Robotic Pancreaticoduodenectomy with 'SMA-First Approach (Posterior and Right Medial)' and 'Triangle Operation'.

BACKGROUND: Notable improvements in pancreatic cancer surgery have been due to utilization of the superior mesenteric artery (SMA)-first approach1 and triangle operation (clearance of triangle tissue between origin of SMA and celiac artery).2 The SMA-first approach was originally defined to assess resectability before taking the irreversible surgical steps. However, in the present era, resectability is judged by the preoperative radiology, and the benefit of the SMA-first approach is by improving the R0 resection rate and reducing blood loss. The basic principle is to identify the SMA at its origin and in the distal part, to guide the plane of uncinate dissection. This video demonstrates the combination of the posterior and right medial SMA-first approach along with triangle clearance during robotic pancreaticoduodenectomy (RPD). METHODS: The technique consisted of early dissection of SMA from the posterior aspect, by performing a Kocher maneuver using the 'posterior SMA-first approach'. The origin of the celiac artery, along with the SMA, was defined early in the surgery. During uncinate process dissection, the 'right/medial uncinate approach' was used to approach the SMA. 'Level 3 systematic mesopancreatic dissection' was performed along the SMA,3 culminating in the 'triangle operation'.2 RESULTS: The procedure was performed within 600 min, with a blood loss of 150 mL and no intraoperative or postoperative complications. The final histopathology report showed a moderately differentiated adenocarcinoma (pT2, pN2), with all resection margins free. CONCLUSION: The standardized technique of the SMA-first approach and triangle clearance during RPD is demonstrated in the video. Prospective studies should further evaluate the benefits of this procedure.

Periarterial and Sub-adventitial Divestment Along with Triangle Operation and RAMPS for Pancreatic Body Cancer.

BACKGROUND: Locally advanced cancers of the pancreatic body can abut or involve the celiac axis, hepatic artery, or superior mesenteric artery. Recent evidence suggests that these tumors are amenable to surgery after neoadjuvant chemotherapy (Hackert et al., Locally advanced pancreatic cancer: neoadjuvant therapy with FOLFIRINOX results in resectability in 60 % of the patients. Ann Surg 264:457-463, 2016; Rangelova et al., Surgery improves survival after neoadjuvant therapy for borderline and locally advanced pancreatic cancer: a single-institution experience. Ann Surg 273:579-86, 2021). An arterial divestment technique can be used for these cancers to get an R0 clearance, thereby avoiding morbid arterial resections (Miao et al., Arterial divestment instead of resection for locally advanced pancreatic cancer (LAPC). Pancreatology 16:S59, 2016; Habib et al., Periadventitial dissection of the superior mesenteric artery for locally advanced pancreatic cancer: surgical planning with the "halo sign" and "string sign." Surgery 169(5):1026-1031, 2021; Diener et al., Periarterial divestment in pancreatic cancer surgery. Surgery 169(5):1026-31, 2020). Two techniques are described for arterial divestment. In the periarterial divestment technique, the plane of the dissection is between the tumor and the adventitia (Habib et al., Periadventitial dissection of the superior mesenteric artery for locally advanced pancreatic cancer: surgical planning with the "halo sign" and "string sign." Surgery 169(5):1026-1031, 2021; Diener et al., Periarterial divestment in pancreatic cancer surgery. Surgery 169(5):1026-31, 2020). In sub-adventitial dissection, the plane of dissection is between the tunica adventitia and the external elastic lamina (Gao et al., Sub-adventitial divestment technique for resecting artery-involved pancreatic cancer: a retrospective cohort study. Langenbecks Arch Surg 406:691-701, 2021). The TRIANGLE operation also is one of the surgical techniques to achieve R0 resection in locally advanced pancreatic cancer (Hackert et al., The TRIANGLE operation: radical surgery after neoadjuvant treatment for advanced pancreatic cancer: a single-arm observational study. HPB Oxford 19:1001-1007, 2017). This multimedia article aims to demonstrate peri-arterial and sub-adventitial divestment techniques as well as the TRIANGLE operation for a locally advanced cancer of the body of the pancreas. The video also highlights the technique of posterior radical antegrade modular pancreato-splenectomy (RAMPS) together with lymph node clearance. PATIENT AND METHODS: A 57-year-old women was detected to have pancreatic body adenocarcinoma with tumor contact of the artery and superior mesenteric artery. After neoadjuvant chemotherapy, she was planned to undergo surgical resection. RESULTS: The surgical technique consisted of peri-arterial and sub-adventitial divestment, the TRIANGLE operation and RAMPS (Fig. 1). The procedure was performed within 240 min and involved blood loss of 250 mL. After the procedure, pancreatic leak (POPF-B), chyle leak and diarrhea developed, which were managed conservatively. The final histopathology showed residual, viable, moderately differentiated adenocarcinoma (ypT2N1M0) with all resection margins free. CONCLUSION: The surgical technique consisting of peri-arterial and sub-adventitial divestment, the TRIANGLE operation and RAMPS helps in R0 resection of locally advanced pancreatic body cancer without any compromise in oncologic outcomes and offers an alternative surgical approach to morbid arterial resection.

