A gastroduodenal artery that branched from the celiac artery in gastrectomy: A rare case of an anatomical variant.

Understanding anatomical anomalies of the branch of the celiac artery for safe gastrectomy is important. We report a case of laparoscopic distal gastrectomy with D1+ lymph node dissection for early gastric cancer with a vascular anatomical anomaly of the celiac artery. A 45-year-old woman was referred to our hospital because of early gastric cancer. Computed tomography showed an anatomical variation of the gastroduodenal artery, which branched from the celiac artery. The celiac artery also branched into the left gastric artery, the splenic artery, and the common hepatic artery. Preoperative understanding of an unusual branch of the celiac artery enabled a safe laparoscopic surgery. There were no postoperative complications. The Adachi classification or Michel classification is used for an anatomical anomaly of the celiac artery, but to the best of our knowledge, this case has not been previously classified and is the first reported case.

Kimura's vs Warshaw's technique for spleen preserving distal pancreatectomy: a systematic review and meta-analysis of high-quality studies.

BACKGROUND: Spleen preserving distal pancreatectomy (SPDP) represents a widely adopted procedure in the presence of benign or low-grade malignant tumors. Splenic vessels preservation and resection (Kimura and Warshaw techniques respectively) represent the two main surgical modalities to avoid splenic resection. Each one is characterized by strengths and drawbacks. The aim of the present study is to systematically review the current high-quality evidence regarding these two techniques and analyze their short-term outcomes. METHODS: A systematic review was conducted according to PRISMA, AMSTAR II and MOOSE guidelines. The primary endpoint was to assess the incidence of splenic infarction and splenic infarction leading to splenectomy. As secondary endpoints, specific intraoperative variables and postoperative complications were explored. Metaregression analysis was conducted to evaluate the effect of general variables on specific outcomes. RESULTS: Seventeen high-quality studies were included in quantitative analysis. A significantly lower risk of splenic infarction for patients undergoing Kimura SPDP (OR = 0.14; p < 0.0001). Similarly, splenic vessel preservation was associated with a reduced risk of gastric varices (OR = 0.1; 95% p < 0.0001). Regarding all secondary outcome variables, no differences between the two techniques were noticed. Metaregression analysis failed to identify independent predictors of splenic infarction, blood loss, and operative time among general variables. CONCLUSIONS: Although Kimura and Warshaw SPDP have been demonstrated comparable for most of postoperative outcomes, the former resulted superior compared to the latter in reducing the risk of splenic infarction and gastric varices. For benign pancreatic tumors and low-grade malignancies Kimura SPDP may be preferred.

Aneurismas múltiples de arteria esplénica / Multiple splenic artery aneurysm / Aneurismas múltiplos de artéria esplénica

Introducción: los aneurismas de la arteria esplénica son los más frecuentes de aquellos que asientan en arterias viscerales. La existencia de múltiples aneurismas esplénicos es rara, existiendo pocos casos publicados. Generalmente son asintomáticos y constituyen un hallazgo, es poco frecuente la presentación en nuestra paciente, con dolor inespecífico de hemiabdomen superior. Existen diferentes alternativas terapéuticas, son de primera línea la angio-embolización y colocación de stent endovasculares, tienen como principales limitantes el tamaño del aneurisma y la tortuosidad de la arteria esplénica que dificultan acceso endovascular. El tratamiento quirúrgico queda reservado, para situaciones especiales. Puede realizarse con conservación esplénica (actuando únicamente sobre el aneurisma) o mediante esplenectomía. Descripción de contenido: el video presenta un caso clínico, de aneurismas múltiples de arteria esplénica. El mismo expone presentación clínica, diagnóstico, opciones terapéuticas y la optada en este caso: esplenectomía laparoscópica. Conclusiones: se trata de una entidad poco frecuente, por lo que consideramos fundamental la comunicación del caso. Si bien generalmente constituyen un hallazgo imagenológico, resulta de vital importancia el tratamiento oportuno a fin de prevenir complicaciones graves como la rotura del aneurisma. Ver video en: https://www.youtube.com/watch?v=5IS2BxgeuxY

