Pancreaticoduodenectomy with hepatic arterial revascularization for pancreatic head cancer with stenosis of the celiac axis due to compression by the median arcuate ligament: a case report

Pancreaticoduodenectomy with hepatic arterial revascularization for pancreatic head cancer with... A 71-year-old woman presented to our hospital because pancreatic head cancer was suspected on a medical checkup. Computed tomography showed a 30 mm low-density lesion in the pancreatic head, and the stenosis of the celiac axis (CA) due to the median arcuate ligament (MAL) compression. We made a preoperative diagnosis of pancreatic head cancer and performed laparotomy. Transection of the MAL failed to restore adequate hepatic arterial flow, necessitating arterial revas- cularization, which was achieved by end-to-end anastomosis between the gastroduodenal artery and the middle colic artery. After reconstruction, Doppler ultrasonography showed improved hepatic arterial signal. The patient was discharged 16 days after surgery with no complications. When planning pancreaticoduodenectomy (PD) for such patients with CA stenosis due to MAL compression, surgeons should simulate a situation of insufficient hepatic arterial flow after division of the MAL, and prepare for reconstruction of the hepatic artery during PD. INTRODUCTION to the liver. However, in some cases, the hepatic arterial flow Celiac axis (CA) stenosis is not a rare condition [1], and com- cannot be resolved by division of the MAL, and the diminished hepatic arterial flow induces hepatic ischemia [3]. To prevent pression by the median arcuate ligament (MAL) has been reported as its cause [2]. When performing pancreaticoduode- hepatic ischemia, the surgical procedure, including the preser- vation of the pancreatic arcade [3] or revascularization of the nectomy (PD) in such patients, MAL division during surgery is recommended because CA stenosis influences the blood supply hepatic artery [4], must be considered. Received: September 16, 2017. Accepted: January 14, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjy002/4825118 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 T. Miyata et al. We herein report a case of pancreatic head cancer suc- reconstruction by end-to-end anastomosis of the GDA and cessfully treated by PD and hepatic arterial revascularization MCA was planned. between of gastroduodenal artery (GDA) and middle colic After laparotomy we identified the MAL, which had com- artery (MCA) in a patient with CA stenosis due to MAL pressed the origin of the CA (Fig. 2a), and Doppler ultrasonog- compression. raphy showed that the hepatic arterial flow was hepatopetal, but the common hepatic arterial flow was hepatofugal (no record available). First, the MAL was divided (Fig. 2b). After CASE REPORT clamping the GDA (Fig. 2c), the hepatic arterial flow was not satisfactory (Fig. 2d). We continued the operation under GDA A 71-year-old woman was admitted because pancreatic head cancer was suspected on a medical checkup. Enhanced abdom- clamping. Finally, the specimen was connected only by the IPDA, SMV and GDA. The IPDA and aneurysm were ligated and inal computed tomography (CT) revealed a low-density tumor, 30 mm in diameter, in the pancreatic head, and involvement of divided (Fig. 3a). At this time, 92 min after clamping the GDA, however, the hepatic arterial flow was not improved. We were the superior mesenteric vein (SMV) with the tumor was noted (Fig. 1a). The distal side of the GDA was involved by this tumor, able to preserve the GDA 10 mm from its root, we divided the GDA and SMV and extracted the specimen. Arterial reconstruc- however, the proximal side of the GDA was not involved. CA stenosis was revealed (Fig. 1b). In addition, the developed tion by end-to-end anastomosis of the GDA and MCA was per- formed by plastic surgeons (Fig. 3b). After reconstruction, the arcade of the peri-pancreatic arteries and an aneurysm of the inferior pancreaticoduodenal artery (IPDA), 20 mm in