Prognostic impact of the distance from the root of splenic artery to tumor in the patients with pancreatic body or tail cancer.

BACKGROUND: The impact of the distance from the root of splenic artery to tumor (DST) on the prognosis and optimal surgical procedures in the patients with pancreatic body/tail cancer has been unclear. METHODS: We retrospectively analyzed 94 patients who underwent distal pancreatectomy (DP) and 17 patients who underwent DP with celiac axis resection (DP-CAR) between 2008 and 2018. RESULTS: The 111 patients were assigned by DST length (in mm) as DST = 0: n = 14, 0

Clinical Outcomes after Median Arcuate Ligament Release in Patients Responsive to Celiac Plexus Block.

PURPOSE: To determine if symptom relief with celiac plexus block (CPB) is associated with favorable clinical outcomes after median arcuate ligament release (MALR) surgery. MATERIALS AND METHODS: A retrospective review was performed from January 2000 to December 2021. Fifty-seven patients (42 women, 15 men; mean age, 43 years [range, 18-84 years]) with clinical and radiographic features suggestive of median arcuate ligament syndrome (MALS) underwent computed tomography (CT)-guided percutaneous CPB for suspected MALS. Clinical outcomes of CPB and MALR surgery were correlated. Adverse events were classified according to the Society of Interventional Radiology (SIR) guidelines. RESULTS: CT-guided percutaneous CPB was successfully performed in all 57 (100%) patients with suspected MALS. A cohort of 38 (67%) patients showed clinical improvement with CPB. A subset of 28 (74%) patients in this group subsequently underwent open MALR surgery; 27 (96%) responders to CPB showed favorable clinical outcomes with surgery. There was 1 (4%) CPB-related mild adverse event. There were no moderate, severe, or life-threatening adverse events. CONCLUSIONS: Patients who responded to CPB were selected to undergo surgery, and 96% of them improved after surgery.

Dissection of the Celiac Trunk Is a Mild Disease.

BACKGROUND: The purpose of this study was to assess whether the presence of an aneurysmal or dissecting arterial disease was a risk factor of poor prognosis in patients presenting a dissection of the celiac trunk (CT). METHODS: All patients presenting a CT dissection between January 1, 2014, and June 30, 2022, were included. Patients with a CT dissection due to the extension of an aortic dissection were excluded. Les antécédents familiaux de dissection, de maladie anévrysmale, de maladie athéromateuse ou du tissu conjonctif, la pratique d'une activité physique ou sportive, un effort inhabituel les jours précédant la dissection ainsi qu'un traumatisme étaient recherchés. Family history of dissection, aneurysmal disease, atheromatous or connective tissue disease, physical activity or sport, an unusual effort in the days prior to the dissection and trauma were sought after. Ischemic or aneurysmal complications in the acute phase and the evolution of the dissection were evaluated and compared between patients with an isolated dissection and those presenting an aneurysmal or dissecting arterial disease. RESULTS: 45 patients were included in the study. Twenty-three (51.1%) patients presented with symptomatic CT dissection, and 22 (48.9%) with asymptomatic CT dissection. All the patients initially had medical management alone. The mean follow-up was 32 ± 25 months and all patients were asymptomatic at the time last news. 24 (53.3%) presented an isolated CT dissection, and 21 (46.7%) a CT dissection associated with aneurysmal or dissecting arterial disease. There was no significant difference between patients with an isolated CT dissection and those with an associated dissecting or aneurysmal pathology. CONCLUSIONS: CT dissection is a stable disease in the midterm, which makes it a mild arterial pathology, with or without aneurysmal or dissecting anomalies in another territory. The mechanical stress exerted on the CT by the arcuate ligament could be responsible for parietal trauma and favor the occurrence of a CT dissection.

The anatomical relationship between the celiac artery and the median arch ligament in degenerative spinal surgery.

