Inferior Pancreaticoduodenal Research Articles

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.

Occlusion of the Superior Mesenteric Artery in Rats Reversed by Collateral Pathways Activation: Gastric Pentadecapeptide BPC 157 Therapy Counteracts Multiple Organ Dysfunction Syndrome; Intracranial, Portal, and Caval Hypertension; and Aortal Hypotension.

Gastric pentadecapeptide BPC 157 therapy counteracts multiple organ dysfunction syndrome in rats, which have permanent occlusion of the superior mesenteric artery close to the abdominal aorta. Previously, when confronted with major vessel occlusion, its effect would rapidly activate collateral vessel pathways and resolve major venous occlusion syndromes (Pringle maneuver ischemia, reperfusion, Budd–Chiari syndrome) in rats. This would overwhelm superior mesenteric artery permanent occlusion, and result in local, peripheral, and central disturbances. Methods: Assessments, for 30 min (gross recording, angiography, ECG, pressure, microscopy, biochemistry, and oxidative stress), included the portal hypertension, caval hypertension, and aortal hypotension, and centrally, the superior sagittal sinus hypertension; systemic arterial and venous thrombosis; ECG disturbances; MDA-tissue increase; and multiple organ lesions and disturbances, including the heart, lung, liver, kidney, and gastrointestinal tract, in particular, as well as brain (cortex (cerebral, cerebellar), hypothalamus/thalamus, hippocampus). BPC 157 therapy (/kg, abdominal bath) (10 µg, 10 ng) was given for a 1-min ligation time. Results: BPC 157 rapidly recruits collateral vessels (inferior anterior pancreaticoduodenal artery and inferior mesenteric artery) that circumvent occlusion and ascertains blood flow distant from the occlusion in the superior mesenteric artery. Portal and caval hypertension, aortal hypotension, and, centrally, superior sagittal sinus hypertension were attenuated or eliminated, and ECG disturbances markedly mitigated. BPC 157 therapy almost annihilated venous and arterial thrombosis. Multiple organ lesions and disturbances (i.e., heart, lung, liver, and gastrointestinal tract, in particular, as well as brain) were largely attenuated. Conclusions: Rats with superior mesenteric artery occlusion may additionally undergo BPC 157 therapy as full counteraction of vascular occlusion-induced multiple organ dysfunction syndrome.

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.

English

BACKGROUND Superior Mesenteric Artery (SMA) is one of the anterior branches of the abdominal aorta. It originates from abdominal aorta at the level of lower border of first lumbar vertebra, one centimeter below the coeliac trunk. It gives the first branch inferior pancreaticoduodenal artery (IPDA), The colic branches arise from concave right side of the superior mesenteric artery, these are middle colic artery (MCA), right colic artery (RCA), ileo colic artery (ICA). Jejunal and ileal branches arise from left side of the SMA. Superior mesenteric artery supplies derivatives of midgut. Knowledge of branching pattern of the SMA is clinically important to gastroenterologists operating on gut and neighboring structures like pancreas, duodenum, and liver. We wanted to study the variations in the branches of superior mesenteric artery. METHODS This is a descriptive study conducted on 50 adult embalmed human cadavers by conventional dissection method, the findings were noted and tabulated. RESULTS Present study shows that inferior pancreatic duodenal artery orginated from SMA in 47 (94 %) specimens. IPDA was absent in 3 (6 %) specimens. Middle colic artery was found to arise from SMA in 48 (94 %) and MCA was absent in 2 (4 %) specimens. Right colic artery was found to arise from SMA in 47 (94 %) specimens and it was absent in 3 (6 %) specimens. Ileo-colic artery was found to arise from SMA in all 50 (100 %) specimens. CONCLUSIONS Awareness of these complex variations may prevent devastating complications during colonic surgeries. Variations in the branching pattern of superior mesenteric artery is essential for surgeons operating on derivatives of midgut, liver, pancreas. KEY WORDS Branches, Colic, Superior Mesenteric Artery, Variations

