Left Gastric Research Articles

Celiac Trunk Quadrification, Replaced Common Hepatic Artery, and Double Cystic Arteries

Understanding the gastrointestinal system's anatomical variants is vital for surgeons, anatomists, and those who deal with referred abdominal pain, such as physical therapists. Direct access physical therapists must diligently diagnose symptoms to determine the cause of either real musculoskeletal pain or insidious symptoms masquerading as an ischemic insult. Variants of the celiac trunk and common hepatic artery were found in an 80-year-old cadaver-donor during an educational student dissection. The objective of this study was to classify and evaluate this variant in comparison to previous literature. The celiac trunk typically (95%) branches into the left gastric, splenic, and common hepatic arteries to supply the foregut, while the superior mesenteric artery (SMA) branches supply the midgut. In place of the celiac trunk, a gastrosplenic trunk (Uflacker Type V), a common inferior phrenic trunk, and a middle suprarenal artery emerged during dissection. Additionally, a replaced common hepatic artery (RCHA) originated from the superior mesenteric artery (Michels Type IX) – the presence of the CHA as a hepatomesenteric trunk is rare, a 0.07-6% prevalence. The combination of the Uflacker Type V and the Michels Type IX has a prevalence of 0.4-4.37%, while an inferior phrenic trunk originating from the celiac trunk has a reported prevalence of 7.69-13.6%. Many reports state that the RCHA variant courses posterior to the hepatic portal vein. In this case, the RCHA and associated branches were anteromedial for most of its course. The right hepatic artery took a tortuous path posterior to the common bile duct and did not enter the hepatobiliary (Calot's) triangle. Inferior to the gallbladder, double cystic arteries emerged from the right hepatic artery, previously reported with a 2-18% prevalence. Knowledge of arterial branching patterns and the variants – both common and rare – is vital for anatomists and surgeons performing dissections or operations within the abdominal area to ensure success and maximal safety. The combination of variants reported in this case is rare and has not been reported previously. This case may provide additional evidence for future studies on the morphologic and embryologic basis of vascular development. Specifically, studies that aim to evaluate a temporal relationship of combined vascular anomalies during embryologic development.

Successful laparoscopic resection of gastric lymphangioma under the intraoperative guidance of indocyanine green fluorescence imaging: A case report

Gastric lymphangioma (GLA) is an extremely rare tumor without an established therapeutic strategy. Surgical resection is considered the mainstay of treatment, although there is a high risk of local recurrence if negative margins are not achieved. A 51-year-old man underwent routine abdominal ultrasonography, which incidentally detected a 20-mm tumor adjacent to the lesser curvature of the stomach. GLA was suspected based on its polycystic appearance. After a 16-month monitoring period, laparoscopic resection was performed because of tumor growth and involvement of the left gastric artery. Intraoperative indocyanine green (ICG) navigation system revealed lymphatic drainage from the tumor, which we used to help determine the optimal excision line and minimize the loss of gastric volume. Pathological examination confirmed complete resection with negative margins and supported a diagnosis of lymphangioma. We performed laparoscopic radical resection of GLA under guidance from intraoperative ICG fluorescence imaging, which allowed us to maximize residual gastric volume.

Pancreas-left gastric artery angle is associated with postoperative inflammation and drain amylase after laparoscopic gastrectomy.

The pancreas often interferes with the surgical field during laparoscopic gastrectomy (LG) and its disorders cause severe postoperative complications. This study aimed to evaluate the association between the anatomical location of the pancreas and surgical outcome and to investigate the optimal surgical position in LG. We newly defined the angle formed between the supra-pancreatic region and the root of the left gastric artery (LGA) as the pancreas-LGA angle (PLA). The association between PLA and surgical outcomes in 107 consecutive patients who underwent laparoscopic distal gastrectomy (LDG) was investigated. Then, the change in PLA before and after insertion of the back pillow in 30 patients with gastric cancer was examined. The median PLA was 62° (range, 2°-157°). No differences were found in the patient background between patients with small PLA (PLA < 62°; n=53) and those with large PLA (PLA≧62°; n=54). The postoperative inflammation response (white blood cells, neutrophils, and C-reactive protein) and amylase concentration in the drainage fluid (D-AMY) were significantly higher in the small PLA group than large PLA group. Multivariable analyses demonstrated that small PLA was an independent risk factor for high D-AMY. After insertion of a back pillow, PLA was noninvasively increased in all patients, and the median PLA was changed to 92° (range, 8°-151°) from 61° (range, 2°-140°). Of 17 patients with small PLA, nine developed large PLA. These results suggest that PLA can become one of the indicators of postoperative complications related to anatomical patient factors in LDG.