BACKGROUND: This study aimed to characterize the anatomical relationship between the spine, the celiac artery (CA), and the median arcuate ligament using preoperative contrast-enhanced computed tomography (CT) images of patients with spinal deformity who underwent surgical correction. METHODS: This retrospective study included 81 consecutive patients (34 males, 47 females; average age: 70.2 years). The spinal level at which the CA originated, the diameter, extent of stenosis, and calcification were determined using CT sagittal images. Patients were divided into two groups: CA stenosis group and non-stenosis group. Factors associated with stenosis were examined. RESULTS: CA stenosis was observed in 17 (21%) patients. CA stenosis group had significantly higher body mass index (24.9 ± 3.9 vs. 22.7 ± 3.7, p = 0.03). In the CA stenosis group, J-type CA (upward angling of the course by more than 90° immediately after descending) was more frequently observed (64.7% vs. 18.8%, p < 0.001). The CA stenosis group had lower pelvic tilt (18.6 ± 6.7 vs. 25.1 ± 9.9, p = 0.02) than non-stenosis group. CONCLUSIONS: High BMI, J-type, and shorter distance between CA and MAL were risk factors for CA stenosis in this study. Patients with high BMI undergoing fixation of multiple intervertebral corrective fusions at the thoracolumbar junction should undergo preoperative CT evaluation of the anatomy of CA to assess the poteitial risk of celiac artery compression syndrome.

[Diagnosis and treatment of Dunbar syndrome]. / Diagnostik und Therapie des Dunbar-Syndroms.

The rare Dunbar syndrome or medial arcuate ligament syndrome (MALS) is defined as compression of the celiac trunk and/or ganglion by the medial arcuate ligament. It is often diagnosed after patients have suffered for a long time and is characterized by intermittent food-related pain, nausea, and unexplained weight loss. After exclusion of other causes of the above symptoms by gastroscopy, colonoscopy, CT, or MRI, the gold standard for diagnosis is dynamic color-coded duplex sonography, which may be supplemented by CT or MR angiography. The treatment of choice is a laparoscopic division of the arcuate ligament at the celiac trunk, although percutaneous transluminal angioplasty (PTA) with stent implantation may be performed in cases of postoperative persistence of symptoms or recurrent stenosis. Since symptoms persist postoperatively in up to 50% of cases, strict indication and complete diagnosis in designated centers are of great importance for successful treatment.

Celiac trunk stenosis by median arcuate ligament in orthotopic liver transplantation: a potential hidden foe to the biliary tree.

BACKGROUND: Celiac trunk compression by the median arcuate ligament (MAL) increases the risk of ischemic complications following gastrointestinal surgical procedures. Previous studies suggest increased risk of hepatic artery thrombosis (HAT) in orthotopic liver transplant (OLT) recipients. The aim of this study is to investigate the impact of untreated MAL compression (MAL-C) on biliary complications in OLT. METHODS: Contrast-enhanced imaging was used to classify celiac trunk stenosis by MAL-C. Medical records were reviewed to extract pre-transplant, transplant and post-transplant data. Patients were divided into two groups: no MAL compression (nMAL-C) and MAL-C. The primary endpoint was biliary complications. Secondary endpoints were HAT and graft survival. RESULTS: 305 OLT were performed from 2010 to 2021, of which 219 were included for analysis: 185 (84.5%) patients without and 34 (15.5%) with MAL-C. The incidence of HAT was 5.9% in both groups. Biliary complications were more common in the MAL-C group (35.3% vs. 17.8%, p = 0.035). Graft survival was decreased in patients with MAL-C (p = 0.035). CONCLUSIONS: MAL-C of the celiac trunk was associated with increased risk of biliary complications and inferior graft survival in OLT patients. These findings highlight the importance of preoperative screening and treatment of MAL in this population.

[A Case of Adenocarcinoma of Pancreatic Head of Liver Disfunction after Pancreaticoduodenectomy with Celiac Artery Stenosis Treated by Urgent Median Arcuate Ligament Release].

This patient visited our hospital for the purpose of detailed examination of prostate cancer in his seventies. Abdominal contrast-enhanced computed tomography(CT)revealed a low-density mass of 2 cm in the pancreatic head. He was diagnosed with pancreatic cancer. Pancreaticoduodenectomy was performed after 2 courses of gemcitabine and S-1 therapy were performed as neoadjuvant chemotherapy. An intraoperative clamp test of the gastroduodenal artery showed that the pulsation of the common hepatic artery and the proper hepatic artery was weak but sufficient, so the gastroduodenal artery was cut and the operation was completed as planned. A blood test on the 1st day after the operation showed elevated levels of AST 537 U/L, ALT 616 U/L, and 7 hours later blood sampling showed further increases in AST 1,455 U/L, ALT 1,314 U/L. After a detailed review of the preoperative CT, celiac artery stenosis due to compression of the arcuate ligament was suspected, and urgent median arcuate ligament release was performed on the same day. Dissection of the arcuate ligament significantly improved the pulsation of the common hepatic artery and proper hepatic artery. Postoperatively, hepatic enzymes improved and ISGPS showed Grade B pancreatic juice leakage, but the patient was discharged from the hospital on the 49th postoperative day without any other complications. He took S-1 as adjuvant chemotherapy, and no signs of recurrence have been observed 9 months after the operation.

