Superior Pancreaticoduodenal Research Articles

Understanding Vascular Anatomy is Key to Successful Endovascular Treatment of Pancreaticoduodenal Artery Aneurysms.

Pancreaticoduodenal artery aneurysm (PDAA) is a rare disease without treatment guidelines. We present two patients with PDAA. The first patient was a 70-year-old man with a pseudoaneurysm in the anterior superior pancreaticoduodenal artery (ASPDA), for which we achieved exclusion by endovascular coil embolization. The second patient was a 63-year-old woman with a PDAA in the ASPDA with celiac axis obstruction. Endovascular coil embolization of the aneurysm and the ASPDA was successful without visceral organ ischemia. Endovascular treatment is effective for PDAAs, but careful evaluation of collateral circulation is vital in PDAAs with celiac axis obstruction.

Spontaneous rupture of the pancreatic arcade artery caused by neurofibromatosis type 1 successfully treated using emergency transcatheter arterial embolization, partial intra-aortic balloon occlusion, and stent graft placement: a case report and review of the literature

BackgroundVascular abnormalities in neurofibromatosis type 1 (NF1) are rare, but are the second leading cause of death in persons with NF1. In NF1 vasculopathy (NF-V), fatal bleeding due to a spontaneous arterial rupture sometimes occurs. Ruptured extracranial arteries in patients with NF1 often involve thoracic vessels, such as the intercostal and subclavian arteries; very few reports exist regarding the abdominal region. Herein, we present the first case of intraperitoneal bleeding due to spontaneous pancreatic arcade artery (PAA) rupture associated with NF1, successfully treated by transcatheter arterial embolization (TAE) combined with stent-graft placement and partial intra-aortic balloon occlusion (IABO).Case presentationA 40-year-old woman complained of back and abdominal pain. Upon admission, her blood pressure was 85/41 mmHg and heart rate was 129 beats/min. Computed tomography (CT) showed large intraperitoneal bleeding due to PAA rupture. After CT scanning, her systolic blood pressure decreased to 50 mmHg. Therefore, we performed emergency TAE with partial IABO. She was treated by TAE of the anterior superior pancreaticoduodenal artery, anterior inferior pancreaticoduodenal artery, and inferior pancreaticoduodenal artery. However, even after TAE, minor extravasation around the superior mesenteric artery continued, and her vital signs remained unstable. Stent-graft placement was selected to stop the haemorrhage, preserving normal blood flow of the superior mesenteric artery trunk. Excellent patency of the stent graft was confirmed on follow-up CT, and she was discharged on postoperative day 56.ConclusionPAA rupture associated with NF1 can be successfully treated by TAE combined with partial intra-aortic balloon occlusion, and stent-graft placement.

Gastric remnant necrosis secondary to cholesterol crystal embolization after distal gastrectomy in a gastric cancer patient: a case report

BackgroundDistal gastrectomy with lymph node dissection, a standard operative technique for gastric cancer treatment, is safely performed because the stomach has a rich vascular supply. Gastric remnant necrosis caused by cholesterol crystal embolization following distal gastrectomy has not been described previously. We report a case of gastric remnant necrosis in a patient with cholesterol crystal embolization.Case presentationA 70-year-old man with a history of cholesterol crystal embolization presented to our surgery department with complaints of anorexia and dysphasia. He was diagnosed with gastric cancer invading the pyloric antrum and underwent distal gastrectomy with Billroth 2 reconstruction. On postoperative day 11, he developed abdominal pain without fever. Emergency laparotomy revealed that most parts of the remnant stomach were necrosed. Total gastrectomy with Roux-en-Y reconstruction and abscess drainage were performed. After surgery, anastomotic leakage occurred and was treated conservatively. However, the superior pancreaticoduodenal artery aneurysm suddenly ruptured and he expired.ConclusionsGastric remnant necrosis after distal gastrectomy can be a gastrointestinal presentation of cholesterol crystal embolization. Perioperative/intraoperative risk assessments such as preventive total gastrectomy or intraoperative assessment with indocyanine green fluorescence angiography may be desirable to avoid this complication.