Transarterial embolisation for gastroduodenal bleeding following endoscopic resection.

Transcatheter arterial embolisation (TAE) is widely used to treat gastrointestinal bleeding. This paper reports the safety and efficacy of TAE for bleeding following endoscopic resection, including endoscopic mucosal resection and endoscopic submucosal dissection. Fifteen consecutive patients (13 males, two females; mean age 62.2 years) from two tertiary medical centres who underwent TAE for gastroduodenal bleeding after endoscopic resection from November 2001 to December 2020 were included. Patient demographics, clinical presentations, angiographic findings, and TAE details were retrospectively reviewed. Immediate bleeding during endoscopic resection was noted in four patients. Delayed bleeding 1-30 days after endoscopic resection in nine patients presented with haematochezia (n = 4), haematemesis (n = 6) and melaena (n = 1). Endoscopic haemostasis was attempted in 11 patients (73.3%) but failed due to continued bleeding despite haemostasis (n = 6), failure to secure endoscopic field (n = 3) and unstable vital signs (n = 2). Eleven patients had positive angiographic findings for bleeding, and all bleeding arteries were embolised except one owing to failed superselection of the bleeder. In the other four patients with negative angiographic findings, the left gastric artery with/without the right gastric artery or the accessory left gastric artery was empirically embolised using gelatin sponge particles. Both technical and clinical success rates were 93.3% (14/15). No procedure-related complications occurred during follow-up. TAE is safe and effective in the treatment of immediate and delayed bleeding after endoscopic resection procedures. This is the first and largest 20-year bicentric study published in English on this topic. Empirical TAE for angiographically negative bleeding sites was also effective without significant complications.

Left gastric artery embolization for obesity treatment: a systematic review and meta-analysis of human and animal studies.

The main purpose of this systematic review was to reflect on recent literature on bariatric LGA embolization for obesity treatment and to compare this new procedure in human and animal studies. A systematic search of Scopus, MEDLINE, Web of Science, Embase, and Google Scholar was performed to identify human and animal studies employing bariatric LGA embolization to treat obesity. As well, Cochrane's Q test and the I2 statistic were utilized to determine heterogeneity. Nine human and four animal studies recruiting a total of 118 cases (n = 78 patients and n = 40 animals) were included in analysis. All assessments on body mass index (BMI), weight, and ghrelin levels had been fulfilled based on before-after (human studies) and intervention-control designs (animal studies) using bariatric LGA embolization. The findings suggested that bariatric LGA embolization had significantly decreased BMI (mean difference (MD): - 2.66, 95% confidence interval [CI] - 3.74, - 1.58, P < 0.001) and weight (MD: - 8.69, 95% CI - 10.48, - 6.89, P < 0.001) in humans. Although overall pooled estimate showed no significant changes in ghrelin levels following this procedure (Hedges' g statistic: - 0.91, 95% CI - 1.83, 0.01, P = 0.05) in humans, a significant reduction was observed in animal studies (MD: - 756.56, 95% CI - 1098.79, - 414.33, P < 0.001) along with a significant drop in weight (MD: - 7.64, 95% CI - 13.73, - 1.54, P < 0.001). The present study concluded that ghrelin levels in humans had not been affected, although bariatric LGA embolization might significantly improve BMI and weight.