Distal Pancreatectomy With En Bloc Celiac Axis Resection (DP-CAR) for Locally Advanced Pancreatic Cancer: A Safe and Effective Procedure.

OBJECTIVE: To determine perioperative and oncologic outcomes after distal pancreatectomy with en bloc resection of the celiac axis (DP-CAR). BACKGROUND: DP-CAR can be used in a selective group of patients to resect locally advanced pancreatic cancer involving the celiac axis or common hepatic artery without arterial reconstruction by preserving retrograde blood flow via the gastroduodenal artery to the liver and stomach. METHODS: We analyzed all consecutive patients who had undergone DP-CAR between May 2003 and April 2022 at a tertiary hospital specialized in pancreatic surgery and present one of the largest single-center studies. RESULTS: A total of 71 patients underwent DP-CAR. Additional venous resection (VR) of the mesenterico-portal axis was performed in 31 patients (44%) and multivisceral resection (MVR) in 42 patients (59%). Margin-free (R0) resection was achieved in 40 patients (56%). The overall 90-day mortality rate was 8.4% for the entire patient cohort. After a cumulated experience of 16 cases, the 90-day mortality dropped to 3.6% in the following 55 patients. Extended procedures with (+) additional MVR with or without (+/-) VR resulted in higher major morbidity (Clavien-Dindo ≥IIIB; standard DP-CAR: 19%; DP-CAR + MVR +/- VR: 36%) and higher 90-day mortality (standard DP-CAR: 0%; DP-CAR + MVR +/- VR: 11%). Median overall survival after DP-CAR was 28 months. CONCLUSIONS: DP-CAR is a safe and effective procedure but requires experience. Frequently, surgical resection has to be extended with MVR and VR to accomplish tumor resection, which results in promising oncologic outcomes. However, extended resections were associated with increased morbidity and mortality.

Risk factor analysis and treatment outcome of patients with spontaneous isolated celiac axis or superior mesenteric artery dissection.

BACKGROUND: Spontaneous isolated mesenteric artery (celiac axis or superior mesenteric artery [SMA]) dissection (IMAD) is a rare clinical entity. The aim of the present study was to examine the patient demographics, comorbidities, clinical and radiologic features, management, and prognosis and to identify the risk factors predictive of symptoms. METHODS: We performed a single-center, retrospective review from November 2005 to November 2021 of prospectively collected data from patients with a diagnosis of IMAD. The clinical data and radiologic images were reviewed, and statistical analysis was performed to compare the symptomatic and asymptomatic groups. RESULTS: A total of 78 patients were identified. Of the 78 patients, 24 (31%) had had celiac dissections, 51 (65%) had had SMA dissections, and 3 (4%) had had both celiac and SMA dissections. The mean age was 57.7 years (range, 36-84 years), with a male predominance (86%). More than one half (55%) of the patients had had hypertension. In addition, 29 patients (37%) were symptomatic, and 24 (31%) had been admitted to the hospital. The symptomatic patients with celiac axis dissections were more likely to have thrombosis (P = .02), significant stenosis (P = .01) or branch extension (P = .02). The symptomatic patients with SMA dissections were more likely to have a smaller artery diameter (P = .07), a longer dissection length (P = .05), thrombosis (P < .001), significant stenosis (P < .001), or branch extension (P = .003). The symptomatic patients were more likely to have been treated with antiplatelet or anticoagulant therapy (P < .001). Only three patients had undergone an intervention. Seven patients (9%) had died of unrelated causes. The Kaplan-Meier survival analysis showed a 5-year survival rate of 96% and 10-year survival rate of 91%. CONCLUSIONS: IMAD is an uncommon disease entity with a risk of visceral ischemia. Nonetheless, most of these patients can be treated conservatively with medication, with only a small minority requiring emergency surgery.

Renovisceral artery alterations due to branched endovascular aortic repair and respiratory-induced deformations.

