How to Deal with Median Arcuate Ligament during Pancreaticoduodenectomy? Management Strategies and Impact on Perioperative Outcomes

BACKGROUND: Median arcuate ligament (MAL) can cause coeliac trunk (CT) stenosis, which is often asymptomatic but may lead to severe hepatic, splenic, or digestive ischemia following pancreaticoduodenectomy (PD). Optimal diagnosis and management remain debated. The purpose of this study was to evaluate management strategies and perioperative outcomes of patients with MAL undergoing PD. PATIENTS AND METHODS: A retrospective multicenter study across ten high-volume French centers included patients diagnosed with MAL (hemodynamically significant or not) who underwent PD between 2005 and 2024. Diagnosis and management strategies and postoperative outcomes were collected. RESULTS: MAL stenosis was suspected in 1.3% of patients (115/8676), with 59 cases (0.7%) showing hemodynamically significant MAL. MAL stenosis was suspected before surgery in 90% of patients (n = 104). Overall, 8 patients (13.8%) underwent preoperative stenting, 48 patients (82.8%) underwent intraoperative MAL division, and 2 patients (3.4%) underwent primary vascular reconstruction. Seven failures of MAL division (14%) required vascular reconstruction. Overall morbidity (Clavien-Dindo ≥ III) was 25%, pancreatic fistula B-C was 10%, biliary fistula was 6.9%, hemorrhage was 15%, and mortality was 4.3% (n = 5). Ischemic complications were observed in five patients (4.5%), including four hepatic ischemias and one bowel ischemia; two hepatic ischemias were directly related to MAL management. Overall postoperative mortality was 4.3%, with two deaths attributable to MAL-related hepatic ischemia. CONCLUSIONS: MAL is rare but clinically impactful in patients undergoing PD. Early recognition and appropriate intraoperative assessment are essential to prevent ischemic complications. When properly identified and managed, MAL does not appear to significantly worsen overall postoperative outcomes. Management should remain individualized, and pancreatic surgeons should be prepared to perform MAL division and vascular reconstruction when indicated.