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Median arcuate ligament release at the time of pancreaticoduodenectomy or total pancreatectomy. Surgery 2024 May;175(5):1386-1393



Pubmed ID




Scopus ID

2-s2.0-85186348752 (requires institutional sign-in at Scopus site)


BACKGROUND: Celiac artery compression can complicate the performance of pancreaticoduodenectomy or total pancreatectomy due to the need for ligation of the gastroduodenal artery. Median arcuate ligament release restores normal arterial flow to the liver, spleen, and stomach and may avoid complications related to poor perfusion of the foregut.

METHODS: All patients who underwent median arcuate ligament release for celiac artery compression at the time of pancreatectomy between 2009 and 2023 were reviewed. Pre- and postoperative computed tomography was used to categorize celiac artery compression by the extent of compression (types A [<50%], B [50%-80%], and C [>80%]).

RESULTS: Of 695 patients who underwent pancreatectomy, 22 (3%) had celiac artery compression, and a majority (17) were identified on preoperative imaging. Median celiac artery compression was 52% (interquartile range = 18); 8 (36%) patients had type A and 14 (64%) had type B compression with a median celiac artery compression of 39% (interquartile range = 18) and 59% (interquartile range = 14), respectively (P < .001). Postoperative imaging was available for 20 (90%) patients, and a reduction in the median celiac artery compression occurred in all patients: type A, 14%, and type B, 31%. Complications included 1 (5%) death after hospital discharge, 1 (5%) pancreatic fistula, 1 (5%) delayed gastric emptying, and 4 (18%) readmissions. No patient had evidence of a biliary leak or liver dysfunction.

CONCLUSION: Preoperative computed tomography allows accurate identification of celiac artery compression. Ligation of the gastroduodenal artery during pancreaticoduodenectomy or total pancreatectomy in the setting of celiac artery compression requires median arcuate ligament release to restore normal arterial flow to the foregut and avoid preventable complications.

Author List

Ward EP, Vincent-Sheldon S, Tolat P, Kulkarni N, Aldakkak M, Budithi R, Clarke CN, Tsai S, Evans DB, Christians KK


Rachel Budithi MD Associate Professor in the Anesthesiology department at Medical College of Wisconsin
Kathleen K. Christians MD Professor in the Surgery department at Medical College of Wisconsin
Callisia N. Clarke MD Chief, Associate Professor in the Surgery department at Medical College of Wisconsin
Douglas B. Evans MD Chair, Professor in the Surgery department at Medical College of Wisconsin
Parag P. Tolat MD Chief, Associate Professor in the Radiology department at Medical College of Wisconsin

MESH terms used to index this publication - Major topics in bold

Celiac Artery
Median Arcuate Ligament Syndrome