OBJECTIVE: This study quantified respiratory-induced dynamics of branch vessels before and after thoracoabdominal aortic aneurysm (TAAA) branched endovascular aneurysm repair (bEVAR). METHODS: Patients with TAAA were recruited prospectively and treated with bEVAR, predominantly with Zenith t-Branch and BeGraft Peripheral PLUS bridging stents. Using SimVascular software, three-dimensional geometric models of the vessels and implants were constructed from computed tomography angiograms during both inspiratory and expiratory breath-holds, preoperatively and postoperatively. From these models, branch take-off angles, end-stent angles (transition from distal end of stent to native artery), and curvatures were computed. Paired, two-tailed t tests were performed to compare inspiratory vs expiratory geometry and pre- vs postoperative deformations. RESULTS: We evaluated 52 (12 celiac arteries [CA], 15 superior mesenteric arteries [SMA], and 25 renal arteries [RA]) branched renovisceral vessels with bridging stents in 15 patients. Implantation of bridging stents caused branch take-off angle to shift inferiorly in the SMA (P = .015) and RA (P = .014) and decreased the respiratory-induced branch angle motion in the CA and SMA by approximately 50%. End-stent angle increased from before to after bEVAR for the CA (P = .005), SMA (P = .020), and RA (P < .001); however, respiratory-induced deformation was unchanged. Bridging stents did not experience significant bending owing to respiration. CONCLUSIONS: The decrease in respiratory-induced deformation of branch take-off angle from before to after bEVAR should decrease the risk of device disengagement and endoleak. The unchanging respiratory-induced end-stent bending, from before to after bEVAR, means that bEVAR maintains native vessel dynamics distal to the bridging stents. This factor minimizes the risk of tissue irritation owing to respiratory cycles, boding well for branch vessel patency. The longer bridging stent paths associated with bEVAR may enable smoother paths subject to less dynamic bending, and potentially lower fatigue risk, compared with fenestrated EVAR.

Factors associated with successful median arcuate ligament release in an international, multi-institutional cohort.

OBJECTIVE: Prior research on median arcuate ligament syndrome has been limited to institutional case series, making the optimal approach to median arcuate ligament release (MALR) and resulting outcomes unclear. In the present study, we compared the outcomes of different approaches to MALR and determined the predictors of long-term treatment failure. METHODS: The Vascular Low Frequency Disease Consortium is an international, multi-institutional research consortium. Data on open, laparoscopic, and robotic MALR performed from 2000 to 2020 were gathered. The primary outcome was treatment failure, defined as no improvement in median arcuate ligament syndrome symptoms after MALR or symptom recurrence between MALR and the last clinical follow-up. RESULTS: For 516 patients treated at 24 institutions, open, laparoscopic, and robotic MALR had been performed in 227 (44.0%), 235 (45.5%), and 54 (10.5%) patients, respectively. Perioperative complications (ileus, cardiac, and wound complications; readmissions; unplanned procedures) occurred in 19.2% (open, 30.0%; laparoscopic, 8.9%; robotic, 18.5%; P < .001). The median follow-up was 1.59 years (interquartile range, 0.38-4.35 years). For the 488 patients with follow-up data available, 287 (58.8%) had had full relief, 119 (24.4%) had had partial relief, and 82 (16.8%) had derived no benefit from MALR. The 1- and 3-year freedom from treatment failure for the overall cohort was 63.8% (95% confidence interval [CI], 59.0%-68.3%) and 51.9% (95% CI, 46.1%-57.3%), respectively. The factors associated with an increased hazard of treatment failure on multivariable analysis included robotic MALR (hazard ratio [HR], 1.73; 95% CI, 1.16-2.59; P = .007), a history of gastroparesis (HR, 1.83; 95% CI, 1.09-3.09; P = .023), abdominal cancer (HR, 10.3; 95% CI, 3.06-34.6; P < .001), dysphagia and/or odynophagia (HR, 2.44; 95% CI, 1.27-4.69; P = .008), no relief from a celiac plexus block (HR, 2.18; 95% CI, 1.00-4.72; P = .049), and an increasing number of preoperative pain locations (HR, 1.12 per location; 95% CI, 1.00-1.25; P = .042). The factors associated with a lower hazard included increasing age (HR, 0.99 per increasing year; 95% CI, 0.98-1.0; P = .012) and an increasing number of preoperative diagnostic gastrointestinal studies (HR, 0.84 per study; 95% CI, 0.74-0.96; P = .012) Open and laparoscopic MALR resulted in similar long-term freedom from treatment failure. No radiographic parameters were associated with differences in treatment failure. CONCLUSIONS: No difference was found in long-term failure after open vs laparoscopic MALR; however, open release was associated with higher perioperative morbidity. These results support the use of a preoperative celiac plexus block to aid in patient selection. Operative candidates for MALR should be counseled regarding the factors associated with treatment failure and the relatively high overall rate of treatment failure.

Insights from managing clinical issues in distal pancreatectomy with en bloc coeliac axis resection: experiences from 626 patients.

