Totally laparoscopic spleen-preserving splenic hilum lymph nodes dissection in radical total gastrectomy: an omnibearing method.

OBJECTIVE: To investigate the feasibility and safety of laparoscopic spleen-preserving splenic hilum lymph nodes (LNs) dissection for advanced proximal gastric cancer using an omnibearing method. METHODS: Between August 2013 and December 2014, 16 patients with advanced proximal gastric cancer treated in Guangdong Province Hospital of Chinese Medicine, were enrolled and subsequently underwent laparoscopic radical total gastrectomy (TG) with spleen-preserving splenic hilum LNs dissection. During dissecting Nos. 10 and 11 LNs, we divided them into two parts, namely LNs anterosuperior and posterior to the splenic vessel. The clinicopathological characteristics, intraoperative outcomes and postoperative courses were retrospectively collected and analyzed in the study. RESULTS: Laparoscopic surgery was successfully completed in all 16 patients without conversion to open surgery, and no perioperative death occurred. The mean operating time was 328.75 ± 46.96 min, and the mean estimated blood loss was 135.63 ± 62.07 ml. One patient experienced intraoperative bleeding due to the splenic vein injury which was successfully handled with laparoscopic vessel suturing, and one postoperative pulmonary infection was recorded. The mean time to first flatus was 3.56 ± 1.03 days with a mean 9.63 ± 1.50 days of postoperative hospital stay. The mean number of retrieved LNs was 28.31 ± 5.99, in which LNs anterosuperior to splenic artery was 2.88 ± 2.66 and LNs posterior was 1.38 ± 1.75. CONCLUSION: Laparoscopic TG with spleen-preserving splenic hilum LNs dissection using an omnibearing method for advanced proximal gastric cancer was safe and technically feasible in experienced hands. Further studies in terms of its clinical significance are needed.

Two anatomical pathways for retroperitoneoscopic pancreatectomy: indications for the posterior and lateral approaches.

BACKGROUND: Retroperitoneoscopic pancreatectomy (RP) is a novel surgical procedure that is safe and feasible in animal models and clinical practice. However, the optimal approach for RP has not been established. OBJECTIVE: This study aimed to introduce the posterior and lateral approaches for RP. METHODS: This prospective study included 19 patients with suspected pancreatic lesions who underwent RP. RP was performed using either a posterior or a lateral approach. RESULTS: The posterior, lateral, and jointed approaches were used in 13 (68.4 %), 3 (15.8 %), and 3 (15.8 %) cases, respectively. Patients underwent enucleation (N = 8), distal pancreatectomy (N = 4), and resection of cystic pancreatic lesions (N = 2) and non-pancreatic lesions (N = 5). All retroperitoneoscopic procedures were successfully accomplished with no conversion to open or laparoscopic surgery. Intraoperative complications occurred in two (12.5 %) cases, including one case with injury to the peritoneum and one case with injury to the peritoneum and splenic vein. Postoperative grade A pancreatic fistulas occurred in six cases, and were cured by delayed drainage. No disease recurrence or abnormal symptoms were observed during the mean follow-up period of 14.06 ± 9.60 months. CONCLUSIONS: RP using the posterior or lateral approach is feasible and effective, but has different indications. The posterior approach is useful for distal pancreatectomy, as well as resection of pancreatic lesions in the posterior or superoposterior region of the distal pancreas. The lateral approach is useful for resection of pancreatic lesions in the anterior or inferior region of the body and tail. The two approaches can be used in combination or conversion.

Splenic arteriovenous fistula: successful treatment with an Amplatz occlusion device.

Splenic artery and vein aneurysm with splenic arteriovenous fistula (SAVF) is a rare entity. We report the case of a 72-year-old woman who presented with signs and symptoms of portal hypertension after a laparoscopic Nissen fundoplication. The diagnosis of a 37-mm SAVF was confirmed by a computed tomographic angiogram. The arteriovenous fistula was successfully treated with placement of a 20-mm Amplatz occlusion device. Surgical ligation and percutaneous embolization have been reported to be equally successful in managing SAVF. We present a review of the literature and report on a novel approach to this rare and challenging diagnosis.

Pancreatic transection from blunt trauma associated with vascular and biliary lesions: a case report.

