Gastric Artery Research Articles

Multimodal Imaging of an Atherosclerotic Splenic Artery Aneurysm Enables Endovascular Treatment of a Potentially Lethal Entity

Splenic artery aneurysms (SAAs) are the third most frequent site of intraabdominal aneurysm and the most frequent splanchnic artery aneurysm. Surgery may be morbid and may include splenectomy and distal pancreatectomy. True aneurysm needs differentiation from a pseudoaneurysm caused by pancreatic enzymatic destruction. A giant SAA was diagnosed in an elderly atherosclerotic male with chronic calcific pancreatitis. Layered thrombus on multimodal imaging ruled out enzyme action and excluded possibility of a pseudoaneurysm. The distal splenic artery beyond the aneurysm was collateralized by left gastric artery. The aneurysm was closed with multiple coils and a vascular plug. Imaging after 6 months confirmed complete closure. Endovascular closure of SAA needs strategies to avoid an endoleak from the distal splenic artery. Pseudoaneurysm of splenic artery should be excluded, as they do not respond to the same strategies applied for true atherosclerotic aneurysms.

Fatal pancreatic fistula after laparoscopic distal pancreatectomy for intraductal papillary mucinous carcinoma with pancreaticobiliary maljunction and sphincterotomized papilla: a case report

BackgroundPancreatic juice is constantly activated by contaminated bile in patients with pancreaticobiliary maljunction (PBM). Here, we report a case of laparoscopic distal pancreatectomy for a patient with PBM and sphincterotomized papilla, resulting in fatal pancreatic fistula.Case presentationA 79-year-old man was diagnosed with pancreatic intraductal papillary mucinous neoplasm and common bile duct stones. Endoscopic sphincterotomy was performed prior to surgery. The pancreatic duct was simultaneously visualized when the contrast agent was injected into the common bile duct. Sudden bleeding was observed from the abdominal drain on postoperative day (POD) 6. Emergent stent graft placement and coil embolization were performed for bleeding from the splenic artery. On POD 9, the drainage fluid changed to yellowish in color with bile contamination. For internal drainage of the digestive fluid, endoscopic retrograde biliary tube and pancreatic drainage tube were placed. On POD 24, second emergent coil embolization was performed for bleeding from the left gastric artery. On POD 25, open abdominal drainage was performed. On POD 32, third emergent coil embolization was performed for bleeding from the gastroduodenal artery. Subsequently, remnant pancreatic resection was performed. On POD 39, massive bleeding was again observed from the abdominal drain. Emergency arterial portography revealed bleeding in the right wall of the superior mesenteric vein. The patient died of hemorrhagic shock on the same day.ConclusionsThe extreme risk of severe pancreatic fistula after distal pancreatectomy should be considered in patients with PBM and sphincterotomized papilla. In this extraordinary situation, surgeons should promptly decide whether to resect the remnant pancreas to prevent losing the patient.

Roles of Endothelial Motilin Receptor and Its Signal Transduction Pathway in Motilin-Induced Left Gastric Artery Relaxation in Dogs.

Background: Motilin increases left gastric artery (LGA) blood flow in dogs via the endothelial motilin receptor (MLNR). This article investigates the signaling pathways of endothelial MLNR.Methods: Motilin-induced relaxation of LGA rings was assessed using wire myography. Nitric oxide (NO), and cyclic guanosine monophosphate (cGMP) levels were measured using an NO assay kit and cGMP ELISA kit, respectively.Results: Motilin concentration-dependently (EC50=9.1±1.2×10−8M) relaxed LGA rings precontracted with U46619 (thromboxane A2 receptor agonist). GM-109 (MLNR antagonist) significantly inhibited motilin-induced LGA relaxation and the production of NO and cGMP. N-ethylmaleimide (NEM; G-protein antagonist), U73122 [phospholipase C (PLC) inhibitor], and 2-aminoethyl diphenylborinate [2-APB; inositol trisphosphate (IP3) blocker] partially or completely blocked vasorelaxation. In contrast, chelerythrine [protein kinase C (PKC) inhibitor] and H89 [protein kinase A (PKA) inhibitor] had no such effect. Low-calcium or calcium-free Krebs solutions also reduced vasorelaxation. N-nitro-L-arginine methyl ester [L-NAME; nitric oxide synthase (NOS) inhibitor] and ODQ [soluble guanylyl cyclase (sGC) inhibitor] completely abolished vasodilation and synthesis of NO and cGMP. Indomethacin (cyclooxygenase inhibitor), 18α-glycyrrhetinic acid [18α-GA; myoendothelial gap junction (MEGJ) inhibitor], and K+ channel inhibition through high K+ concentrations or tetraethylammonium (TEA-Cl; KCa channel blocker) partially decreased vasorelaxation, whereas glibenclamide (KATP channel blocker) had no such effect.Conclusion: The current study suggests that motilin-induced LGA relaxation is dependent on endothelial MLNR through the G protein-PLC-IP3 pathway and Ca2+ influx. The NOS-NO-sGC-cGMP pathway, prostacyclin, MEGJ, and K+ channels (especially KCa) are involved in endothelial-dependent relaxation of vascular smooth muscle (VSM) cells.

