Gastroduodenal Artery Research Articles

S1949 An Unusual Case of Chronic Pancreatitis Presenting With Recurrent Obscure Gastrointestinal Bleeding

Introduction: Chronic pancreatitis (CP) is a sequela of repeated pancreatic injury resulting in loss of exocrine and endocrine function of the pancreas. In most cases, CP presents with chronic abdominal pain and patients usually have either clinical and radiological features of CP, with gastrointestinal bleeding (GIB) as a very rare occurrence. Herein is a presentation of recurrent obscure GIB caused by chronic pancreatitis. Case Description/Methods: A 48-year-old male with a prior history of PUD and recurrent GIB episodes for several years presents with dark red bleeding per rectum for two days. Of note, the patient had undergone several endoscopies and the most recent endoscopies done six months prior were all unremarkable. He denied hematemesis, NSAIDs, or anticoagulant use. Denied liver or pancreatic disease but endorsed a prior history of moderate alcohol intake. Physical examination was unremarkable except for tachycardia and epigastric tenderness. He was mildly anemic with leukocytosis. The abdominal and pelvic CT scan was unremarkable. EGD revealed a small gastric oozing site (Figure) suspected to be an AVM or dieulafoy's lesion and clipped. He continued to have a frank bloody stool and developed hemorrhagic shock requiring multiple transfusions and vasopressors. Findings on two additional EGDs were unremarkable. He had mesenteric angiography performed with ligation of the gastroduodenal artery empirically. Despite the intervention, he continued to bleed. Abdominal CTA (Figure) noted active extravasation in the 2nd segment of the duodenum. Explorative laparotomy revealed an edematous head and uncinate portion of the pancreas with venous engorgement. There was erosion into the duodenum with acute hemorrhage (Figure). A duodenotomy and Roux-en-y (duodenojejunostomy and jejunojejunostomy) were performed. On account of the above findings, a tissue biopsy was not obtained. Following surgery, he remained hemodynamically stable and got discharged. Discussion: Massive obscure GIB due to complications of pancreatitis rarely does occur. A few cases reported are due to complications resulting from hemosuccus pancreaticus, pseudoaneurysm from a vascular supply, or erosion into adjacent viscus in the setting of known pancreatitis. Our patient represents an unusual presentation in which his recurrent obscure massive GI bleeding was the initial presentation of CP. We present this case to broaden our knowledge that obscure GI bleeding can be a complication of CP and the only manifestation of the disease.Figure 1.: The image on the left shows an EGD with the gastric oozing site with clips, and the middle image shows CTA with extravasation in the second segment of the duodenum. The image on the right shows the posterior aspect of the head of the pancreas, the uncinate, and venous engorgement.

S2642 Rare Case of Upper Gastrointestinal Bleeding Secondary to Hepatocellular Carcinoma

Introduction: Among gastrointestinal pathologies, gastrointestinal bleeding (GIB) is the most common cause of hospitalization within the United States, and consequently costing the healthcare system $5 billion.1 Common causes of upper gastrointestinal bleeding(UGIB) are gastric or duodenal ulcers, gastritis or duodenitis, and esophagitis. We present a rare case of hepatocellular carcinoma (HCC) extending into the duodenum causing an UGIB. Case Description/Methods: 64 year old male with history of alcohol abuse, developed multifocal HCC and decompensated cirrhosis presents with fatigue and weakness. Additionally, patient has multiple admissions for UGIB stabilized by gastroduodenal artery embolization after failing endoscopic treatment. At admission, patient was hypotensive at 100/57 and anemic with a hemoglobin 5.8. Computed tomography and angiogram showed a exophytic lesion supplied by the cystic artery eroding into the duodenal bulb. Band and coil embolization of the tumoral arteries arising from the cystic artery was performed. The patient had worsening hematochezia and hemodynamic instability, and deemed inoperable. He was not a transplant candidate given his cancer burden and later expired. (Figure) Discussion: Esophagogastroduodenoscopy (EGD) and angioembolization play vital roles in treatment of UGIB and surgery is used as salvage therapy. EGD is used to provide diagnosis and therapy. In an acute setting the Glasgow Blatchford Score (GBS) is used for risk assessment. EGD within 24 hours is recommended for patients and within 12 hours for variceal bleeding. A combination of thermal and nonthermal coagulation, submucosal injection, and clipping can facilitate hemostasis. Contact thermal therapy, includes bipolar and unipolar cautery, allows for pressure application at the bleeding point with thermal energy for the coagulation. Non-contact thermal technique such as argon plasma coagulation uses ionized argon gas to ablate hemorrhagic tissue. Multiple nonthermal techniques including injection sclerotherapy and clipping. Injection sclerotherapy consists of injections of epinephrine, or other substances, surrounding the bleeding site with thermal therapy. Angioembolization is used for bleeding when endoscopic interventions fail. A tumor rupture is life-threatening and there are limited reports of UGIB secondary to HCC, emphasizing the importance of our case.Figure 1.: A: Prior gastroduodenal artery embolization B: Proper hepatic artery C: Common hepatic artery D: Left hepatic artery E: Right hepatic artery F: Cystic artery.

