to the angio-intervention room while under general anesthesia so that an angiographic intervention for her celiac stenosis could be performed. Angiography showed severe stenosis of the celiac orifice (os). Stent insertion failed, however, because of the acute angle of the celiac os. We decided to take the patient back to the operating room and inserted the celiac stent successfully through the GDA stump intraoperatively (Fig. 1). The return of flow in the hepatic artery proper was checked and we found that the flow in the common hepatic artery (CHA) just after the procedure had disappeared. For occlusion of CHA, because approaching the celiac trunk was impossible due to the stent, we performed a segmental resection and created an anastomosis between the CHA and aorta. The patient's arterial flow recovered. She was discharged without complications on the day 18 postoperatively. Her most recent follow-up CT performed about 2 years postoperatively showed that her arterial flow was patent (Fig. 2).


Celiac axis stenosis as a rare but critical condition treated with pancreatoduodenectomy: report of 2 cases
A 57-year-old female who received pylorus-resecting PD for pancreatic head cancer, after the resection of gastroduodenal artery (GDA); the flow of common hepatic artery was not detected and celiac axis stenosis was identified intraoperatively. (A) Intervention failed due to acute angulation (full line, arrow) of the celiac orifice. (B) The patient was sent back to operating room, and stent insertion (circle) was performed through GDA stump intraoperatively.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5016606&req=5

Figure 1: A 57-year-old female who received pylorus-resecting PD for pancreatic head cancer, after the resection of gastroduodenal artery (GDA); the flow of common hepatic artery was not detected and celiac axis stenosis was identified intraoperatively. (A) Intervention failed due to acute angulation (full line, arrow) of the celiac orifice. (B) The patient was sent back to operating room, and stent insertion (circle) was performed through GDA stump intraoperatively.
Mentions: A 57-year-old woman was referred to our institution with a 2-month history of painless jaundice. Other than that, she was healthy. Her serum total bilirubin level was 6.5 mg/dL, her CA 19-9 concentration was 3,243 U/mL, and her CEA level was 6.9 ng/mL. Preoperative abdominal CT revealed a mass in the pancreatic head with the double duct sign. The patient underwent a pylorus-resecting PD (PrPD). Intraoperatively, after the gastroduodenal artery (GDA) was resected, a significant decrease in blood flow through the hepatic artery proper was detected. MAL was incidentally observed to be compressing the celiac axis. Therefore, we released the MAL and subsequently finished the PD. However, the celiac trunk was found to be hypotrophic and failed to fully expand, and the patient's arterial flow did not recover. The patient was transferred to the angio-intervention room while under general anesthesia so that an angiographic intervention for her celiac stenosis could be performed. Angiography showed severe stenosis of the celiac orifice (os). Stent insertion failed, however, because of the acute angle of the celiac os. We decided to take the patient back to the operating room and inserted the celiac stent successfully through the GDA stump intraoperatively (Fig. 1). The return of flow in the hepatic artery proper was checked and we found that the flow in the common hepatic artery (CHA) just after the procedure had disappeared. For occlusion of CHA, because approaching the celiac trunk was impossible due to the stent, we performed a segmental resection and created an anastomosis between the CHA and aorta. The patient's arterial flow recovered. She was discharged without complications on the day 18 postoperatively. Her most recent follow-up CT performed about 2 years postoperatively showed that her arterial flow was patent (Fig. 2).

View Article: PubMed Central - PubMed

ABSTRACT

We describe 2 cases of patients with loss of hepatic arterial flow during surgery for pancreatic head cancer due to celiac stenosis caused by median arcuate ligament compression. The first case underwent pylorus-resecting pancreatoduodenectomy for pancreatic head cancer. After resection of the gastroduodenal artery, flow in the common hepatic artery disappeared, and celiac axis stenosis was identified. Interventional stent insertion was attempted, however, it failed due to the acute angle of the celiac orifice (os). This problem was resolved by arterial reconstruction. The second case underwent pylorus-preserving pancreatoduodenectomy for pancreatic head cancer and the same phenomenon occurred during the procedure. Interventional stent insertion was also tried; in this patient, however, it failed due to the acute angle of the celiac os. The problem was resolved by changing a femoral approach to a brachial approach, and the stent was inserted into the celiac os successfully.

No MeSH data available.


Related in: MedlinePlus