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

Pancreaticoduodenectomy involves a division of the gastroduodenal artery and resection of the pancreaticoduodenal arcades, which depend on both the GDA and the superior mesenteric artery

Théophile Guilbaud

2017

Scholarcy highlights

  • Pancreaticoduodenectomy involves a division of the gastroduodenal artery and resection of the pancreaticoduodenal arcades, which depend on both the GDA and the superior mesenteric artery
  • In cases of failure in median arcuate ligament release, postponed PD with secondary stenting of the celiac axis and reoperation for PD should be considered as an alternative to immediate hepatic artery re­ construction, which involves the risk of postoperative thrombosis of the arterial reconstruction
  • MAL is diagnosed by computed tomography in about 10% of the candidates for PD, but only half are found to be hemodynamically significant during the GDA clamping test with Doppler assessment, which is mandatory before any resection
  • CA stenosis is detected during the preoperative staging of pancreatic cancer in 4%-11% of patients scheduled for PD. The majority of these detected stenoses are asymptomatic before the diagnosis of the tumor
  • Most cases are asymptomatic and hemodynamically significant stenosis during the GDA clamping test has been reported to be present in about 40% of the cases, which represents 5% of the patients submitted to PD
  • In cases of CA stenosis detected by a multidetector CT scan before PD of a clearly resectable pancreatic adenocarcinoma, the following strategy should be considered as an option: in cases with a hemodynamically significant stenosis, as assessed by GDA clamping and Doppler ultrasound, perform a firststep, including MAL release, with abdominal exploration and a para-aortic lymph node biopsy; in cases involving a failure of MAL release to restore the liver blood inflow, perform secondary cautious endovascular stenting of the CA in order to avoid the risk of postpancreatectomy arterial reconstruction thrombosis and postpone PD
  • Preoperative median arcuate ligament stenting is technically challenging and proves mostly ineffective by the default of expanding and restenosis; in the current report, stenting was easier after MAL release and this strategy should be considered as an alternative to vascular bypass, avoiding the risk of postoperative thrombosis; secondary stenting should proceed with cautious regarding the potential risk of injury during the procedure due to the fragility of the artery after ligament release

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