diameter, hepatic arterial signal was improved (Fig. 3c). The patient was discharged 16 days after surgery with no were found (Fig. 1c). We preoperatively diagnosed the patient with pancreatic head cancer with CA stenosis due to MAL com- complications. We made the final diagnosis of the pancreatic head invasive ductal carcinoma, T3N1M0 Stage IIB (UICC sev- pression and aneurysm of IPDA, T3N0M0 Stage IIA (UICC sev- enth). We planned PD and SMV resection and reconstruction enth). Adjuvant chemotherapy with S-1 was performed for 6 months. The patient did not develop recurrence in 14 months with opening of the MAL. If the hepatic arterial flow was found to be inadequate after division of the MAL, arterial following the operation. (a) (b) (c) CHA PHA CA GDA SMA MCA IPDA Figure 1: (a) Enhanced abdominal CT showed a low-density tumor (red arrow), 30 mm in diameter, in the pancreatic head. The superior mesenteric vein (SMV, blue arrow) and gastroduodenal artery (GDA, yellow arrow) were involved by this tumor. (b) Stenosis of the celiac artery (CA) was shown (green arrow). (c) Preoperative 3D CT angiogram showed the development of pancreatic artery arcade and a saccular aneurysm (purple arrow) of the inferior pancreaticoduodenal artery (IPDA), 20 mm in diameter. CHA, common hepatic artery; PHA, proper hepatic artery; SMA, superior mesenteric artery; MCA, middle colic artery. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjy002/4825118 by Ed 'DeepDyve' Gillespie user on 16 March 2018 PD for a patient with celiac axis stenosis 3 (a) (b) (c) (d) PHA CHA GDA Figure 2: (a) The median arcuate ligament (green arrow) compressed the CA. (b) Compression of the origin of the CA by the ligament was released. (c) The image shows that the GDA was clamped. (d) We checked the hepatic artery flow under GDA clamping, but the flow had not improved satisfactory. arcade, surgeons often cannot preserve the pancreatic arterial DISCUSSION arcade in radical surgery. CA stenosis is not a particularly rare clinical entity, and a previ- Several methods for surgical reconstruction of the hepatic ous report in a large series described an incidence of 10.5% [1]. artery have been reported. One is bypass grafting between such And the most common cause of CA stenosis in Eastern coun- as aorta and CA, using a graft such as the saphenous vein [10]. tries is the MAL [2]. CA stenosis is usually asymptomatic, due And the other is end-to-end arterial anastomosis method such to the rich collateral mainly through the pancreaticoduodenal as our case. In bypass method, grafts extraction and two recon- arcades. However, it is particularly critical to maintain the hep- structions are necessary. In contrast, end-to-end arterial anas- atic arterial flow when performing PD. tomosis method could be achieved without the use of grafts. This method of preoperative stent insertion may be helpful Previous reports have described anastomosis between GDA and for CA stenosis, and many reports of endovascular treatment MCA [4, 7], splenic artery and superior mesenteric artery [1], have been published. This procedure can be fatal, however, if and MCA and right gastroepiploic artery [6]. Of these, end-to- thrombosis or stent occlusion occurs [5]. MAL division may be end anastomosis between GDA and MCA, if both the MCA and able to resolve this issue and prevent problems, such as ische- the root of GDA were not involved by tumor, seems to be a mic complications [5]. Therefore, in this case, preoperative viable and simple option in reconstruction during PD [4, 7]. transluminal angioplasty or stenting were not considered. When planning PD for the patients with CA stenosis, sur- For CA stenosis due to MAL compression, MAL division is geons should simulate various situations for maintaining the considered the primary procedure for surgical treatment. hepatic arterial flow. Revascularization between the GDA and However, if the hepatic arterial flow cannot be resolved, sur- MCA is one way to maintain the