Surgical therapy of celiac axis and superior mesenteric artery syndrome

Abstract

Introduction: Compression syndromes of the celiac artery (CAS) or superior mesenteric artery (SMAS) are rare conditions that are difficult to diagnose; optimal treatment remains complex, and symptoms often persist after surgery. We aim to review the literature on surgical treatment and postoperative outcome in CAS and SMAS syndrome.

Methods: A systematic literature review of medical literature databases on the surgical treatment of CAS and SMAS syndrome was performed from 2000 to 2022. Articles were included according to PROSPERO guidelines. The primary endpoint was the failure-to-treat rate, defined as persistence of symptoms at first follow-up.

Results: Twenty-three studies on CAS (n = 548) and 11 on SMAS (n = 168) undergoing surgery were included. Failure-to-treat rate was 28% for CAS and 21% for SMAS. Intraoperative blood loss was 95 ml (0-217) and 31 ml (21-50), respectively, and conversion rate was 4% in CAS patients and 0% for SMAS. Major postoperative morbidity was 2% for each group, and mortality was described in 0% of CAS and 0.4% of SMAS patients. Median length of stay was 3 days (1-12) for CAS and 5 days (1-10) for SMAS patients. Consequently, 47% of CAS and 5% of SMAS patients underwent subsequent interventions for persisting symptoms.

Conclusion: Failure of surgical treatment was observed in up to every forth patient with a high rate of subsequent interventions. A thorough preoperative work-up with a careful patient selection is of paramount importance. Nevertheless, the surgical procedure was associated with a beneficial risk profile and can be performed minimally invasive.

Keywords: Dunbar; Failure to treat; Median arcuate ligament syndrome; Superior mesenteric artery syndrome; Surgery; Wilkie.

Fig. 1

Celiac artery syndrome. Sagittal images (A) and 3D reconstruction (B) or MR angiography showing severe stenosis of the proximal celiac artery (white arrow in A and B) due to compression by the median arcuate ligament. Images after surgical release (C and D) show resolved stenosis (white arrow in C and D)

Fig. 2

Superior mesenteric artery syndrome. Axial contrast-enhanced CT images at the level of the upper abdomen. A Mild distension of the stomach and proximal duodenum (white arrows). B Compression of the third portion of the duodenum (white arrows) between the superior mesenteric artery (white arrowhead) and abdominal aorta (black arrow). C Sagittal images show reduced angle and distance between the superior mesenteric artery (white arrow) and abdominal aorta (black arrow) (aorto-mesenteric angle of 18°, aorto-mesenteric distance of 5 mm). D Sagittal 3D reconstruction again shows the reduced angle between the superior mesenteric artery (white arrow) and abdominal aorta (black arrow)

Fig. 3

PRISMA workflow diagram 2020

Fig. 4

A Celiac artery syndrome work-up and treatment algorithm. B Superior mesenteric artery syndrome work-up and treatment algorithm. HP, Helicobacter pylori; GERD, gastroesophageal reflux disease; US, ultrasound; contrast enhanced computed tomography (CT)