Introduction: splenic artery aneurysms are the most frequent kind among aneurysms in visceral arteries. The existence of multiple aneurysms is rather unusual, there being few cases published. In general they constitute findings as they are asymptomatic. The presentation of the patient in the study, with non-specific upper abdominal pain is rather infrequent. Among the different therapeutic options, angio-embolization and the collocation of endovascular stents are the front line approaches, the main limitations being the size of the aneurysm and the tortuous nature of the splenic artery which makes endovascular access difficult. Surgical treatment is reserved for special situations and it May preserve the spleen (only acting on the aneurysm) or may involve a splenectomy. Content description: the video presents a clinical case of multiple splenic artery aneurysms covering clinical presentation, diagnosis and therapeutic options - the chosen one in this case being laparoscopic spenectomy. Conclusions: it is rather an unusual condition, and therefore dissemination of the case is key. Despite their generally being image studies findings, it is of the essence to apply timely therapy to prevent serious complications like the rupture of the aneurysm. Watch video at: https://www.youtube.com/watch?v=5IS2BxgeuxY

Introdução: os aneurismas da artéria esplênica são os mais comuns nas artérias viscerais. A existência de múltiplos aneurismas esplênicos é rara, com poucos casos publicados. Geralmente são assintomáticos e constituem um achado acidental, sendo rara a apresentação observada na nossa paciente, com dor inespecífica no hemiabdome superior. Existem diferentes alternativas terapêuticas sendo a angioembolização e a colocação de stent endovascular as de primeira linha, suas principais limitações são o tamanho do aneurisma e a tortuosidade da artéria esplênica que dificultam o acesso endovascular. O tratamento cirúrgico é reservado para situações especiais. Pode ser realizada com preservação esplênica (atuando apenas no aneurisma) ou por esplenectomia. Descrição do conteúdo: o vídeo apresenta um caso clínico de múltiplos aneurismas de artéria esplênica. Expõe apresentação clínica, diagnóstico, opções terapêuticas e a escolhida neste caso: esplenectomia laparoscópica. Conclusões: é uma entidade rara, pelo que consideramos essencial a comunicação do caso. Embora geralmente constituam um achado de imagem, o tratamento oportuno é de vital importância para evitar complicações graves, como a ruptura do aneurisma. Veja o vídeo em: https://www.youtube.com/watch?v=5IS2BxgeuxY

Hemorragia digestiva alta grave por fistula entre arteria esplénica y manga gástrica / Severe upper gastrointestinal bleeding due to fistula between splenic artery and gastric sleeve / Hemorragia digestiva alta grave devido a fístula entre artéria esplênica e manga gástrica

La hemorragia digestiva determinada por una fístula entre manga gástrica y seudoaneurisma de arteria esplénica o polo superior de bazo es infrecuente. Se presenta un caso clínico de una paciente de 52 años con antecedentes de cirugía de manga gástrica y fuga anastomótica. Ingresó por hemorragia digestiva alta grave. Se operó de emergencia y realizó punto hemostático sobre cara posterior de manga gástrica. Se reintervino por resangrado realizándose la gastrectomía y esplenopancreatectomía distal por solución de continuidad de arteria esplénica. Dada la inestabilidad hemodinámica se efectuó un esofagostoma y yeyunostomía, reconstruyéndose a los 8 meses con buena evolución.

Gastrointestinal bleeding caused by a fistula between the gastric sleeve and a pseudoaneurysm of the splenic artery or upper pole of the spleen is uncommon. A clinical case of a 52-year-old patient with a history of gastric sleeve surgery and anastomotic leak is presented. She was admitted for severe upper gastrointestinal bleeding. She underwent emergency surgery and performed a hemostatic stitch on the posterior face of the gastric sleeve. She underwent reoperation due to rebleeding, performing gastrectomy and distal splenopancreatectomy due to discontinuation of the splenic artery. Given the hemodynamic instability, an esophagostomy and jejunostomy were performed, reconstructing at 8 months with good evolution.

