What are the treatment options for celiac plexus stenosis?

Treatment of Celiac Artery Stenosis

Surgical release of the median arcuate ligament is the definitive first-line treatment for symptomatic celiac artery stenosis caused by median arcuate ligament syndrome (MALS), achieving 84.6% symptomatic relief and 93% improvement compared to 33% with conservative management. 1, 2

Primary Treatment Algorithm

For Median Arcuate Ligament Syndrome (MALS)

Surgical intervention is medically indicated when patients meet diagnostic criteria: imaging confirmation of celiac artery compression with expiration, chronic abdominal pain (particularly postprandial), and positive response to celiac plexus block. 1

The surgical procedure must include:

• Complete median arcuate ligament release 1, 2
• Concurrent celiac ganglion sympathectomy 1
• Evaluation for need of revascularization 1
• If residual celiac stenosis >30% persists after ligament release, additional revascularization (stenting or bypass) must be performed to achieve optimal outcomes, with 76% persistent symptom resolution when revascularization is added. 1, 2

Surgical Approach Options

Robot-assisted or endoscopic retroperitoneal approaches are preferred over open surgery, offering:

• 100% completion rates without conversion to open 3, 4
• Minimal blood loss (<50 mL) 3
• 2-day median hospital stay 3
• 89% primary-assisted anatomic patency when combined with endovascular treatment of persistent stenosis 4

The retroperitoneal endoscopic approach has demonstrated feasibility in 46 patients with only 2% conversion rate and 89% freedom from symptoms at 20-month follow-up. 4

For Atherosclerotic Celiac Stenosis

Endovascular therapy (angioplasty with stent placement) is first-line treatment with technical success rates of 85-100% and lower perioperative risks than open surgery. 2 Surgical bypass or endarterectomy is reserved for patients unsuitable for endovascular intervention. 2

Critical Contraindications

Endovascular stenting alone without surgical ligament release is absolutely contraindicated in MALS due to persistent extrinsic compression causing stent slippage, fracture, or migration. 1, 2 This approach will fail and should never be attempted as monotherapy.

Role of Celiac Plexus Block/Neurolysis

For Cancer-Related Pain

EUS-guided celiac plexus neurolysis (CPN) is recommended for pain from unresectable upper abdominal cancer, particularly pancreatic cancer (high evidence level, appropriateness rating 8.0). 5 The procedure uses 10-20 mL of absolute ethanol, with phenol as an alternative for alcohol-intolerant patients. 5

The EUS-guided approach is superior to percutaneous image-guided techniques (appropriateness rating 9.0). 5 Early EUS-CPN at the time of EUS-guided fine needle aspiration reduces pain and moderates opioid consumption. 5

For Chronic Pancreatitis

Celiac plexus block (CPB) should NOT be routinely performed for chronic pancreatitis pain (AGA 2022 guidelines). 5 The evidence is weak, with only 50-60% achieving pain relief lasting ≤6 months, and almost all patients requiring additional analgesics. 5

CPB may be considered only in highly selected patients with debilitating pain after all other therapeutic measures have failed, and only after thorough discussion of unclear outcomes and procedural risks (diarrhea, orthostatic hypotension common; major complications <1%). 5

EUS-guided CPN for chronic pancreatitis is NOT recommended (appropriateness rating 7.0, moderate evidence). 5

Procedural Requirements

All interventional procedures must be performed at expert centers with:

• Multidisciplinary support including interventional radiologists, surgeons, and anesthesiologists 5
• Facilities and expertise in interventional EUS and advanced ERCP 5
• Experienced endoscopists in EUS, wire manipulation, and stent placement 5

This is critical because adverse event rates are 18.9% with technical success of only 76.6% for complex interventional procedures. 5

Key Predictors of Surgical Success

Best surgical outcomes occur in patients with:

• Postprandial pain pattern (81% cure rate) 2
• Age 40-60 years (77% cure rate) 2
• Weight loss ≥20 pounds (67% cure rate) 2
• Absence of angiographic collateralization 1

Important Caveats

Not all patients with imaging evidence of celiac compression are symptomatic - compression may be a normal finding in up to 20% of the population. 2 Alternative diagnoses must be considered if symptoms persist after intervention, as celiac compression may be incidental rather than causative. 2