Successful Interventional Radiology for Acute Median Arcuate Ligament Syndrome After Pancreaticoduodenectomy.

Takehiko Hanaki,Yuki Murakami,Yoshiyuki Fujiwara,Shinsaku Yata,Teruhisa Sakamoto

doi:10.7759/cureus.13540

Abstract

Background: Median arcuate ligament (MAL) syndrome (MALS), also known as celiac artery (CA) compression syndrome and Dunbar syndrome, occurs because of extraluminal compression of the CA root by the MAL, which is part of the diaphragm. In MALS, a malposition of the MAL compresses the CA and causes nonspecific symptoms, including epigastric pain after eating, weight loss, nausea, and vomiting and can sometimes cause visceral aneurysms. Typically, in MALS, various chronic ischemic symptoms and visceral aneurysms due to changes in arterial blood flow are observed; however, in acute-onset MALS, acute organ failure due to ischemic changes may be problematic. Surgical treatment is the recommended treatment for MALS, but the optimal treatment of acute MALS that occurs after laparotomy remains controversial because of its rarity. Here, we present the first case of acute MALS, which occurred after pancreaticoduodenectomy (PD) that was successfully treated with interventional radiology (IVR) without reoperation.Case presentation: A 75-year-old man presented with liver infarction after subtotal stomach-preserving PD using the Child method plus Braun enteroenterostomy. As a result of contrast-enhanced computed tomography for the investigation of elevated hepatic cytolysis-related enzymes on the first postoperative day, he was diagnosed with acute MALS resulting from gastrointestinal reconstruction after PD. The patient underwent IVR to restore blood flow of the CA, and an intraluminal stent was inserted. Despite the development of ischemic gastropathy, splenic infarction, and pancreatic fistula, the patient was eventually discharged on postoperative day 82 without any disability.Conclusion: Many studies have reported open, laparoscopic, and robot-assisted MAL incisions for MALS, but few reports have detailed the treatment for postoperative MALS. Here, we report the first case of acute MALS developed after PD that was successfully treated with endovascular CA stenting. For acute MALS after PD, early endovascular treatment may be more useful than re-laparotomy.

Highlights

Because median arcuate ligament (MAL) syndrome (MALS), called “celiac axis compression syndrome” [1,2], may be fatal if left untreated at the time of pancreaticoduodenectomy (PD) [3,4], it is diagnosed preoperatively and treated with preoperative interventional radiology (IVR) or intraoperative surgical treatment
For acute MALS after PD, early endovascular treatment may be more useful than re-laparotomy
We present the first case of acute MALS, which occurred after PD that was successfully treated with IVR without reoperation

Summary

Conclusion

Many studies have reported open, laparoscopic, and robot-assisted MAL incisions for MALS, but few reports have detailed the treatment for postoperative MALS. We report the first case of acute MALS developed after PD that was successfully treated with endovascular CA stenting. For acute MALS after PD, early endovascular treatment may be more useful than re-laparotomy. Categories: Radiology, Gastroenterology, General Surgery Keywords: median arcuate ligament syndrome, celiac artery compression syndrome, acute-onset, pancreaticoduodenectomy, interventional radiology

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