Gastroduodenal Artery Research Articles

S671 Visceral Artery Aneurysms – An Indian Gastroenterologist’s Perspective

Introduction: To evaluate the etiology, presentation, risk factors for rupture, management and outcomes at 1 month in a tertiary care center for mesenteric aneurysms and pseudoaneurysms. Methods: We performed retrospective analysis of data from 2017-2021 at a tertiary care centre in Western India of all the patients who were diagnosed with mesenteric aneurysms and pseudoaneurysms. Results: Fifty-seven aneurysms and 48 pseudoaneurysms in 74 patients were studied. The most commonly involved vessels were splenic artery (69.5%) & gastroduodenal artery (GDA) (17.1%). About 75.6% patients were symptomatic, 51.3% had gastrointestinal bleeding (GI bleeding) & 24.3% abdominal pain. The most common etiologies noted were - Chronic Pancreatitis (35.1%) & decompensated cirrhosis (20.1%). Almost all patients with pseudoaneurysms were symptomatic (p< 0.0001). True aneurysms were more likely to be multiple, as compared to pseudoaneurysms (1.84+1.93 v/s 1.12+0.32; p=0.009). There was no significant difference in mortality and rebleed at one month between aneurysms and pseudoaneurysms (p=0.4887 & p=0.873). Male patients were found to have a higher risk of GI bleeding, irrespective of etiology (p=0.006), whereas female patients were more likely to have complications post intervention (p=0.04). Conservative treatment was given to 32.4% of patients who had a mean size of aneurysm being 1.2+0.77cm. Three out of 24 patients who were managed conservatively bled within a month. Interventional radiology guided treatment was offered in the form of angiographic coiling (40.5%), angiographic glue injection (17.6%) and angiographic glue+coiling respectively (5.4%). There was no significant difference between the risk of rebleeding or mortality amongst the modes of interventional therapy. One patient underwent surgical management for aneurysmal rupture. The mean amount of N-cyanoacrylate & coils used was 1.45+0.72mL & 3.89+1.87 respectively. Around 8.1% patients had complications post intervention, most common being Gram negative septicemia; all managed medically with no mortality & were commonly seen with interventions relating to the splenic artery. Three patients rebled, 2 of those bled post intervention. 4% patients died due to aneurysm rupture or rebled post intervention. Size >2cm did not correlate with GI bleeding or hemodynamic instability. Conclusion: Pseudoaneurysms have a high risk of rupture, regardless of the size and hence must be treated. Radiological intervention in form of coil or glue is safe and effective.

S2364 Migrating Coil Visualized on Endoscopy - A Rare Encounter

Introduction: The relationship between coil migration following an embolization and gastrointestinal bleeding has been reported but its mechanism remains unclear. Further cases should be identified in order to establish the risks associated with coil visualization on endoscopy. We present a case of a bleeding duodenal ulcer secondary to a migrated coil placed during interventional radiology (IR) guided coil embolization of the gastroduodenal artery (GDA). Case Description/Methods: A 75-year-old female with history of acid reflux, coronary artery disease and pulmonary embolism on Coumadin presented with hematemesis. One month prior, she underwent coronary artery bypass grafting and developed hematemesis post-operatively. Esophagogastroduodenoscopy (EGD) showed a 1cm duodenal apex bulb ulcer with a clean base (Forrest III) and a 3cm duodenal bulb ulcer with an actively spurting vessel (Forrest IA). Successful hemostasis was achieved after injection of diluted epinephrine (1:10 000) and placement of 5 hemoclips. Patient developed melena 1 day later and was taken for IR guided embolization of the GDA. This admission, she presented with 1 day of hematemesis. She was normotensive but had a heart rate of 120. Hemoglobin was 9.8 g/dL (baseline of 12) and INR 3.37. EGD demonstrated a cratered, 3cm duodenal ulcer with a clean ulcer base (Forrest Class III) and oozing edges in the first portion of the duodenum. A coil from recent IR embolization was seen protruding through the clean based ulcer within the vessel (Figure 1). No other source of bleeding was identified, her hemoglobin remained stable and she was discharged on twice daily pantoprazole. Discussion: Bleeding from gastrointestinal ulcers often requires interventions in addition to endoscopy, like trans-arterial embolization (TAE) of the GDA. Coil migration following this procedure can occur and has been reported to occur from days to years following TAE. Its incidence may be higher than expected as patients do not undergo routine endoscopy surveillance. While the clinical significance of a coil protruding through a vessel from an ulcer base is unclear, it is important for endoscopists to be aware of this complication. More cases should be identified in order to establish a protocol to ensure adequate ulcer healing and reduce risk of re-bleeding.Figure 1.: One cratered, 3 cm duodenal ulcer with a clean ulcer base (Forrest Class III) and oozing edges from the first portion of the duodenum. Coil from prior angiogram seen within the vessel and at the ulcer base.