Ruptured visceral artery aneurysms in a patient of neurofibromatosis type 1 (NF-1) successfully treated by endovascular treatment

BackgroundNeurofibromatosis type 1 (NF-1) is an autosomal dominant disease and arteriovenous abnormalities are a well-recognized complication. There are several case reports of ruptured aneurysms; however, among them, reports of superior pancreaticoduodenal artery (PDA) and superior mesenteric artery (SMA) aneurysms are rare. We experienced the case of ruptured PDA and SMA aneurysms in a patient of neurofibromatosis type I successfully treated by endovascular treatment.Case presentationA 55-year-old woman with NF-1 came to our hospital with abdominal pain and vomiting. Enhanced abdominal computed tomography revealed a hematoma in the retroperitoneum and an aneurysm in the head of the pancreas. Angiography was performed, and a ruptured aneurysm was suspected the periphery of the PDA, and we embolized it using coils. However, on postoperative day 2, the hemoglobin level decreased, and a branch of the SMA was ruptured. She underwent embolization using coils again and discharged on postoperative day 27 without any further hemorrhage.ConclusionsTo our knowledge, this is the first successfully treated case of ruptured SMA and PDA aneurysms in a patient with NF-1.

A case of duodenal duplication cyst mimicking a pancreatic pseudocyst with intracystic hemorrhage

BackgroundDuodenal duplication cysts in adults are rare, and a preoperative diagnosis remains difficult because clinical manifestations are nonspecific and variable. We describe a case of a duodenal duplication cyst mimicking a pancreatic pseudocyst with repeated intracystic hemorrhage.Case presentationA 47-year-old male who complained of upper abdominal pain and vomiting was referred to our hospital. He was a heavy drinker and had a past history of hospitalization for alcoholic chronic pancreatitis. Plain abdominal computed tomography (CT) showed a cystic lesion of 7 cm in size in the lumen near the second part of the duodenum. The cystic lesion showed high density inside. Gastrointestinal endoscopy revealed that the lumen of the duodenum was deformed by a submucosal tumor-like mass and the endoscope could not pass through it, but active bleeding was not seen in the lumen of the duodenum. On the fourth day of hospitalization, anemia progressed and contrast-enhanced CT demonstrated a high-density spot on the wall of the cystic lesion. A pancreatic pseudocyst complicated with intracystic hemorrhage was preliminarily considered. Angiography was immediately performed, and a pseudoaneurysm was identified in the branch of the anterior superior pancreaticoduodenal artery (ASPDA). Transcatheter arterial embolization (TAE) was performed. Anemia did not progress after that, and follow-up CT showed reduction in the size of the cystic lesion. Afterward, the same symptoms recurred twice and surgical treatment was performed for the pancreatic pseudocyst with repeated intracystic hemorrhage. Macroscopically, a cystic mass of 5 cm in size was adjacent to the second part of the duodenum on the pancreas side. A pinhole-sized communication was identified between the cyst and the duodenum lumen. Microscopically, the cyst wall was composed of gastric mucosa and shared a common proper muscle layer with the duodenum. Chronic ulcers and erosions were seen in the cyst. Based on these findings, a diagnosis of duodenal duplication cyst was made.ConclusionsDuodenal duplication cysts in adults have seldom been reported and should be considered as a differential diagnosis for a patient with a cystic lesion adjoining the duodenum.

MDCT with three-dimensional fusion images in the preoperative evaluation of pancreaticoduodenectomy

Objective To study the role of MDCT with 3D fusion images in the preoperative evaluation of pancreaticoduodenectomy. Methods 37 patients who underwent pancreaticoduodenectomy from March 2016 to May 2018 in the Affiliated Wuxi No.2 People’s Hospital of Nanjing Medical University were included in this retrospective study. All patients underwent a dual-phase enhanced MDCT before operation. The volume data of enhanced MDCT were transmitted to a dedicated CT post-processing workstation. The 3D images, including the tumor, pancreas, portal vein system, arterial system, pancreatic and biliary tract, were reformatted respectively before the fusion imaging. Two reviewers analyzed the tumor location and its spatial relations with the pancreaticobiliary system, peripancreatic vessels and vascular variations by means of zooming, rotating, splitting and transparent displaying on fusion images. Then, the assessed items were compared to the surgical and pathological findings. Results The 3D fusion images of 37 patients in this study depicted the tumor, pancreas, peripancreatic vessels and pancreatic and biliary tract clearly. Compared with the intraoperative and pathological findings, the accuracy of both tumor detection and localization with the 3D fusion images was 100%. To compare the intraoperative findings, visualization and variation detection of the celiac, splenic, common hepatic, gastroduodenal, hepatic, and superior mesenteric arteries, and the superior mesenteric and portal veins were all 100%. Visualizations of the anterior superior pancreaticoduodenal artery (ASPDA), posterior superior pancreaticoduodenal artery (PSPDA), inferior pancreaticoduodenal artery (IPA) and dorsal pancreatic artery (DPA) were 85.7%, 82.8%, 72.2% and 75.8%, respectively. Conclusion The MDCT 3D fusion imaging technology allowed one stop preoperative assessment of pancrea-ticoduodenectomy, especially in clearly outlining the tumor location and its spatial relations with the surrounding surgical anatomies before surgery. Key words: Pancreaticoduodenectomy; Multi-detector computed tomography; 3-dimensional reconstruction; Evaluation

