Strategies for management of coeliac axis stenosis during pancreatic resection

Abstract

Aim: Coeliac axis stenosis and median arcuate compression syndrome are increasingly diagnosed on the multidetector computed tomography. We report the cases of coeliac stenosis and strategies used to avoid postoperative visceral ischaemia. Methods: We utilised a prospectively maintained database of pancreatic resections for the period of 2010–2015. The radiological findings, surgical and interventional radiological procedures, and outcomes analysed. Results: Of the 331 pancreatic resections during this period, 8 (2.4%) were found to have coeliac stenosis. Median age was 69 years (48–80). Abnormal collateralisation around the head of pancreas or retroperitoneum was a constant feature in all these cases. 3 patients had post stenotic dilatation of coeliac artery. 4 patients underwent angiogram and coeliac artery stenting and subsequent Whipple's resection, 1 patient had reconstruction of vascular inflow to hepatic artery from prominent inferior pancreaticoduodenal artery collateral after Whipple's resection, 1 patient had hepatic artery inflow via infrarenal aortic conduit with saphenous vein graft during Whipple's resection, 1 patient had total pancreatectomy with preservation of retroperitoneal collateral from SMA to splenic artery and 1 patient had distal subtotal pancreatectomy instead of Whipple's procedure to remove a neuroendocrine tumour from neck of pancreas with preservation of collaterals around the head of pancreas. All seven patients recovered with any features of visceral ischaemia. The patient who underwent total pancreatectomy developed early liver dysfunction secondary to ischaemia. Conclusion: Possibility of coeliac stenosis should be borne in mind when there are abnormal collaterals around the pancreas. Angiographic stenting gives the best outcome.