S1745 Immune-Mediated Colitis Complicated by Peri-Colonic Abscess and Colonic Perforation Managed by Percutaneous CT-Guided Drainage

Introduction: Immune checkpoint inhibitors have revolutionized the field of oncology, but they are associated with many gastrointestinal adverse effects. Management includes high-dose steroids but may require a second-line immunosuppressant. However, severe cases can be refractory to standard treatment. Case Description/Methods: We present a case of a 73-year-old male with metastatic renal cell carcinoma status post left nephrectomy on nivolumab who presented to an outside institution with painless hematochezia. Colonoscopy demonstrated pan-diverticulosis with ascending and transverse colitis with ulcerations, however biopsies were negative for cytomegalovirus DNA. Extended enteric pathogen stool and Clostridium difficile stool studies were negative. These studies lowered the suspicion of infectious colitis and suggested the diagnosis of immunotherapy-induced colitis. Therefore, he was initiated on steroids. During the hospitalization, patient continued to have copious amounts of diarrhea, which led to hypovolemic shock and vasopressor support. The diarrhea subsequently turned into large volumes of hematochezia and the patient required multiple transfusions for his anemia. He was then transferred to our institution for further workup of immunotherapy-induced colitis refractory to steroid therapy. At our institution, repeat colonoscopy demonstrated severe inflammation in the transverse and descending colon, characterized by deep ulcerations (Fig. 1A and B). Hospital course was complicated by uncontrolled duodenal ulcer hemorrhage despite epinephrine injection, which necessitated embolization of the gastroduodenal artery. Subsequent computed tomography (CT) angiography showed perforated descending colonic diverticulitis and air collection adjacent to the descending colon. Due to his multiple comorbidities, the risks of surgery outweighed the benefits. He underwent CT-guided aspiration and drain placement for the fluid collection. Due to continued bleeding, another colonoscopy was repeated, but was aborted due to presence of medium sized tear (Fig. 1C). The patient continued to decompensate throughout a prolonged hospitalization and later passed away. Discussion: To our knowledge, this is the first case of immune checkpoint inhibitor colitis that led to concomitant colonic perforation and peri-colonic abscess. Our case highlights a rare but potential fatal complication associated with immune check point inhibitors.Figure 1.: ∼7cm pedunculated polyp in the ascending colon.

Surgical glance at pancreatic arterial anatomy

Aim. Study of anatomical variations of the pancreatic neck blood supply, which may affect the results of pancreaticoduodenectomy.Material and methods. Anatomic characteristics of arterial blood supply of pancreas were studied in 42 autopsied cases, who died from diseases not associated with abdominal organs failure. Clinical part of our study included 62 patients. Arterial anatomy was examined during early arterial phase of computer tomography. Options of the origin of the dorsa pancreatic artery were noted. All patients had “soft” pancreas confirmed by morphological examination and computer tomography. Main group included 20 patients. Dissection of the pancreas during pancreatoduodenectomy in this group were performed 10–15 mm left of portal vein confluence. Control (retrospective) group included 42 patients performed standard procedure, when pancreas was dissected above the portal vein confluence.Results. It was found that the neck of pancreas was supplied from dorsal pancreatic artery, found in all specimens. In 76% of cases it was a branch of splenic artery, in other cases – a branch of superior mesenteric artery. CT scan revealed the dorsal pancreatic artery in 54 (87.1%) people, in 8 patients the artery could not be identified. The dorsal pancreatic artery was a branch of the splenic artery in 64.8% of cases. In other cases it was a branch of the superior mesenteric artery, common hepatic artery, gastroduodenal artery and middle colon artery. If the dorsal pancreatic artery was a branch of the superior mesenteric, common hepatic, gastroduodenal artery, it was transected during lymphadenectomy. This led to higher frequency of postoperative pancreatic fistula.Conclusion. Localization of dorsal pancreatic artery must be taken into account during the pancreatoduodenectomy. That allows to decrease probability of postoperative pancreatic fistula.

Radioactive Particle Implantation Combined with Chemotherapy for Treatment of Pancreatic Adenocarcinoma.