An arc of Bühler variant

The celiaco-mesenteric anastomoses occur either directly between the celiac trunk and the superior mesenteric artery (SMA), or between different branches of them. A rarely occurring such anastomosis is the arc of Bühler. A new variant of arc of Bühler was found incidentally during a retrospective study of the computed tomography angiograms of a 62 y.o. male patient. In that case, the arc of Bühler left from the splenic artery and inserted into the inferior pancreaticoduodenal artery (IPDA), proximally to the IPDA division into its anterior and posterior branches. Moreover, that arc of Bühler was giving off a mesenterico-jejunal branch, which descended applied on the anterior side of the SMA. Such anatomic variants could impede on the surgical or interventional procedures in the duodenopancreatic region, or could be physiologically useful to divert the celiac flow towards the mesenteric territory, or vice versa.

What comprises the plate-like structure between the pancreatic head and the celiac trunk and superior mesenteric artery? A proposal for the term \u201cP\u2013A ligament\u201d based on anatomical findings

A plate-like structure is located posterior to the portal vein system, between the pancreatic head and roots and/or branches of two major arteries of the aorta: the celiac trunk and superior mesenteric artery. We aimed to clarify the distribution and components of this plate-like structure. Macroscopic examination of the upper abdomen and histological examination of the plate-like structure were performed on 26 cadavers. The plate-like structure is connected to major arteries (aorta, celiac trunk, superior mesenteric artery) and the pancreatic head; it contains abundant fibrous bundles comprising nerves, vessels, collagen fibers, and adipose tissue. Furthermore, it consists of three partly overlapping fibrous components: rich fibrous bundles (superior mesenteric artery plexus) fused to the uncinate process of the pancreas; fibrous bundles arising from the right celiac ganglion and celiac trunk that spread radially to the dorsal side of the pancreatic head and superior mesenteric artery plexus; and fibrous bundles, accompanied by the inferior pancreaticoduodenal artery, entering the pancreatic head. The plate-like structure is the pancreas–major arteries (aorta, celiac trunk, superior mesenteric artery) ligament (P–A ligament). The term “P–A ligament” may be clinically useful and can facilitate comprehensive understanding of the anatomy surrounding the pancreatic head and provide an anatomical basis for further pancreatic surgery studies.

Anatomy of peripancreatic arteries and pancreaticoduodenal arterial arcades in the human pancreas: a cadaveric study.

The purpose of this work was to evaluate the arteries supplying the pancreaticoduodenal (PD) complex. The study was conducted on 15 fresh enbloc pancreatic specimens by latex injection method which enabled the visualization of the peripancreatic arteries and their minute branches. The gastroduodenal (GDA), anterior superior pancreaticoduodenal (ASPD), and anterior inferior pancreaticoduodenal (AIPD) artery was found in all the cases, whereas the posterior superior pancreaticoduodenal (PSPD) and posterior inferior pancreaticoduodenal (PIPD) artery was present in 93.34% cases. The ASPD artery originated from GDA in all the cases. Two types of variations were observed in the origin of PSPD artery and four types each in the origin of AIPD and PIPD artery. Anatomical and numerical variations were observed in both anterior and posterior arches, posterior arch being absent in 20% cases. In the present study, an attempt was made to systematically describe the individual arterial configurations of the PD complex. The information provided here has important implications for preoperative planning of technically challenging surgeries and interventions around the pancreatic head.

Superior perianastomotic fluid collection in the early postoperative period affects pseudoaneurysm occurrence after pancreaticoduodenectomy.

Pseudoaneurysm (PA) after pancreaticoduodenectomy (PD) is a harmful complication due to postoperative pancreatic fistula. However, the preventive method for PA is unclear. This study aimed to assess the risk factors for PA after PD and to evaluate the clinical features of patients with PA. Medical records of 54 patients who underwent PD and developed clinically relevant postoperative pancreatic fistula (POPF) were retrospectively reviewed. We evaluated postoperative computed tomography (CT) findings, including the perianastomotic fluid collection (PFC) location on postoperative day 4. Perioperative findings and postoperative CT findings were compared between patients with and without PA after PD. The PA group included nine patients (17%). The median postoperative day of diagnosis of PA was 17 (range, 7-33). The PA locations were the gastroduodenal artery stump (n= 3), dorsal pancreatic artery (DPA) stump from the common hepatic artery (n= 4), DPA stump from the replaced right hepatic artery (n= 1), and inferior pancreaticoduodenal artery stump (n= 1). The prevalence of falciform ligament wrap to the hepatic artery was lower (33% vs. 78%, p = 0.014) and superior PFC prevalence was higher (100% vs. 58%, p = 0.019) in the PA group than in the non-PA group. Superior PFC reached the dorsal part of the caudate lobe of the liver in all patients with PA. Furthermore, all PAs occurred at the arteries that could not be wrapped by the falciform ligament. Prevention of superior PFC and falciform ligament wrapping may reduce PA occurrence after PD with clinically relevant POPF.