S2694 An Uncommon Cause of Upper Gastrointestinal Bleeding

Introduction: We present a case of GI bleeding due to a direct communication between a pancreatic fistula and the splenic vein. Case Description/Methods: A 55 year-old female with a history of endometrial cancer, superficial lower extremity thrombus, and alcohol use presented with abdominal pain and dark red blood in her stools requiring blood transfusion. She reported recent ibuprofen use. An upper endoscopy showed small esophageal varices without red wales or stigmata of recent hemorrhage. A CT demonstrated extensive subacute thrombosis of the right and left portal veins, main portal vein (PV), proximal superior mesenteric vein (SMV) and splenic vein (SV). The pancreas appeared atrophic and contained small cysts. There was small ascites. Liver biopsy demonstrated mild steatohepatitis without fibrosis. She underwent placement of a transjugular intrahepatic portosystemic shunt (TIPS) with thrombectomy from the PV, SMV, and SV and was started on anticoagulation. Due to bleeding recurrence, she underwent TIPS revision with tPA injection and additional mechanical thrombectomy. Subsequently on an ultrasound, TIPS thrombosis was again noted and during TIPS revision, a communication was noted between the pancreatic duct and splenic vein, finally identifying the likely source of bleeding. A splenic vein stent was placed. Discussion: This case highlights an uncommon cause of upper GI bleeding and reinforces the importance of keeping a broad differential diagnosis for a patient with portal hypertension. Our patient had a complicated course with 2 TIPS revisions and esophageal varices, but the source of her bleeding was neither variceal nor mucosal. (Figure) Splenic vein thrombus can result as a complication of pancreatitis and subsequently lead to “sinestrial” (left-sided) portal hypertension and the formation of gastric varices which can also present with gastrointestinal bleed (GIB). Our patient did not have the classic finding of sinestral portal hypertension associated with SV thrombosis: gastric varices. Furthermore, during her initial TIPS placement and even her initial thrombectomy, no pancreatic fistula was observed. Although not always visualized due to the intermittent nature of bleeding, hemosuccus pancreaticus in the setting of chronic alcoholic pancreatitis most commonly involves the splenic artery (60-65%) and less commonly involves the gastroduodenal artery. Our patient’s case is unusual because angiogram demonstrated direct communication between a pancreatic fistula and the splenic vein, not the splenic artery.Figure 1.: Large clot burden at superior mesenteric vein.

Gastroduodenal Artery Pseudoaneurysm

Gastroduodenal artery pseudoaneurysms are rare complications of pancreatitis and commonly manifest as abdominal pain and gut bleeding due to rupture. Usually, these vascular complications are asymptomatic and are thus diagnosed incidentally on magnetic resonance imaging or computed tomography examination. Pseudoaneurysms should be treated immediately after diagnosis because of the higher rate of mortality (90%) in untreated cases, whereas 12% in treated cases. Herein, we describe a unique case of gastroduodenal artery pseudoaneurysm in a 29-year-old male patient with chronic pancreatitis, which was treated successfully with embolization.