Safety Profile and Efficacy of Chemoembolization with Doxorubicin - Loaded Polyethylene Glycol Microspheres in Patients with Hepatocellular Carcinoma.

AIM:This study was designed as a preliminary investigation of safety and efficacy of LifePearl, polyethylene glycol microspheres loaded with doxorubicin for treatment of locally untreatable (i.e., unresectable and not suitable for local thermal ablation) hepatocellular carcinoma (HCC).MATERIAL AND METHODS:Patients with locally untreatable HCC (mono- or bilobar disease, ECOG performance status 0-1, Chilg-Pugh score < 11) were analysed for this single arm Unicenter retrospective study. All the information were acquired through our local hospital information system. DEB-TACE was performed with 100-200 microns LifePearl loaded with 75-150 mg of doxorubicin depending on tumour size. One interventional radiologist with experience of more than 350 TACE procedures and one fellow in radiology performed all embolisations.RESULTS:Twenty subjects with 29 tumours were treated (mean age 66.2 years). Child-Pugh status was A for 12 pts. (60%), B for 6 pts. (30%) and C for 2 pts. (10%). Three patients had insignificant ascites. Most patients (70%) underwent < 3 DEB-TACE procedures. Average doxorubicin dose was 71.1 mg per procedure. One patient had procedure-related SAE (acute pancreatitis) within the postembolization period which was induced due to non-target embolisation of the superior pancreaticoduodenal artery. Six-month freedom from procedure-related SAE or death was 95% (one necrotizing pancreatitis). Tumor response or stable disease was achieved in 95% (19/20) of subjects. Freedom from tumor progression or death at 6 months was 95%. One-year survival rate was 90% overall.CONCLUSION:The results from this investigation suggest that LifePearl microspheres, Terumo loaded with doxorubicin can provide an excellent local tumour control with very few side effects in a relatively homogeneous group of patients with locally untreatable HCC.

Computed Tomography Arteriography for Detecting the Origin of the Inferior Pyloric Artery in Patients with Gastric Cancer.

To analyze the detection rate of the inferior pyloric artery (IPA) in patients with gastric cancer by computed tomography arteriography (CTA). Fifty-four patients (48 males and 6 females; mean age, 59.0 ± 1.5 years) who had undergone radical gastrectomy for gastric cancer from September 2016 to July 2017 at our institution were recruited prospectively. Patients underwent abdominal contrast-enhanced CT scans and CTA imaging reconstruction before the operation. The origin of the IPA in all cases was determined by a radiologist based on CTA images and verified by the surgeon. The accuracy of CTA in diagnosing the origin of the IPA was calculated. Dominant vessels of the origin were analyzed. IPAs were detected by CTA in 51 patients (94.4%). Among these, IPAs originated from the right gastroepiploic artery (RGEA) (24 cases), the gastroduodenal artery (GDA) (4 cases), and the anterior superior pancreaticoduodenal artery (ASPDA) (20 cases). In the remaining 3 cases, the IPAs contained two branches originating from the RGEA and ASPDA, respectively. During surgery, in 2 (3.7%) of the 54 cases of gastric cancer, IPAs could not be detected; the IPAs originated from the RGEA (22 cases), GDA (5 cases), and ASPDA (24 cases). One case had an IPA originating from both the RGEA and the GDA. Finally, the accuracy of CTA in diagnosing the origin artery of the IPA was 85.2% (46/54). CTA can detect the origin of the IPA accurately, which can aid surgeons while performing pylorus-preserving operations.