BACKGROUND: Distal pancreatectomy with en bloc coeliac axis resection (DP-CAR) for pancreatic body cancer has been reported increasingly. However, its large-scale outcomes remain undocumented. This study aimed to evaluate DP-CAR volume and mortality, preoperative arterial embolization for ischaemic gastropathy, the oncological benefit for resectable tumours close to the bifurcation of the splenic artery and coeliac artery using propensity score matching, and prognostic factors in DP-CAR. METHODS: In a multi-institutional analysis, 626 DP-CARs were analysed retrospectively and compared with 1325 distal pancreatectomies undertaken in the same interval. RESULTS: Ninety-day mortality was observed in 7 of 21 high-volume centres (1 or more DP-CARs per year) and 1 of 41 low-volume centres (OR 20.00, 95 per cent c.i. 2.26 to 177.26). The incidence of ischaemic gastropathy was 19.2 per cent in the embolization group and 7.9 per cent in the no-embolization group (OR 2.77, 1.48 to 5.19). Propensity score matching analysis showed that median overall survival was 33.5 (95 per cent c.i. 27.4 to 42.0) months in the DP-CAR and 37.9 (32.8 to 53.3) months in the DP group. Multivariable analysis identified age at least 67 years (HR 1.40, 95 per cent c.i. 1.12 to 1.75), preoperative tumour size 30 mm or more (HR 1.42, 1.12 to 1.80), and preoperative carbohydrate antigen 19-9 level over 37 units/ml (HR 1.43, 1.11 to 1.83) as adverse prognostic factors. CONCLUSION: DP-CAR can be performed safely in centres for general pancreatic surgery regardless of DP-CAR volume, and preoperative embolization may not be required. This procedure has no oncological advantage for resectable tumour close to the bifurcation of the splenic artery, and should be performed after appropriate patient selection.

Surgical anatomy of the dorsal pancreatic artery: Considering embryonic development.

OBJECTIVES: The dorsal pancreatic artery (DPA) is a pancreatic branch with various anatomical variations. Previous studies mostly focused on the origin of the DPA, and its pathways and branching patterns have rarely been examined. The purpose of this study was to investigate the branching patterns and pathways of the DPA. METHODS: This study included 110 patients who underwent computed tomography scans. We examined the pathways and branching patterns of the DPA. RESULTS: The DPA was identified in 101 patients (92%), and originated from the splenic artery in 30 patients (31%), the common hepatic artery in 17 patients (17%), the celiac trunk in 10 patients (10%), the superior mesenteric artery in 27 patients (27%), the replaced right hepatic artery in 7 patients (7%), the inferior pancreaticoduodenal artery in 5 patients (5%), and other arteries in 3 patients (3%). Four distinct types of branches were identified as follows: the superior branch (32%), the inferior branch (86%), the right branch (80%), and the accessory middle colic artery (12%). Additionally, the arcs of Buhler and Riolan were observed in two patients each and their anastomotic vessels followed almost the same pathway as the DPA. CONCLUSION: A number of variations of the DPA were observed with regard to its origin and branching pattern; however, the DPA and its branches always ran along the same pathway, as summarized in Fig. 4. The anatomical information gained from this study may contribute to performing safe pancreatic resections.

Celiac Artery Coverage After Thoracic Endovascular Aortic Procedure: A Meta-Analysis of Early and Late Results.

BACKGROUND/AIM: Clinical outcomes of celiac artery (CA) coverage during aortic procedures are often contradicting and the fate of this additional maneuver is still unclear. This study summarizes the results of available literature and aims to clarify the impact of CA coverage during thoracic endovascular aneurysm repair (TEVAR) in patients with inadequate distal sealing zone. METHODS: Prospective and retrospective, observational original articles focused on CA coverage during elective/urgent TEVAR for descending thoracic aortic pathology (DTAP) were included. PubMed/MEDLINE, Embase, and Cochrane Central Register of Controlled Trials database were examined to identify articles published from January 2007 to December 2020, according to PRISMA guidelines. Early and late visceral (any sign or symptom reported) and neurological (both transient and permanent) complications were considered as primary outcomes. Onset of any endoleak, type IB endoleak, need of reintervention, and TEVAR-related mortality were considered as secondary outcomes. RESULTS: A total of 5618 articles were extracted for analysis and 13 studies were finally included in the synthesis. A total of 178 CAs were covered during 2653 TEVAR (7%). Spinal cord ischemia was 8% (95% CI, 5-14%, I2 0%) Any endoleak and type IB endoleak was observed in 12% (95% CI, 6-21%, I2 17%) and 5% (95% CI, 2-11%, I2 0%), respectively. Thoracic endovascular aneurysm repair-related reoperation was necessary in 8% (95% CI, 4-14%, I2 0%), the majority of which (14/18, 78%) performed for distal sealing failure; mortality rate was 9% (95% CI, 5-14%, I2 0%). Out of 178 patients, 168 (94%) were available for follow-up, ranged 12 to 42 months. Visceral complications, any endoleak, and type IB endoleak were identified in 15% (95% CI, 10-23%, I2 45%), 20% (95% CI, 13-29%, I2 8%), and 8% (95% CI, 4-15%, I2 0%), respectively. Thoracic endovascular aneurysm repair-related reintervention was required in 8% (95% CI, 4-14%, I2 0%). Mortality rate was 17% (95% CI, 12-25%, I2 4%). CONCLUSIONS: Celiac artery coverage in DTAP should be regarded as a "bailout" procedure especially in urgent/emergent settings but requires caution in elective cases. Even if transient visceral ischemia is frequent, life-threatening complications are rare. Early and late mortality rates are similar to standard TEVAR although the risk of type IB endoleak and reintervention may be an issue.