Gastroduodenal artery disconnection during liver transplantation decreases non-anastomotic stricture incidence

BackgroundThe hepatic artery is the only blood source nourishing the biliary duct and associated with biliary complication after liver transplantation (LT). Gastroduodenal artery (GDA) disconnection increased proper hepatic artery flow. Whether this procedure attenuates biliary non-anastomotic stricture (NAS) is not clear. MethodsA total of 241 patients with LT were retrospectively analyzed. The patients were divided into the GDA disconnection (GDA-) and GDA preservation (GDA+) groups. Propensity score matching (PSM) was administrated to reduce bias. Logistic regression was conducted to analyze risk factors for biliary NAS before and after PSM. Postoperative complications were compared. Kaplan-Meier survival analysis and log-rank tests were performed to compare overall survival. ResultsIn all, 99 patients (41.1%) underwent GDA disconnection, and 49 (20.3%) developed NAS. Multivariate logistic regression revealed that GDA preservation (OR = 2.24, 95% CI: 1.11-4.53; P = 0.025) and model for end-stage liver disease (MELD) score > 15 (OR = 2.14, 95% CI: 1.12-4.11; P = 0.022) were risk factors for biliary NAS. PSM provided 66 pairs using 1:2 matching method, including 66 GDA disconnection and 99 GDA preservation patients. Multivariate logistic regression after PSM also showed that GDA preservation (OR = 3.15, 95% CI: 1.26-7.89; P = 0.014) and MELD score > 15 (OR = 2.41, 95% CI: 1.08-5.36; P = 0.031) were risk factors for NAS. When comparing complications between the two groups, GDA preservation was associated with a higher incidence of biliary NAS before and after PSM (P = 0.031 and 0.017, respectively). In contrast, other complications including early allograft dysfunction (P = 0.620), small-for-size graft syndrome (P = 0.441), abdominal hemorrhage (P = 1.000), major complications (Clavien-Dindo grade ≥ 3, P = 0.318), and overall survival (P = 0.088) were not significantly different between the two groups. ConclusionsGDA disconnection during LT ameliorates biliary NAS incidence and may be recommended for application in clinical practice.

Feasible management of median arcuate ligament syndrome in orthotopic liver transplantation recipients.

BACKGROUNDIn orthotopic liver transplantation (OLT) recipients, median arcuate ligament syndrome (MALS) is considered a risk factor for hepatic arterial thrombosis (HAT), which is dreadful for OLT recipients. Different alternative surgical procedures have been proposed to overcome the impact of MALS on transplantation, but clinical evidence is still scarce. AIMTo evaluate the feasible surgical management of MALS to reduce complications in OLT patients.METHODSData for 288 consecutive patients who underwent OLT at The First Hospital of Jilin University between January 2017 and July 2020 were retrospectively reviewed. The surgical management of median arcuate ligament (MAL) and modifications to the arterial anastomosis were recorded. The perioperative and long-term prognosis of MALS recipients were noted. Detailed preoperative and postoperative data of patients were analyzed in a descriptive manner.RESULTSEight patients with MALS were included in this study. The first patient with MALS received no intervention during the primary surgery and developed postoperative HAT. Salvage liver transplantation with MAL division was successfully performed. Gastroduodenal artery (GDA) preservation with splenic artery ligation was performed on three patients, only GDA preservation was performed on two patients, and no intervention was performed on two patients. No patient developed HAT after surgery and postoperative recovery was satisfactory. CONCLUSIONThe preservation of collateral circulation between the superior mesenteric artery and celiac trunk via the GDA with or without splenic artery ligation is a safe and feasible alternative to MAL division.

Covered stent placement for gastroduodenal artery stump hemorrhage after pancreaticoduodenectomy: long-term patency and risk factor of stent failure.

