Pancreaticoduodenectomy combined Gastroduodenal Collateral Reconstruction and Preservation due to Median Arcuate Ligament Syndrome: Technical notes with two surgical cases report (with video)

Introduction: Pancreaticoduodenectomy in patients with CA stenosis due to median arcuate ligament often required carefully collateral pathways management to avoid hepatic ischemic complications. Cases presentation. Case 1: A 63-year-old man was referred to our department because of jaundice with distal common bile duct tumor. Three-dimensional reconstruction images showed developed collateral pathways around the pancreatic head and the CA was compressed by the median arcuate ligament (MAL), which developed caudally. Pancreaticoduodenectomy with left-posterior SMA first-approach and circumferential lymphadenectomy was performed. Since the CA flow was insufficient before the surgery, the surgical procedure was routinely performed, without any special preoperative arterial interventional techniques. After clamping the GDA and MAL division, we confirmed poor blood flow in the proper hepatic artery (PHA) by palpation, so that we have decided to proceed a no-touch technique of GDA segmental resection en bloc with the tumor, in order to avoid bleeding from enlarged dorsal pancreatic branches from PDAs and reconstructed with an end-to-end GDA anastomosis. Case 2: A 48-year-old man was referred to our department because of right-upper-quadrant abdominal pain with Vater tumor. Three-dimensional reconstruction images showed developed collateral pathways around the pancreatic head and the CA was stenosis in 70% due to MAL. Laparoscopic pancreaticoduodenectomy with left posterior SMA first approach and circumferential lymphadenectomy was performed. Intraoperatively, we confirmed poor blood flow in the common hepatic artery (CHA) by palpation, so that we have decided to proceed gastroduodenal collateral preservation. When preserving these collateral pathways, we confirmed that the PHA flow remained pulsatile as an indicator that the blood flow was adequate. Conclusion: Celiac axis stenosis was a rare but difficult-to-managed condition associated with pancreaticoduodenectomy. Collateral pathways management depends on varies of collateral pathways.