hepatic arterial flow and allow geon should consider saving the pancreatic collateral arcade or for radical surgery. To our knowledge, although only two revascularization of the hepatic artery. There have been several reports [4, 7] have applied this procedure with end-to-end anas- reports of simultaneous vascular reconstruction with PD for tomosis between GDA and MCA, the patient was able to be suc- patients with CA stenosis due to MAL compression [1, 4, 6–8]. cessfully treated in both cases. Simultaneous vascular reconstruction with PD carries an increased risk of thromboembolism and postoperative bleeding CONFLICT OF INTEREST STATEMENT caused by pancreatic fistula [4]. While saving the pancreatic collateral arcade is one way of avoiding vascular reconstruc- The authors declare no conflicts of interest. tion, preserving the collateral arcade carries a risk of losing positive surgical margins, particularly in cases of pancreatic FUNDING head cancer. Furthermore, true aneurysms of the PDA are fre- quently coexistent with CA stenosis [9]. When PD is planned No authors have direct or indirect commercial and financial for patients with CA stenosis and aneurysms in the pancreatic incentives associated with publishing the article. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjy002/4825118 by Ed 'DeepDyve' Gillespie user on 16 March 2018 4 T. Miyata et al. CHA (a) (b) PHA GDA SMV (c) Figure 3: (a) The purple arrow indicates the stump of the aneurysm. (b) The image was after reconstruction by end-to-end anastomosis of the GDA and the MCA (yel- low arrow). The blue arrow indicates the anastomotic part of the SMV. (c) We checked the hepatic arterial flow after reconstruction, the hepatic arterial signal had increased. 5. Sharafuddin MJ, Olson CH, Sun S, Kresowik TF, Corson JD. CONSENT Endovascular treatment of celiac and mesenteric arteries The patient discussed in this case report provided her informed stenoses: applications and results. J Vasc Surg 2003;38:692–8. consent for publishing the information in this report. 6. Nara S, Sakamoto Y, Shimada K, Sano T, Kosuge T, Takahashi Y, et al. Arterial reconstruction during pancrea- toduodenectomy in patients with celiac axis stenosis: utility REFERENCES of doppler ultrasonography. World J Surg 2005;29:885–9. 7. Machado MC, Penteado S, Montagnini AL, Machado MA. An 1. Thompson NW, Eckhauser FE, Talpos G, Cho KJ. Pancreaticoduodenectomy and celiac occlusive disease. Ann alternative technique in the treatment of celiac axis sten- Surg 1981;193:399–406. osis diagnosed during pancreaticoduodenectomy. HPB Surg 2. Peros G, Sakorafas GH, Giannopoulos GA, Manikis D, 1998;10:371–3. 8. Hayashibe A, Sakamoto K, Shinbo M, Makimoto S, Vassiliu P, Brountzos EN. Successful pancreaticoduodenect- omy with immediate vascular reconstruction in a patient Nakamoto T, Higashiue S, et al. A resected case of advanced with cancer of the pancreatic head and celiac artery sten- duodenal carcinoma with occlusion of the celiac artery. osis. A case report. JOP 2009;10:667–70. J Surg Oncol 2005;91:270–2. 9. Quandalle P, Chambon JP, Marache P, Saundemont A, Maes 3. Kurosaki I, Hatakeyama K, Nihei KE, Oyamatsu M. Celiac axis stenosis in pancreaticoduodenectomy. J Hepatobiliary B. Pancreaticoduodenal artery aneurysms associated with Pancreat Surg 2004;11:119–24. celiac axis stenosis: report of two cases and review of the 4. Machado MA, Herman P, Montagnini AL, Costa ML, Nishinari literature. Ann Vasc Surg 1990;4:540–5. K, Wolosker N, et al. A new test to avoid arterial complications 10. Takach TJ, Livesay JJ, Reul GJ Jr, Cooley DA. Celiac compres- during pancreaticoduodenectomy. HepatoGastroenterology 2004; sion syndrome: tailored therapy based on intraoperative findings. J Am Coll Surg 1996;183:606–10. 51:1671–3. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjy002/4825118 by Ed 'DeepDyve' Gillespie user on 16 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Pancreaticoduodenectomy with hepatic arterial revascularization for pancreatic head cancer with stenosis of the celiac axis due to compression by the median arcuate ligament: a case report

