Impact of Celiac Axis Stenosis in Patients Undergoing Pancreatoduodenectomy and Total Pancreatectomy

Objective: To assess the impact of celiac axis stenosis (CAS) on postoperative outcome after pancreatoduodenectomy (PD) and total pancreatectomy (TP), and to describe treatment strategies based on CAS severity and etiology. Summary background data: Asymptomatic CAS may compromise hepatic and gastric perfusion after PD and TP, potentially increasing morbidity. The role of preoperative CAS detection and treatment remains unknown. Methods: International retrospective study at four high-volume centers in four countries (2018-2024). All preoperative CT imaging was re-assessed. CAS >50% stenosis was graded as B/C and considered clinically relevant. Etiology was classified as atherosclerotic, median arcuate ligament [MAL]-related, or mixed. Outcome was associated with CAS severity, etiology, and treatment. Standardized management protocols per center were identified. Results: Among 1,698 patients undergoing PD and TP, CAS was identified in 16% (n=279). CAS grade B/C (6.5%, n=111) was independently associated with severe complications (OR 2.20, P<0.001), bile leak (OR 2.67, P=0.007), liver perfusion failure (OR 2.60, P<0.001), and gastric ischemia (OR 11.29, P<0.001). Outcomes differed by etiology: atherosclerotic CAS was associated with higher bile leak rate (22.7% vs. 5.7%; P=0.018) than MAL-related CAS. Centers with standardized protocols identified and treated CAS more frequently. Conclusions: CAS grade B/C is an underrecognized yet potentially modifiable risk factor for severe complications after PD and TP. Preoperative identification of CAS grade B/C, including etiology, may allow targeted intervention but larger studies are required.