Anomalous Anatomical Variations of Coeliac Trunk: A Cadaveric Study.

BackgroundThe celiac trunk, celiac axis or celiac artery is the first major abdominal branch of the aorta. Anatomical variations of the coeliac trunk and along with the other branches of the abdominal aorta result from changes in the ventral segmental arteries supplying the digestive tube during foetal development. Panagouli performed a systemaic review and proposed a new classification describing all celiac trunk variations through a systematic review. Knowledge of the celiac trunk anatomy and any variations is clinically relevant in esophageal, gastroduodenal, hepatic, biliary and pancreatic angiographic and surgical procedures. The purpose of this study is to report the pattern of the celiac trunk and its variations in a sample of the Indian population as per the Panagouli classification.MethodsThis was an observational study done in the period from September 2018 to October 2020 in the department of surgery of Gandhi Medical College & Hamidia Hospital, Bhopal, India. Cadaveric dissection was carried out in the department of forensic medicine and toxicology after obtaining approval from the ethical committee.ResultsWe did our study in 50 cadavers to look for further anatomical variations. The most common form found was true tripus Halleri. The rest of the variations noted included false tripus Halleri. Other variations were hepatosplenic trunk with left gastric artery arising from the aorta (6%), hepatosplenic trunk with no normal left gastric artery (2%), Hepatosplenic trunk with gastromesenteric trunk (2%) and coeliacomesenteric trunk (2%).ConclusionsThe congenital anomalies of the coeliac trunk have been long recognized and are of significant clinical importance as they may surprise the surgeon during surgery. Also, the wide spectrum of anomalies present in this area can be recognized by modern radiological evaluations like multi-detector helical computed tomography, MRI and magnetic resonance cholangiopancreatography (MRCP). Having the knowledge of these anatomical variations in mind may prevent inadvertent injuries during routine and complex hepato-pancreaticobiliary procedures.

Coexistence of aberrant left hepatic artery and duplicated left gastric artery: a potential surgical pitfall.

Coexistence of aberrant left hepatic artery and duplicated left gastric artery: a potential surgical pitfall.

Metabolic outcomes of left gastric artery embolization in obese patients (a pilot study)