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Abstract

A 71-year-old woman presented to our hospital because pancreatic head cancer was suspected on a medical checkup. Computed tomography showed a 30 mm low-density lesion in the pancreatic head, and the stenosis of the celiac axis (CA) due to the median arcuate ligament (MAL) compression. We made a preoperative diagnosis of pancreatic head cancer and performed laparotomy. Transection of the MAL failed to restore adequate hepatic arterial flow, necessitating arterial revas- cularization, which was achieved by end-to-end anastomosis between the gastroduodenal artery and the middle colic artery. After reconstruction, Doppler ultrasonography showed improved hepatic arterial signal. The patient was discharged 16 days after surgery with no complications. When planning pancreaticoduodenectomy (PD) for such patients with CA stenosis due to MAL compression, surgeons should simulate a situation of insufficient hepatic arterial flow after division of the MAL, and prepare for reconstruction of the hepatic artery during PD. INTRODUCTION to the liver. However, in some cases, the hepatic arterial flow Celiac axis (CA) stenosis is not a rare condition [1], and com- cannot be resolved by division of the MAL, and the diminished hepatic arterial flow induces hepatic ischemia [3]. To prevent pression by the median arcuate ligament (MAL) has been reported as its cause [2]. When performing pancreaticoduode- hepatic ischemia, the surgical procedure, including the preser- vation of the pancreatic arcade [3] or revascularization of the nectomy (PD) in such patients, MAL division during surgery is recommended because CA stenosis influences the blood supply hepatic artery [4], must be considered. Received: September 16, 2017. Accepted: January 14, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjy002/4825118 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 T. Miyata et al. We herein report a case of pancreatic head cancer suc- reconstruction by end-to-end anastomosis of the GDA and cessfully treated by PD and hepatic arterial revascularization MCA was planned. between of gastroduodenal artery (GDA) and middle colic After laparotomy we identified the MAL, which had com- artery (MCA) in a patient with CA stenosis due to MAL pressed the origin of the CA (Fig. 2a), and Doppler ultrasonog- compression. raphy showed that the hepatic arterial flow was hepatopetal, but the common hepatic arterial flow was hepatofugal (no record available). First, the MAL was divided (Fig. 2b). After CASE REPORT clamping the GDA (Fig. 2c), the hepatic arterial flow was not satisfactory (Fig. 2d). We continued the operation under GDA A 71-year-old woman was admitted because pancreatic head cancer was suspected on a medical checkup. Enhanced abdom- clamping. Finally, the specimen was connected only by the IPDA, SMV and GDA. The IPDA and aneurysm were ligated and inal computed tomography (CT) revealed a low-density tumor, 30 mm in diameter, in the pancreatic head, and involvement of divided (Fig. 3a). At this time, 92 min after clamping the GDA, however, the hepatic arterial flow was not improved. We were the superior mesenteric vein (SMV) with the tumor was noted (Fig. 1a). The distal side of the GDA was involved by this tumor, able to preserve the GDA 10 mm from its root, we divided the GDA and SMV and extracted the specimen. Arterial reconstruc- however, the proximal side of the GDA was not involved. CA stenosis was revealed (Fig. 1b). In addition, the developed tion by end-to-end anastomosis of the GDA and MCA was per- formed by plastic surgeons (Fig. 3b). After reconstruction, the arcade of the peri-pancreatic arteries and an aneurysm of the inferior pancreaticoduodenal artery (IPDA), 20 mm in diameter, hepatic arterial signal was improved (Fig. 3c). The patient was discharged 16 days