Inferior pancreaticoduodenal artery pseudoaneurysm rupture caused by the pancreatic neuroendocrine tumor: a case report

Introduction: Inferior pancreaticoduodenal artery (IPDA) pseudoaneurysms rupture caused by the pancreatic neuroendocrine tumor (PNET) are extremely rare. Methods: Here we report an interesting case of emerging IPDA pseudoaneurysm rupture caused by PNET. Results: A 49-year-old man was referred to our hospital for epigastric pain. Dynamic computed tomography showed a heterogeneously enhancing pancreatic head mass measuring 12 cm in diameter with hypervascular lesion. In addition, an irregular aneurysm was found in the branch from the superior mesenteric artery (SMA) to the pancreatic head. Selective angiography of the SMA confirmed an aneurysm of the IPDA, from which a jet blood flow was observed into the pancreatic head mass. The high blood flow resulted in the cavernomatous transformation of the hepatoduodenal ligament. The next day, total pancreatectomy was performed in the hybrid operating room. Laparotomy revealed a large pancreatic head mass, 12 cm in diameter and highly vascular. Left side pancreas demonstrated necrotizing pancreatitis, so the distal pancreatosplenectomy was performed in advance. The intermittent inflow occlusion of IPDA was obtained by a balloon catheter, and pancreaticoduodenectomy was safely achievable. The pseudoaneurysm at the root of IPDA was blocked with vascular clip. The postoperative course was uneventful. Immunohistochemical examination was positive for chromogranin A and synaptophysin. The final pathological diagnosis was PNET G1. In addition, arterial invasion of tumor cells was observed. Conclusions: This case demonstrates that PNET can cause IPDA pseudoaneurysm rupture. The hybrid operation is advisable in pancreatic surgery for patients associating complicated vascular event.

Hanging spleno-mesenteric confluence - approach to minimal invasive pancreatoduodenectomy

Presenter: Omero Costa Filho MD, MSc | Hospital Militar de Área de Porto Alegre (HMAPA) Methods: Description of our conventional technique for LPD using hanging maneuver to expose uncinate process with the principles of “artery-first” approach. Results: LPD is performed with the patient placed in a supine, split-leg position and carefully secured to the operative table, and the surgeon on foot between the patient legs, and an assistant at each side. A 12-mm Hasson trocar is placed at about 16 cm from the xyphoid, and a pneumoperitoneum is established. A total of four additional trocars, two 12 mm and two 5 mm, are placed in the abdomen with a semi-circular pattern centered around the head of the pancreas. All the steps to LPD was following our institutional protocol and we focus on uncinate process time. After the surgeon switches position to the right side of the patient, an instrument is used partially open to retract the uncinate process to the right of the patient and dissect freely the splenic mesenteric venous confluence (SMVC). The uncinate process is carefully dissected from the lateral aspect of the superior mesenteric vein (SMV) while small vessels clipped. To best expose, we ligate the gastrocolic trunk (Henle’s trunk) at this time. Then portal vein (PV) and SMV are carefully looped with two penrose drain number 2 to have proximal and distal control, if needed, and to facilitate retraction by the assistant on the left side of the patient. The SMV is retracted medially with penrose. Care must be taken with the first jejunal vein, that was our inferior limit and start point of dissection. The SMA can be found directly under and slightly medial to the SMV. The SMA dissection is carried out using a vessel sealing device. The inferior pancreaticoduodenal artery is usually ligated with clips. During all dissection, release of hanging PV and SMV was done to ensure hepatic inflow. When the dissection found SMVC, we hung the PV with penrose, to expose the mesopancreas and nodes at take off SMA and celiac trunk (CT). A complete, en-bloc resection of the uncinate process is assured, looking to expose SMA and CT emergence from Abdominal Aorta. Conclusion: This is technique description of our actual LPD in approach of uncinate process but can be extend to robotic pancreatic surgery. We continue to track our cases to improve our results with secure issues and oncology outcomes. Until now, with use of initial experience of hanging spleno-mesenteric confluence show a better view of mesopancreas and SMA. Further evaluation with our historical cohort may show beneficial use of our suggestion to such challenge MIS procedure.