Rationale: According to the published data, bariatric procedure of left gastric artery embolization (LGAE) as one of the minimally invasive and innovative methods for obesity treatment promotes reductions in bodyweight and ghrelin levels.Aim: To evaluate the effect of LGAE on the parameters of fat and carbohydrate metabolism in obese patients.Materials and methods: Twenty three (23) patients (10 male and 13 female, mean age 40.2 ± 10.6 years) with morbid obesity (body mass index [BMI] > 40 kg/m2) and obesity grade 2 (BMI > 35 kg/m2) underwent a minimally invasive procedure in the form of bariatric embolization of the left gastric artery with polyvinyl alcohol particles of 500 to 700 mcm in diameter. We compared anthropometric parameters (height in cm, body-weight in kg, BMI in kg/m2, waist circumference in cm) at baseline and at 6 months after LGAE. Laboratory examinations included measurements of plasma adiponectin, ghrelin, leptin, fasting glucose, HbA1c, insulin, and HOMA-IR (insulin resistance index).Results: At 6 month after LGAE, the patients' bodyweight decreased from 138.1 ± 33.2 kg to 113 ± 26 kg (p < 0.01) (by 18.2%), BMI from 47.4 ± 9.3 kg/m2 to 38.1 ± 7.4 kg/m2 (p < 0.01) (by 19.6%), waist circumference from 130.4 ± 9.7 cm to 115 ± 10.3 cm (p < 0.01) (by 11.8%). Mean adiponectin levels increased significantly from 22.5 ± 8.1 μg/ml before LGAE to 42.4 ± 11 μg/ml at 6 months (p < 0.001) (by 88.4%). Baseline ghrelin levels of 20.23 ± 4.8 femtomol/μL decreased to 2.09 ± 0.6 femtomol/μL at 6 months (p < 0.001) (by 89.6%). Mean leptin levels were 23.3 ± 4.9 ng/ml and 10.5 ± 3.7 ng/ml at baseline and at 6 months, respectively (p < 0.001) (by 54.9%). At 6 months after LGAE, there was a positive and significant trends in the parameters of carbohydrate metabolism: fasting glucose decreased from 6.9 ± 1.5 mmol/L to 5.1 ± 0.9 mmol/L (p < 0.001) (by 26%), HbA1c from 6.2 ± 1% to 5.3 ± 0.6% (p < 0.01) (by 14.5%), insulin from 15.6 ± 7.7 μU/ml to 8.1 ± 0.7 μU/ml (p < 0.001) (by 48%), and the HOMA-IR index from 4.5 ± 1.2 to 1.9 ± 0.32 (p < 0.001) (by 57.7%).Conclusion: At 6 months after LGAE, the patients with obesity grades 2 and 3 have demonstrated a reduction in bodyweight of 18–19%, with a decrease in the levels of leptin (the obesity hormone), ghrelin (hunger inducing hormone), and an increase in adiponectin levels, which is a marker of metabolic health. The patients also achieved their individual glycemic goals with a decrease in fasting glucose, insulin, glycated hemoglobin, and demonstrated an improvement in HOMA-IR.