HomeRadiology: Imaging CancerVol. 3, No. 5 PreviousNext Research HighlightsFree AccessRadioactive Particle Implantation Combined with Chemotherapy for Treatment of Pancreatic AdenocarcinomaFrancesca RigiroliFrancesca RigiroliFrancesca RigiroliPublished Online:Sep 17 2021https://doi.org/10.1148/rycan.2021219020MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In Take-Away Points■ Major Focus: To determine the efficacy of iodine 125 (125I) radioactive particle implantation plus regional arterial chemotherapy perfusion versus regional arterial chemotherapy perfusion therapy alone for treatment of patients with advanced pancreatic ductal adenocarcinoma.■ Key Result: This retrospective study showed significantly improved survival and overall clinical benefit of 125I radioactive particle implantation plus regional arterial chemotherapy.■ Impact: This preliminary study supports further evaluation of combined 125I radioactive particle implantation plus regional arterial chemotherapy to improve outcomes in advanced stage pancreatic ductal adenocarcinoma.Pancreatic ductal adenocarcinoma is often diagnosed at an advanced stage of disease, causing an extremely low survival rate at 1 year. While regional arterial infusion chemotherapy, obtained through catheterization of gastroduodenal, superior mesenteric, or splenic arteries, increases regional drug concentrations, responses remain low. Recent studies suggest that combining this therapy with 125I radioactive particle implantation improves inhibition of tumor growth and pain management.This retrospective study compared patients treated with 125I radioactive particle implantation plus arterial infusion chemotherapy (n = 11) versus those treated only with arterial infusion chemotherapy (n = 12). Treatment with combined 125I radioactive particle implantation plus regional arterial chemotherapy significantly improved radiologic response to therapy (73% vs 42%, P < .05) and 6-month and 9-month survival (91.7% and 50% vs 63.6% and 18.2%, respectively; P < .05) as compared with regional arterial chemotherapy alone. Combined therapy also reduced pain and improved overall quality of life to a greater extent.This study describing benefits of a “double” interventional radiologic approach suggests that development of upgraded materials and novel interventional techniques can improve treatment outcomes in pancreatic ductal adenocarcinoma. Several limits may affect the applicability of this approach, including the retrospective nature, small sample size, and preliminary application only to patients with advanced-stage disease. A future prospective study is needed to confirm these results.Highlighted ArticleYang L, Li C, Wang Z, et al. The clinical efficacy of computed tomography-guided 125I particle implantation combined with arterial infusion chemotherapy in the treatment of pancreatic cancer. J Cancer Res Ther 2021;17(3):720–725. doi: doi.org/10.4103/jcrt.jcrt_563_20Highlighted Article1. Yang L, Li C, Wang Z, et al. The clinical efficacy of computed tomography-guided 125I particle implantation combined with arterial infusion chemotherapy in the treatment of pancreatic cancer. J Cancer Res Ther 2021;17(3):720–725.doi: doi.org/10.4103/jcrt.jcrt_563_20 Crossref, Medline, Google ScholarArticle HistoryPublished online: Sept 17 2021 FiguresReferencesRelatedDetailsRecommended Articles Tumor-Vessel Relationships in Pancreatic Ductal Adenocarcinoma at Multidetector CT: Different Classification Systems and Their Influence on Treatment PlanningRadioGraphics2016Volume: 37Issue: 1pp. 93-112Preoperative CT Classification of the Resectability of Pancreatic Cancer: Interobserver AgreementRadiology2019Volume: 293Issue: 2pp. 343-349CT Radiomic Features of Superior Mesenteric Artery Involvement in Pancreatic Ductal Adenocarcinoma: A Pilot StudyRadiology2021Volume: 301Issue: 3pp. 610-622Pancreatic Adenocarcinoma Staging in the Era of Preoperative Chemotherapy and Radiation TherapyRadiology2018Volume: 287Issue: 2pp. 374-390Imaging-based Risk Scores for Treatment Selection in Early Pancreatic Cancer: A Step Forward for Tailored TreatmentRadiology2020Volume: 296Issue: 3pp. 552-553See More RSNA Education Exhibits Pancreatic Cancer: Early Detection, Diagnosis and StagingDigital Posters2020Beyond Surgical Resectability: Pearls and Pitfalls in Preoperative Imaging for PancreatoduodenectomyDigital Posters2020Missed Imaging Findings of Pancreatic Ductal Adenocarcinoma: Lessons Learned from Difficult Cases  Digital Posters2020 RSNA Case Collection Superior Mesenteric Artery SyndromeRSNA Case Collection2021Primary pancreatic lymphoma RSNA Case Collection2020Flipped hepatic Artery Infusion Pump ReservoirRSNA Case Collection2022 Vol. 3, No. 5 Metrics Altmetric Score PDF download

Anatomical variation in arterial supply of liver – Case study

The variations of blood supply of liver is of great importance for general surgery, particularly hepatic surgery. Blood supply of liver is significant for liver transplantations, radiological procedures, and laparoscopic method of operation and for the healing of penetrating injuries, including the space close to the hepatic area.The pattern of the normal vascular system of the liver comes from the common hepatic artery (CHA), originating from the celiac trunk. The gastroduodenal artery (GDA), right gastric artery (RGA) and proper hepatic artery (PHA) are the main branches of the CHA. After that, the division of the PHA composes the left and right hepatic branches.During a routine dissection with medical students from the Department of Anatomy, Parul institute of Medical sciences and research Vadodara, We found on one cadaver that the blood supply of the liver differed from a normal blood supply of liver.In one cadaver we found that liver is supplied by a direct branch from celiac trunk and in same cadaver liver is also supplied by proper hepatic artery. The knowledge about the variations in hepatic arterial anatomy is very important for surgical gastroenterologists and interventional radiologists for preoperative planning and intraoperative imaging during procedures like liver transplantation, cholecystectomy, gastrectomy, hiatal hernia repair, trans-arterial chemotherapy and hepatic arteriography.