A nationwide analysis of median arcuate ligament release between 2010 and 2020: a NSQIP Study.

BACKGROUND: Median arcuate ligament syndrome is a rare disease with overlapping symptoms of broad foregut pathology. Appropriately selected patients can benefit from a laparoscopic or open median arcuate ligament release. Institutional series have reported the outcomes of open and laparoscopic techniques but there are no nationwide analysis comparing both techniques and overall trends in treatment. METHODS: Cross-sectional study using the American College of Surgeons-National Surgical Quality Improvement Project from 2010 to 2020. Celiac artery compression syndrome cases were identified by International Classification of Diseases (ICD) codes and categorized as open or laparoscopic. Trends in the use of each technique and 30-day complications were compared between the groups. RESULTS: A total of 578 open cases (76%) and 185 laparoscopic cases (24%) were identified. There was an increase adoption of the laparoscopic approach, with 22% of the cases employing this technique at the end of the study period, compared to 7% at the beginning of the study period. The open group had a higher prevalence of hypertension (26% vs 18%, p = 0.04) and bleeding disorders (5% vs 2%, p 0.03). Laparoscopic approach had a shorter length of stay (2.3 days vs 5.2 days, p < 0.0001), lower major complication rates (0.5% vs 4.0%, p = 0.02) and lower reoperation rates (0% vs 2.6%, p = 0.03). Overall mortality was 0.1%. CONCLUSION: Overall numbers of surgical intervention for treatment of median arcuate ligament increased during this timeframe, as well as increased utilization of the laparoscopic approach. It appears to be an overall safe procedure, offering lower rates of complications and shorter length of stay.

Robotic median arcuate ligament release: management algorithm and clinical outcomes from a large minimally invasive series.

BACKGROUND: Median arcuate ligament syndrome (MALS) is a rare and debilitating condition that remains difficult to diagnose. Proper patient selection remains key to achieving favorable outcomes for those undergoing MALR. The robotic technique facilitates a minimally invasive MALR approach given the fine precision of the instrumentation and stability of visualization. Here we describe our management algorithm and clinical outcomes for a large series of robotic MALR patients. METHODS: This retrospective cohort study analyzed adult patients who underwent robotic MALR performed by a single surgeon at a tertiary academic hospital from 2014 to 2021. The diagnosis of MALS was made using objective criteria from celiac artery duplex ultrasound with a peak systolic velocity of > 350 cm/s combined with a right upper quadrant abdominal ultrasound, esophagogastroduodenoscopy, and computer tomography or magnetic resonance angiography to exclude other diagnoses. Information on patient demographics, perioperative factors, and patient reported symptoms up to 1-year post-operatively were collected. RESULTS: A total of 74 patients underwent robotic MALR during the study period. The mean age was 27.3 ± 7.9 years and the majority of patients were female (n = 60/74, 81.1%). The most common presenting symptom was post-prandial abdominal pain (n = 65/74, 87.7%). The mean operative time was 52.6 ± 18.1 min. There were no conversions to open surgery and minimal blood loss (mean = 13.9 ± 8.4 mL). At 3-months, 12% (n = 9/74) of patients had persistent abdominal pain and underwent additional imaging. 5 of these 9 patients had persistently elevated DUS expiratory PSV and were referred for angioplasty. 3 of these 5 referred patients had resolution of abdominal pain after angioplasty. At 1-year follow up, 90.3% (n = 56/62) continued to have no abdominal pain. CONCLUSIONS: Through this series, the largest set of minimally invasive (laparoscopic or robotic) MALR procedures published to date, we show that with strict adherence to a management algorithm, the robotic approach to MALR is safe and feasible, with good patient outcomes.

Outcomes of Median Arcuate Ligament Release: A Single Institution Retrospective Review.