Celiac Artery Aneurysm and Pseudoaneurysm Caused by Median Arcuate Ligament Syndrome (MALS) with Different Presentation: A Case Series

Introduction: The median arcuate ligament syndrome (MALS) is a rare vascular disorder caused by an extrinsic compression of the celiac artery from the median arcuate ligament.It is associated with aneurysmal dilatation due to compression. Although it usually comes with the classical triad of chronic abdominal pain, weight loss and epigastric bruit , it still manifests a wide variety of symptoms. Method: We observed 3 cases of celiac trunk aneurysm associated with this condition presented to us initially with different symptoms and MALS were detected by computed tomography scan. Results: Case 1: a 67 year old lady presented with epigastric pain underwent CT showed superior and inferior pancreaticoduodenal artery aneurysm. Successful angioembolisation of aneurysm done and proceeded with release of median arcuate ligament. Case 2: A 56 year old gentleman presented with symptoms of gastric outlet obstruction, CT scan showed duodenal mass with GDA pseudoaneuryms, Whipple procedure was performed. Case 3. A 51 year old gentleman presented with obstructive jaundice and was diagnosed with pancreatic head carcinoma, proceeded with Whipple procedure, only to discover common hepatic and superior anterior pancreaticoduodenal artery pseudoaneurysm post surgery via digital subtraction angiography. Conclusion: Aneurysms associated with MAL syndrome is quite rare and may present with different symptoms at time of diagnosis. Angioembolisation should be the treatment of choice and followup for recurrence is warranted.

Quadrifurcation Variants of the Celiac Trunk

The celiac trunk (CT) commonly trifurcates into the left gastric artery, common hepatic artery (CHA), and splenic artery (SA). The CHA then sends off the proper hepatic artery and gastroduodenal artery (GDA). The arcades of the head of the pancreas are celiacomesenteric anastomoses between branches of the GDA and the superior mesenteric artery. A quadrifurcation of the CT commonly occurs when a different branch is added to the 3 normal ones. An uncommon quadrifurcation of the CT occurs when only one or 2 of the normal branches of the CT participate. The CT quadrifurcations were documented on 112 computed tomography angiograms. Five different types of CT quadrifurcation-3 uncommon (types 1-3) and 2 common (types 4-5)-were found in 15/112 cases (13.39%). A marginal significant association was found between the presence of quadrifurcations and male gender (P=0.05; Fisher's exact test). Type 1 showed a hepatogastric trunk+SA+right hepatic artery+GDA pattern, type 2 had an HGT+right inferior phrenic artery+CHA+SA pattern, type 3 had a gastrophrenic trunk+left inferior phrenic artery+CHA+SA pattern, type 4 showed an left gastric artery+CHA+SA+left inferior phrenic artery combination, and type 5 had an additional common inferior phrenic trunk. One of the type 4 cases showed a buildup of a mesentericomesenteric anastomotic pancreatic arcade between the inferior pancreaticoduodenal arteries, rather than a celiacomesenteric one. Anatomic variation of the celiacomesenteric axis is important during hepatobiliary and duodenopancreatic approaches. Therefore, preoperative evaluation is essential because theoretical anatomic possibilities could be real arterial variants.