Robot Assisted Distal Pancreatectomy with Celiac Axis Resection (DP-CAR) for Pancreatic Cancer: Surgical Planning and Technique.

Malignant pancreatic tumors involving the celiac artery can be resected with a distal pancreatectomy, splenectomy and celiac axis resection (DP-CAR), relying on collateral flow to the liver through the gastroduodenal artery (GDA). In the current manuscript, the technical conduct of robotic DP-CAR is outlined. The greater curve of the stomach is mobilized with care to avoid sacrificing the gastroepiploic vessels. The stomach and liver are retracted cephalad to facilitate dissection of the porta hepatis. The hepatic artery (HA) is dissected and encircled with a vessel loop. The gastroduodenal artery (GDA) is carefully preserved. The common HA is clamped and triphasic flow in the proper HA via the GDA is confirmed using intra-operative ultrasound. A retropancreatic tunnel is made over the superior mesenteric vein (SMV). The pancreas is divided with an endovascular stapler at the neck. The inferior mesenteric vein (IMV) and splenic vein are ligated. The HA is stapled proximal to the GDA. The entire specimen is retracted laterally with further dissection cephalad to expose the superior mesenteric artery (SMA). The SMA is then traced back to the aorta. The dissection continues cephalad along the aorta with the bipolar energy device used to divide the crural fibers and celiac nerve plexus. The specimen is mobilized from the patient's right to left until the origin of the celiac axis is identified and oriented towards the left. The trunk is circumferentially dissected and stapled. Additional dissection with hook cautery and the bipolar energy device fully mobilizes the pancreatic tail and spleen. The specimen is removed from the left lower quadrant extraction site and one drain is left in the resection bed. A final intra-operative ultrasound of the proper HA confirms pulsatile, triphasic flow in the artery and liver parenchyma. The stomach is inspected for evidence of ischemia. Robotic DP-CAR is safe, feasible and when used in conjunction with multi-modality therapy, offers potential for long-term survival in selected patients.

A new software tool for planning interventional procedures in liver cancer

Introduction Intra-arterial therapy is an effective way of performing chemotherapy or radiation therapy in patients with primary liver cancer (i.e. hepatocellular carcinoma). Although this minimally invasive approach is now an established treatment option, support tools for pre-operative planning and intra-operative assistance might be helpful. Material and methods We developed an approach for semi-automatic segmentation of computed tomography angiography images of the main arterial branches (required for access path to the treatment site), automatic segmentation of the liver, arterial and venous tree, and interactive segmentation of the tumors (required for procedure-specific planning). This approach was then integrated into a liver-specific workflow within EndoSize® solution, a planning software for endovascular procedures. The main branches extraction approach was qualitatively evaluated inside the software, while the automatic segmentation methods were quantitatively assessed. Results Main branches extraction provides a success rate of 85% (i.e. all arteries correctly extracted) in a dataset of 172 patients. On public databases, a mean DICE of 0.91, 0.47 and 0.92 was obtained for liver, venous and arterial trees segmentation, respectively. Conclusions This pipeline is suitable for directly accessing the treatment site, giving anatomic measurements, and visualizing the hepatic trees, liver, and surrounding arteries during the pre-operative planning. Abbreviations HCC: hepatocellular carcinoma; TACE: transarterial chemoembolization; SIRT: selective internal radiation therapy; CT: computed tomography; CTA: computed tomography angiography; AMS: superior mesenteric artery; LGA: left gastric artery; RHA: right hepatic artery; LHA: left hepatic artery; rbHA: right branch of the hepatic artery; lbHA: left branch of the hepatic artery; GDA: gastroduodenal artery; VOI: volume of interest; SD: standard deviation; MICCAI: medical image computing and computer assisted interventions; MR: magnetic resonance

Anatomic Variations of the Hepatic Artery in 5625 Patients.

To analyze the origin and anatomic course of the hepatic arteries by using digital subtraction angiography (DSA) and multidetector CT in a large study sample. This retrospective study included 5625 patients who underwent liver CT and chemoembolization between January 2005 and December 2018 (mean age, 60 years ± 11 [range, 11-99 years]; 4464 males). The CT and DSA images were reviewed to evaluate the visceral arterial anatomy for variations in the celiac axis and hepatic arteries. Aberrant right hepatic arteries (aRHAs) and aberrant left hepatic arteries (aLHAs) were defined on the basis of their origin and anatomic course. Statistical analyses were performed to evaluate the association between aRHAs and aLHAs and the association between variations in the hepatic artery and celiac axis. Right hepatic arteries were categorized as being aRHAs (if originating from the proximal to middle common hepatic artery, gastroduodenal artery, superior mesenteric artery [SMA], celiac axis, aorta, splenic artery, or left gastric artery [LGA]) or as being aLHAs (if arising from the LGA, celiac axis, aorta, or SMA). The prevalence of aRHAs (15.63%; 879 of 5625) and the prevalence aLHAs (16.32%; 918 of 5625) were similar. Patients with an aRHA were more likely to have an aLHA than those without an aRHA (29.01% vs 13.97%; P < .001), and patients with an aLHA were more likely to have an aRHA than those without an aLHA (27.78% vs 13.26%; P < .001). There was no association between the hepatic arterial variations and celiac axis variations. A hypothetical anatomic model summarizing the observed variations was created. A comprehensive list of hepatic arterial variations and a three-dimensional hypothetical model for the observed variations were described.Keywords: CT, Angiography, Liver, Anatomy, Arteries© RSNA, 2021 Supplemental material is available for this article. See also commentary by Sutphin and Kalva in this issue.

