Markedly elevated liver transaminases following pancreaticoduodenectomy: celiac artery thrombosis in disguise
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Markedly elevated liver transaminases following pancreaticoduodenectomy: celiac artery thrombosis in disguise

Durgatosh Pandey1, Pankaj Kumar Garg1,2, Ashish Jakhetiya1, Jyoti Sharma1, S. H. Chandrashekhara3

1Department of Surgical Oncology, Dr BRA Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi 110029, India; 2Department of Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, University of Delhi, Delhi 110095, India; 3Department of Radiodiagnosis, Dr BRA Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi 110029, India

Correspondence to: Dr. Pankaj Kumar Garg. Department of Surgical Oncology, Dr BRA Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi 110029, India. Email: dr.pankajgarg@gmail.com.

Submitted Mar 13, 2015. Accepted for publication May 26, 2015.

doi: 10.3978/j.issn.2304-3881.2015.05.03

A 63-year-old lady underwent classical pancreaticoduodenectomy with regional lymphadenectomy for periampullary cancer. Preoperative contrast-enhanced computed tomography (CECT) of abdomen revealed dilated common bile duct which showed abrupt cut-off at ampulla. CECT also revealed replaced right hepatic artery arising from the left gastric artery (Panels A-C). During surgery, gastroduodenal artery was test-clamped to confirm pulsations in the hepatic artery before being ligated. On third postoperative day, she was found to have altered sensorium. Liver function tests showed bilirubin of 10.9 mg%; however, liver transaminases were markedly elevated (AST of 2,095 U/L and ALT of 1,243 U/L)—prothrombin time was also elevated [international normalized ratio (INR) =2.2]. Postoperative CECT of abdomen and pelvis revealed thrombosis of celiac artery trunk resulting in marked liver and spleen necrosis. Distal right hepatic artery was reformed by the collaterals; it explains relative sparing of right lobe of liver (Panels D-F).

Marked elevation of liver transaminases suggesting acute hepatic insult is a rare immediate postoperative complication following pancreaticoduodenectomy; however, if present, this may be caused by drug induced hepatotoxicity, blood transfusion reaction, co-existent viral hepatitis, sepsis or perioperative hypotension. The etiological factors for celiac artery thrombosis are arteriosclerosis, hyper-coagulable states, extrinsic stenosis (celiac artery stenosis—compression by median arcuate ligament, the celiac ganglia or surrounding local fibro-inflammatory tissue), cancer, surgical trauma, congenital stenosis, catheter related injury during endovascular therapy, and idiopathic. Presence of celiac artery stenosis is not-so-uncommon entity; pancreatic surgeons must be aware of this vascular entity to avoid potentially catastrophic ischemic complications after pancreaticoduodenectomy.

Acknowledgements

None.

Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

Informed Consent: Informed consent was obtained from the patient for publication of this article and any accompanying images.

Cite this article as: Pandey D, Garg PK, Jakhetiya A, Sharma J, Chandrashekhara SH. Markedly elevated liver transaminases following pancreaticoduodenectomy: celiac artery thrombosis in disguise. Hepatobiliary Surg Nutr 2015;4(5):367-368. doi: 10.3978/j.issn.2304-3881.2015.05.03

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