after surgery with no were found (Fig. 1c). We preoperatively diagnosed the patient with pancreatic head cancer with CA stenosis due to MAL com- complications. We made the final diagnosis of the pancreatic head invasive ductal carcinoma, T3N1M0 Stage IIB (UICC sev- pression and aneurysm of IPDA, T3N0M0 Stage IIA (UICC sev- enth). We planned PD and SMV resection and reconstruction enth). Adjuvant chemotherapy with S-1 was performed for 6 months. The patient did not develop recurrence in 14 months with opening of the MAL. If the hepatic arterial flow was found to be inadequate after division of the MAL, arterial following the operation. (a) (b) (c) CHA PHA CA GDA SMA MCA IPDA Figure 1: (a) Enhanced abdominal CT showed a low-density tumor (red arrow), 30 mm in diameter, in the pancreatic head. The superior mesenteric vein (SMV, blue arrow) and gastroduodenal artery (GDA, yellow arrow) were involved by this tumor. (b) Stenosis of the celiac artery (CA) was shown (green arrow). (c) Preoperative 3D CT angiogram showed the development of pancreatic artery arcade and a saccular aneurysm (purple arrow) of the inferior pancreaticoduodenal artery (IPDA), 20 mm in diameter. CHA, common hepatic artery; PHA, proper hepatic artery; SMA, superior mesenteric artery; MCA, middle colic artery. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjy002/4825118 by Ed 'DeepDyve' Gillespie user on 16 March 2018 PD for a patient with celiac axis stenosis 3 (a) (b) (c) (d) PHA CHA GDA Figure 2: (a) The median arcuate ligament (green arrow) compressed the CA. (b) Compression of the origin of the CA by the ligament was released. (c) The image shows that the GDA was clamped. (d) We checked the hepatic artery flow under GDA clamping, but the flow had not improved satisfactory. arcade, surgeons often cannot preserve the pancreatic arterial DISCUSSION arcade in radical surgery. CA stenosis is not a particularly rare clinical entity, and a previ- Several methods for surgical reconstruction of the hepatic ous report in a large series described an incidence of 10.5% [1]. artery have been reported. One is bypass grafting between such And the most common cause of CA stenosis in Eastern coun- as aorta and CA, using a graft such as the saphenous vein [10]. tries is the MAL [2]. CA stenosis is usually asymptomatic, due And the other is end-to-end arterial anastomosis method such to the rich collateral mainly through the pancreaticoduodenal as our case. In bypass method, grafts extraction and two recon- arcades. However, it is particularly critical to maintain the hep- structions are necessary. In contrast, end-to-end arterial anas- atic arterial flow when performing PD. tomosis method could be achieved without the use of grafts. This method of preoperative stent insertion may be helpful Previous reports have described anastomosis between GDA and for CA stenosis, and many reports of endovascular treatment MCA [4, 7], splenic artery and superior mesenteric artery [1], have been published. This procedure can be fatal, however, if and MCA and right gastroepiploic artery [6]. Of these, end-to- thrombosis or stent occlusion occurs [5]. MAL division may be end anastomosis between GDA and MCA, if both the MCA and able to resolve this issue and prevent problems, such as ische- the root of GDA were not involved by tumor, seems to be a mic complications [5]. Therefore, in this case, preoperative viable and simple option in reconstruction during PD [4, 7]. transluminal angioplasty or stenting were not considered. When planning PD for the patients with CA stenosis, sur- For CA stenosis due to MAL compression, MAL division is geons should simulate various situations for maintaining the considered the primary procedure for surgical treatment. hepatic arterial flow. Revascularization between the GDA and However, if the hepatic arterial flow cannot be resolved, sur- MCA is one way to maintain the hepatic arterial flow and allow geon should consider saving the pancreatic collateral arcade