Management of Median Arcuate Ligament Compression in Patients Undergoing Pancreaticoduodenectomy: A Systematic Review and Consensus Statements

BACKGROUND AND AIMS: Division of the pancreatic arterial arcade during pancreaticoduodenectomy (PD) can precipitate visceral ischemia in patients with celiac artery stenosis (CAS). This study investigated optimal management of CAS for patients undergoing PD-particularly stenosis caused by median arcuate ligament (MAL) compression-through a systematic review and a nationwide survey. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we searched for studies indexed with the Medical Subject Headings terms celiac artery stenosis, median arcuate ligament syndrome, and pancreaticoduodenectomy. In parallel, a questionnaire on CAS management during PD was distributed to 67 major hepatobiliary and pancreatic surgery centers in Japan. RESULTS: Fifty-five studies met the inclusion criteria, comprising eight retrospective studies, and 47 case reports/series. Meta-analysis showed a prevalence of CAS in 6.1% of patients undergoing PD or total pancreatectomy, while preemptive MAL release was performed in only 2.2%. The risk of postoperative ischemic complications increased substantially when stenosis exceeded 80%. Among 108 patients with detailed postoperative data, those diagnosed with CAS preoperatively experienced significantly fewer ischemic events (5/85, 5.8%) compared with those diagnosed intraoperatively or postoperatively (8/22, 36%, p = 0.0006). Survey results indicated that the gastroduodenal artery (GDA) clamping test, supplemented with intraoperative Doppler ultrasonography in addition to visual inspection, was a common method to guide immediate MAL release. Repeated flow measurements after MAL release with GDA clamping were often required to confirm adequate visceral perfusion. CONCLUSIONS: Accurate preoperative identification of CAS and deliberate surgical planning are essential when PD is anticipated. Intraoperative hemodynamic reassessment remains critical, with consideration of arterial reconstruction when MAL release alone fails to restore sufficient splanchnic perfusion.