O sangramento gastrointestinal causado por uma fístula entre a manga gástrica e um pseudoaneurisma da artéria esplênica ou pólo superior do baço é incomum. Apresenta-se o caso clínico de um paciente de 52 anos com história de cirurgia de manga gástrica e fístula anastomótica. Ele foi internado por hemorragia digestiva alta grave. Uma operação de emergência foi realizada e um ponto hemostático foi realizado na face posterior da manga gástrica. Foi reoperado por ressangramento, realizando gastrectomia e esplenopancreatectomia distal por descontinuação da artéria esplênica. Dada a instabilidade hemodinâmica, foi realizada esofagostomia e jejunostomia, reconstruindo aos 8 meses com boa evolução.

Spontaneous rupture of a large splenic artery aneurysm in a 59-year-old male patient with pemphigus vulgaris: a case report.

BACKGROUND: There is currently no information on the anatomical risk factors for splenic artery aneurysm rupture, specifically the location or size of the lesion; therefore, reporting this entity to obtain data and ultimately reduce morbidity and mortality is essential. Here we report a case of a male patient with spontaneous rupture of a large splenic artery aneurysm presenting with abdominal pain. CASE PRESENTATION: A 59-year middle-eastern male, with known pemphigus vulgaris presented with a chief complaint of headache and syncope, followed by abdominal pain along with severe metabolic acidosis. A contrast-enhanced computed tomography scan of the abdomen and pelvic showed a splenic artery aneurysm of 33 × 30 mm with a 150 × 90 mm hematoma formation around the aneurysm site. The patient underwent an operation and splenectomy, with confirmation of the diagnosis of ruptured splenic artery aneurysm. CONCLUSION: It is essential to consider splenic aneurysm rupture as a second-line differential diagnosis, especially among patients with comorbid diseases, as this can lead to timely and appropriate lifesaving intervention.

Hemosuccus Pancreaticus: A Rare Cause of Gastrointestinal Bleeding.

Hemosuccus pancreaticus or bleeding from the pancreatic duct into the gastrointestinal tract via the ampulla of Vater is caused by rupture of the pseudoaneurysm of a peripancreatic vessel into pancreatic duct or pancreatic pseudocyst in the context of pancreatitis or pancreatic tumour or trauma. It produces diagnostic and therapeutic dilemma due to its anatomical location and that bleeding into the duodenum is intermittent and cannot be easily diagnosed by endoscopy, often needs CE-CT and angiography. In August 2019, a 60-year-old male presented with intermittent abdominal pain, gastrointestinal bleeding and high serum lipase. Upper GIT endoscopy showed blood mixed bile coming out through ampulla, suspecting Hemosuccus pancreaticus. Contrast-enhanced computed tomography (CT) scan demonstrated pancreatic pseudo cyst with partially thrombosed splenic artery pseudoaneurysm. At laparotomy, splenic artery pseudoaneurysm was ligated along with splenectomy. Later on, the patient had no further occurrence of gastrointestinal bleeding.

Laparoscopic splenic vessel-preserving distal pancreatectomy after laparoscopic pylorus-preserving gastrectomy: A case report.

A 77-year-old woman who had undergone laparoscopic pylorus-preserving gastrectomy for gastric cancer showed dilatation of the main pancreatic duct in the distal pancreas on ultrasonography during postoperative surveillance. Detailed examination revealed that she had a main-duct type intraductal papillary mucinous neoplasm with high-risk stigmata. As invasive malignancy was not suggested, laparoscopic splenic vessel-preserving distal pancreatectomy was performed to preserve the remnant stomach. Although adhesions around the gastroduodenostomy and splenic artery were severe, the magnified laparoscopic view facilitated the identification of appropriate dissection layers, resulting in limited blood loss. The distal pancreas was successfully resected without sacrificing blood flow to the remnant stomach. The postoperative course was uneventful. The pathological diagnosis was low-grade intraductal papillary mucinous neoplasm. Laparoscopic splenic vessel-preserving distal pancreatectomy for benign or low-grade malignant disease of the distal pancreas can be useful for preserving the remnant stomach in patients with a history of gastrectomy.

Splenic vessels preserving versus Warshaw technique in spleen preserving distal pancreatectomy: A systematic review and meta-analysis.