Usefulness of computed tomography during arteriography in a selective arterial calcium agent injection test for pancreatic gastrinoma: a case description.

Pancreatic gastrinoma is a rare pancreatic neuroendocrine tumor with an incidence of about 0.5–21.5 cases per million people worldwide. The most common sites are the duodenum (75%), pancreas (20%), and other organs (5%). Gastrinomas are malignant in about 60–90% of cases (1-5). Malignant gastrinomas originating beneath the duodenal mucosa often metastasize to the liver, even if the tumor diameter is ≤1 cm. Therefore, in patients with gastrinoma and Zollinger–Ellison syndrome, it is important to determine the number and site(s) of gastrinoma(s), as well as the presence or absence of liver metastases. However, the detection sensitivity of computed tomography (CT) and magnetic resonance imaging is about 10–50%, that of angiography is 20–50%, and that of somatostatin receptor scintigraphy is 30–70%. Tumor size is strongly correlated with the detection sensitivity of any examination modality, and tumors of <1 cm in diameter are often difficult to detect (1,2). Therefore, the selective arterial calcium agent injection (SACI) test was developed as an effective method to detect small gastrinomas (2,6,7). In the SACI test, calcium gluconate is injected via a microcatheter into selected arterial branches to stimulate gastrin secretion from the gastrinoma located in the corresponding arterial territory. Generally, calcium gluconate is selectively injected into the gastroduodenal artery (GDA), superior mesenteric artery (SMA), distal or proximal portion of the splenic artery (distal SpA, proximal SpA), and the proper hepatic artery (PHA). The subsequent increase in the serum gastrin level is monitored using blood samples taken from the hepatic vein before and at 30, 60, 90, and 120 s after the injection. The location of the gastrinoma is determined based on a significant increase in serum gastrin levels in response to calcium gluconate (maximum serum gastrin level after calcium injection/serum gastrin level before calcium agent injection; with a median change of about 4.21 times baseline) (8). However, there are two limitations of the SACI test. First, the distribution of calcium varies between individual patients due to anatomical differences in the pancreatic arterial branches and the arterial territories. Second, there are many false positives following the injection of calcium gluconate into the GDA (median change of 4.15 times the baseline value) because calcium gluconate may stimulate normal gastrin-secreting cells in the gastric prepylorus and duodenal bulbus (8,9). It is possible to visualize the distribution of calcium following its injection by performing CT during arteriography (CTA). Here, we report a case in which the SACI test was combined with CTA for the diagnosis of a gastrinoma located in the pancreatic head and to exclude the presence of liver metastases.

Gastroduodenal artery steal syndrome treated with coil embolization after orthotopic liver transplantation

Gastroduodenal artery steal syndrome treated with coil embolization after orthotopic liver transplantation

Massive hemobilia caused by rupture of gastroduodenal artery pseudoaneurysm, a delayed complication of laparoscopic cholecystectomy: a case report

BackgroundHemobilia is a rare cause of upper gastrointestinal bleeding that originates from the biliary tract. It is infrequently considered in diagnosis, especially in the absence of abdominal trauma or history of hepatopancreatobiliary procedure, such as cholecystectomy, which can cause arterial pseudoaneurysm. Prompt diagnosis is crucial because its management strategy is distinct from other types of upper gastrointestinal bleeding. Here, we present a case of massive hemobilia caused by the rupture of a gastroduodenal artery pseudoaneurysm in a patient with a history of laparoscopic cholecystectomy 3 years prior to presentation.Case presentationA 44-year-old Indonesian female presented to the emergency department with complaint of hematemesis and melena accompanied by abdominal pain and icterus. History of an abdominal trauma was denied. However, she reported having undergone a laparoscopic cholecystectomy 3 years prior to presentation. On physical examination, we found anemic conjunctiva and icteric sclera. Nonvariceal bleeding was suspected, but esophagogastroduodenoscopy showed a blood clot at the ampulla of Vater. Angiography showed contrast extravasation from a gastroduodenal artery pseudoaneurysm. The patient underwent pseudoaneurysm ligation and excision surgery to stop the bleeding. After surgery, the patient’s vital signs were stable, and there was no sign of rebleeding.ConclusionGastroduodenal artery pseudoaneurysm is a rare complication of laparoscopic cholecystectomy. The prolonged time interval, as compared with other postcholecystectomy hemobilia cases, resulted in hemobilia not being considered as an etiology of the gastrointestinal bleeding at presentation. Hemobilia should be considered as a possible etiology of gastrointestinal bleeding in patients with history of cholecystectomy, regardless of the time interval between the invasive procedure and onset of bleeding.