BACKGROUND: Median arcuate ligament syndrome (MALS) is an uncommon diagnosis that is often associated with variable clinical presentation and inconsistent response to treatment. Due to the nature of MALS, the optimal treatment modality and predictors of outcomes remain unclear. METHODS: A retrospective review was performed of all median arcuate ligament release (MALR) procedures at a single academic institution between 2000 and 2020. Variables examined included patient demographics, symptom characteristics, operative technique (open, robotic, laparoscopic), patient symptoms before release, symptom relief within 1 year, and recurrence of symptoms between release and last clinical follow-up. RESULTS: During the study period, 47 patients (75% female, mean age 42.1 years) underwent MALR with 19 (36%) robotic, 18 (34%) open, 14 (26%) laparoscopic, and 2 (4%) laparoscopic converted to open procedures. Abdominal pain, weight loss, and nausea and vomiting were the most common symptoms. Postoperatively, 19 (40%) had complete symptom relief within 1 year, 18 (38%) had partial relief, and 10 (21%) had no symptom improvement. 6 were excluded due to loss of follow-up. Laparoscopic and open procedures had the highest rate of complete symptom relief by year 1 with 7 (58%) and 8 (50%) respectively. Twenty-one (57%) patients had recurrence with the greatest rate of recurrence seen among laparoscopic (80%), compared to robotic (57%) and open (38%). Patients reporting a weight loss of 20 pounds or more before surgery were more likely to have partial or complete symptom relief after 1 year compared to those reporting less than 20-pound weight loss (92% vs. 64%). Furthermore, 84% of patients younger than 60 years old reported partial or complete symptom relief compared to only 56% of those older than 60. CONCLUSIONS: MALS continues to be a rare disorder with widely variable surgical outcomes, requiring further study. While our patients presented with several gastrointestinal symptoms, the most common was postprandial pain. Our center employed laparoscopic, open, and robotic operative techniques with varying success rates, in terms of symptom relief and recurrence. Consistent with current literature, our study found greater surgical success among patients younger than 60 years regardless of operative technique. This suggests the need for better predictors to determine which patients are the most likely to have complete or prolonged remission of symptoms following MALR.

Celiac Artery Coverage During TEVAR for Dissection and Acute Aortic Injury is Not Associated with Worse Outcomes.

BACKGROUND: Studies have previously identified increased morbidity and mortality with celiac artery coverage during thoracic endovascular aortic repair (TEVAR) for aneurysmal disease. This study aimed to delineate the risks associated with celiac artery coverage in all patients undergoing TEVAR for dissection, trauma, or aneurysmal disease. METHODS: Using the Vascular Quality Initiative database, we identified all patients undergoing TEVAR from 2012 to 2020 and categorized them based on the underlying pathology (aneurysm, dissection, or acute/trauma). Patients were excluded if their endograft was deployed distal to aortic zone 6 or if they had any preoperative/operative celiac revascularization procedure. Univariate, regression, and Kaplan-Meier analysis were performed for all 3 groups, focusing on postoperative complications and survival. RESULTS: There were 8,265 patients who underwent TEVAR over the 8-year study period with 142 (1.7%) having celiac artery coverage during their index procedure. Of those patients, the celiac artery was covered during TEVAR in 1.2% of patients with dissection, 1.3% with aneurysm, and 0.7% with trauma. On unadjusted analysis, celiac artery coverage in TEVAR for aneurysmal disease was associated with increased in-hospital mortality (16% vs. 5%, P < 0.001), 30-day mortality (33% vs. 23%, P = 0.029), any postoperative complication (excluding death) (42% vs. 25%, P < 0.001), and postoperative bowel complication (3% vs. 0.7%, P = 0.003). There were no differences in outcomes for patients treated with celiac coverage versus those without celiac coverage during TEVAR for dissection or trauma on univariate analysis. After risk adjustment, celiac artery coverage remained predictive of worse postoperative outcomes in patients with aneurysmal disease: in-hospital mortality (odds ratio [OR] = 3.6, confidence interval [CI] 1.8-6.9), 30-day death (OR = 1.6, CI 1.0-2.4), any postoperative complication (OR 2.2, CI 1.4-3.5), and bowel-specific postoperative complication (3.3, CI 1.0-10.8). There were no differences in patient outcomes for those treated with celiac coverage versus those without celiac coverage during TEVAR for dissection or trauma on multivariate analysis. Kaplan-Meier curves show a significant difference in overall survival based on pathology, specifically lower survival rates for patients with celiac coverage treated for aneurysmal disease. Cox regression analysis showed that celiac artery coverage for aneurysmal disease was associated with significantly increased hazard ratio affecting overall survival (hazard ratio = 2.6, P < 0.001), but there was no impact on survival in patients who underwent TEVAR with celiac coverage for dissection or trauma. CONCLUSIONS: Celiac artery coverage for patients with aneurysmal disease was correlated with a significant increase in postoperative morbidity, mortality, and lowers overall survival. However, for patients with dissection or acute/traumatic aortic pathology, celiac artery coverage does not portend worse outcomes.