BACKGROUND: Spleen-preserving distal pancreatectomy is widely used to remove benign or low-grade malignant neoplasms located in the pancreatic body and tail. Both splenic vessels preserving (SVP-DP) and splenic vessels ligating (Warshaw technique [WT]) distal pancreatectomy are safe and effective methods but which technique is superior remains controversial. Thus, this study aimed to evaluate the clinical outcomes of patients who underwent both methods. MATERIAL AND METHODS: Major databases, including PubMed, Embase, Science Citation Index Expanded, and The Cochrane Library, were searched for studies comparing SVP-DP and the WT for spleen-preserving distal pancreatectomy up to December 2021. The perioperative and postoperative outcomes were compared between the SVP-DP and WT groups. Pooled odds ratios (ORs) and weighted mean differences (WMDs) with 95% confidence intervals (CIs) were calculated using fixed- or random-effects models. RESULTS: Twenty retrospective studies with 2173 patients were analyzed. A total of 1467 (67.5%) patients underwent SVP-DP, while 706 (32.5%) patients underwent WT. Patients in the SVP-DP group had a significantly lower rate of splenic infarction (OR: 0.17; 95% CI, 0.11-0.25; P < 0.00001) and incidence of gastric varices (OR: 0.19; 95% CI, 0.11-0.32; P < 0.00001) compared to the patients in the WT group; furthermore, they had a shorter length of hospital stay (WMD: 0.71; 95% CI, -1.13 to -0.29; P = 0.0008). There were no significant differences between the two groups in terms of major complication, postoperative pancreatic fistula (B/C), reoperation, blood loss, or operation time. CONCLUSIONS: Compared to WT, SVP-DP should be preferred to reduce splenic infarction and gastric varices, and WT may be more suitable for large tumors. Moreover, considering the shortcomings of retrospective study, a multicenter randomized controlled study with a large sample size should be conducted to verify our results.

A case of splenic artery aneurysm and rupture in a patient on a vascular endothelial growth factor inhibitor for renal cell carcinoma.

BACKGROUND: Pazopanib is a vascular endothelial growth factor inhibitor that is used in the treatment of metastatic renal cell carcinoma. Post market reports demonstrate an increasing awareness of the association of arterial aneurysms and dissections with vascular endothelial growth factor inhibitor use, although, few reports exist for pazopanib. CASE: Here we report a 69-year-old patient with minimal cardiovascular risk factors who developed a rupture of a splenic arterial aneurysm after more than 5 years of effective treatment with pazopanib for metastatic renal cell carcinoma. CONCLUSION: This case report outlines the necessity to monitor patients while on pazopanib, even when there are minimal risk factors and long periods of tolerance.

Sudden death due to non-traumatic rupture of splenic artery aneurysm.

INTRODUCTION: Splenic artery aneurysm is a rare form of vascular pathology that carries a high risk of mortality once it gets ruptured. It has a prevalence of 1% and occurs due to thinning and dilatation of the arterial wall. CASE: We describe a case of a 35-year-old policeman who died suddenly. At medico-legal autopsy, intraperitoneal clotted blood about 1000 g and liquid blood about 3000 ml were seen. On further exploration, ruptured splenic artery aneurysm about 2.0 cm in diameter became visible near the hilum. CONCLUSION: Rare cases typically present as sudden and unexpected death with intraperitoneal bleed and may be confused with blunt trauma abdomen. Therefore, splenic artery aneurysm is an appropriate differential diagnosis for sudden deaths and intraperitoneal bleeding, respectively.

Radiological tumour invasion of splenic artery or vein in patients with pancreatic body or tail adenocarcinoma and effect on recurrence and survival.