Robotic pancreatoduodenectomy for large solid pseudopapillary tumor of the pancreas using precise and systematic vascular control technique

Large tumors in the head of the pancreas pose technical challenges during resection in minimally invasive pancreatoduodenectomy (PD). The precise and systematic vascular control of the pancreaticoduodenal branches of the superior mesenteric artery and vein during robotic PD for a large solid pseudopapillary tumor of the pancreas is described in this video. A 16-year-old female presented with a lump in the abdomen, early satiety, and epigastric pain of 3 months duration. Contrast-enhanced computed tomography abdomen revealed 7.1 × 6.2 cm solid mass with cystic areas in the head of the pancreas. The tumor was compressing the portal vein with dilated pancreaticoduodenal veins. In the present technique, the anterosuperior pancreaticoduodenal vein is controlled first, followed by the superior pancreaticoduodenal artery (by ligating Gastroduodenal artery). This is followed by the control of inferior pancreaticoduodenal veins and arteries. The posterosuperior pancreaticoduodenal vein is ligated at the end to prevent vascular congestion of the uncinate region. The duration of surgery and intraoperative blood loss were 440 minutes and 200 mL, respectively. The patient had an uneventful postoperative course and discharged on the sixth postoperative day. Histopathological examination confirmed the diagnosis of the solid pseudopapillary tumor. At nine months follow-up, the patient remains asymptomatic with no recurrence. A stepwise precise vascular control described in this report could minimize intraoperative bleeding during robotic PD for large tumors in the head of the pancreas.

Intractable bleeding: the role of embolization in a resource-limited country

Transarterial catheter embolization is novel in Ghana, even though it has been practiced over three decades in certain parts of the world. The procedure is safer with the advent of new catheter techniques and embolic agents which place interventional radiology at the forefront of the treatment of bleeding due to myriad of indications. It is fast, safe, and minimally invasive relative to open surgery, especially when other conventional minimally invasive procedures such as endoscopic banding and sclerotherapy fail. This paper presents two cases involving pre-and post-embolization digital subtraction angiogram (DSA) of gastroduodenal artery and bilateral iliac arteries. Findings of DSA of the gastroduodenal artery and bilateral iliac arteries showed florid extravasation and extensive neovascularity. Post embolization DSA showed absent extravasation and near total devascularization. The inclusion of embolization to the management protocols of upper gastrointestinal bleeding and intractable haematuria is recommended

Use of Hemoglobin Based Oxygen Carrier HBOC-021 (Hemopure) As a Bridge during Emergencies in Patients Unable to Receive Blood Products: Experience at a Tertiary Care Center