Major injuries of the pancreas may result in considerable morbidity and mortality when associated with vascular and visceral injuries. In such cases, a right diagnosis and a prompt surgical intervention are necessary to give a chance to the patient. We herein describe a case of blunt abdominal trauma in a 29-year-old man whose pancreatic rupture was associated with hepatic artery, splenic vein and extrahepatic bile duct damage. Immediate surgery was performed after computer tomograghy (CT), the haemorrhagic lesions dictat the emergency transfer to the operating room. Spleno-pancreatic resection was done with reconstruction of the hepatic artery, ligation of the splenic vein and a Roux-en-Y bilio-jejunal diversion. The early post-operative course was complicated by stenosis of the arterial reconstruction, which was treated by endovascular angioplasty followed by percutaneous drainage of symptomatic pseudocyst, rest and antibiotics. Finally, the patient was discharged and was alive without clinical problems at the time when we wrote this case report. The present case underlines the clinical relevance of vascular and visceral injuries associated with pancreatic trauma and the problems arising in the diagnostic evaluation and the surgical strategy of complex multiple visceral and vascular lesions in blunt abdominal trauma.

Comparison of MDCT protocols in trauma patients with suspected splenic injury: superior results with protocol that includes arterial and portal venous phase imaging.

PURPOSE: We aimed to determine which intravenous contrast-enhanced multidetector computed tomography (MDCT) protocol produced the most accurate results for the detection of splenic vascular injury in hemodynamically stable patients who had sustained blunt abdominal trauma. METHODS: We retrospectively reviewed 88 patients from 2003 to 2011 who sustained blunt splenic trauma and underwent contrast-enhanced MDCT and subsequent angiography. Results of MDCT scans utilizing single phase (portal venous only, n=8), dual phase (arterial + portal venous or portal venous + delayed, n=42), or triple phase (arterial + portal venous + delayed, n=38) were compared with results of subsequent splenic angiograms for the detection of splenic vascular injury. RESULTS: Dual phase imaging was more sensitive and accurate than single phase imaging (P = 0.016 and P = 0.029, respectively). When the subsets of dual phase imaging were compared, arterial + portal venous phase imaging was more sensitive and accurate than portal venous + delayed phase imaging (P = 0.005 and P = 0.002, respectively). Triple phase imaging was more accurate (P = 0.015) than dual phase; however, when compared with the dual phase subset of arterial + portal venous, there was no statistical difference in either sensitivity or accuracy. CONCLUSION: Our results support the use of dual phase contrast-enhanced MDCT, which includes the arterial phase, in patients with suspected splenic injury and question the utility of obtaining a delayed sequence.

Laparoscopic resection of splenic artery aneurysms.

BACKGROUND: Laparoscopic techniques used to manage asymptomatic splenic artery aneurysms have been reported infrequently. METHODS: A laparoscopic splenic artery aneurysm resection was attempted for six consecutive patients. RESULTS: One patient underwent conversion to laparotomy because of a tear in the splenic vein. Among the five successful laparoscopic splenic artery aneurysm resections, the mean estimated blood loss was 37 +/- 12.6 ml, the mean operative time was 187.6 +/- 79.2 min, and the mean postoperative length of hospital stay was 1.8 +/- 1.3 days. The mean time to a clear liquid diet was 5.3 +/- 0.5 h, and the mean time to a regular diet was 1 +/- 0 day. The mean duration of narcotic analgesic use was 5.4 +/- 1.5 days, and the mean time to resumption of regular activities was 12.7 +/- 1.6 days. CONCLUSIONS: These cases illustrate the benefit of a laparoscopic approach with brief hospitalizations, early resumption of diet and regular activity, and minimal use of postoperative narcotic analgesics.

Endovascular treatment of post-laparoscopic pancreatectomy splenic arteriovenous fistula with splenic vein aneurysm.

Splenic arteriovenous fistulas (SAVFs) with splenic vein aneurysms are extremely rare entities. There have been no prior reports of SAVFs developing after laparoscopic pancreatectomy. Here, we report the first case. A 40-year-old man underwent a laparoscopic, spleen-preserving, distal pancreatectomy for an endocrine neoplasm of the pancreatic tail. Three months after surgery, a computed tomography (CT) scan demonstrated an SAVF with a dilated splenic vein. The SAVF, together with the splenic vein aneurysm, was successfully treated using percutaneous transarterial coil embolization of the splenic artery, including the SAVF and drainage vein. After the endovascular treatment, the patient's recovery was uneventful. He was discharged on postoperative day 6 and continues to be well 3 mo after discharge. An abdominal CT scan performed at his 3-mo follow-up demonstrated complete thrombosis of the splenic vein aneurysm, which had decreased to a 40 mm diameter. This is the first reported case of SAVF following a laparoscopic pancreatectomy and demonstrates the usefulness of endovascular treatment for this type of complication.