To evaluate the long-term outcomes of covered stent placement in patients with gastroduodenal artery (GDA) stump hemorrhage after pancreaticoduodenectomy (PD) and to identify risk factors of stent failure. Covered stent was placed in total of 21 patients for GDA stump hemorrhage after PD from September 2012 to March 2021. Technical and clinical success, complications, and stent patency were retrospectively evaluated. Nine relevant variables were analyzed to determine risk factors for stent failure. In 20 of 21 patients (95.2%), the GDA stump was completely excluded with covered stent placement. Immediate hemostasis was achieved in the 20 patients and rebleeding from jejunal artery occurred in one patient which was successfully embolized one day after the stent placement. There was no procedure-related complication or early mortality (<30 days). During follow-up period (median 655.5 days), stent thrombosis was found on CT in 10 patients (50.0%, 10/20) without any laboratory or CT abnormalities. One thrombosed stent migrated into the jejunum 20 months after placement. The six-month, one-year, and two-year stent patency were 81.9%, 52.9%, and 37.8%, respectively (median 620 days). The recurrence of primary malignancy was associated with stent failure (HR 5.70; 95% CI 1.18-27.76, p = 0.03). Covered stent placement is an effective and safe management of postoperative GDA stump hemorrhage. Stent failure occurred frequently (50%) but did not cause liver ischemia. Stent failure was associated with recurrence of primary malignancy. 1. Covered stent placement is an effective and safe management of postoperative GDA stump hemorrhage.2. Stent failure occurred frequently (50%) but did not cause liver ischemia.3. Stent failure was associated with recurrence of primary malignancy.

Regional vessels wrapping following pancreaticoduodenectomy reduces the risk of post-operative extra-luminal bleeding. A systematic review.

BackgroundPost-pancreatectomy bleeding is a potentially fatal complication which results from the erosion of the regional visceral arteries, mainly the hepatic artery and stump of the gastro-duodenal artery, caused by a leak or fistula from the pancreatic anastomosis. The objective of this article is to assess whether wrapping of regional vessels with omentum or falciform/teres ligament following pancreaticoduodenectomy reduces the risk of extra-luminal bleeding.Materials and methodStandard medical electronic databases were searched with the help of a local librarian and relevant published randomised controlled trials (RCT) and any type of comparative trial were shortlisted according to the inclusion criteria. The summated outcome of post-operative extra-luminal bleeding in patients undergoing pancreaticoduodenectomy was evaluated using the principles of meta-analysis on RevMan 5 statistical software.ResultTwo RCTs and 5 retrospective studies on 4100 patients undergoing pancreaticoduodenectomy were found suitable for this meta-analysis. There were 1404 patients in the wrapping-group (WG) and 2696 patients in the no-wrapping group (NWG). In the random effects model analysis, the incidence of extra-luminal haemorrhage was statistically lower in WG [odds ratio 0.51, 95%, CI (0.31, 0.85), Z = 2.59, P = 0.01]. There was moderate heterogeneity between the studies; however it was not statistically significant.ConclusionThe wrapping of regional vessels (using omentum, falciform ligament or ligamentum teres) following pancreaticoduodenectomy seems to reduce the risk of post-operative extra-luminal bleeding. However, more RCTs of robust quality recruiting a greater number of patients are required to validate these findings as this study presents the combined data of two RCTs and 5 retrospective studies.

P9.36: Impact and Consequences of Recipient Gastroduodenal Artery (GDA) Ligation Prior to Hepatic Artery (HA) Anastomosis During Orthotopic Liver Transplantation (OLT)

P9.36: Impact and Consequences of Recipient Gastroduodenal Artery (GDA) Ligation Prior to Hepatic Artery (HA) Anastomosis During Orthotopic Liver Transplantation (OLT)

Da Vinci robotic assisted pancreaticoduodenectomy with superior mesenteric vein resection and reconstruction