Painful pulsatile epigastric mass

A 40-year-old woman with obesity and hypertension presented to the emergency department with abdominal pain. Physical examination revealed a tender, pulsatile, epigastric abdominal mass. A 6.5 × 6.5-cm fusiform common hepatic artery aneurysm, extending from the celiac bifurcation to the origin of the gastroduodenal artery, was seen on a computed tomography scan (A, B, C/Cover, D). Pulse examination was normal. She denied a smoking history or a family history of aneurysm. The patient was admitted for blood pressure control, and the following day was taken for urgent aneurysm repair. Proximal control of the celiac artery was obtained. The left gastric and splenic arteries were ligated to mobilize celiac artery for adequate exposure and control. Distally, the proper hepatic artery and gastroduodenal artery were controlled. The aneurysm sac was opened and reconstructed using a saphenous vein interposition extending from the celiac artery to the common origin of the proper hepatic and gastroduodenal arteries. The aneurysm sac was closed over the graft. Postoperatively, the patient developed elevations of the hepatic transaminases, which soon normalized. Aspirin was administered for antiplatelet therapy and the patient was discharged home on postoperative day 6 and was advised to return to normal activity. At 6 months, she had no pain and fully resumed her daily activities. Hepatic artery aneurysm has an incidence of 0.002% in the population.1Abbas M.A. Fowl R.J. Stone W.M. Panneton J.M. Oldenburg W.A. Bower T.C. et al.Hepatic artery aneurysm: factors that predict complications.J Vasc Surg. 2003; 38: 41-45Abstract Full Text Full Text PDF PubMed Scopus (229) Google Scholar The causes of hepatic artery aneurysms are unclear, but they are most frequently associated with fibromuscular dysplasia, Takayasu arteritis, vasculitis, Wegner granulomatosis, and connective tissue disorders such as Marfan syndrome and Ehlers-Danlos syndrome.2Chaer R.A. Abularrage C.J. Coleman D.M. Eslami M.H. Kashyap V.S. Rockman C. et al.The Society for Vascular Surgery clinical practice guidelines on the management of visceral aneurysms.J Vasc Surg. 2020; 72S: 3S-39SAbstract Full Text Full Text PDF Scopus (94) Google Scholar Repair is recommended for aneurysms larger than 2 cm in size or if they are symptomatic or ruptured.1Abbas M.A. Fowl R.J. Stone W.M. Panneton J.M. Oldenburg W.A. Bower T.C. et al.Hepatic artery aneurysm: factors that predict complications.J Vasc Surg. 2003; 38: 41-45Abstract Full Text Full Text PDF PubMed Scopus (229) Google Scholar, 2Chaer R.A. Abularrage C.J. Coleman D.M. Eslami M.H. Kashyap V.S. Rockman C. et al.The Society for Vascular Surgery clinical practice guidelines on the management of visceral aneurysms.J Vasc Surg. 2020; 72S: 3S-39SAbstract Full Text Full Text PDF Scopus (94) Google Scholar, 3Berceli S.A. Hepatic and splenic artery aneurysms.Semin Vasc Surg. 2005; 18: 196-201Crossref PubMed Scopus (159) Google Scholar, 4Lumsden A.B. Mattar S.G. Allen R.C. Bacha E.A. Hepatic artery aneurysms: the management of 22 patients.J Surg Res. 1996; 60: 345-350Abstract Full Text PDF PubMed Scopus (82) Google Scholar Endovascular and open repair are viable options. The hepatic circulation should be maintained and ligation is recommended only if adequate collateral circulation is present.2Chaer R.A. Abularrage C.J. Coleman D.M. Eslami M.H. Kashyap V.S. Rockman C. et al.The Society for Vascular Surgery clinical practice guidelines on the management of visceral aneurysms.J Vasc Surg. 2020; 72S: 3S-39SAbstract Full Text Full Text PDF Scopus (94) Google Scholar,3Berceli S.A. Hepatic and splenic artery aneurysms.Semin Vasc Surg. 2005; 18: 196-201Crossref PubMed Scopus (159) Google Scholar Although combined left gastric and splenic ligations can lead to proximal gastric ischemia, if the gastroepiploic artery is preserved, ischemic complications are rare. Open repair was chosen in this case owing to an inadequate distal landing zone for stent placement. Publication was discussed with the patient and consent obtained.

Lymph node metastasis pattern and significance of left gastric artery lymph node dissection in esophagectomy for esophageal cancers

PurposeTo investigate the lymph node metastasis pattern and significance of dissection of the left gastric artery lymph nodes in radical en bloc esophagectomy for esophageal squamous carcinomas based on the lymphatic drainage pathway revealed by carbon nanoparticle labeling.Materials and methodsPatients who underwent en bloc esophagectomy endoscopically were retrospectively enrolled. Carbon nanoparticles were injected in the submucosa of upper thoracic esophagus to label the relevant draining lymph nodes. The clinical data, lymph nodes dissected, surgical technique, and complications were analyzed.ResultsEn bloc esophagectomy was successful in all 179 patients. Metastases to the left gastric artery lymph nodes were positive in 42 patients (23.5%) but negative in 137 (76.5%). The left gastric lymph nodes were labeled, whereas no celiac lymph nodes were labeled by carbon nanoparticles. A total of 4652 lymph nodes were resected, with 26 lymph nodes per patient. Seventy-three patients had lymph node metastasis (73/179). Seventeen patients had metastasis to the recurrent laryngeal nerve lymph nodes (9.5%). The metastasis rate of the lower thoracic esophageal cancer to the left gastric artery lymph nodes was 37.0%, significantly greater than that at the middle (15.4%) or upper (6.7%) thoracic segment. The lymph node metastasis rate was significantly (P < 0.05) increased with the length of the cancerous lesion, infiltration depth, and poor differentiation. Univariate analysis revealed that the metastasis rate to the left gastric artery lymph nodes was significantly (P < 0.05) associated with paraesophageal lymph node metastasis, para-cardial lymph metastasis, and TNM classification. Multivariate analysis indicated that cancer location (odds ratio 8.32, 95% confidence interval 2.12–32.24) was significantly (P < 0.05) associated with metastasis to the left gastric artery lymph nodes, with the cancer at the middle and lower thoracic segments significantly more than in the upper thoracic segment.ConclusionCertain patterns exist in lymph node metastasis of esophageal cancer, and in radical esophagectomy of esophageal cancers, dissection of the left gastric artery lymph nodes is necessary to prevent possible residual or metastasis of esophageal squamous carcinomas based on the lymphatic drainage pathway of esophageal carcinomas demonstrated by carbon nanoparticle labeling.