Vascular injuries during pancreatobiliary surgery.

Fourteen cases of vascular injury during pancreatobiliary surgery have been treated at our institution. The patients' mean age was 49 years, and nine were males. Six operations were performed for chronic pancreatitis, six for cancer, and two for an inflammatory process. Operations included 11 pancreatic resections and one laparoscopic cholecystectomy, one sphincteroplasty, and one pseudocyst drainage. Vessels injured included the portal vein (7), superior mesenteric vein (6), superior mesenteric artery (3), hepatic arteries (4), splenic vein (3). Six patients experienced more than one vascular injury. In all but one case, the injury was recognized and repaired during the initial operation. Primary repair was possible in seven cases. Six cases utilized autogenous tissue for repair. The one unrecognized injury was a right hepatic artery ligation, and a delayed repair was not possible. Follow-up demonstrated two occlusions, one following a portal vein repair without clinical sequela and a superior mesenteric artery repair which resulted in a small bowel stricture. The one unrecognized hepatic artery injury resulted in necrosis of the proximal common hepatic duct. Vascular injury following pancreatobiliary injury tends to occur in the presence of pancreatitis or cancer with its associated dense adhesions and inflammatory process. The variable anatomy of this area contributes to vascular injuries. Immediate recognition of the injury and repair appears to yield excellent results.

Fatal retroperitoneal haemorrhage: an unusual complication of percutaneous endoscopic gastrostomy.

A 93-year-old lady with dementia, neurological dysphagia and aspiration pneumonia, died from massive retroperitoneal haemorrhage which developed as a rare and, it is believed, hitherto unreported, complication of percutaneous endoscopic gastrostomy (PEG), which was performed for feeding purposes. It is postulated that the initial, unsuccessful attempt at needle puncture of the stomach, under endoscopic guidance, had resulted in iatrogenic perforation and laceration of the splenic and superior mesenteric veins close to their confluence with the portal vein. It would also appear that dense fibrous adhesions between the pyloro-antral region of the stomach and the posterior hepatic surface had altered the immediate anatomical relations of the stomach in such a manner as to have predisposed to these events.

Aneurysmatic arteriovenous fistula complicating splenic injury.

A child with a posttraumatic aneurysmatic arteriovenous (AV) fistula located in the spleen is presented. The fact that the increased use of more conservative diagnostic and therapeutic approaches in splenic injuries might lead to underestimation of some uncommon complications is discussed.

[Post-traumatic arteriovenous fistula between splenic artery and vein as a rare cause of acute myocardial ischemia]. / Posttraumatische arteriovenöse Fistel zwischen Arteria und Vena lienalis als seltene Ursache akuter Myokardischämie.

Arteriovenous fistulas of the portal system are rare. Congenital fistulas have to be differentiated from acquired fistulas; the latter are of posttraumatic or iatrogenic origin. The case presented demonstrates a history of diffuse abdominal pain and the first description of myocardial ischemia caused by a posttraumatic splenic arterioportal fistula. After diagnostic and therapeutic difficulties, the definitive treatment consisted in resection of the fistula system including the pancreatic tail.

Posttraumatic intrapancreatic aortosplenic fistula causing portal hypertension.

Arterioportal fistulas are uncommon. The case of a patient with massive uncontrollable esophageal variceal bleeding is presented. Reversible portal hypertension was caused by a posttraumatic giant intrapancreatic aortosplenic fistula. Percutaneous closure was unsuccessful, and pancreatectomy was performed to control the bleeding. The case is discussed and the literature on this exceptional cause of portal hypertension is reviewed.

A case report of acute gastric volvulus with avulsion of the splenic vessels.