Arteriovenous malformation in the pancreatic head initially mimicking a hypervascular mass treated with duodenum-preserving pancreatic head resection: a case report

BackgroundThe mainstay treatment for arteriovenous malformation in the pancreatic head (Ph-AVM) is standard pancreatectomy, especially pancreaticoduodenectomy (PD), or interventional endovascular treatment. We report the first case of Ph-AVM treated with duodenum-preserving pancreatic head resection (DPPHR) performed to preserve the periampullary organs.Case presentationA 59-year-old man presenting with back pain underwent contrast-enhanced computed tomography followed by angiography of the anterior superior pancreaticoduodenal artery. He was diagnosed with Ph-AVM and indicated for DPPHR with preservation of the periampullary organs; Ph-AVM’s benign nature seldom requires lymph node dissection. During the operation, the right colon was mobilized and the omental bursa was released to expose the periampullary structures. The pancreas was transected just above the superior mesenteric vein. The inferior pancreaticoduodenal artery and papillary arteries branching from the posterior superior pancreaticoduodenal artery were carefully preserved to maintain the blood flow to the lower bile duct and papilla of Vater. The remnant pancreas was reconstructed with pancreaticogastrostomy using the modified Blumgart method. Pathological examination of the resected specimen revealed an irregular course of the arteries and veins concomitant with marked dilation throughout the pancreatic head. The patient was pathologically diagnosed with Ph-AVM. He developed hematemesis caused by a rupture of the pseudoaneurysm on postoperative day 20 and underwent coil embolization. A bilio-enteric fistula and stenosis of the common bile duct were found and treated by placement of an endoscopic biliary stent. At the 8-month follow-up, the Ph-AVM had not recurred.ConclusionsCompared to PD, DPPHR confers the clinical benefit of preserving the periampullary organs, although further studies are needed to confirm this. Therefore, the choice of this procedure should be based on the surgical morbidities and long-term outcome of the patient.

S1384 Acute Pancreatitis Secondary to Type B Aortic Dissection and Celiac Artery Hematoma

INTRODUCTION: Acute pancreatitis is one of the most common gastrointestinal diagnoses seen in inpatients, accounting for almost 280,000 hospital admissions annually. Cholelithiasis is the most common cause, followed by prolonged alcohol abuse. Hypertriglyceridemia, drugs, autoimmune disease, and infection each account for less than 5% of cases. Here we present a rare case of acute pancreatitis secondary to Type B aortic dissection. CASE DESCRIPTION/METHODS: A 61-year-old male presented with sudden onset right-sided and periumbilical abdominal pain with radiation to the epigastrium and mild chest pain. He had no pertinent medical history and no significant alcohol use history. On presentation, he was hypertensive and tachypneic. Physical examination revealed a diaphoretic male with diffuse abdominal tenderness. Laboratory work up showed a leukocytosis of 17.24 K/uL, lactate 4mmol/L, LDH 374 U/L, and lipase 383 U/L. CT angiography showed a prominent Stanford Type B aortic dissection with an intramural hematoma extending along the descending thoracic aorta through the upper abdominal aorta leading to occlusion of the celiac artery. His dissection was treated with esmolol drip with rapid correction of blood pressure to goal systolic blood pressure 100-120. Due to persistent leukocytosis, on hospital day 3 repeat CT imaging was performed revealing increasing irregular fluid scattered throughout the upper abdomen consistent with acute pancreatitis. Alternative etiologies were ruled out and this pancreatitis was presumed to be caused by vascular compromise in the setting of a type B aortic dissection and celiac artery hematoma. He showed gradual clinical improvement with medical management and was discharged home. DISCUSSION: Blood supply to the pancreas is provided by pancreatic branches of the splenic artery (from the celiac artery), and the superior and inferior pancreaticoduodenal arteries (from the superior mesenteric artery). The mechanism of pancreatitis caused by type B aortic dissection is organ ischemia, through occlusion of either the celiac artery or the superior mesenteric artery SMA. Most type B aortic dissections are managed conservatively with antihypertensives, but end organ ischemia can be an indication for surgical management. This presentation is exceedingly rare; we note only 6 similar cases in the literature. As our case demonstrates, acute pancreatitis as a complication of aortic dissection can be managed with standard conservative measures and does not necessitate surgical intervention.Figure 1.: Computed tomography angiogram shows a Stanford Type B Aortic Dissection (2 views).Figure 2.: Chest computed tomography imaging shows irregular fluid scattered throughout the upper abdomen representative of acute pancreatitis.Figure 3.: Computed tomography angiography reveals mild interval increase in peripancreatic fluid collections.