Spontaneous rupture of a left gastric artery aneurysm.

Spontaneous rupture of a left gastric artery aneurysm.

S2342 An Unusual Cause of Hematemesis Heralding as a Case of Polyarteritis Nodosa (PAN)

Introduction: Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis predominantly affecting medium-sized arteries, with incidence ranging from 2-9 cases per million individuals and peak prevalence in the 6th decade of life. While most cases of PAN are idiopathic in origin, about 7% of cases have been linked to hepatitis B infection. This disease tends to manifest with systemic symptoms and multi-organ involvement and can have gastrointestinal involvement in up to 65% of patients, including abdominal pain from mesenteric arteritis, vasculitis-induced ischemia, and gastrointestinal bleeding. We describe a rare case of PAN in a young male presenting with non-specific symptoms of subacute abdominal pain and gastrointestinal bleeding. Case Description/Methods: A 20-year-old man presented with a 3 week history of intermittent epigastric pain unrelated to meals, nearly daily episodes of hematemesis, as well as hematochezia, anorexia, weakness, and fatigue. Initial evaluation revealed a normocytic anemia with hemoglobin of 8.8 g/dL and hematocrit of 28%. Computed tomography (CT) angiography revealed greater than 20 aneurysms arising from the medium-sized and small branches of the splanchnic abdominal arterial vasculature, with the largest aneurysm being 1.8 x 1.7 cm (Figure 1). Given concern for underlying vasculitis, the patient completed an extensive workup (Table 1). He received a diagnosis of PAN and was started on a high dose prednisone course. Post hospital discharge he was found to have interval growth of underlying abdominal aneurysms after a month and thus was started on cyclophosphamide therapy. He eventually underwent prophylactic coil embolization of the left hepatic and gastric artery aneurysms with interventional radiology to prevent future rupture. Discussion: Our case demonstrates a rare presentation of gastrointestinal bleeding and subacute symptoms heralding a diagnosis of PAN in a young male. While these nonspecific complaints carry a very broad differential diagnosis, this case highlights the need to consider vasculitis in the right clinical context. PAN is diagnostically challenging due to its diverse presentation and lack of specific markers for diagnosis. Prompt identification is critical given PAN has an untreated 5-year mortality rate of 13% which improves to 80% with treatment. Underlying mesenteric arteritis can lead to serious complications, such as refractory ulcers, intestinal ischemia, and bowel perforation.Figure 1.: A) CT abdomen and pelvis with IV contrast showing a large left hepatic artery aneurysm (measured up to 16.5 x 15.9 mm). B) Abdominal arteriogram depicting numerous aneurysms of mid-sized and small branches in the splanchnic abdominal arterial vasculature.Table 1:: Inpatient labwork obtained for workup of vasculitis.

S3205 A Successfully Medically Managed Case of Gastric Emphysema from Gastric Artery Embolism

S3205 A Successfully Medically Managed Case of Gastric Emphysema from Gastric Artery Embolism

Anomalous vascular anatomy of the left gastric artery in oesophagectomy.

Anomalous vascular anatomy of the left gastric artery in oesophagectomy.