Quadrifurcation of Coeliac Trunk- A Case Report

During routine dissection of a cadaver in the department of anatomy at Seth GS Medical College and KEMHospital, we discovered a very rare type of branching pattern of the Coeliac Trunk (CT). The CT measured3cm in length and was quadrifurcating into replaced right hepatic artery, common hepatic artery, left gastricartery and splenic artery. The replaced right hepatic artery had unusual course where it ran behind theportal vein and bile duct to reach the right lobe of liver. Common hepatic artery after giving gastroduodenaland right gastric artery continued as middle hepatic artery while left hepatic artery originated from leftgastric artery. A complete knowledge of these variations are helpful for hepatobiliary surgeons and also forradiologists.

Hepatopancreatoduodenectomy with simultaneous resection of the portal vein and hepatic artery for locally advanced cholangiocarcinoma: Short- and long-term outcomes of superextended surgery.

Only a few authors have reported negative results for hepatopancreatoduodenectomy (HPD) with simultaneous resection of the portal vein and hepatic artery in a limited number of patients. The aim of the current study was to outline our experience with this superextended surgery and to discuss its clinical value. Medical records of consecutive patients who underwent resection of perihilar cholangiocarcinoma between 2007 and 2020 were retrospectively reviewed. During the study interval, 650 patients with perihilar cholangiocarcinoma underwent resection. The superextended surgery was performed in only nine (1.4%) patients. Left or right trisectionectomy was primarily performed. For portal vein reconstruction, external iliac vein graft was required in seven patients. For hepatic artery reconstruction, rotating left gastric artery was often used. The median operative time was 870minutes and blood loss was 2,598mL. Postoperatively, pancreatic fistula and liver failure occurred in all patients, followed by intraabdominal abscess (n=8), and bacteremia (n=4). One patient died on day 86 due to multiple organ failure. Two patients survived for more than 7years. HPD with simultaneous resection of the portal vein and hepatic artery is demanding but worth performing as the last option, with careful patient selection in experienced centers.

Coeliac trunk and its anatomic variations: a cadaveric study.

Coeliac trunk (CT) is the first major visceral branch of the abdominal aorta. The aim of this work was to present the CT division pattern and its anatomical variants in a sample of Polish population. Coeliac trunk dissection was performed in 50 adult cadavers in the Department of Anatomy, Jagiellonian University Medical College. Cadavers of Polish subjects were included. Cadavers with previous upper abdominal surgery, abdominal trauma, disease process that distorted arterial anatomy or signs of putrefaction were excluded. CT variations, accessory vessels, and vertebral level of origin were described. CT patterns were reported according to the Adachi classification. This study was reviewed and approved by the local Ethics Committee. Coeliac trunk consisting of the left gastric, common hepatic and splenic artery (type 1 according to the Adachi classification) was found in 82% of cadavers. The true tripod was found in 20% and the false one in 80%. Additional vessels were also found: greater pancreatic from the splenic artery and left inferior phrenic from the left gastric artery, which accounted for 2% sections. Type 2 according to the Adachi classification (i.e. the hepatosplenic trunk) was found in 16% of the sections. Other types of CT were not observed. The level of origin was found to be at the inter-vertebral disc between T12 and L1 in all of the cases. Based on the analysis of the sectional material of the Department of Anatomy, it was found that the typical visceral segmental division is approximate to that observed by Adachi in its classification, whereas the second type of CT was twice as frequent and no other, less frequent types were found.

Distal pancreatectomy with en bloc celiac axis resection (DP‐CAR) and arterial reconstruction: Techniques and outcomes

Ischemic complications are still prevalent after distal pancreatectomy with en bloc celiac axis resection (DP-CAR) despite the use of preoperative arterial embolization. We described our institutional experience with arterial reconstruction during DP-CAR. We retrospectively reviewed short- and long-term outcomes of all DP-CAR performed for pancreatic adenocarcinoma between January 1, 1995 and March 30, 2020. Outcomes were compared according to the presence of arterial reconstruction. Sixty consecutive DP-CARs were reviewed. Most patients underwent induction chemotherapy (85%) based on FOLFIRINOX protocol (80.3%). The hepatic artery was reconstructed in 50 patients (83.3%). The left gastric artery was reconstructed in 4 and preserved in 14 patients. A venous resection was associated during 44 DP-CARs (36 segmental venous resections/8 lateral venous resections). Ninety days mortality was 5.0% with 48.3% (n = 29) overall rate of morbidity. Postoperative outcomes in term of mortality, morbidity, and ischemic events between patients with and without arterial reconstruction were similar despite a higher rate of venous resection (81% vs. 40%; p = 0.005) and more complex cases (Mayo clinic DP-CARs class1B, 2A, and 3A) in the reconstructed group. Arterial reconstruction represents a safe surgical option during DP-CAR to lessen postoperative ischemic events. This technique, reserved to high volume centers expert in vascular resection during pancreatectomy, deserves further comparison with standard technique in a larger setting.