Value of the multi-slice spiral CT angiography, CT colonography and image fusion technology in preoperative evaluation of laparoscopic right colon cancer

Objective To observe the distribution and variation of right colonic vessels, and investigate the clinical value of computed tomography angiography (CTA), computed tomography colonography (CTC) and image fusion technology in preoperative evaluation of laparoscopic right colonic cancer (RCC). Methods The retrospective and descriptive study was conducted. The clinicopathological data of 38 patients who underwent laparoscopic extended radical resection of RCC + D3 lymphadenectomy in the Affiliated Wuxi Second People′s Hospital of Nanjing Medical University between January 2015 and July 2017 were collected. Patients received preoperative plain and enhanced scans of abdominal and pelvic CT. The original images were reconstructed and fused by CTA and CTC, and then coming out with three-dimensional images of blood vessels and gut. Observation indicators: (1) branches of superior mesenteric artery (SMA); (2) positional relationship between SMA and superior mesenteric vein (SMV); (3) composition of gastrocolic venous trunk. Results Scan images of 38 patients had fused with scan images of vessels and primary tumors and reached the diagnostic standard, with a good imaging performance. Distribution of blood vessels of virtual reality (VR) images and were compared with that of naked blood vessels under intraoperative laparoscopy, showing a coincidence rate of 100.0%(38/38). (1) Branches of SMA: results of CTA and intraoperative anatomy showed that the occurrence rate of the right colonic artery, middle colonic artery and ileocolic artery were respectively 94.7%(36/38), 92.1%(35/38) and 100.0%(38/38). A right colonic artery was found in 28 patients. Ten patients had structure variation of right colonic artery, including 3 with 2 right colonic arteries and 2 without right colonic artery. The right colonic artery and middle colonic artery merged into the same trunk and then flowed into SMA were detected in 2 patients; the right colonic artery and ileocolic artery merged into the same trunk and then flowed into SMA were detected in 3 patients. (2) Positional relationship between SMA and SMV: results of CTA and intraoperative anatomy showed that the occurrence rate of both SMA and SMV was 100.0%(38/38). The SMA in 20 patients was located in the ventral side of SMV; SMA in 18 patients was located in the dorsal side of SMV. (3) Composition of gastrocolic venous trunk: results of CTA and intraoperative anatomy showed that 29 of 38 patients had gastrocolic venous trunks, which belonged to four sources, including right colonic vein, middle colonic vein, right gastric epiploic vein and anterior superior pancreaticoduodenal vein. Among 29 patients, 18 had 2- or 3-branch type of gastrocolic trunk that consisted of the right gastric epiploic vein, middle colonic vein and right colonic vein; 3 had 2-branch type of gastric pancreatic trunk that consisted of the right gastric epiploic vein and anterior superior pancreaticoduodenal vein; 8 had 3- or 4-branch type of stomach-pancreas-colon trunk that consisted of right gastric epiploic vein, anterior superior pancreaticoduodenal vein, right colonic vein and middle colonic vein. Conclusion CTA, CTC and image fusion technology can intuitively show the anatomy and variation of right colonic vessels, with a high clinical value. Key words: Colonic neoplasms; Preoperative evaluation; Vascular reconstruction; Computed tomography angiography; Computed tomography colonography; Extend right hemicolectomy; Laparoscopy

Time-resolved magnetic resonance angiography as a follow-up method for visceral artery aneurysm treated with coil-embolisation.

PurposeThe purpose of this study is to assess the feasibility and usefulness of time-resolved magnetic resonance angiography (TR-MRA) for follow-up of visceral artery aneurysms (VAAs) after embolotherapy.Material and methodsTwenty-one VAAs (11 splenic, six renal, three internal iliac, and one superior pancreaticoduodenal artery aneurysms) in 18 patients (median age, 64 years; range, 36-88 years) previously treated by embolisation with platinum coils, were evaluated. The mean size of the aneurysm was 10.5 cm3 (range, 0.3-132 cm3). Among them, 19 lesions were treated by aneurysmal packing with or without distal-to-proximal embolisation. For the remaining two lesions, distal-to-proximal embolization alone was performed. The mean observation period after embolotherapy was 35 weeks (range, 4-216). All patients underwent TR-MRA following an intravenous bolus injection of gadolinium chelate. Recanalisation was diagnosed when any portion of the aneurysmal sac was enhanced in the arterial phase.ResultsOn TR-MRA, two lesions were diagnosed as recanalised. They were confirmed by transcatheter arteriography and re-treated by embolotherapy. For the remaining 19 lesions, there were no findings of recanalisation on TR-MRA.ConclusionsTR-MRA appears to be a feasible method for follow-up examination of VAAs treated by embolotherapy.