Patterns of Regional Failure after Pancreaticoduodenectomy in Patients with Distal Extrahepatic Cholangiocarcinoma: Suggestion of the Clinical Target Volume for Elective Nodal Irradiation

AimsTo evaluate the pattern of locoregional recurrence (LRR) after pancreaticoduodenectomy in patients with distal extrahepatic cholangiocarcinoma (DEHC) and to identify an optimal target volume for elective nodal irradiation. Materials and methodsWe analysed the medical records of DEHC patients who underwent pancreaticoduodenectomy and had LRR between 1991 and 2015. Among these patients, 30 received adjuvant chemotherapy alone, 14 underwent radiotherapy with or without chemotherapy and 28 received no treatment. After reviewing computed tomography or magnetic resonance imaging scans, the sites of LRR were identified and mapped to the corresponding locations on the representative computed tomography images. ResultsIn total, 136 LRRs were identified in 72 patients from four institutions. Local recurrences were observed at 44 sites (32.4%): tumour bed in 15, choledochojejunostomy in 25 and pancreaticojejunostomy in four. Regional recurrences were observed at 92 sites (67.6%); the most common site was the portal vein area (n = 18), followed by the para-aortic area (n = 17). Based on the mapped plots of regional recurrence, a clinical target volume covering 90% of regional recurrences was generated using the appropriate margin for the vascular structures of the portal vein, celiac axis, superior mesenteric artery, left gastric artery and aorta. ConclusionsGiven the pattern of LRR, we showed that the nodal clinical target volume based on vascular structures could appropriately cover high-risk regions of nodal involvement. These findings may help physicians construct a target volume in postoperative radiotherapy for DEHC patients undergoing pancreaticoduodenectomy.

Da Vinci robot-assisted pylorus and vagus nerve-preserving partial gastrectomy for gastric cancer

Objective: To investigate the safety and feasibility of Da Vinci robot-assisted pylorus and vagus nerve-preserving partial gastrectomy for gastric cancer. Methods: In this study, descriptive case series method was used to retrospectively analyze the data of 3 patients with gastric cancer who underwent Da Vinci robot-assisted pylorus and vagus nerve-preserving partial gastrectomy in the First Affiliated Hospital of Dalian Medical University from December 2020 to February 2021. The linear layout was adopted for the setting of trocar, and the co-axial direction was the line connecting the umbilicus and splenic hilum. The inferior pyloric arteries and veins need to be preserved. The center was the bifurcation of the right gastroepiploic vessel and the inferior pyloric vessel. Dissection and exposure were performed from the upper, lower, right and left sides, and ventral and dorsal sides to complete the dissection of the inferior pyloric lymph nodes. The superior border of the pancreas was treated by the right diaphragmatic crus approach, the left retroperitoneal approach and the esophageal approach to determine the distribution of the posterior vagal trunk and its branches, and to determine the anatomical relationship with the left gastric artery. The left gastric artery was cut off while the celiac branch of vagus nerve and cardia branch of left gastric artery were preserved. Lymph node dissection was performed on the lateral side of nerve fibers around the blood vessels. Result: All the 3 patients successfully completed the robotic surgery without conversion to laparoscopy or laparotomy. The operation time was (340.0±26.4) (300-390) minutes, the intraoperative blood loss was (13.3±3.3) (10-20) ml, the number of dissected lymph nodes was 26.7±3.9 (19-32), the length of pylorus canal preserved was (3.3±0.3) (3-4) cm, the distal margin was (2.3±0.3) (2-3) cm, and the proximal margin was (3.0±0.6) (2-4) cm. No postoperative complications occurred in all the 3 patients. The first flatus time was 2-3 days after operation, and the postoperative hospital stay was 6-7 days. The operation cost of the 3 patients was (40±7) (33-53) thousand yuan. Conclusion: Da Vinci robot-assisted pylorus and vagus nerve-preserving partial gastrectomy is safe and feasible.