Gastric volvulus is a rare condition which usually presents with intermittent abdominal pain. It is typically associated with a paraoesophageal hiatus hernia and may present with acute strangulation or perforation. The mortality associated with an acutely obstructed volvulus may be up to 50%. Correspondingly, this condition is regarded as a surgical emergency. We present the history of a patient with an acute gastric volvulus and unexplained hypotension.

Traumatic complex splenic arteriovenous fistula causing prehepatic portal hypertension and variceal bleeding: the importance of the diagnosis for the endovascular treatment approach.

We report a case of a 68-year-old female patient presenting with portal hypertension and variceal bleeding in the absence of any liver disease. After performing a computed tomography angiogram, the cause of her condition was identified to be a splenic arteriovenous fistula (SAVF). After confirming the findings with angiography, we opted to treat the condition with coil embolization as an alternative to a more invasive surgical treatment. Coil embolization of the SAVF was performed successfully resulting in the improvement of the patient's variceal congestion. Our case highlights the importance of identifying SAVF as a potentially curable cause of variceal bleeding in the absence of liver disease. Seeking this diagnosis is of utmost importance since it completely changes the endovascular approach and management of these patients with variceal bleeding. We describe a minimally invasive endovascular technique for treatment of these critically ill patients.

Percutaneous transhepatic and transsplenic portal vein access: embolization of the puncture tract using amplatzer vascular plugs.

PURPOSE: To report on first results of the embolization of transhepatic and transsplenic puncture tracts using an Amplatzer Vascular Plug (AVP) after percutaneous portal vein intervention. MATERIALS AND METHODS: Embolization of transhepatic and transsplenic puncture tracts with AVP was attempted in 5 patients (3 females; age range: 3 - 71 years). Portal vein access was gained by a transhepatic (n = 4) or transsplenic (n = 1) approach, and stenosis (n = 2) or thrombosis (n = 3) of the portal vein was successfully treated by percutaneous stenting or thrombus aspiration and thrombolysis using 6 to 10 French sheaths. Due to the relatively large bore and/or short transparenchymal puncture tracts, it was considered favorable to use AVPs as an embolic agent. The medical records, the radiological reports and images of these 5 patients were retrospectively evaluated. RESULT: In three cases one AVP II (diameter, 4 mm), in one case one AVP IV (diameter, 4 mm) and in one case two AVPs II (diameter, 8 and 6 mm) were used for embolization of the puncture tract. In all five cases embolization was technically successful. There was no bleeding from the puncture tract. During a median follow-up of 14 months (range, 21 days to 21 months), one patient developed a focal liver abscess adjacent to the AVP which was successfully treated by antimicrobial and drainage therapy. There were no further embolization-related complications. CONCLUSION: AVPs are suited to embolize large bore and/or short transhepatic and transsplenic puncture tracts effectively, safely, and precisely. Caution is required in patients with an increased risk for infectious complications. KEY POINTS: • Embolization of transhepatic and transsplenic puncture tracts with AVPs is feasible• Large and/or short puncture tracts can be effectively embolized with AVPs• The risk of infectious complications has to be considered Citation Format: • Dollinger M, Goessmann H, Mueller-Wille R et al. Percutaneous Transhepatic and Transsplenic Portal Vein Access: Embolization of the Puncture Tract Using Amplatzer Vascular Plugs. Fortschr Röntgenstr 2014; 186: 142 - 150.

[Haemorrhagic shock after severe abdominal trauma in children: knowing when to change from conservative to surgical management]. / Choc hémorragique après traumatisme abdominal grave chez l'enfant : savoir opter pour l'attitude interventionnelle chirurgicale.

Abdominal vascular injuries following a serious falling out are quite rare in children. They can lead to haemorrhagic shock whose etiological diagnosis may be difficult in children in case of multiple trauma. The current management of abdominal injuries in the child is usually conservative, surgery being indicated in haemodynamically unstable patients. We report the case of a 7-year-old girl who presented with abdominal trauma with rupture of the hepatic artery and shredding of the splenic vein following a falling out of 10 meters. Aggressive resuscitation associated with early laparotomy for haemostasis, contrary to usual practices advocated in such a context, have helped control the hemorrhagic shock and stabilize the haemodynamic status of the child. The subsequent evolution was favourable, with full recovery. While a conservative attitude usually prevails in the management of traumatic intra abdominal bleeding in children an interventional attitude with emergency surgery must be sometimes considered.