Risk factors for lymph node metastasis of the left recurrent laryngeal nerve in patients with esophageal squamous cell carcinoma.

BackgroundThe factors for left recurrent laryngeal nerve (RLN) lymph node (LN) metastasis have important guiding significance for whether the left RLN LNs should be dissected in patients with esophageal squamous cell carcinoma (ESCC), but few studies are currently available. To analyze the risk factors of LN metastasis of the left RLN area and to assess which LNs should be dissected in ESCC.MethodsThis was a retrospective study of patients who underwent McKeown minimally invasive esophagectomy (MIE) (no neoadjuvant therapy) at Tianjin Medical University Cancer Institute and Hospital (from January 2016 to December 2019). The detection of left RLN LNs using enhanced computed tomography (CT) was compared with the pathological examination.ResultsOf the total 94 participants, 43 had LN metastasis. The metastatic LNs were mainly located next to left (18.1%) and right (14.9%) RLN, and the left gastric artery (13.8%). Tumor size, LN size, tumor invasion (T stage), N stage, and tumor node metastasis (TNM) stage were associated with left RLN LNs metastasis, while LN size was the only independently associated factor [odds ratio (OR) =1.569, 95% confidence interval (CI): 0.259–1.956, P=0.0012]. The area under receiver operating characteristic (ROC) curve (AUC) reached 0.877, with 64% sensitivity and 75% specificity using a cutoff of 5.5 mm LN size.ConclusionsThe size of left RLN LN is independently associated with metastasis. Left RLN LNs >5.5 mm at CT examination are more likely to be positive and should probably be dissected.

Laparoscopic lymph node sampling: a new concept for patients with high-risk early esophagogastric junction cancer resected endoscopically

Endoscopic resection is considered a curative treatment for early upper GI cancers under certain histologic (low-risk) criteria. In tumors not completely fulfilling these criteria but resected R0 endoscopically, esophagectomy is still advised because of an increased risk of lymph node (LN) metastases (LNM). However, the benefit-risk ratio, especially in elderly patients at higher risk for radical surgery, can be debated. We now present the outcome of our case series of laparoscopic LN sampling (LLS) in patients with T1 esophagogastric junction tumors, which had been completely resected by endoscopy but did not fulfill the low-risk criteria (G1/2, m, L0, V0). Retrospective review was done of all patients with T1 cancer undergoing LLS with at least 1 high-risk parameter after endoscopic resection during an 8-year period. Repeated endoscopy with biopsy and abdominothoracic CT had been performed before. The patients were divided into 2 periods: before (n= 8) and after (n= 12) the introduction of an extended LLS protocol (additional resection of the left gastric artery). In cases of positive LN, patients underwent conventional oncologic surgery; if negative, follow-up was performed. The main outcome was the number of harvested LNs by means of LLS and the percentage of positive LNs found. Twenty patients with cardia (n= 1) and distal esophageal/Barrett's cancer (n= 19) were included. The LN rate with use of the extended LLS technique increased by 12% (period 1: median 12 [range, 5-19; 95% CI, 3.4-15.4] vs period 2: median 17.5 [range, 12-40; 95% CI, 12.8-22.2]; P= .013). There were 2 adverse events: 1 inadvertent chest tube removal and 1 postoperative pneumonia. In 15% of cases, patients had positive LNs. and in 2 cases there was local recurrence at the endoscopic resection site, all necessitating surgery. An extended technique of laparoscopic LN sampling appears to provide adequate LN numbers and is a safe approach with short hospital stay only. Only long-term follow-up of larger patient numbers will allow conclusions about miss rate as well as oncologic adequacy of this concept.