This study demonstrated Da Vinci robot assisted pancreaticoduodenectomy with superior mesenteric vein (SMV) resection and reconstruction. The patient was diagnosed with pancreatic head cancer preoperatively. After anesthesia, trocars were placed by “six-hole method”, and then constant pressure pneumoperitoneum was established. The first step was to remove the gallbladder, open the gastrocolonic ligament, and expose the pancreas and surrounding tissues. After making a Kocher incision, we dissected duodenum, inferior vena cava and uncinate process of pancreas, and then cleaned lymph nodes in groups 13 and 16A. After the stomach was severed using linear stapler, the right gastric artery was dissected and ligated. In this case, the adhesion around the pancreas and common hepatic artery was serious, so the pancreas was transected firstly. The gastroduodenal artery was dissected from the upper edge of the pancreas, and the lymph nodes in groups 7, 8, 9 and 12 were cleaned to expose the common bile duct and portal vein. The common bile duct was transected above the confluence plane of the cystic duct. After opening the colonic mesentery on the left side of the superior mesenteric artery (SMA), the jejunum was severed with a linear cutting obturator. The uncinate process was treated through the middle artery approach; the inferior pancreaticoduodenal artery was severed and lymph nodes were cleaned to the root of SMA and celiac trunk. The tumor and part of the invaded SMV were removed and end-to-end SMV anastomosis was performed. The proper hepatic artery was wrapped with the round hepatic ligament. To protect the stump of gastroduodenal artery, we padded the round hepatic ligament below the pancreaticoduodenal anastomosis. The modified Blumgart method was used for pancreaticointestinal duct to mucosal anastomosis. 4-0 ​V-Lock suture was used for continuous suture of posterior wall and anterior wall respectively, and finally gastrointestinal side-to-side anastomosis was performed. The operation time was 360 ​min and the intraoperative bleeding was 200 ​mL. The patient was discharged 7 days after operation.

Unconventional treatment in a Rare Case of Complex Coral Reef Aorta

Unconventional treatment in a Rare Case of Complex Coral Reef Aorta

525 A Review of Literature on Anatomical Variation of the Extrahepatic Biliary Tree Using Cadaveric Dissection and Imaging Modalities

Abstract Aim The aim of this project was to examine world literature to establish the various types and frequencies of anatomical variants within the extrahepatic biliary tree, thereby contributing to the body of information available to anatomists, surgeons, and radiologists. Knowledge of the notoriously variable anatomy of the extrahepatic biliary tree is of greater importance than ever, given the increased occurrence and complexity of hepatobiliary and laparoscopic surgeries. Method A database search of MEDLINE, EMBASE and PubMed was conducted in June 2021 and returned 3440 articles, of which 29 were deemed eligible for inclusion. Results A rare malposition, the left-sided gallbladder, was observed in 0.04–0.60% across five studies. A normal cystic artery origin, that is, from the right hepatic artery was observed in 73.3–92% with variations being seen from the left hepatic artery (1–1.9%), gastroduodenal artery (1–7.5%) and the aberrant right hepatic artery (3–12.1%). It was also noted that in 3.6–32% of subjects the course of the cystic artery lay extraneous to Calot's triangle. Michels’ and Hiatt's classification systems were used to define the anatomical variations of the hepatic arteries: studies using Michels’ Type III reported a prevalence from 6.4–15%, Michels’ Type VI from 0.6–7% and Hiatt's Type III recorded an incidence ranging from 9.7–14.8%. Conclusion The most obvious finding to emerge from this project was the widely variable anatomy of the extrahepatic biliary tract and the contrasting reported data. Surgeons should therefore anticipate such complexities and adapt techniques to avoid biliary and arterial injuries and associated intra- and postoperative complications.

WE2.10 Regional vessels wrapping following pancreaticoduodenectomy reduce the risk of post-operative extra-luminal bleeding. A systematic review

Abstract Aim Post-pancreatectomy bleeding which may be a potentially fatal complication, usually resulting from the erosion of the regional visceral arteries mainly the hepatic artery and stump of the gastro-duodenal artery, caused by a leak or fistula from the pancreatic anastomosis. The objective of this article is to assess whether regional vessels wrapping omentum or falciform/teres ligament following pancreaticoduodenectomy reduce the risk of post-operative extra-luminal bleeding. Method Standard medical electronic databases were searched with the help of local librarian and relevant published randomized controlled trial (RCT) and any type of comparative trials were shortlisted according to the inclusion criteria. Summated outcome of post-operative extra-luminal bleeding in patients undergoing pancreaticoduodenectomy was evaluated using the principles of meta-analysis on RevMan 5 statistical software. Result One RCT and 6 retrospective trials on 4100 patients undergoing pancreaticoduodenectomy for any indication were found suitable for this met-analysis. There were 1404 patients in the wrap-group (WG) group and 2696 patients in the no-wrap group (NWG). In the random effects model analysis, the incidence of extra-luminal hemorrhage rate was statistically lower in WG [odd ratio 0.51, 95%, CI (0.31, 0.85), Z=2.59, P=0.01]. There was moderate heterogeneity between the studies; however it was not statistically significant. Conclusion The wrapping of regional vessels (using omentum, falciform ligament or ligamentum teres following pancreaticoduodenectomy seems to reduce the risk of post-operative extra-luminal bleeding. However, more RCTs of robust quality recruiting higher number of patients are required to validate these findings because current study presented combined data of one RCT and 6 retrospective studies.