BACKGROUND: Major vessel invasion is an important factor for determining the surgical approach and long-term prognosis for patients with pancreatic head cancer. However, clinical implications of vessel invasion have seldom been reported in pancreatic body or tail cancer. This study aimed to evaluate the clinical relevance of splenic vessel invasion with pancreatic body or tail cancer compared with no invasion and investigate prognostic factors. METHODS: This study enrolled patients who underwent upfront distal pancreatectomy from 2005 to 2018. The circular degree of splenic vessel invasion was investigated and categorized into three groups (group 1, no invasion; group 2, 0-180°; group 3, 180° or more). Clinicopathological variables and perioperative and survival outcomes were evaluated, and multivariable Cox proportional analysis was performed to evaluate prognostic factors. RESULTS: Among 249 enrolled patients, tumour size was larger in patients with splenic vessel invasion (3.9 versus 2.9 cm, P = 0.001), but the number of metastatic lymph nodes was comparable to that in patients with no vessel invasion (1.7 versus 1.4, P = 0.241). The 5-year overall survival rates differed significantly between the three groups (group 1, 38.4 per cent; group 2, 16.8 per cent; group 3, 9.7 per cent, P < 0.001). Patients with both splenic artery and vein invasion had lower 5-year overall survival rates than those with one vessel (7.5 versus 20.2 per cent, P = 0.021). Cox proportional analysis revealed adjuvant treatment, R0 resection and splenic artery invasion as independent prognostic factors for adverse outcomes in pancreatic body or tail cancer. CONCLUSION: Splenic vessel invasion was associated with higher recurrence and lower overall survival in pancreatic body or tail cancers suggesting a need for a neoadjuvant approach.

Cirsoid aneurysm rupture of the splenic artery as a rare cause of fatal hemoperitoneum.

Cirsoid aneurysms are rare arteriovenous malformations without any capillaries interposed and almost always observed in the scalp region. These types of aneurysms are so-called "cirsoid" because of their serpiginous appearance. In this report, the authors present the first case of a lethal spontaneous rupture of a cirsoid aneurysm of the splenic artery, which could be diagnosed only by post-mortem histologic examination. The victim was a 70-year-old man who was suddenly found dead in bed while he was hospitalized and waiting for a scheduled cardiac surgery. A forensic autopsy was ordered due to the suspicion that the man's death could have been related to medical malpractice. An accurate autopsy and a complete forensic histologic examination could clarify the cause of death, which was identified in the spontaneous rupture of a cirsoid aneurysm of the splenic artery. The case is intended to be used as source data for similar forensic cases, where the cause of a massive hemoperitoneum is difficult to be identified.

Vascular Remodeling and Immune Cell Infiltration in Splenic Artery Aneurysms.

Rupture of splenic artery aneurysms (SAAs) is associated with a high mortality rate. The aim of this study was to identify the features of SAAs. Tissue sections from SAAs were compared to nonaneurysmal splenic arteries using various stains. The presence of intraluminal thrombus (ILT), vascular smooth muscle cells (VSMCs), cluster of differentiation (CD)-68+ phagocytes, myeloperoxidase+ neutrophils, CD3+, and CD20+ adaptive immune cells were studied using immunofluorescence microscopy. Analysis of SAAs revealed the presence of atherosclerotic lesions, calcifications, and ILT. Splenic artery aneurysms were characterized by a profound vascular remodeling with a dramatic loss of VSMCs, elastin degradation, adventitial fibrosis associated with enhanced apoptosis, and increased matrix metalloproteinase 9 expression. We observed an infiltration of immune cells comprising macrophages, neutrophils, T, and B cells. The T and B cells were found in the adventitial layer of SAAs, but their organization into tertiary lymphoid organs was halted. We failed to detect germinal centers even in the most organized T/B cell follicles and these lymphoid clusters lacked lymphoid stromal cells. This detailed histopathological characterization of the vascular remodeling during SAA showed that lymphoid neogenesis was incomplete, suggesting that critical mediators of their development must be missing.

Anomalous Course of Accessory Splenic Arteries in Gastrosplenic Ligament: Case Report and Clinico-Embryological Basis.

Accessory splenic arteries in the gastrosplenic ligament constitute one of the extremely sub-component of abdominal vasculature variations and it is imperative to recognize this anomaly while planning for complex surgeries in the supra-colic compartment. We report the case of accessory splenic arteries in an approximately 50-year-old male cadaver encountered during routine educational dissection. One of them arising from left gastroepiploic artery supplies the spleen in addition to splenic artery. Another variant vessel bifurcated to enter greater omentum and anterior pole of spleen, as discrete branches. The anatomical vascular variation, if recognized during the imaging work-ups for elective surgical procedures could avoid potential iatrogenic blood loss.