Balloon-assisted coil embolization (BACE) of a wide-necked aneurysm of the inferior pancreaticoduodenal artery

BackgroundAneurysms of the pancreaticoduodenal arcades are an uncommon pathology, with a prevalence of 2%, and could be congenital or acquired. Treatment of visceral aneurysms is therefore generally recommended when the aneurysmal sac equals or exceeds 2 cm. Wide-necked (> 4 mm) and main artery branch aneurysms represent a challenge for conventional endovascular coil embolization due to the risk of coil migration.Main bodyThis case describes the technical feasibility of balloon-assisted coil embolization (BACE) in the treatment a wide neck aneurysm of inferior pancreatic duodenal artery due to celiac axis occlusion.Short conclusionIn case of celiac trunk occlusion, BACE is a safe procedure associated with optimal technical success rates, in order to treat the aneurysms and to preserve splanchnic vascularization.

Patients with type 2 diabetes present with multiple anomalies of the pancreatic arterial tree on abdominal computed tomography: comparison between patients with type 2 diabetes and a matched control group

BackgroundStudies suggest that cardio-vascular risk factors could foster the development of type 2 diabetes (T2D). This could partly be mediated by pancreatic atherosclerosis resulting in pancreatic ischemia. We hypothesized that patients with T2D present with more severe atherosclerosis of pancreas-bound arteries than control patients without T2D.MethodsWe performed a retrospective study comparing the abdominal computed tomography of patients with T2D and of control subjects matched for gender and for age. We performed a multivariate logistic regression with adjustment for age, gender, BMI and the presence or absence of hypertension.ResultsForty-eight patients with T2D and 48 control subjects were included. A calcification score of the splenic artery was defined (from 0: no calcification to 3: continuous linear calcifications). Seventeen percent of the patients with T2D presented with a high calcification score (i.e. 2 or 3), versus only 2% of the control subjects (p = 0.04). The mean number of pancreas-bound branches among the greater pancreatic artery, dorsal pancreatic artery and inferior pancreatic artery (from 0 to 3) was lower in patients with T2D than in control subjects (1.1 vs 1.7, p = 0.003). The mean number of visible intrapancreatic arterial subdivisions (from 0 to 2) was lower in patients with T2D than in control subjects (0.7 vs 1.3, p = 0.0017). All these differences hold true using multivariate logistic regression. None of these differences correlated with the duration of diabetes. The relationship between pancreas volume and BMI seen in control subjects was not confirmed in patients with T2D. Conversely, in patients with T2D but not in control subjects, the splenic artery diameter correlated with the pancreas volume.ConclusionsPatients with T2D present with more calcifications of the splenic artery and with a less dense pancreatic arterial tree than control subjects.

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

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

1434-P: Patients with Type 2 Diabetes Present with Multiple Anomalies of the Pancreatic Arterial Tree

Epidemiological and experimental studies suggest that cardio-vascular risk factors could foster the development of type 2 diabetes (T2D). This could partly be mediated by pancreatic atherosclerosis resulting in pancreatic ischemia. We hypothesized that patients with T2D present with more severe atherosclerosis of pancreas-bound arteries than control patients without T2D. We performed a case-control retrospective study comparing the abdominal computed tomography of patients with T2D and of control subjects matched for gender and for age. Forty-eight patients with T2D and 48 control subjects were included. A calcification score of the splenic artery was defined (from 0: no calcification to 3: continuous linear calcifications). It was higher in patients with T2D than in control subjects (0.6 versus 0.2, p=0.02). The mean number of pancreas-bound branches among the greater pancreatic artery, the dorsal pancreatic artery and the inferior pancreatic artery (from 0 to 3) and of visible intrapancreatic arterial subdivisions (from 0 to 2) was lower in patients with T2D than in control subjects (1.1 versus 1.7, p=0.003 and 0.7 versus 1.3, p=0.0017, respectively). Post-injection enhancement of the pancreas tended to be lower in patients with T2D than in control subjects (57 versus 68 Hounsfield units, p=0.06). None of these differences correlated with the duration of diabetes. Moreover, in control subjects, the pancreas volume was higher and the pancreas density and enhancement were lower with higher BMI. This relationship was not confirmed in patients with T2D. Thus, it could be hypothesized that more powerful factors than BMI could impact pancreas volume and density in patients with T2D. Pancreatic atherosclerosis could be one of these. Patients with T2D present with more anomalies of the pancreatic arterial tree than control subjects. These anomalies do not correlate with the duration of diabetes, which may imply an early role of pancreatic atherosclerosis in T2D natural history. Disclosure L. Alexandre-Heymann: None. M. Barral: None. A. Dohan: None. E. Larger: None.