Society of Interventional Radiology Quality Improvement Standards for Percutaneous Transcatheter Embolization

Percutaneous embolization procedures are commonly performed by interventional radiologists. This quality improvement (QI) standard was first published in 2010 (1), and this document represents the second update. Since the 2010 standards, many additional randomized controlled trials, meta-analyses, and observational studies have been published on transcatheter embolization for various disease entities, further establishing embolization as an effective treatment. Additionally, the indications of embolization have expanded with newer procedures, like prostatic embolization for benign prostatic hyperplasia (BPH), and emerging procedures, such as left gastric artery embolization for the treatment of obesity and genicular artery embolization for the treatment of pain related to osteoarthritis (OA).

Early gastric cancer with an Adachi type VI (group 26) vascular anomaly diagnosed preoperatively and treated by laparoscopic surgery: a case report

BackgroundIt is important to understand the branching pattern of the celiac artery for a safe surgery. Various branching anomalies of the celiac artery were classified by Adachi in 1928. In Adachi’s classification, type VI (group 26) is a rare anatomical anomaly (0.4%) that requires care when carrying out a surgery in gastric cancer patients with this anomaly. Herein, we reported a case treated successfully with laparoscopic distal gastrectomy with D1+ lymph node dissection for early gastric cancer.Case presentationAn 84-year-old female was referred to our division for an additional surgical treatment for early gastric cancer that was resected by endoscopic submucosal dissection. A three-dimensional computed tomography angiography revealed an angioplany of the common hepatic artery branching from the left gastric artery. According to Adachi’s classification, the anomaly of this patient corresponded to type VI (group 26). Preoperative anatomical information of this rare anomaly helped us to safely perform a laparoscopic distal gastrectomy and lymph node dissection with common hepatic artery preservation. The patient had an uneventful postoperative course and was discharged on postoperative day 11.ConclusionsWe consider that Group 26 anomalies require the most precise anatomical understanding among Adachi classification type VIs, since it affects hepatic blood flow and can cause serious complications. In this time, we reported a successful case to perform laparoscopic distal gastrectomy with safety and accuracy by preoperative understanding of the precise vascular anatomy.

Extended Right-hemihepatectomy Is Preferred for Perihilar Cholangiocarcinoma.

Extended Right-hemihepatectomy Is Preferred for Perihilar Cholangiocarcinoma.

The topographic and systematic anatomy of the alpaca stomach.

The gastric anatomy of the alpaca (Vicugna pacos) is adapted to the physiological process of ruminating and the degradation of plant cell wall contents to a great extent. Most alpaca husbandries consist of only few animals and with the still increasing number of alpacas worldwide the number of persons who are responsible for these animals is increasing as well. Despite this, little research has been done with regard to the clinical anatomy of the stomach of alpacas. Six animals were used for dissection. The vascular system of two alpacas was injected with latex milk to illustrate the course of the blood supply to the viscera. One stomach was used to prepare formalin-fixed preparations. The stomach consisted of three compartments (C1-C3) and showed two sacculated areas in C1 and another comb-like system in C2. The compartments were lined by a smooth mucosa. Only the deep cells of C2 were lined by a papillated mucosa. The main blood supply was provided by the coeliac artery which was divided into the hepatic artery and the left gastric artery, supplying abdominal organs like liver, spleen, pancreas, and the initial part of the duodenum. Literature research on the llama stomach showed that the alpaca stomachs that were used resembled each other to a very large degree. The specific design of the stomach together with its related functions and physiological processes confirm that the evolution of Tylopoda and Ruminantia took place in parallel and not in homology.

Bariatric Embolization in the Treatment of Patients with a Body Mass Index Between 30 and 39.9kg/m2 (Obesity Class I and II) and Metabolic Syndrome, a Pilot Study.