Virtual Reality to Teach Human Anatomy – An Interactive and Accessible Educational Tool

Virtual reality (VR) is a revolutionizing technology. Prior to 2016 VR systems were cost prohibitive, and user‐unfriendly. The Oculus Rift, first introduced in 2013, revolutionized the VR field by bringing forth the first commercialized VR system. In 2017, many affordable VR systems have been introduced into the commercial market, some costing less than a typical cellphone. The VR systems consist of a wearable headset, two controllers that allow the user to naturally interact with objects in the VR space, and lastly sensors connected to a computer allow for precise tracking of all head and hand movements.VR is a tool with endless possibilities, it can be implemented in any course as a teaching or supplementary resource. Within the VR space, users may play a PowerPoint presentation or a video, open a document, draw in 3D VR space any object. In VR, users can also host a live class; students may watch on their mobile devices, or enter the interactive VR space with their own system. Additionally, in VR, a user can change their environment to anything they desire, including access to any space, anywhere in the world with internet access. Therefore, bringing the laboratory to the student and the instructor. VR is the tool that can revolutionize the delivery of distance education material.The University of Guelph offers a comprehensive dissection‐based human anatomy course to approximately 400 third‐ and fourth‐year undergraduate students yearly. Additionally, in collaboration with Guelph Humber, a first‐year anatomy course is offered off‐site to 120 kinesiology students, with a laboratory component hosted weekly at the University of Guelph. In the fall of 2017, a strike affecting all colleges in Ontario limited the ability to deliver off‐site lectures for 5 weeks. During the strike, innovate ways of lecture delivery were successfully used to meet course objectives, including narrated PowerPoint presentations and virtual reality lessons.Various anatomical lessons were delivered online to students in various formats, addressing the thorax and abdominal regions. In week 3, students were sent a video (Abd1) demonstrating the blood supply of the abdomen (Celiac Trunk, SMA, IMA and all associated branches, relationships, and developmental concepts) (Fig. 1). A week later, students were sent another video, demonstrating the same lesson, however in VR format (AbdVR) (Fig. 2). Abd1 is 22.5 minutes in length, attained an average view duration of 4.05 min, a total view time of 280 min, and average view percentage of 18%. Whereas AbdVR is 20 minutes in length, attained an average view duration of 9.1 min, a total view time of 542 min, and an average view percentage of 45%. Abd1 audience retention decreased gradually throughout the video, whereas AbdVR performed with an above‐average retention rate, and had several large peaks of retention throughout, all corresponding to important concepts being shown, such as the visualization of anterior and posterior branches of the superior pancreaticoduodenal artery – a concept that would be difficult to show two‐dimensionally (Fig 3). Through an online survey, students indicated that VR videos allowed them a better understanding of the complex 3D nature of the human body.Concepts such as the blood anastomosis of the elbow became easier to understand and visualize. Students also appreciated having a “person” speak to them as opposed to a narrated video. Overall, VR educational videos performed exceptionally well in showcasing anatomical concepts with depth.This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Key vessels assessment and operation highlights in laparoscopic extended right hemicolectomy

Laparoscopic radical colectomies have been more widely used gradually, among which laparoscopic extended right hemicolectomy is considered as the most difficult procedure. The difficulty of extended right hemicolectomy lies in the need to dissect lymph nodes along the superior mesenteric vein (SMV) and disconnect numerous and possible aberrant vessels. To address this problem, we emphasize two points in key vessel assessment: getting familiar with the anatomy along the medial-to-lateral approach and having a good understanding about the preoperative imaging presentations. An accurately preoperative imaging assessment by abdominal enhanced CT can help the surgeon understand the relative position of the key vessels to be dealt with during operation and the situation of the possible aberrant vessels so as to guide the procedure more effectively and facilitate the prevention and management of the intraoperative complications. During operation, the operator should pay special attention to the management of the vessels in the ileocolic vessel region, Henle's trunk and middle colon vessels. The operation highlights of the key vessels are as follows: (1) The ileocolic vessels: identifying the Toldt's gap correctly and opening the vascular sheath of the SMV securely; making sure that the duodenum is well protected. (2) Henle's trunk: dissecting along the surface of the Henle's trunk; preserving the anterior superior pancreaticoduodenal vein (ASPDV) and main trunk of the Henle's trunk; disconnecting the roots of the right colic vein (RCV) and right gastroepiploic vein (RGEV), and then dissecting lymph nodes along the surface of the pancreas. (3) The middle colon vessels: identifying the root of the middle colon vessel along the lower edge of the pancreas; avoiding entering behind the pancreas; mobilizing the transverse mesocolon sufficiently along the surface of the pancreas. Finally, we discuss and analyze the disputes currently existing in laparoscopic extended right hemicolectomy, including dissection of No.6 lymph nodes, naking the SMA and dissecting lymph nodes around the roots of the branches of SMA. This article shares our experience about laparoscopic extended right hemicolectomy, hoping that it could help beginners master the technique more safely and skillfully.