Laparoscopic management of hemosuccus pancreaticus from the left gastric artery pseudoaneurysm secondary to traumatic pancreatitis and open splenectomy

Laparoscopic management of hemosuccus pancreaticus from the left gastric artery pseudoaneurysm secondary to traumatic pancreatitis and open splenectomy

649 EFFECTS OF THE PREPARATION METHOD ON THE ICG FLUORESCENCE BLOOD FLOW IN THE GASTRIC CONDUIT AFTER ESOPHAGECTOMY

Abstract In this study, we investigated how the blood flow of gastric conduit changed due to the difference in the lesser curvature cut line using ICG fluorescence imaging in patients with esophageal cancer. Methods A total of 193 cases of esophageal cancer surgery with gastric conduit reconstruction were included. (Conventional method) The lesser curvature cut line of the stomach was started from a distance of 5 cm from the pylorus (141 cases). (Current method) Gastric lesser curvature dissection was started from the last branch of the left gastric artery (52 cases). Blood flow of the gastric conduit was measured by the ICG fluorescence imaging, and the correlation between the changes in the gastric conduit and both blood flow and anastomotic failure was examined. Results Median length of the lesser curvature cut line was 10 cm from the pylorus in the current method, which was significantly longer than that in the conventional method (P &amp;lt; 0.001). Congestion at the tip of the gastric conduit were more observed in the conventional method (P = 0.02). The ICG fluorescent blood flow speed in the gastric conduit wall was 2.54 cm/s by the conventional method and 2.82 cm/s by the current method (P = 0.03). There were 23 cases (16.3%) of anastomotic leakage in the conventional method and 4 cases (7.7%) in the current method (P = 0.09). Conclusion By preserving the right gastric artery and vein, improvement of venous return is expected, and it is suggested that blood flow in the gastric conduit wall can be well maintained.

856 NODAL METASTASES AFTER NEOADJUVANT CHEMORADIATION AND R0 RESECTION IN ESOPHAGEAL ADENOCARCINOMA: PATTERNS AND PROGNOSIS

Abstract Although the pattern of nodal metastasis and the prognosis of number and location of positive nodes have been well described with esophageal cancer undergoing upfront surgery, little is known about nodal metastasis after neoadjuvant treatment. The aim of this study is to assess the pattern of nodal metastases in esophageal adenocarcinoma treated with neoadjuvant chemoradiation and surgery and evaluate its effect on prognosis. Methods All patients with esophageal adenocarcinoma who had undergone neoadjuvant chemoradiation and an R0 esophagectomy between 2010 and 2018 at our institution were included (n = 577). Pathology reports were reviewed for sites of lymph node metastases. Patients were excluded if nodal stations were not listed separately (n = 40). Age, sex, race, tumor location, TRG, pT stage, number of positive lymph nodes, number of positive nodal stations, and specific nodal stations were analyzed for risk of recurrence using univariable Cox regression, and significant covariates were included in multivariable Cox regression model. Results Of 537 patients, 193(36%) had pathologic nodal metastases. 153 patients(28%) had single-station disease: 135(88%) at the paraesophageal station, 16(10%) at the left gastric, 1 at the subcarinal and 1 at the paratracheal station(0.65% each). 32 patients(6.0%) had two-station and 8(1.5%) had three-station disease. The majority of patients with multiple positive nodal stations had positive nodes in the paraesophageal(90%) and/or left gastric artery stations(60%). On multivariable analysis, the number of positive nodal stations (HR 1.59, CI 1.35–1.84, p &amp;lt; 0.001), subcarinal (HR 2.78, CI 1.54–5.03, p &amp;lt; 0.001), and paraesophageal stations (HR 2.0, CI 1.58–2.54, p &amp;lt; 0.001) were associated with increased risk of recurrence. Conclusion Patients who have undergone neoadjuvant and R0 esophagectomy for adenocarcinoma often have lymph node metastases at time of surgery, most commonly at the paraesophageal station. The number of nodal stations, along with subcarinal and paraesophageal metastases, were associated with increased risk of recurrence.

Types of inferior phrenic arteries: a new point of view based on a cadaveric study.

