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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.

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A 56-year-old male received pylorus-preserving PD for pancreatic head cancer, and loss of hepatic artery flow was detected after gastroduodenal artery ligation. (A) On abdominal arteriography, the flow to the celiac trunk was delayed severely. (B) Approach of the balloon and stent was impossible due to acute angulation (dotted line) of the celiac orifice. (C) Ballooning and stent insertion for stenotic lesion (circle) by the brachial approach (full line) was performed. (D) Arterial flow was improved after the procedure.
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Figure 3: A 56-year-old male received pylorus-preserving PD for pancreatic head cancer, and loss of hepatic artery flow was detected after gastroduodenal artery ligation. (A) On abdominal arteriography, the flow to the celiac trunk was delayed severely. (B) Approach of the balloon and stent was impossible due to acute angulation (dotted line) of the celiac orifice. (C) Ballooning and stent insertion for stenotic lesion (circle) by the brachial approach (full line) was performed. (D) Arterial flow was improved after the procedure.

Mentions: A 56-year-old man visited our institution for the evaluation and treatment of indigestion that had started a month earlier. His serum total bilirubin level was 1.0 mg/dL, his CA 19-9 concentration was 284 U/mL, and his CEA level was 3.5 ng/mL. Preoperative abdominal CT revealed an ill-defined, low attenuation lesion at the head of the pancreas with distal pancreatic duct dilation that suggested pancreatic cancer. The patient had an abnormality in his vascular anatomy; the celiac os was not shown clearly, and the GDA originated from the SMA. He underwent pylorus-preserving PD (PPPD). During the operation, flow in the hepatic artery proper was not detected after resection of the GDA. Angiography was performed just after the operation while the patient was under general anesthesia. Severe stenosis of the celiac os was found. A femoral artery approach for ballooning and stent insertion failed because of the acute angle and stenosis of the celiac os. Therefore, the vascular approach was changed from the femoral to the left brachial approach, and stent insertion into the celiac trunk was performed successfully (Fig. 3). The patient was discharged without complications on the 28th day postoperatively. His last CT performed 14 months postoperatively showed that his arterial flow was patent; however, he died 15 months postoperatively due to the recurrence of the tumor.


Celiac axis stenosis as a rare but critical condition treated with pancreatoduodenectomy: report of 2 cases
A 56-year-old male received pylorus-preserving PD for pancreatic head cancer, and loss of hepatic artery flow was detected after gastroduodenal artery ligation. (A) On abdominal arteriography, the flow to the celiac trunk was delayed severely. (B) Approach of the balloon and stent was impossible due to acute angulation (dotted line) of the celiac orifice. (C) Ballooning and stent insertion for stenotic lesion (circle) by the brachial approach (full line) was performed. (D) Arterial flow was improved after the procedure.
© Copyright Policy - open-access
Related In: Results  -  Collection

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

Figure 3: A 56-year-old male received pylorus-preserving PD for pancreatic head cancer, and loss of hepatic artery flow was detected after gastroduodenal artery ligation. (A) On abdominal arteriography, the flow to the celiac trunk was delayed severely. (B) Approach of the balloon and stent was impossible due to acute angulation (dotted line) of the celiac orifice. (C) Ballooning and stent insertion for stenotic lesion (circle) by the brachial approach (full line) was performed. (D) Arterial flow was improved after the procedure.
Mentions: A 56-year-old man visited our institution for the evaluation and treatment of indigestion that had started a month earlier. His serum total bilirubin level was 1.0 mg/dL, his CA 19-9 concentration was 284 U/mL, and his CEA level was 3.5 ng/mL. Preoperative abdominal CT revealed an ill-defined, low attenuation lesion at the head of the pancreas with distal pancreatic duct dilation that suggested pancreatic cancer. The patient had an abnormality in his vascular anatomy; the celiac os was not shown clearly, and the GDA originated from the SMA. He underwent pylorus-preserving PD (PPPD). During the operation, flow in the hepatic artery proper was not detected after resection of the GDA. Angiography was performed just after the operation while the patient was under general anesthesia. Severe stenosis of the celiac os was found. A femoral artery approach for ballooning and stent insertion failed because of the acute angle and stenosis of the celiac os. Therefore, the vascular approach was changed from the femoral to the left brachial approach, and stent insertion into the celiac trunk was performed successfully (Fig. 3). The patient was discharged without complications on the 28th day postoperatively. His last CT performed 14 months postoperatively showed that his arterial flow was patent; however, he died 15 months postoperatively due to the recurrence of the tumor.

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