or for radical surgery. To our knowledge, although only two revascularization of the hepatic artery. There have been several reports [4, 7] have applied this procedure with end-to-end anas- reports of simultaneous vascular reconstruction with PD for tomosis between GDA and MCA, the patient was able to be suc- patients with CA stenosis due to MAL compression [1, 4, 6–8]. cessfully treated in both cases. Simultaneous vascular reconstruction with PD carries an increased risk of thromboembolism and postoperative bleeding CONFLICT OF INTEREST STATEMENT caused by pancreatic fistula [4]. While saving the pancreatic collateral arcade is one way of avoiding vascular reconstruc- The authors declare no conflicts of interest. tion, preserving the collateral arcade carries a risk of losing positive surgical margins, particularly in cases of pancreatic FUNDING head cancer. Furthermore, true aneurysms of the PDA are fre- quently coexistent with CA stenosis [9]. When PD is planned No authors have direct or indirect commercial and financial for patients with CA stenosis and aneurysms in the pancreatic incentives associated with publishing the article. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjy002/4825118 by Ed 'DeepDyve' Gillespie user on 16 March 2018 4 T. Miyata et al. CHA (a) (b) PHA GDA SMV (c) Figure 3: (a) The purple arrow indicates the stump of the aneurysm. (b) The image was after reconstruction by end-to-end anastomosis of the GDA and the MCA (yel- low arrow). The blue arrow indicates the anastomotic part of the SMV. (c) We checked the hepatic arterial flow after reconstruction, the hepatic arterial signal had increased. 5. Sharafuddin MJ, Olson CH, Sun S, Kresowik TF, Corson JD. CONSENT Endovascular treatment of celiac and mesenteric arteries The patient discussed in this case report provided her informed stenoses: applications and results. J Vasc Surg 2003;38:692–8. consent for publishing the information in this report. 6. Nara S, Sakamoto Y, Shimada K, Sano T, Kosuge T, Takahashi Y, et al. Arterial reconstruction during pancrea- toduodenectomy in patients with celiac axis stenosis: utility REFERENCES of doppler ultrasonography. World J Surg 2005;29:885–9. 7. Machado MC, Penteado S, Montagnini AL, Machado MA. An 1. Thompson NW, Eckhauser FE, Talpos G, Cho KJ. Pancreaticoduodenectomy and celiac occlusive disease. Ann alternative technique in the treatment of celiac axis sten- Surg 1981;193:399–406. osis diagnosed during pancreaticoduodenectomy. HPB Surg 2. Peros G, Sakorafas GH, Giannopoulos GA, Manikis D, 1998;10:371–3. 8. Hayashibe A, Sakamoto K, Shinbo M, Makimoto S, Vassiliu P, Brountzos EN. Successful pancreaticoduodenect- omy with immediate vascular reconstruction in a patient Nakamoto T, Higashiue S, et al. A resected case of advanced with cancer of the pancreatic head and celiac artery sten- duodenal carcinoma with occlusion of the celiac artery. osis. A case report. JOP 2009;10:667–70. J Surg Oncol 2005;91:270–2. 9. Quandalle P, Chambon JP, Marache P, Saundemont A, Maes 3. Kurosaki I, Hatakeyama K, Nihei KE, Oyamatsu M. Celiac axis stenosis in pancreaticoduodenectomy. J Hepatobiliary B. Pancreaticoduodenal artery aneurysms associated with Pancreat Surg 2004;11:119–24. celiac axis stenosis: report of two cases and review of the 4. Machado MA, Herman P, Montagnini AL, Costa ML, Nishinari literature. Ann Vasc Surg 1990;4:540–5. K, Wolosker N, et al. A new test to avoid arterial complications 10. Takach TJ, Livesay JJ, Reul GJ Jr, Cooley DA. Celiac compres- during pancreaticoduodenectomy. HepatoGastroenterology 2004; sion syndrome: tailored therapy based on intraoperative findings. J Am Coll Surg 1996;183:606–10. 51:1671–3. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjy002/4825118 by Ed 'DeepDyve' Gillespie user on 16 March 2018

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Journal of Surgical Case ReportsOxford University Press

Published: Jan 1, 2018

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