Management of Median Arcuate Ligament Compression in Patients Undergoing Pancreaticoduodenectomy - A Systematic Review and Consensus Statements

Sep 29, 2026

Background and aims: Division of the pancreatic arterial arcade during pancreaticoduodenectomy can trigger visceral ischemia in patients with celiac artery stenosis, particularly when stenosis results from median arcuate ligament compression. Methods: A systematic review following PRISMA searched indexed studies, and a nationwide questionnaire surveyed 67 major centers in Japan on CAS management during PD. Results: Fifty-five studies were included; meta-analysis estimated CAS prevalence at 6.1% and showed preemptive MAL release in 2.2%. Ischemic complications increased when stenosis exceeded 80%, and preoperative CAS diagnosis reduced events versus intra/postoperative detection. Conclusions: Accurate preoperative identification and planned surgery are essential, with intraoperative hemodynamic reassessment and possible arterial reconstruction if MAL release fails to restore perfusion.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages11

Reading Time28 min

AccessFree to download

Abstract

Introduction

Materials and Methods

Search Strategy and Study Selection

Asian Journal of Endoscopic Surgery ORIGINAL ARTICLE OPEN ACCESS Management of Median Arcuate Ligament Compression in Patients Undergoing Pancreaticoduodenectomy: A Systematic Review and Consensus Statements Noboru Ideno1 | Naoki Ikenaga1 | Yasunaru Sakuma2 | Saya Chiba2 | Tomotaka Ueno3 | Masaharu Higashida4 | Toshio Takayama5 | Hidenori Haruta6 | Shunji Endo4 | Katsuyuki Hoshina5 | Toshiya Abe1 | Kenoki Ohuchida1 | Akiko Umezawa6 | Yuko Kitagawa7 | Masafumi Nakamura1 1Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan | 2Department of Surgery, Division of Gastroenterological, General and Translational Surgery, Jichi Medical University, Tochigi, Japan | 3Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan | 4Department of Digestive Surgery, Kawasaki Medical School, Okayama, Japan | 5Department of Vascular Surgery, The University of Tokyo, Tokyo, Japan | 6Minimally Invasive Surgery Center, Yotsuya Medical Cube, Tokyo, Japan | 7Department of Surgery, Keio University School of Medicine, Tokyo, Japan Correspondence: Masafumi Nakamura ([nakamura.masafumi.861@m.kyushu-u.ac.jp](nakamura.masafumi.861@m.kyushu-u.ac.jp)) Received: 17 November 2025 | Accepted: 23 November 2025 Keywords: celiac artery stenosis | median arcuate ligament | Pancreaticoduodenectomy ABSTRACT Background and Aims: Division of the pancreatic arterial arcade during pancreaticoduodenectomy (PD) can precipitate visceral ischemia in patients with celiac artery stenosis (CAS) . This study investigated optimal management of CAS for patients undergoing PD—particularly stenosis caused by median arcuate ligament (MAL) compression—through a systematic review and a nationwide survey. Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we searched for studies indexed with the Medical Subject Headings terms celiac artery stenosis, median arcuate ligament syndrome, and pancreaticoduodenectomy. In parallel, a questionnaire on CAS management during PD was distributed to 67 major hepatobiliary and pancreatic surgery centers in Japan. Results: Fifty-five studies met the inclusion criteria, comprising eight retrospective studies, and 47 case reports/series. Metaanalysis showed a prevalence of CAS in 6.1% of patients undergoing PD or total pancreatectomy, while preemptive MAL release was performed in only 2.2% . The risk of postoperative ischemic complications increased substantially when stenosis exceeded 80%. Among 108 patients with detailed postoperative data, those diagnosed with CAS preoperatively experienced significantly fewer ischemic events (5/85, 5.8%) compared with those diagnosed intraoperatively or postoperatively (8/22, 36%, p = 0.0006) . Survey results indicated that the gastroduodenal artery (GDA) clamping test, supplemented with intraoperative Doppler ultrasonography in addition to visual inspection, was a common method to guide immediate MAL release. Repeated flow measurements after MAL release with GDA clamping were often required to confirm adequate visceral perfusion. Conclusions: Accurate preoperative identification of CAS and deliberate surgical planning are essential when PD is anticipated. Intraoperative hemodynamic reassessment remains critical, with consideration of arterial reconstruction when MAL release alone fails to restore sufficient splanchnic perfusion. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. © 2026 The Author(s). Asian Journal of Endoscopic Surgery published by Asia Endosurgery Task Force and Japan Society of Endoscopic Surgery and John Wiley & Sons Australia, Ltd. Asian Journal of Endoscopic Surgery, 2026; 19:e70206 1 of 11 [https://doi.org/10.1111/ases.70206](ht

FAQs

What clinical problem does the paper address in pancreaticoduodenectomy patients?

It focuses on management of median arcuate ligament (MAL) compression causing celiac artery stenosis and the resulting risk of visceral ischemia during pancreaticoduodenectomy.

How were studies and expert center experiences collected?

The authors performed a systematic review using PRISMA-guided searching, and conducted a nationwide survey by distributing a questionnaire on CAS management during PD to 67 major centers in Japan.

What factors were associated with higher postoperative ischemic complications?

Postoperative ischemic complications increased substantially when celiac artery stenosis exceeded 80%, and preoperative diagnosis of CAS was associated with fewer ischemic events than intraoperative or postoperative diagnosis.

What intraoperative assessment approach is highlighted for guiding MAL release?

The gastroduodenal artery (GDA) clamping test, supplemented by intraoperative Doppler ultrasonography in addition to visual inspection, was commonly used, with repeated flow measurements often required after MAL release.

Sep 29, 2026

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