Vascular Anatomy of Mesopancreas in Pancreatoduodenectomy Using an Intestinal Derotation Procedure.

Mesopancreas excision in pancreatoduodenectomy is technically complicated because of the anatomical complexity of the mesopancreas with the inferior peripancreatic blood vessels which is caused by intestinal rotation in fetal life. We have developed a novel artery-first approach (the intestinal derotation procedure) for facilitating mesopancreas excision. The aim of this study was to clarify the vascular anatomy of the mesopancreas after derotation. The right-sided colon and small intestine are mobilized from the retroperitoneum, and the intestinal loop is then derotated. In 136 cases of pancreatoduodenectomy employing the derotation procedure, we analyzed the vascular anatomy of the mesopancreas. After derotation, the anatomy was simplified. The mesopancreas extended from the right aspect of the superior mesenteric artery (SMA), forming a horizontal plane. The first jejunal trunk (FJT) was situated in parallel with the second jejunal artery and was anterior (91%) or posterior (9%) to the SMA. The inferior pancreaticoduodenal vein (IPDV) entered the right side of the FJT (83%) or the superior mesenteric vein (17%). Besides the IPDV, 1-4 tributaries entered the right wall of the FJT, in 89% of cases. The inferior pancreaticoduodenal artery was observed to originate from the right wall of the SMA, sharing a common stem with the first jejunal artery (70%) or branching directly from the SMA (29%). Intestinal derotation simplifies the mesopancreas anatomy and reveals the anatomical details of the inferior peripancreatic blood vessels in pancreatoduodenectomy.

Optimal Lymphadenectomy of the Mesopancreas Based on Fluorescence Imaging During Pancreaticoduodenectomy

BackgroundExcision of the mesopancreas with lymphadenectomy is an important component of pancreatoduodenectomy. However, the optimal extent of lymphadenectomy remains unclear. Furthermore, accurate description of the mesopancreatic lymphatic pathways is difficult, probably because of the complex anatomy. Intestinal derotation simplifies the anatomy and facilitates both examination of lymphatic flow and the surgical procedure. The aim of this study was to evaluate lymphatic flow in the mesopancreas using indocyanine green fluorescence imaging with an intestinal derotation technique, and to clarify the optimal extent of mesopancreas excision and lymphadenectomy in pancreatoduodenectomy. MethodsIndocyanine green solution (2.5 × 10−3 mg) was injected into the pancreatic head parenchyma. After intestinal derotation, the spread of indocyanine green was observed using near-infrared imaging. ResultsParticipants comprised 10 patients who underwent pancreatoduodenectomy for periampullary neoplasms. With indocyanine green fluorescence imaging, 9 of the 10 patients showed lymphatic flow from the pancreatic head to the superior mesenteric artery via the inferior pancreaticoduodenal artery and first jejunal artery (but not via the second and more distant arteries), with eventual drainage into the paraaortic region. ConclusionsLymphatic pathways from the pancreatic head were connected to the superior mesenteric artery via the inferior pancreaticoduodenal artery and first jejunal artery. Excision of the mesopancreas with the inferior pancreaticoduodenal artery and first jejunal artery while preserving the second or more distant arteries appears optimal in pancreatoduodenectomy for periampullary malignancies.