Case Report
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Feb 28, 2022; 28(8): 868-877
Published online Feb 28, 2022. doi: 10.3748/wjg.v28.i8.868
Treatment strategy for pancreatic head cancer with celiac axis stenosis in pancreaticoduodenectomy: A case report and review of literature
Eiji Yoshida, Yasutoshi Kimura, Takuro Kyuno, Ryoko Kawagishi, Kei Sato, Tsuyoshi Kono, Takehiro Chiba, Toshimoto Kimura, Hitoshi Yonezawa, Osamu Funato, Makoto Kobayashi, Kenji Murakami, Akinori Takagane, Ichiro Takemasa
Eiji Yoshida, Takuro Kyuno, Ryoko Kawagishi, Kei Sato, Tsuyoshi Kono, Takehiro Chiba, Toshimoto Kimura, Hitoshi Yonezawa, Osamu Funato, Makoto Kobayashi, Akinori Takagane, Department of Surgery, Hakodate Goryoukaku Hospital, Hakodate City 040-8611, Japan
Yasutoshi Kimura, Ichiro Takemasa, Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo City 060-8543, Hokkaido, Japan
Kenji Murakami, Department of Diagnostic Radiology, Hakodate Goryoukaku Hospital, Hakodate City 040-8611, Japan
Author contributions: Yoshida E was the patient’s surgeon, reviewed the literature, and contributed to drafting the manuscript; Yoshida E and Kimura Y wrote the paper; Kawagishi R, Sato K, Chiba T, Kimura T, Yonezawa H, and Kobayashi M were involved in the clinical management; Kyuno T, Kono T, and Funato O were assistants at the radical surgery; Murakami K was the radiologist who performed the endovascular stenting; Takagane A and Takemasa I were responsible for the conceptualization and supervision; all authors issued final approval for the version to be submitted.
Informed consent statement: Written informed consent was obtained from the patient for publication of this report and all accompanying images.
Conflict-of-interest statement: The authors declare that they have no conflicts of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Yasutoshi Kimura, MD, PhD, Associate Professor, Surgeon, Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, S-1, W-16, Chuo-ku, Sapporo City 060-8543, Hokkaido, Japan.
Received: August 29, 2021
Peer-review started: August 29, 2021
First decision: September 29, 2021
Revised: October 7, 2021
Accepted: January 22, 2022
Article in press: January 22, 2022
Published online: February 28, 2022

During pancreaticoduodenectomy in patients with celiac axis (CA) stenosis due to compression by the median arcuate ligament (MAL), the MAL has to be divided to maintain hepatic blood flow in many cases. However, MAL division often fails, and success can only be determined intraoperatively. To overcome this problem, we performed endovascular CA stenting preoperatively, and thereafter safely performed pancreaticoduodenectomy. We present this case as a new preoperative treatment strategy that was successful.


A 77-year-old man with a diagnosis of pancreatic head cancer presented to our department for surgery. Preoperative assessment revealed CA stenosis caused by MAL. We performed endovascular stenting in the CA preoperatively because we knew that going into the operation without a strategy could lead to ischemic complications. Double-antiplatelet therapy (DAPT) – which is needed when a stent is inserted – was then administered in parallel with neoadjuvant chemotherapy (NAC). This allowed us to administer DAPT for a sufficient period before the main pancreaticoduodenectomy procedure while obtaining therapeutic effects from NAC. Subtotal stomach-preserving pancreaticoduodenectomy was then performed. The operation did not require any unusual techniques and was performed safely. Postoperatively, the patient progressed well, without any ischemic complications. Histopathologically, curative resection was confirmed, and the patient had no recurrence or complications due to ischemia up to six months postoperatively.


Preoperative endovascular stenting, with NAC and DAPT, is effective and safe prior to pancreaticoduodenectomy in potentially resectable pancreatic cancer.

Keywords: Pancreaticoduodenectomy, Celiac axis stenosis, Median arcuate ligament, Endovascular stenting, Pancreatic head cancer, Case report

Core Tip: Celiac axis stenosis (CAS), caused by the median arcuate ligament, is an anatomical anomaly that should be noted when performing pancreaticoduodenectomy. In this case, an endovascular stent was placed preoperatively to recanalize the stenotic celiac axis, allowing the patient to safely undergo radical surgery without concern for intraoperative organ perfusion. The point to be highlighted with this preoperative strategy, was the use of double-antiplatelet therapy following endovascular stenting, during the interval when for neoadjuvant chemotherapy for pancreatic cancer (PC), thus providing a rational and effective combination of the two preoperative treatments for patients with PC and CAS.