Celiac artery patency is vital to successful outcome after PD; impairment of celiac flow results in potentially catastrophic hepatic, biliary, gastric, splenic, and pancreatic ischemia [9]. The preoperative diagnosis of MALS is essential so that this arcade may be preserved [5]. Three-dimensional CT angiography shows a characteristic hook pattern on the anterior proximal celiac axis when it is compressed by the MAL [10]. Gaujoux et al. reported that multidetector CT, especially its lateral views, can detect significant arterial stenosis with 96% sensitivity and determine the etiology of celiac axis stenosis with 92% accuracy [11]. If MALS is diagnosed before PD, various methods are available for revascularization before or during the procedure; these include open or laparoscopic MAL division, vascular bypass procedure, or endovascular stenting [7, 8, 12, 13]. Sharafuddin et al. reported 25 cases treated with stent-assisted angioplasty for stenosis of the celiac artery or the superior mesenteric artery with a 96% success rate [7].
Intraoperative assessment of the flow through the hepatic artery should be performed in pancreatic resection, even if preoperative CT does not demonstrate MALS [13]. However, this may not be reliable. Hemodynamically significant stenosis during the GDA clamping test has been reported to be present in about 40% of cases [11]. If MALS is diagnosed during PD, the MAL must be divided at the beginning of the procedure, before GDA ligation or pancreatic division [11, 13]. This safe and fast procedure permits trunk decompression and resolution of ischemic disorders in up to 87% (20 out of 23 cases) of patients [11]. They reported only 1 case with celiac axis occlusion even after MAL division, in which they considered that an ineffective MAL division resulted in celiac axis fibromuscular dysplasia. In this current case, we confirmed a dramatic resumption of the blood flow through the celiac axis and the hepatic artery after MAL division. Therefore, we considered that an effective MAL division could be performed. However, even after such an effective procedure, the celiac axis exhibited re-occlusion, causing many complications. We considered that the radiological procedure before MAL division might have caused the re-occlusion of the celiac axis in this patient. In this radiological procedure, even cannulation of the catheter did not go smoothly because of the tight stenosis of the celiac artery. This procedure might have damaged the endothelial cells of the celiac artery, causing the subsequent re-occlusion. The CT at POD 20 showed that re-occlusion of the celiac artery had occurred near its root, where the stenosis had been. This fact may support our suggestion. We cannot deny the possibility that the MAL might not have been completely released and might have caused the re-occlusion of the celiac artery. In fact, the aortic wall was visible after division of the MAL (Fig. 3). And, we were sure that the celiac stenosis had been completely released at that time because there was significant resumption of the blood flow after the procedure.
MALS can develop acutely after PD even if it has not been diagnosed pre- or peri-operatively. This is the third case which showed no evidence of hepatic artery flow impairment before PD or during GDA clamping or pancreatic transection [4, 13]. There is no known explanation for this acute onset of MALS after PD in a patient with normal celiac anatomy. However, we considered, like two other authors, that this phenomenon might be induced by pre-existing non-significant celiac axis stenosis, with a very tight median arcuate ligament that is exacerbated by lymphadenectomy of the celiac region.