IntroductionThere are about 1.1 million Jehovah's witnesses (JW) in the United States who do not accept blood transfusions due to religious beliefs. When these patients present with severe anemia, management is challenging and mortality high. Hemoglobin based Oxygen Carrier HBOC-201 has been available for compassionate use, but its use is limited due to lack of experience. Here we present the experience of a tertiary care center with HBOC-201 to better manage critically ill JW patients with anemia.Case159 y.o. JW female was admitted with diabetic ketoacidosis, right lower extremity gangrene, and sepsis. Labs showed WBC 17.4, Hgb 7.9, and platelets 434. Within hours, the patient went into septic shock requiring vasopressors and mechanical ventilation, AKI requiring dialysis, and transaminitis. Her Hgb dropped to 6.9. She was started on insulin drip and broad-spectrum antibiotics. Her clinical condition improved, vasopressors were discontinued and she was extubated. She subsequently had a below knee amputation. On post-operative day 2, her condition worsened. She developed fevers and vasopressors were restarted. Her Hgb dropped to 5.8. Erythropoietin injections and Iron supplementation were initiated. At this point, the surgical team planned for an above knee amputation for better control of the infection, with a pre-operative goal Hgb of 8. On post-op day 7, the patient's clinical status deteriorated, and she was re-intubated and found to have an embolic stroke. Her Hgb continued to drop to 5.3 and she subsequently received 2 units of HBOC in preparation for urgent surgical intervention for infection control. Her Hgb improved to 6.5 following administration of 2 units of HBOC. Despite the improvement in Hgb, she acutely worsened with increased vasopressor and ventilation requirement, severe acidosis, methemoglobinemia, elevated troponin (0.5), and hypoglycemia. On the next day, she went into cardiac arrest and died.Case249 y.o. JW male was admitted with acute pancreatitis. Labs showed WBC 12.9, Hgb 18.6, transaminitis and lipase >600. The patient's clinical status improved with conservative management but on day 3 developed hematemesis with a drop in Hgb to 9.7. He became lethargic and was subsequently intubated. Esophagogastroduodenoscopy (EGD) showed a gastroesophageal junction clot. Gastrointestinal bleeding persisted over the next 3 days with drop in Hgb to 5. EGD showed an ulcer with visible vessel. Apart from proton pump inhibitor drip, he was also started on Erythropoeitin , B12 and Iron Despite these measures, his Hgb continued to drop with a nadir of 3.3 and worsening clinical status requiring multiple vasopressors. On Day 9, HBOC was approved for compassionate use. The patient was infused 4 units of HBOC. Hgb improved to 5.2, and the patient was weaned off vasopressors. A repeat EGD with injection and cauterization of the bleeding vessel were performed. The patient received one unit of HBOC daily to keep Hgb>5 (figure 1) and the gastroduodenal artery was embolized. The patient developed complications from HBOC, including hypernatremia, alkalosis and methemoglobinemia successfully treated with ascorbic acid and methylene blue. Troponin was normal and EKG was normal. Two days later, he developed lactic acidosis, ventilator associated pneumonia, acute respiratory distress syndrome, shock and multiorgan failure and succumbed to his illness. During this time, his Hgb was stable at 6.1 and there was no further bleeding.ConclusionHBOC-021 (Hemopureâ) is a polymerized bovine hemoglobin. It has been used for management of anemia in JW patients under compassionate-use FDA guidelines with varying success. Our experience with HBOC shows that it can be used successfully in emergencies to hemodynamically stabilize patients. Our first patient showed an improvement in Hgb while our second patient attained a stable Hgb and recovered from his hemorrhagic shock. With clinical improvement, he could get an EGD and embolization done which controlled his bleeding. The side effects of HBOC are easily managed with supportive care and methylene blue. We believe that Intensivists and Hematologists should be aggressively involved in JW patients who urgently need but refuse blood transfusion. An institution based protocol should be available to rapidly obtain HBOC. Efforts should be made to minimize blood loss and the use of erythropoiesis stimulating agents should be maximized. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Hyperspectral Imaging (HSI)-A New Tool to Estimate the Perfusion of Upper Abdominal Organs during Pancreatoduodenectomy.

Simple SummaryNovel intraoperative imaging systems may have a critical impact on intraoperative decision-making. Hyperspectral imaging (HSI) is one of the leading new imaging systems, providing color pictures of tissue characterization, such as oxygen saturation (StO2) and Near-Infrared Perfusion Index (NIR-PI). Several surgical disciplines have already used HSI in detecting tissue perfusion with a proven record of success. To the best of our knowledge, HSI has not been used in the field of pancreatic surgery yet.Hyperspectral imaging (HSI) in abdominal surgery is a new non-invasive tool for the assessment of the perfusion and oxygenation of various tissues and organs. Its benefit in pancreatic surgery is still unknown. The aim of this study was to evaluate the key impact of using HSI during pancreatoduodenectomy (PD). In total, 20 consecutive patients were included. HSI was recorded during surgery as part of a pilot study approved by the local Ethics Committee. Data were collected prospectively with the TIVITA® Tissue System. Intraoperative HS images were recorded before and after gastroduodenal artery (GDA) clamping. We detected four patients with celiac artery stenosis (CAS) caused by a median arcuate ligament (MAL). In two of these patients, a reduction in liver oxygenation (StO2) was discovered 15 and 30 min after GDA clamping. The MAL was divided in these patients. HSI showed an improvement of liver StO2 after MAL division (from 61% to 73%) in one of these two patients. There was no obvious decrease in liver StO2 in the other two patients with CAS. HSI, as a non-invasive procedure, could be helpful in evaluating liver and gastric perfusion during PD, which might assist surgeons in choosing the best surgical approach and in improving patients’ outcomes.

A MDCT study on the analysis of Coeliac trunk and its branching pattern in the north Indian population

Introduction: The coeliac trunk, which emerges from the AA at the level of T12-L1 vertebra immediately before the aortic hiatus, is the first anterior branch. The left stomach artery is the first branch, and the coeliac trunk divides into the common hepatic and splenic arteries. It divides into three branches: the left gastric artery, common hepatic artery, and splenic artery. Materials and methods: Hundred patients (aged 18 to 70) referred to the Department of Radiodiagnosis at Subharti Medical College &amp; Hospital, Meerut, and neighbouring Imaging Centers in the NCR underwent the cross-sectional study (MDCT). From August 2019 to October 2022, MDCT scan images of the abdomen region were examined for the normal anatomy of the coeliac trunk and its branches to determine their changes and type. Results: According to Uflacker's classification, type-1 coeliac trunk branching pattern is the most frequently observed variant in the current study, whereas type-2 is the least frequently observed variety. In 2% of the population, there are variations in the type-1 coeliac trunk, such as the gastroduodenal artery and accessory hepatic artery that immediately emerge from the coeliac trunk. Common hepatic artery emerging from superior mesenteric artery in 2% of the population of type-5 variant. Left gastric artery takes a distinct origin from the abdominal aorta in 1% of type-6 coeliac trunks. Conclusions: The most prevalent coeliac trunk branching pattern linked with other variations is type -1 variety. Each variation is distinct, and the carelessness of a combination of such variances may pose a serious risk and result in fatal complications. Understanding the coeliac trunk branching pattern precisely is crucial. Keywords: Coeliac trunk (CT), Abdominal aorta (AA), Multidetector computerised tomography (MDCT), Common hepatic artery (CHA), Uflackers Classification.

