Hepatic ischemia, caused by celiac axis compression, complicating pancreaticoduodenectomy

Objective: In the course of pancreaticoduodenectomy, profound hepatic ischemia developed in two patients (one with ampullary carcinoma, the other with chronic pancreatitis). This article addresses the diagnosis and correction of the celiac axis compression responsible in this complication. Summary Background Data: Since hepatic ischemia appeared immediately after division of the gastroduodenal-pancreaticoduodenal arcade, which provides mesenteric to celiac collateral circulation, celiac axis narrowing or occlusion was suspected. Previous reports have indicated that celiac axis disease may be present in about 10% of such patients. Methods: Doppler flow studies, and in the second patient, intraoperative angiography were performed. The celiac axis was exposed and mobilized in both. Results: Initially, no flow could be detected in the celiac axis. Dense fibrous tissue was found encasing it. Division of the entrapping tissue restored flow to the upper abdominal viscera. Conclusions: The anatomic deformation of the celiac axis predisposing to this complication is detectable on the lateral projection of a preoperative celiac angiogram. If, however, an angiogram has not been done, an initial test occlusion of the gastroduodenal artery before its division permits anticipation of the complication, correction of the celiac impingement, and hence, avoidance of hepatic ischemia.