Outermost layer-oriented medial approach for infrapyloric nodal dissection in laparoscopic distal gastrectomy.

Based on our experience of suprapancreatic nodal dissection in laparoscopic gastrectomy, we developed an outermost layer-oriented medial approach for infrapyloric nodal dissection. The objective of this single-institution retrospective study was to determine the feasibility, safety, and reproducibility of this novel and unique dissection procedure. This approach can be performed in the same manner as suprapancreatic nodal dissection but by replacing the left gastric artery with the right gastroepiploic artery (RGEA), the common hepatic artery with the anterior superior pancreaticoduodenal artery (ASPDA), and the splenic artery with the gastroduodenal artery. It comprises five steps: (1) mobilization of the transverse mesocolon along the prepancreatic membrane, (2) medial dissection along the dissectable layer between the pancreatic head and the dorsal side of the right gastroepiploic vein (RGEV), (3) division of the RGEV and determination of the lateral and cranial borders, (4) dissection along the outermost layer of the RGEA and ASPDA and transection of the infrapyloric artery and RGEA, and (5) transection of the duodenal bulb. This novel method was applied in 112 patients who underwent laparoscopic distal gastrectomy from 2014 to 2015. The anatomical landmarks that we determined to appropriately identify the outermost layer were highly reproducible, and our novel procedure based on these landmarks was successfully completed in all cases, without any intraoperative complications. Furthermore, in all cases, no. 6 lymph nodes were fully and adequately dissected within the infrapyloric area anatomically defined in the Japanese Classification of Gastric Carcinoma ver. 14. Pancreatic fistula occurred only in 1.8% cases. This novel outermost layer-oriented medial approach is a robust procedure that may help laparoscopic surgeons in performing safe and reproducible infrapyloric nodal dissection.

Case of laparoscopic right hemicolectomy for ascending colon cancer after aortic graft replacement and revascularization of the superior mesenteric artery

A 67-year-old man who presented with a bloody stool was diagnosed with ascending colon cancer. He had previously experienced thoracic and abdominal aortic dissections, which were treated with thoracic and abdominal aortic grafts and superior mesenteric artery revascularization. We performed a laparoscopic right hemicolectomy with a D3 lymph node dissection. During the laparotomy, we identified the superior mesenteric artery and an enlarged anterior superior pancreaticoduodenal artery. Injury to the latter artery could lead to severe ischemia in multiple organs; therefore, it was crucial to identify the primary feeding artery and vascular anatomy before and during surgery. We chose the laparoscopic right hemicolectomy to avoid injuring the anterior superior pancreaticoduodenal artery and the intra-abdominal abscess. This case study was the first to describe a laparoscopic hemicolectomy after thoracic and abdominal aortic grafts and superior mesenteric artery revascularization.

Anatomical variation of infra-pyloric artery origination: A prospective multicenter observational study (IPA-Origin).

ObjectiveInfra-pyloric artery (IPA) is an important anatomical landmark in treatment of gastric cancer and is the key vessel for pylorus-preserving gastrectomy and subgroup of infra-pyloric lymph nodes. However, its anatomical variation is not thoroughly understood. Our study aimed to clarify the origination of the IPA.MethodsWe did this prospective, multicenter, open-label, observational study at gastric surgery departments of 34 hospitals in China. Gastric cancer patients aged 18 years or older and scheduled to undergo elective total or distal gastrectomy were assigned. During the surgery, IPA dissecting and exposing the origination point with photographs or video clips were required. The primary outcome was the origination of the IPA. Analysis of variance, χ2 tests and Fisher’s tests were used to analyze the differences between groups. The study is registered at Clinicaltrials.gov (No. NCT03071237). ResultsBetween May 8 and July 31, 2017, 429 patients were assigned for the study, and 419 (97.7%) patients had the IPA dissected and recorded through photograph or video and were included in the primary outcome analysis. The median age was 62 years old, and 73.7% were male. Among the patients, 78.5% received laparoscopic surgery. Single IPA origination was identified in 398 (95.0%) patients, including gastroduodenal artery (GDA) in 154 (36.8%) patients, anterior superior pancreaticoduodenal artery (ASPDA) in 130 (31.0%) patients, and right gastroepiploic artery (RGEA) in 114 (27.2%) patients. Fifteen (3.6%) patients were identified with multiple IPA and 6 (1.4%) patients were identified as IPA absence. The differences in the distribution of surgical approach (P=0.003) and geographic area (P=0.030) were statistically significant. No difference was shown in sex, age, gastrectomy type, tumor location, and clinical T, N and M stage.ConclusionsOur study found that the IPA originates from GDA, ASPDA and RGEA in similar proportions. Laparoscopic surgery may be more helpful in dissection of the IPA than open surgery.