Modern management of splenomegaly in patients with myelofibrosis.

Myelofibrosis (MF) is a chronic myeloproliferative neoplasm which can lead to massive splenomegaly secondary to extramedullary hematopoiesis. Patients frequently exhibit debilitating symptoms including pain and early satiety, in addition to cellular sequestration causing severe cytopenias. JAK 1/2 inhibitors, such as ruxolitinib and fedratinib, are the mainstay of therapy and produce significant and durable reductions in spleen volume. However, many patients are not eligible for JAK 2 inhibitor therapy or become refractory to treatment over time. Novel therapies are in development that can reduce the degree of splenomegaly for some of these patients. However, splenectomy, splenic irradiation, and partial splenic artery embolization remain valuable therapeutic options in select patients. In this review, we will discuss currently available pharmacologic therapies and describe promising drugs currently in development. We will also delve into the efficacy and safety concerns of splenectomy, splenic irradiation, and partial splenic artery embolization. Finally, we will propose a treatment algorithm to help guide clinicians in the management of symptomatic splenomegaly in patients with MF.

Intermittent Splenic Artery Occlusion Plus Gauze Compression Is a Simple and Effective Treatment for Iatrogenic Splenic Injury.

BACKGROUND The aim of this study was to evaluate the feasibility and safety of intermittent splenic artery occlusion plus gauze compression in treating iatrogenic splenic injury. MATERIAL AND METHODS We retrospectively analyzed 12 iatrogenic splenic injury cases (grade I to III) treated with intermittent splenic artery occlusion plus gauze compression. The hemostatic effect was then observed after unblocking and decompression. The total operation time, gauze compression time, total blood loss, blood loss from the injured spleen, and platelet counts of each patient before and 1 week after surgery were noted. RESULTS The average operation time was 209.58±57.11 min, and the average gauze compression time after spleen artery occlusion was 23.75±4.33 min. The average total blood loss and blood loss due to iatrogenic spleen injury were 468.33±138.22 ml and 264.17±165.72 ml, respectively. Two cases (both grade I) had successful hemostasis after 15 min of splenic artery occlusion and wound compression. Another 9 cases (all grade II) and 1 case (grade III) attained hemostasis after 25 min and 30 min, respectively, of splenic artery occlusion and wound compression. The platelet counts of all patients were within the normal range before and 1 week after surgery. No postoperative complications occurred. CONCLUSIONS Intermittent splenic artery occlusion plus gauze compression is a simple and effective treatment for iatrogenic splenic injury.

Higher prevalence of splenic artery aneurysms in hereditary hemorrhagic telangiectasia: Vascular implications and risk factors.

BACKGROUND: Splenic artery aneurysm (SAA) is a rare but potentially fatal condition. Rupture results in 25% mortality up to 75% in pregnant women with 95% fetal mortality. Brief reports suggest an increased risk of developing SAA in patients with HHT. METHODS: We analyzed enhanced multidetector CT data in 186 HHT patients matched (gender and ± 5 year old) with 186 controls. We screened for SAA and recorded diameter of splenic and hepatic arteries and hepatic, pancreatic and splenic parenchymal involvements. We determined by univariate and multivariate analysis, the relationship with age, sex, genetic status, cardiovascular risk factors (CVRF) and visceral involvement. RESULTS: SAA concerned 24.7% of HHT patients and 5.4% of controls, p<0.001. Factors associated with increased risk of SAA in HHT were female gender (p = 0.04, OR = 2.12, IC 95% = 1.03-4.50), age (p = 0.0003, OR = 1.04, 95% CI = 1.02-1.06) and pancreatic parenchymal involvement (p = 0.04, OR = 2.13, 95% CI = 1.01-4.49), but not type of mutation, hepatic or splenic parenchymal involvements, splenic size or splenic artery diameter or CVRF. CONCLUSIONS: We found a 4.57 higher rate of SAA in HHT patients without evidence of splenic high output related disease or increased CVRF. These results suggest the presence of a vascular intrinsic involvement. It should lead to screening all HHT patients for SAA. The vasculopathy hypothesis could require a change in management as screening of all systemic arteries and even the aorta and to further research in the field.