Laparoscopic management of celiac artery compression syndrome

Background: Celiac artery compression syndrome (CACS) remains a controversial diagnosis, despite several reported series documenting therapeutic efficacy of CA decompression. Traditional therapy consists of open surgical decompression, but since 2000, five isolated case reports have been published in which CACS has been successfully treated with laparoscopic techniques. This approach was adopted as the sole initial therapy for CACS at the Johns Hopkins Hospital in 2002. This article reports the results of a unique surgical series that triples the reported worldwide experience with this therapy. Methods: Fifteen patients (median age, 40.6 years) diagnosed with CACS underwent laparoscopic decompression by a single vascular surgeon. CACS was diagnosed by digital subtraction angiography in 14 patients and computed tomography (CT) angiography in one patient, with images acquired in both expiratory and inspiratory phases of respiration. CA decompression was offered after the results of a thorough workup for other pathology were negative, including upper and lower endoscopy, CT scanning, gastric and gallbladder emptying studies, upper gastrointestinal series, and small-bowel follow-through studies. Indications in all patients were abdominal pain and weight loss (average, 9 lbs). The procedure consisted of laparoscopic division of the median arcuate ligament and complete lysis of the CA from its origin on the aorta to its trifurcation. Results: Between November 2002 and September 2007, 15 consecutive patients underwent laparoscopic CA decompression. Median length of follow-up was 44.2 months. There were no operative deaths. Four patients were converted intraoperatively to an open decompression, all for intraoperative bleeding; only one required a blood transfusion. Average operating time was 189 minutes, and the average length of stay was 3.5 days. CA intervention was required in six patients, including three intraoperative procedures (1 patch angioplasty, 1 celiac bypass, 1 percutaneous angioplasty) and six late procedures (2 percutaneous angioplasties, 3 percutaneous stents, 1 celiac bypass). One complication occurred, a severe case of pancreatitis that developed 1 week after discharge. On follow-up, 14 of 15 patients subjectively reported significant improvement, and one patient remains symptomatic with no diagnosis. Conclusion: Laparoscopic decompression of the CA may be a useful therapy for CACS, but there is potential for vascular injury, and adjunctive CA intervention is often required. Surgeons should consider laparoscopic CA decompression as a therapeutic alternative for CACS and should participate in the care of patients with this diagnosis.