Hemosuccus Pancreaticus: A Potentially Life-threatening Cause of Gastrointestinal Bleeding

Hemosuccus pancreaticus (HP) is the least frequent cause of gastrointestinal bleeding (GIB) and even though HP is potentially life threating, it is rarely identified by endoscopy due to its intermittent bleeding and difficulty in obtaining adequate views of the ampulla. We report a case of HP identified by esophagogastroduodenoscopy (EGD) that was successfully treated with microcoil embolization. A 76 year old male with unknown medical history was admitted after being found unresponsive. On initial presentation the patient's vital signs were stable and he was severely anemic with a hemoglobin of 4.5 gm/dl, stools were brown and guaiac positive. CT abdomen was pertinent for chronic calcific pancreatitis with a 2x0.8cm pseudoaneurysm within the body of the pancreas and large stool burden. After transfusion of 3 units of packed red blood cells the patient continued to have worsening of his anemia. EGD was performed and positive for active bleeding coming from the ampulla. Interventional radiology identified the large bleeding pseudoaneurysm at the junction of the dorsal pancreatic and superior pancreaticoduodenal arteries on arteriogram and the patient was treated with microcoil embolization of the transverse pancreatic artery, dorsal pancreatic artery and superior pancreaticoduodenal arteries. HP is defined as bleeding from the pancreas or surrounding structures into the pancreatic duct and ampulla of Vater and occurs approximately once for every 1,500 cases of GIB. HP most commonly occurs from chronic pancreatitis, pancreatic tumors or bleeding of a pseudoaneurysm usually from the splenic artery but approximately 15% will bleed from the pancreaticduodenal artery, as in our case. Due to its location, intermittent bleeding and overall rarity, HP is difficult to identify by endoscopy and must be diagnosed with angiography and treated with surgery or angiographic embolization. Due to the life threating potential of HP, one most thoroughly investigate the ampulla for signs of bleeding and consider HP in the differential diagnosis to allow for early radiologic diagnosis and treatment.Figure: Bleeding from the Ampulla of Vater (Black arrow).

Recombinant human adenovirus-p53 improves the outcome of mid-late stage pancreatic cancer via arterial infusion.

The present study aimed to investigate the therapeutic efficacy and clinical value of recombinant human adenovirus-p53 (rAd-p53) perfusion via the pancreatic artery for the treatment of mid-late stage pancreatic cancer. rAd-p53 (2×1012 virus particles) in 6 ml normal saline was pushed (intravenous bolus) into the gastroduodenal and superior pancreaticoduodenal arteries via interventional superselection, with the catheter retained for subsequent drug administration at a 3-day interval for 4 cycles. Tumor changes in all patients were observed to evaluate tumor response by computed tomography (CT) at 2, 8 and 16 weeks post-treatment. The following improvements were noted in the 23-patient cohort: A total of 73.9% (17/23) of patients demonstrated significant tumor shrinkage (>20%); the symptoms of abdominal and back pain were relieved in 15 patients; the survival time was >12 months in 1 patient and >6 months in 14 patients; the patient's general condition, including appetite, was improved in 13 patients; body weight was increased in 9 patients; jaundice was attenuated in 12 patients; and ascites subsided in 10 patients. However, the therapeutic outcome was poor in 2 patients whose tumors size did not show significant change after treatment as detected by CT. These 2 patients succumbed within 6 months. In conclusion, rAd-p53 perfusion via the pancreatic artery is a safe and minimally invasive option for the treatment of mid-late stage pancreatic cancer.