Feasibility of “cold” triangle robotic pancreatoduodenectomy

BackgroundTriangle pancreatoduodenectomy adds to the conventional procedure the en bloc removal of the retroperitoneal lympho-neural tissue included in the triangular area bounded by the common hepatic artery (CHA), the superior mesenteric artery (SMA), and the superior mesenteric vein/portal vein. We herein aim to show the feasibility of “cold” triangle robotic pancreaticoduodenectomy (C-Tr-RPD) for pancreatic cancer (PDAC).MethodsCold dissection corresponds to sharp arterial divestment performed using only the tips of robotic scissors. After division of the gastroduodenal artery, triangle dissection begins by lateral-to-medial divestment of the CHA and anterior-to-posterior clearance of the right side of the celiac trunk. Next, after a wide Kocher maneuver, the origin of the SMA, and the celiac trunk are identified. After mobilization of the first jejunal loop and attached mesentery, the SMA is identified at the level of the first jejunal vein and is divested along the right margin working in a distal-to-proximal direction. Vein resection and reconstruction can be performed as required.C-Tr-RPD was considered feasible if triangle dissection was successfully completed without conversion to open surgery or need to use energy devices. Postoperative complications and pathology results are presented in detail.ResultsOne hundred twenty-seven consecutive C-Tr-RPDs were successfully performed. There were three conversions to open surgery (2.3%), because of pneumoperitoneum intolerance (n = 2) and difficult digestive reconstruction. Thirty-four patients (26.7%) required associated vascular procedures. No pseudoaneurysm of the gastroduodenal artery was observed. Twenty-eight patients (22.0%) developed severe postoperative complications (≥ grade III). Overall 90-day mortality was 7.1%, declining to 2.3% after completion of the learning curve. The median number of examined lymph nodes was 42 (33–51). The rate of R1 resection (7 margins < 1 mm) was 44.1%.ConclusionC-Tr-RPD is feasible, carries a risk of surgical complications commensurate to the magnitude of the procedure, and improves staging of PDAC.Graphical abstract

Impact of the presence of median arcuate ligament on biliary complications after liver transplantation.

The presence of median arcuate ligament (MAL) during orthotopic liver transplantation (OLT) may cause a significant reduction in the arterial hepatic flow. The aim of the present study is to investigate the impact of MAL on biliary complications in patients who underwent OLT. We performed a retrospective case-control study among patients who underwent OLT in Geneva University Hospital between 2007 and 2017, depending on the presence or absence of MAL. The matching was performed according to age, gender, lab-MELD score at the time of OLT and type of donor (living or dead). The presence of MAL was assessed by an expert liver radiologist on the preoperative CT angiographic evaluation. The incidence of MAL was 6.1% (19 patients). Baseline characteristics were comparable between the two groups. No significant difference in biliary complications was found between patients with and without MAL (37% and 24%, respectively). No patient presented hepatic artery thrombosis. After logistic regression, in patients with MAL, the MAL release and gastroduodenal artery preservation compared to no treatment, showed an odds ratio for post-OLT biliary complications of 1.5 and 1.25, respectively. There was no difference in overall graft survival and in hazard for biliary complications between patients with and without MAL. In the present study, we did not find any difference in the prevalence of biliary and arterial complications between patients with and without MAL. The choice of MAL treatment did not influence in a significant way the overall outcome and development of complications. However, if, at the end of arterial reconstruction, the arterial flow is not adequately established, MAL needs to be treated with the least invasive technique.

Contemporary Management of Median Arcuate Ligament in Liver Transplantation.