To evaluate the efficacyandclinical safetyof bariatric arterial embolization(BAE) inadults with body mass index (BMI) between 30 and 39.9kg/m2 and metabolic syndrome (MS). Between March and August 2018, ten female participants between 21 and 48-years-old,median BMIof36.37±2.58kg/m2 andMSwere enrolled in this prospective trial. We embolized the fundal branches from the left gastric and other artery sources, which resulted in embolization of at least two arteries in 9 out 10 participants. Six months after bariatric embolization, efficacywas assessedby changes in total body weight (TBW), ghrelin and HomeostaticModelAssessment-InsulinResistance (HOMA-IR) levelsand by changes inquality of life (QOL) andinbinge eatingscale (BES) scores. Safety was assessed by the identification of any related complications, including gastric ulcers, screened by gastrointestinal endoscopy, performed before and one week and one month after BAE. Six months after embolization, TBW decreased by 6.8% (6.22kg±3.6;p = .01), serum ghrelin dropped from 25.39pg/ml±10.63 to 17.1±8.07 (p = 0.01), and HOMA-IR decreased from7.29±5.66 to 3.73±1.99 (p = 0.01). The QOL scores improvedfrom 59.64±5.59 to 69.02±11.97 (p < 0.05) and in the BES from 21.50±8.89 to 9.60±4.40(p = 0.01). Endoscopy revealed symptomaticgastric ulcers in two participants, which had healed without sequelae. In one participant, ultrasound revealed an asymptomatic focal arterial thrombus at the left distal radial artery puncture site. BAE is effective in reducing weight, insulin resistance and ghrelin levels and improving BES and QOL scores in patients with class I and II obesity and MS,with no major complications.

The inferior phrenic arteries: A systematic review and meta-analysis

IntroductionThe inferior phrenic artery is a paired artery that supplies the diaphragm from its inferior aspect. It may arise as a common trunk, the common inferior phrenic artery (CIPA), or as two individual arteries, the right and left inferior phrenic arteries (RIPA and LIPA, respectively). The aim of this study was to perform a systematic review and meta-analysis to create pooled prevalence data on the various origins of the inferior phrenic arteries and to discuss their clinical importance. MethodsMajor electronic medical databases were reviewed to identify articles with anatomical prevalence data on the origin of the inferior phrenic arteries. Data on the origin of the left, right and common inferior phrenic arteries were extracted and quantitatively synthesized. ResultsThe CIPA was present in 24.2% of cases and most commonly originated from the aorta, with a pooled prevalence 57.2% (95% CI 52.4–62.0%), and the coeliac trunk, with a pooled prevalence of 41.3% (95% CI 36.8–45.9%). Other origins were much less common (1.00% (95% CI 0.28–1.71%)). Independent origin of the RIPA and LIPA were present in 75.8%. The RIPA arose from the aorta (49.6%, 95% CI 43.2%–55.9%), coeliac trunk (35.7%, 95% CI 28.7–42.6%), right renal artery (10.3%, 95% CI 7.27–13.3%) and left gastric artery (2.07%, 95% CI 0.97–3.16%). Other less common origins had a pooled prevalence of 2.07% (95% CI 0.97–3.16%). The LIPA arose from the aorta (46.8%, 95% CI 39.1–54.6%), coeliac trunk (46.1%, 95 CI 38.6–53.5%), left renal artery (1.47%, 95% CI 0.78–2.15%) and left gastric artery (1.07%, 95% CI 0.25–1.89%). Other less common origins had a pooled prevalence of 1.29% (95% CI 0.44–2.14%). ConclusionThe inferior phrenic arteries express a wide range of variations in origin. Knowledge of their origins are important in interventional radiology, gastroenterology, surgery and traumatology.

Extraordinary first jejunal arterial variation associated with annular pancreas undergoing pancreaticoduodenectomy for pancreatic cancer: a case report

PurposeAnnular pancreas encountered in adults and jejunal arterial variations are rare. Anatomical variations can cause conflicts between oncology and surgical safety.MethodsCase report of a 68-year-old man suffering from vomiting because of an annular pancreas and a ductal adenocarcinoma of the pancreas head invading the second portion of the duodenum.ResultsContrast-enhanced computed tomography showed multiple arterial variations describing the absence of the coeliac trunk such that the left gastric artery (LGA), splenic artery and superior mesenteric artery (SMA) were arising separately from the aorta. The accessory left hepatic artery arose from the LGA; and both the common hepatic artery and combined trunk of the replaced right hepatic artery with the higher replaced first jejunal artery separately arose close to the root of the SMA. The patient underwent curative pancreaticoduodenectomy which achieved 3 years of recurrence-free survival.ConclusionThis was an extraordinary case of annular pancreas with first jejunal arterial variation detailing an embryological interpretation as well as considerations for balancing short- and long-term outcomes.