Novel mouse models of hepatic artery infusion

BackgroundThe liver has unique anatomy in that most blood flow to normal hepatocytes is derived from the portal venous system, whereas liver tumors obtain their nutrient blood supply exclusively from the hepatic artery. The focused arterial delivery of anticancer agents to liver tumors has been performed for decades; however, preclinical models to standardize drug regimens and examine novel agents have been lacking. The purpose of this study was to establish preclinical hepatic artery infusion (HAI) models in a mouse and to evaluate the safety and delivery capability of the models. Material and methodsC57BL/6 and BALB/c mice were used to develop models of HAI via the hepatic artery (HA), superior pancreaticoduodenal artery (SPDA), or lienogastric artery (LGA). Success rates, distribution of perfusion, and associated morbidity and mortality were analyzed between groups. ResultsAll three models were feasible and reproducible in mice, and there was no statistical difference on body weight change between models. The HA model had a 13.3% mortality from acute liver failure, and the SPDA model demonstrated duodenal and pancreatic toxicity. SPDA and LGA routes had the highest success rates (96.7% and 91.4%, respectively) with low mortality, better drug delivery, and preserved physiologic liver function compared with the HA model. ConclusionsThe optimal route of HAI was mouse breed specific; SPDA access in BALB/c mice, and the LGA access in C57BL/6 mice. The described techniques serve as a reproducible platform for the identification and characterization of therapeutics for diverse metastatic liver tumors.

Anatomo-radiological patterns of pancreatic vascularization, with surgical implications: Clinical and anatomical study.

The pancreas receives multiple arterial sources that should be considered in patients undergoing pancreatic surgery. The aim of this study is to describe pancreatic vascularization and to explore the anatomical basis of postoperative complications. Ten specimens from unembalmed cadavers, including the retroperitoneal vessels and organs and spleen, were injected with acrylic resins to obtain vascular casts. Thirty computed tomography angiographies (CTA) of subjects with no pancreatic pathology (mean age 70.9 years) were also analyzed. A paucivascular area at the neck of the pancreas was apparent in all vascular casts. At CTA: (1) the transverse pancreatic artery, the only artery running from the cervicocephalic to the somatocaudal segment, was visible in 76.9% of cases; (2) the splenic artery was suprapancreatic in 66.7% and intrapancreatic with a tortuous course in 33.3%; (3) the posterior superior pancreaticoduodenal artery was visible in 100% of cases, the anterior superior pancreatico-duodenal artery in 92.6%, the anterior inferior pancreaticoduodenal artery in 73.1%, the posterior inferior pancreaticoduodenal artery in 86.4%, the dorsal pancreatic artery in 65.4%, the great pancreatic artery in 73.1%, and the pancreatic arteries to the body and caudal pancreatic arteries in 96.2%. Our study demonstrated great individual variability of the pancreatic vasculature, which can be explored by CTA and could be relevant to surgical procedures. Clin. Anat. 30:614-624, 2017. © 2017 Wiley Periodicals, Inc.

Myopericytoma occurrence in the liver and stomach space: imaging performance

BackgroundMyopericytoma is a rare and usually benign tumor, which is even rarer if it occurs in the liver and stomach space. Previous reports of myopericytoma were mostly related to its pathological manifestations, while imaging reports were rare. Here, we report the computed tomography (CT), computed tomography angiography (CTA) and magnetic resonance imaging (MRI) performance for one deep myopericytoma.Case presentationIn this study, one deep myopericytoma in the liver and stomach space is reported. A CT that was not contrast-enhanced showed a lobulated tumor with heterogeneous density, and a contrast-enhanced CT showed that the mass had progressive enhancement. CTA showed that the blood-supply of the tumor was supplied by the anterior superior pancreaticoduodenal artery and the left gastric artery. An MRI showed the lesion had isointensity on T1-weighted imaging (T1WI) and slight hyperintensity on T2-weighted imaging (T2WI). The lesion MRI enhancement characteristics were similar to the characteristics from the contrast-enhanced CT. In this case, the enhancement pattern of the tumor was the centrifugal enhancement for both the contrast-enhanced CT and MRI. After surgical resection of the tumor, the pathological diagnosis was myopericytoma, and there was no recurrence in a short-term follow-up.ConclusionThe myopericytoma generally has a rich blood supply. When there is necrosis in the center lesion, the lesion has peripheral enhancement. Abdominal myopericytoma could be categorized as having centrifugal enhancement.