We undertook a systematic review according to the Cochrane systematic review protocol and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We analyzed the incidence of MAL, investigations, treatment options, and potential complications associated with MAL intervention in patients undergoing OLT. After the exclusion criteria were implemented, the dataset from the final 21 manuscripts yielded 117 patients who underwent a liver transplant in the presence of MAL. The incidence of MAL in patients undergoing OLT is between 1.6% and 12%. In 63.2% of cases, an open approach for MAL intervention was undertaken. Hepatic artery thrombosis developed in 17% (7) patients without MAL intervention versus 2.6% (2) after MAL intervention. Seven grafts (5.9%) were lost after OLT in patients with MAL. Three (3.9%) patients developed arterial stenosis post-MAL intervention. We propose an algorithm for intraoperative assessment and management of liver transplant arterial inflow in the presence of MAL based on the hepatic artery flow changes with respiration, following clamping of the recipient gastroduodenal artery. In the presence of a 30%-50% flow variation on respiration, the arterial inflow should be established preserving additional inflow from the recipient gastroduodenal artery. Consider an open MAL release if the flow remains insufficient. A poor arterial flow with no variation with respiration and lack of evidence of aortoiliac atherosclerosis indicates the need for arterial jump graft.

A rare case with multiple arterial variations of the liver complicated laparoscopic pancreaticoduodenectomy

BackgroundHepatic arterial variations were fully elaborated in anatomical monographs. Here, we aimed to present a rare case with multiple arterial variations of the liver complicated laparoscopic pancreaticoduodenectomy.Case presentationWe report a 67-year-old woman with a periampullary tumor underwent laparoscopic pancreaticoduodenectomy. Intraoperatively, the aberrant right hepatic artery derived from the gastroduodenal artery (GDA) was observed and had accidentally sacrificed due to untimely ligature of GDA. Three-dimensional reconstruction based on preoperative contrast-enhanced CT performed to better study the anatomy. It demonstrated a replaced right hepatic artery branched from the GDA and supplied right liver lobe. Meanwhile, the middle hepatic artery derived from the common hepatic artery and supplied hepatic segment IV. Additionally, the replaced left hepatic artery emerged from the left gastric artery and fed into left liver lobe.ConclusionsThe origination and course of hepatic arterial anatomy should be thoroughly assessed in planning and performing hepatopancreatobiliary surgeries. Reconstruction images of contrast-enhanced CT are helpful to visualize the vascular variations and its spatial relation with adjacent structures.

Assessment of hepatic arterial hemodynamics with 4D flow MRI: in vitro analysis of motion and spatial resolution related error and in vivo feasibility study in 20 volunteers.

To assess the ability of four-dimensional (4D) flow MRI to measure hepatic arterial hemodynamics by determining the effects of spatial resolution and respiratory motion suppression in vitro and its applicability in vivo with comparison to two-dimensional (2D) phase-contrast MRI. A dynamic hepatic artery phantom and 20 consecutive volunteers were scanned. The accuracies of Cartesian 4D flow sequences with k-space reordering and navigator gating at four spatial resolutions (0.5- to 1-mm isotropic) and navigator acceptance windows (± 8 to ± 2 mm) and one 2D phase-contrast sequence (0.5-mm in -plane) were assessed in vitro at 3 T. Two sequences centered on gastroduodenal and hepatic artery branches were assessedin vivo for intra - and interobserver agreement and compared to 2D phase-contrast. In vitro, higher spatial resolution led to a greater decrease in error than narrower navigator window (30.5 to -4.67% vs -6.64 to -4.67% for flow). In vivo, hepatic and gastroduodenal arteries were more often visualized with the higher resolution sequence (90 vs 71%). Despite similar interobserver agreement (κ = 0.660 and 0.704), the higher resolution sequence had lower variability for area (CV = 20.04 vs 30.67%), flow (CV = 34.92 vs 51.99%), and average velocity (CV = 26.47 vs 44.76%). 4D flow had lower differences between inflow and outflow at the hepatic artery bifurcation (11.03 ± 5.05% and 15.69 ± 6.14%) than 2D phase-contrast (28.77 ± 21.01%). High-resolution 4D flow can assess hepatic artery anatomy and hemodynamics with improved accuracy, greater vessel visibility, better interobserver reliability, and internal consistency. • Motion-suppressed Cartesian four-dimensional (4D) flow MRI with higher spatial resolution provides more accurate measurements even when accepted respiratory motion exceeds voxel size. • 4D flow MRI with higher spatial resolution provides substantial interobserver agreement for visualization of hepatic artery branches. • Lower peak and average velocities and a trend toward better internal consistency were observed with 4D flow MRI as compared to 2D phase-contrast.