Preventive covered stent placement at the gastroduodenal artery stump in angiogram-negative sentinel hemorrhage after pancreaticoduodenectomy.

To evaluate the clinical outcomes of preventive covered stent placement at the gastroduodenal artery stump in patients with angiogram-negative sentinel hemorrhage after pancreaticoduodenectomy. Between July 2006 and September 2018, patients undergoing computed tomography angiography or diagnostic angiography for sentinel hemorrhage after pancreaticoduodenectomy were retrospectively reviewed. Patients having angiogram-negative angiography and undergoing preventive covered stent placement or conservative treatment were included. Clinical outcomes, technique success, and complications were evaluated. A total of 25 patients (mean age 62.5years) were evaluated, including 15 patients underwent preventive covered stent placement at the gastroduodenal artery stump and 10 patients received conservative treatments. The clinical success rates were 50% (5/10) and 86.7% (13/15) for conservative treatments and covered stent groups, respectively (p = 0.07). In the conservative treatment group, delayed massive hemorrhage occurred in five patients, two of whom died of recurrent bleeding due to gastroduodenal artery pseudoaneurysm within 16days, and two had intraluminal hemorrhage within 5days. In the covered stent group, one patient had inferior pancreaticoduodenal artery pseudoaneurysm 1day after the placement of the covered stent, and one had recurrent bleeding due to duodenal ulcer within 14days. The 30-day mortality was 40% (4/10) and 0 in the conservative treatment and covered stent groups, respectively (p = 0.02). The difference in the overall survival was nonsignificant between the two groups (p = 0.23). The preventive covered stent placement at the gastroduodenal artery stump is safe and reduces delayed massive hemorrhage and short-term mortality in patients with angiogram-negative sentinel hemorrhage after pancreaticoduodenectomy.

Stenting of ruptured gastroduodenal artery pseudoaneurysm

Gastroduodenal artery (GDA) aneurysm is a rare surgical entity that causes various symptoms. In the case of rupture, it usually presents an ominous prognosis and mortality rate of up to 40%. Although open surgical procedure is a mainstay, endovascular intervention is emerging a promising treatment in recent years, due to its advantages and safety. We present a case of upper gastrointestinal bleeding caused by ruptured GDA pseudoaneurysmin a 71-year-old woman, with medical episodes of acute pancreatitis, a pancreatic body tumor removal surgery was performed, and now the tumor is relapsing and metastasizing. The treatment approach is blocking off the pseudoaneurysm by a covered stent. The procedure was successful and the patient is asymptomatic. Two months later, the pseudoaneurysm reduces its size and completely excluded from the preservation of the blood flow in the artery.Follow-up to 26 month, patient is well, no symptoms or recurrence. Endovascular interventional treatment in the case of GDA aneurysms is considered a promising alternative not only to open surgery but also to an effective emerging technique even in the acute setting.

Utility of a Suture-Mediated Closure System for Large Bore Arterial Access During Challenging Liver Intra-Arterial Catheters Implantation

To describe and study the utility of vascular suture-mediated closure systems for large bore arterial access during challenging implantation of liver intra-arterial catheters taking as a reference the conventional procedure involving patients without challenging anatomy. Between January 2017 and January 2019, 61 consecutive patients underwent 65 intra-arterial catheter IAC implantations for colorectal cancer. Twenty-three procedures (35%) considered by the operators with challenging coeliac trunk angulations were treated using a vascular suture technique where a 6-F introducer was used, the other patients were treated with a conventional 4F access technique. Clinical and radiological characteristics of patients, technical success (implantation of catheters allowing safe infusion of chemotherapy) and complications (Common Terminology Criteria for Adverse Events, CTCAE 5.0) were recorded. Mean coeliac trunk angulations were 36.3° (± 14.3) for the vascular closure group and 49.6° (± 17.1) for the conventional group. Technical success of the procedures was 100% for the vascular closure group and 80% in the conventional group (p < .05). Four patients with technical failure in the conventional group had a successful IAC implantation on the second attempt using the vascular closure technique. The use of a suture-mediated closure system for large bore arterial access allowed more frequent positioning of the distal tip into the gastro duodenal artery (GDA) (p = .01). No major complication occurred. The use of a large bore arterial access combined with a suture-mediated closure system may be useful for challenging IAC implantation without major complications.