Absence of the celiac trunk and anomalous very low origin of the common hepatic artery arising independently from the abdominal aorta just above aortic bifurcation in patient undergoing radical pancreaticoduodenectomy

PurposeKnowledge of anomalies of the celiac trunk is very important during various surgical procedures (such as pancreatic and gastric resections including Appleby operation, liver resections and liver transplantations) and as well as radiologic procedures (such as chemoembolization of pancreatic and hepatic tumors).MethodsA 77-years-old woman was admitted to our department for surgical treatment of ampullary adenocarcinoma G2 confirmed in endoscopic retrograde cholangiopancreatography (ERCP) with papillotomy and ampullary biopsy. In the contrast-enhanced computed tomography, the ampullary tumor was not visible, but the main pancreatic duct within pancreatic head and isthmus was dilated (indirect radiological tumor signs). An absence of the celiac trunk (CT) was established via computed tomography. Therefore, computed tomography-based angiography (angio-CT) of the abdominal aorta (AA) was performed before operation.ResultsAngio-CT confirmed an extremely rare vascular anomaly: an absence of CT. The left gastric (LGA), splenic (SA), and common hepatic (CHA) arteries connected above origin of the superior mesenteric artery (SMA) from the AA. Pylorus-preserving pancreaticoduodenectomy (PD) was performed. This anomaly was also confirmed intraoperatively. The postoperative course was uneventful and the patient was discharged on postoperative day 10. There were no signs of recurrence of the tumor during the 6 months follow-up.ConclusionThe proper preoperative identification of anomalies within major abdominal vessels and its relationship to the tumor is very important to avoid intraoperative vascular injury and major postoperative complications.

Clinical features and management strategy of symptomatic spontaneous isolated celiac artery dissection

The aim of this study was to evaluate the clinical features and management strategy for patients with symptomatic spontaneous isolated celiac artery dissection (SICAD). In this retrospective study, consecutive patients with symptomatic SICAD from two institutions were included. The demographics, clinical manifestations, comorbidities, imaging findings and treatment strategy selection were obtained from the medical records. The general epidemiological data, treatment regimens and clinical and follow-up outcomes were analysed. Patients were divided into the conservative treatment group (group A, n = 26) and endovascular treatment group (group B, n = 11). Of these 37 patients, extent of dissection in both groups included only celiac trunk (61.54%% vs. 18.18%, p = 0.03), common hepatic artery (CHA) and splenic artery (SA) (3.85%% vs. 54.55%, p = 0.001), CHA (7.69% vs. 18.18%, p = 0.57), SA (23.08% vs. 9.09, p = 0.65) and left gastric artery (LGA) (3.85% vs. 54.55%, p = 0.99). Of note, the extension of the lesion in group A was shorter than that in group B. In addition, there were significantly more type IIb in group A than in group B (42.31% vs. 9.09%, p = 0.06) and the mean length of dissection in group A was 42.3 ± 54.71 mm which was significantly shorter than that in the group B 58.45 ± 3.71 mm (p =0.04). During a median follow-up of 11.5 months, the 1, 3, 6 and 12 month follow-ups were completed in 100% (37/37), 100% (37/37), 94.59% (35/37) and 91.19% (34/37) of patients, respectively. The cumulative rate of persistent disease stability in patients with endovascular treatment group was higher than in that conservative treatment group at the 3, 6, 9 and 12 months (50% vs. 16.67%, p = 0.001; 80% vs. 37.5%, p =0.03; 100% vs. 62.5%, p = 0.012;100% vs. 91.67%, p = 0.02 respectively). Most symptomatic SICAD have a tendency to persistent disease stability after conservative treatment. Risk factors for failed conservative treatment were length of dissection and branch involvement. Furthermore, endovascular treatment was associated with a high technical success and persistent disease stability rate, which might be reserved for patients with failed conservative treatment.