Volumetric computed tomography analysis for gastroduodenal and pancreaticoduodenal artery aneurysm formation: A retrospective single-center study.

Gastroduodenal artery aneurysms (GDAA) and pancreaticoduodenal artery aneurysms (PDAA) are rare, have high rupture risks, and are located in the arcade between the celiac artery and the superior mesenteric artery. Pancreaticoduodenal artery aneurysms are associated with celiac artery stenosis, and it is hypothesized that these celiac lesions might contribute to the formation of aneurysms. In contrast, a few studies have reported an association between a gastroduodenal artery aneurysm and celiac lesions. This study aimed to investigate the potential differences between patients with gastroduodenal and pancreaticoduodenal artery aneurysms and better understand their pathogenesis.We selected patients with GDAA and PDAA who were admitted to our department between January 2010 and December 2020. Aortic wall volume, aortic wall calcification, and pancreaticoduodenal arcade volume of computed tomography images were calculated semi-manually using Horos 3.3.5.Eight GDAAs and 11 PDAAs were analyzed. Celiac lesions were found in all PDAA patients, with none in GDAA cases. Volumetry demonstrated that aortic wall volume and calcification were more prominent in the GDAA group than in the PDAA group (P = .026 and P = .049, respectively). The pancreaticoduodenal arcade volume was larger in the PDAA group (P = .002).In our study, celiac artery lesions were strongly correlated with PDAA. The volume of the pancreaticoduodenal arcade was larger in the PDAA group, and aortic wall volume and calcification were larger in the GDAA group.

Experience of using stent grafts in the treatment of patients with arrosive bleeding after pancreatic surgery

Aim. To evaluate inhospital outcomes of endovascular treatment in patients who underwent endoprosthetic replacement of the culprit vessel due to arrosive bleeding after pancreatic surgery.Material and methods. In the period 2012-2021 at the A. V. Vishnevsky National Medical Research Center of Surgery, 821 operations on the pancreas due to tumors and complicated chronic pancreatitis were performed. Seventy-five (9,1%) patients developed postoperative arrosive bleeding. Stent grafts were used to stop bleeding in 14 (18,7%) of them. There were 9 men (64,3%) and 5 women (35,7%). The median age of patients was 60 years (men — 61 years, women — 59 years). Arrosive bleeding occurred after pancreaticoduodenal resection in 13 patients, while in one case — after distal pancreatic resection. In all 14 cases, postoperative bleeding was severe and classified as grade C according to the International Study Group for Pancreatic Surgery (ISGPS) classification.Results. There were following sources of bleeding: gastroduodenal artery — 4 (28,6%) patients, proximal hepatic arteries (right/left) — in 4 (28,6%) patients, proximal superior mesenteric artery — in 2 (14,3%), dorsal pancreatic artery — in 1 (7,1%), false aneurysm of proximal splenic artery — in 1 (7,1%), proximal common hepatic artery — in 2 (14,3%). In 10 (71,4%) patients, endoprosthetic replacement of the proximal segment of culprit artery was performed, while in 4 (28,6%) patients with arrosion of short gastroduodenal artery stump and false aneurysm, endoprosthesis replacement of the common hepatic artery was performed with a transition to the proper hepatic artery. The technical success of endovascular hemostasis (absence of contrast media extravasation) was achieved in 100% of cases. Three (21,4%) of 14 patients developed rebleeding from another arterial source. Inhospital mortality was 28,6% (n=4). The cause of deaths in 3 cases was the direct complications of endovascular hemostasis, while in one patient — progressive postoperative pancreatitis with the outcome in multiple organ failure.Conclusion. Endovascular hemostasis using a stent graft is an effective surgical method for the treatment of arrosive bleeding after pancreatic surgery. The intervention is associated with possible complications, the risk of which must be taken into account before the procedure. We consider arrosive bleeding from a defect in the main vessel (common/ proper/right or left hepatic arteries, superior mesenteric artery) as an indication for performing endoprosthetic replacement.