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- 저자 : ( Satoshi Hirookaori ) (검색결과 1 건)
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Acute Median Arcuate Ligament Syndrome after Pancreaticoduodenectomy
( Masaya Kotsuka ),( Sohei Satoi ),( Hiroaki Yanagimoto ),( Tomohisa Yamamoto ),( Hisashi Kosaka ),( Satoshi Hirookaori ),( So Yamaki ),( Yoichi Matsui ),( Masanori Kon ) 대한간학회 2017 춘·추계 학술대회 (KASL) Vol.2017 No.1
Aims: Here we report a case of median arcuate ligament syndrome (MALS) which suddenly developed soon after pancreaticoduodenectomy. Methods: 40-year-old male underwent PD by a diagnosis of pancreatic cancer. Results: Intraoperative exploration showed normal anatomy of the celiac trunk, mesenteric vessels, and related branches. Clamp testing of the GDA showed normal hepatic artery pulsation. Before closing the abdomen, we noted that pulsation of the common hepatic artery became weak, but blood regurgitation was of adequate strength after reopening the cut stump of the right gastric artery. On postoperative day 1, within 12 hours of PD, the liver enzymes, INR, WBC, and CRP were abnormal and rapidly worsened over the next 12 hours. Although the preoperative CT had shown normal CA anatomy and no evidence of MALS, a postoperative scan that included a lateral projection of the CA showed an acute extrinsic stenosis caused by newly developed compression caused by the median arcuate ligament. Widespread liver ischemia was also apparent. The patient underwent urgent reoperation for acute onset MALS causing severe hepatic cytolysis. After division of the median arcuate ligament, the patient’s liver enzymes, INR, and WBC gradually normalized. Eleven days after reoperation, CT showed regular flow into the celiac trunk; the area of liver ischemia was reduced. He was eventually discharged 43 days after the original PD. MALS can have an acute postoperative onset after PD even if all preoperative and intraoperative evaluations are normal particularly in young patients. We hypothesize that a very tight median arcuate ligament presented in this young patient in addition to lymph node clearance around the celiac trunk might induce the stenosis. Conclusions: Patients who acutely deteriorate despite medical treatment should undergo surgical exploration to rule out other conditions and division of the median arcuate ligament if MALS is indeed present.
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