# Coexistence of Median Arcuate Ligament Syndrome and Pancreatic Ductal Adenocarcinoma: A Case Report on Pancreaticoduodenectomy with Arterial Reconstruction

## TL;DR

A patient with pancreatic cancer and median arcuate ligament syndrome successfully underwent surgery with arterial reconstruction, avoiding complications.

## Contribution

This case report demonstrates the successful use of arterial bypass during pancreatic surgery in a patient with complex vascular issues.

## Key findings

- A 76-year-old patient with pancreatic cancer and MALS underwent successful surgery with arterial reconstruction.
- The patient remained complication-free and recurrence-free one year postoperatively.
- The procedure proved viable for revascularization without pancreatic leakage.

## Abstract

The celiac axis (CA) is usually dependent on blood supply from the superior mesenteric artery via the pancreatic arcade, particularly in cases of CA stenosis. During pancreaticoduodenectomy, excision of the gastroduodenal artery poses a significant risk of organ ischemia in the CA territory and may compromise anastomotic integrity. In cases of median arcuate ligament syndrome (MALS), blood flow typically improves after ligament transection. However, if atherosclerosis is present and chronic arterial compression is induced by the median arcuate ligament, stenting or revascularization may be required. Although revascularization is the most definitive technique, it raises concerns about anastomotic disruption due to postoperative pancreatic leakage. Considering these complexities, a thorough preoperative assessment of blood flow and the development of strategies to ensure adequate perfusion after resection are critical. Here, we encountered a patient with pancreatic cancer and MALS complicated by atherosclerosis.

A 76-year-old female patient with a history of acute appendicitis presented with generalized pruritus. Laboratory test results revealed significant elevations in her hepatobiliary enzymes and tumor markers. Imaging confirmed a 29-mm tumor in the pancreatic head and severe CA stenosis. Endoscopic ultrasonography and fine-needle aspiration confirmed pancreatic ductal adenocarcinoma. Due to severe CA stenosis and the inability to preserve the collateral vasculature, a multidisciplinary team decided to perform an abdominal aorta-to-splenic artery bypass using a saphenous vein graft. The surgery was successful, lasting 470 min with a blood loss of 700 mL. The patient was discharged on postoperative day 19 without complications and completed adjuvant chemotherapy. One year postoperatively, she remained recurrence-free with a patent graft and good hepatic artery flow.

This report discusses a case of a successful pancreaticoduodenectomy with an abdominal aorta-to-splenic artery bypass without the complication of a pancreatic leak, thereby demonstrating the viability of the procedure for revascularization and reconstruction.