title: Management of median arcuate ligament syndrome in patients who require pancreaticoduodenectomy.
abstract: Pancreaticoduodenectomy is the standard treatment for localised neoplasms of the pancreatic head. The operation can be performed safely in specialist units but good outcome is compromised if postoperative blood flow to the liver and biliary tree is inadequate. Coeliac artery occlusion  with blood supply to the liver arising from the superior mesenteric artery via the gastroduodenal artery is difficult to recognise, especially intraoperatively. Recognition of absent hepatic artery pulsation after occlusion of the gastroduodenal artery opens a dilemma: should the resection  be abandoned or should vascular reconstruction be undertaken, adding risk to an already complex procedure? We describe two cases with a resectable pancreatic endocrine tumour in which coeliac artery occlusion caused by median arcuate ligament compression was identified from cross-sectional  imaging and reconstructions. We highlight two different strategies to correct the vascular insufficiency and allow safe pancreatic resection.
authors.affiliation: Department of Hepatobiliary and Pancreatic Surgery, Southampton General Hospital, UK. robert.whistance@hotmail.co.uk
authors.forename: Robert N
authors.initials: RN
authors.lastname: Whistance
authors.forename: Vallari
authors.initials: V
authors.lastname: Shah
authors.forename: Emily R
authors.initials: ER
authors.lastname: Grist
authors.forename: Clifford P
authors.initials: CP
authors.lastname: Shearman
authors.forename: Neil W
authors.initials: NW
authors.lastname: Pearce
authors.forename: Allan
authors.initials: A
authors.lastname: Odurny
authors.forename: Brian
authors.initials: B
authors.lastname: Stedman
authors.forename: Colin D
authors.initials: CD
authors.lastname: Johnson
mesh_terms: D001157:Arterial Occlusive Diseases / Q000150:complications*; D002445:Celiac Artery; D003251:Constriction, Pathologic / Q000150:complications / Q000601:surgery; D005260:Female; D006801:Humans; D008022:Ligaments / Q000601:surgery*; D008113:Liver Neoplasms / Q000556:secondary*; D008297:Male; D008875:Middle Aged; D010190:Pancreatic Neoplasms / Q000098:blood supply / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000379:methods*; D015642:Radiology, Interventional; D015607:Stents; D013577:Syndrome