The diaphragm is supplied by the superior and inferior phrenic arteries. This present study focusses on the latter. The inferior phrenic arteries (IPA) usually originate from the abdominal aorta. The two arteries have different origins, and knowledge of these is important when performing related surgical interventions and interventional radiological procedures. The aim of this study was to identify variations in the origin of the IPA and conduct relevant morphometric analyses. The anatomical variations in the origins of the left inferior phrenic artery (LIPA) and the right inferior phrenic artery (RIPA) were examined in 48 cadavers fixed in 10% formalin solution. A dissection of the abdominal region of the cadavers was performed according to a pre-established protocol using traditional techniques. Morphometric measurements were then taken twice by two of the researchers. In the cadavers, six types of origin were observed. In type 1, the most common type, the RIPA and LIPA originate from the abdominal aorta (AA) (14 = 29.12%). In type 2, the RIPA and the LIPA originate from the coeliac trunk (CT) (12 = 24.96%). In type 3, the RIPA and the LIPA originate from the left gastric artery, with no CT observed (3 = 6.24%). Type 4 has two subtypes: 4A, in which the LIPA originates from the AA and the RIPA originates from the CT (9 = 18.72%) and 4B, in which the RIPA originates from the AA and the LIPA originates from the CT (6 = 12.48%). In type 5, the LIPA originates from the AA and the RIPA originates from the AA (1 = 2.08%). Type 6 is characterised by the RIPA and LIPA forming a common trunk originating from the CT (3 = 6.24%). Our findings suggest the presence of six different types of LIPA and RIPA origin. The most common form is type 1, characterised by an IPA originating from the abdominal aorta, while the second most common is type 2, in which the IPA originates from the AA by a common trunk. The diversity of other types of origin is associated with the occurrence of coeliac trunk variation (type 3). No significant differences in RIPA diameter could be found, whereas LIPA diameter could vary significantly. No significant differences in RIPA and the LIPA diameter could be found according to sex.

Acute brucellosis associated with isolated splenic and left gastric artery vasculitis and acute ischemic bowel infarction. A systematic review of the most recent cases

Brucellosis is a multisystem bacterial zoonosis caused by Gram-negative bacteria Brucella spp. Ingestion of infected food products, direct contact with an infected animal, or inhalation of aerosols are all ways for germs to spread from animals to humans. Intestinal vasculitis with gangrene due to brucellosis has rarely been reported. We report a 62-year-old male patient presenting with acute onset of recurrent attacks of abdominal pain, remittent fever, malaise, and weight loss, which were followed by severe left hypochondrium abdominal pain with rigidity and signs of acute abdomen. Brucellosis was clinically suspected and confirmed by an enzyme-linked immunosorbent assay against the Brucella melitensis species. An abdominal CT scan revealed isolated splenic and left gastric artery vasculitis, leading to acute bowel ischemia, bowel infarction and gangrenous jejunal bowel segment. Histopathological examination of the resected gangrenous bowel segment revealed leucocytoclastic vasculitis. The patient was successfully treated with a standardized antimicrobial therapy for brucellosis and a short course of steroids with a complete resolution of the symptoms and signs. The case is discussed and the literature is reviewed.

Vascular Complications in Patients with Chronic Pancreatitis.

Introduction: Chronic pancreatitis (CP) is a long-standing progressive inflammation of the pancreas, which can lead to a variety of vascular complications, such as splanchnic venous thrombosis (VT) and arterial pseudoaneurysm (PA). There is a lack of studies on vascular complications in Scandinavian countries. Methods: We performed a retrospective analysis of medical records of patients with CP identified from the Karolinska University Hospital database between 2003 and 2018. A total of 394 patients with definite CP were included in the study. Results: There were 33 patients with vascular complications, with a median age of 62 (IQR 55–72) years. The cumulative incidence of vascular events was 3.2% at 5 years. Thirty patients had isolated VT, whereas three patients had PA (7.6% and 0.8%, respectively). Isolated splenic vein thrombosis was most common (53.3%), followed by a combination with other splanchnic veins. PA was found in the splenic artery in two patients and in the left gastric artery in one patient. Varices were present in three (10%) patients; variceal bleeding was not recorded. All patients had asymptomatic splanchnic VT, most with chronic VT with developed collaterals (83.3% had abdominal collateral vessels). Nearly two-thirds of patients with VT (63.3%) received no treatment, whereas 11 (36.6%) were treated with anticoagulants. Pseudocysts and alcoholic etiology of CP are risk factors for vascular complications. Conclusions: The cumulative incidence of vascular complications was 3.2% at 5 years. Splanchnic VT is more common than PA. Patients were asymptomatic with no variceal bleeding, explained by well-developed collateral vessels and strong study inclusion criteria.