Proximal Splenic Artery Research Articles

1877 An Unfortunate Turn of Events: A Rare Case of Splenic Hematoma Following Colonoscopy for Post-Polypectomy Bleeding

INTRODUCTION: Post-polypectomy bleeding has been reported to occur in 0.3 to 6.1% of colonoscopic polypectomies. Splenic injury after colonoscopy is a rare complication with a described incidence of less than 0.017%. CASE DESCRIPTION/METHODS: A 66-year-old male with a past medical history of hypertension was admitted with post-colonoscopic polypectomy bleed. He underwent a colonoscopy in July 2018 for a history of adenomatous polyps. The colonoscopy revealed multiple non-bleeding polyps (about 15) throughout the large bowel and 8 polyps were removed with endoscopic mucosal resection (EMR). A follow up colonoscopy was performed for resection of the remaining polyps in October 2018. He presented to the hospital one-week post second colonoscopy with acute onset of hematochezia. On presentation, he was afebrile, with HR 64 and BP 108/62. Labs were notable for hemoglobin of 7.1 g/dl (from a baseline of 11 to 12 g/dl) concerning for post-polypectomy bleeding. Colonoscopy repeated after admission showed no active bleeding; a clean based ulcer was noted in the transverse colon at the site of EMR which was the likely source of bleeding. Hospital course was complicated by severe left upper quadrant pain and shock with BP dropping to 70s/40s requiring ICU admission one day after the colonoscopy. He was found to be coagulopathic with an INR of 4.9 requiring vitamin K and FFP. Hemoglobin dropped to 5.3 g/dl and he received a total of 10 units of pRBC transfusions. CTA abdomen/pelvis showed a splenic hematoma measuring 12.3 x 10 x 17 cm. Splenectomy was deferred per surgery recommendations and coil embolization of the proximal splenic artery was successfully performed. He improved clinically after splenic artery embolization and was discharged home with follow-up. DISCUSSION: Splenic injury is a potentially catastrophic complication of colonoscopy with a reported mortality of about 5%. Several mechanisms of splenic injury associated with colonoscopy have been described which include difficult procedure, traction on the splenocolic ligament, external abdominal pressure during colonoscopy, perforation of the splenic flexure and direct trauma to the spleen, and traction of adhesions between the spleen and colon. Patient-related risk factors such as abdominal surgeries leading to adhesions, splenomegaly and pancreatitis increase the likelihood of splenic injury during the procedure. With increasing number of cases, further studies are required to re-assess the incidence and risk factors for splenic injury after colonoscopy.

2823 Spleen Rupture Secondary Colonoscopy Is a Rising Epidemic

INTRODUCTION: Colonoscopy is a safe and routine procedure to evaluate large bowel for diagnostic and therapeutic purposes. Common post procedure complications include bleeding and perforation of gut but rarely splenic Injury. METHODS: A structured search on four databases was done and 68 articles were selected. Three reviewers extracted data into the excel sheet identifying the reason of colonoscopy, presentation of patient with spleen injury, types of injury, diagnosis, management and outcome of all patients with spleen injury. RESULTS: The mean age of all the patients was 62.7 SD 15.7 years, 36% male and 64% female. About 22% had a complete splenic rupture with colonoscopy while 63% had subcapsular hematoma, spleen laceration and spleen avulsion. The most common reason was screening colonoscopy (46%) followed by diagnostic colonoscopy (28%). About 87% patients presented with abdominal pain. Patients with spleen rupture mostly required splenectomy (47%). While minor spleen hematomas and lacerations were managed conservatively (38%). Interestingly, 6% patients were managed with proximal splenic artery splenic embolization (PSAE) and 4% were managed with laparoscopy. The overall mortality was about 10% while 77% had successful recovery. The reason of colonoscopy against presentation specifically abdominal pain showed no statistical significance P = 0.69. Spleen rupture and injury were the most common reason was screening colonoscopy followed by colonoscopy done for bleeding evaluation (not statistically significant). There was no significant association found between the reason of colonoscopy and type of spleen injury management (P 0.89). It is interesting to note that significantly high (74%) of the spleen rupture patients were managed with splenectomy while the rest were managed with conservative management in spleen injury group (P value 0.04) (Figure 1). The strength of association between the management and spleen injury was moderately strong at at a cramer’s V 0.34. The Fisher exact test for the type of spleen injury with the outcome was significant (P = 0.028) indicating a high mortality with spleen rupture. CONCLUSION: Spleen rupture due to colonoscopy is an increasing concern and should physicians should be aware of it as it has been associated with a high mortality. The management of the patients can be individualized based on clinical settings.

Fitz-Hugh-Curtis Syndrome: perihepatitis and sepsis in puerperium

Nonoperative management is currently the preferred treatment for trauma to the liver and spleen in hemodynamically stable patients. Angiography and embolization are an important adjunct to prevent the need for surgery or to postpone the need for surgery to a later and more elective stage, which leads to a better outcome for the patient.Imaging work-up is essential in splenic and liver trauma and indications for angiography and embolization are determined by a combination of clinical and imaging findings, with “contrast blush” at contrast-enhanced computed tomography being the most important imaging feature.Other imaging features indicating the need for angiography and embolization are false aneurysm, vascular cut-offs, and arteriovenous fistulas because these are associated with an increased risk for delayed hemorrhage.The aim of angiography and embolization in trauma of the liver and spleen is to stop ongoing bleeding or to prevent delayed bleeding, thereby making nonoperative management safer.The most commonly used embolic agents for liver and splenic trauma are 0.035-inch coils or microcoils, but in certain instances embolization plugs, Gelfoam, or particles can be used.Embolization for liver injury is preferably performed as selectively as possible. When proximal or central embolization is performed, the so-called front- and backdoor technique should be used. When there is diffuse bleeding, e.g., when there is a ruptured massive subcapsular hematoma, embolization with particles or Gelfoam from a relatively unselective position may be required.Embolization for splenic injury may be performed by occluding the proximal splenic artery, which leads to a decrease in perfusion pressure of the spleen or by performing distal or selective embolization as close to the bleeding location as possible. Both techniques are equivalent in terms of outcome but have somewhat different areas of application.Embolization of hepatic and splenic injury has a >90% technical and >80% clinical success rate with an acceptable number of complications. Complications include all common systemic and angiography complications as well as specific complications such as liver abscess and splenic infarcts and/or abscess.

Splenic artery denervation: target micro-anatomy, feasibility, and early preclinical experience

This study sought to evaluate perisplenic artery nerve distribution and the feasibility of splenic artery denervation (SDN). The NEXION radiofrequency catheter was used to perform SDN in healthy and inflammatory arthritis pigs. Splenic artery anatomy, nerve distribution, and splenic norepinephrine (NEPI) levels were evaluated before and after SDN. Perisplenic artery nerves were primarily distributed within 2.5 mm of the arterial lumen and were largely sympathetic on the basis of tyrosine hydroxylase expression. The pancreas, tended to be circumferentially positioned around the proximal splenic artery, typically >2.5 mm from the lumen, ensuring that most of the nerves could be targeted without affecting this sensitive organ. The mid segment of the splenic artery was relatively free of contact with the adjacent pancreas. Splenic NEPI levels and nerve abundance followed a decreasing gradient from the proximal to distal splenic artery. SDN resulted in significant reductions in splenic NEPI levels at day 14 (60.7%, P = 0.024) in naïve pigs and day 45 (100%, P = 0.001) in inflammatory arthritis pigs. There was no significant effect of SDN on joint soft tissue injury or circulating inflammatory markers in the inflammatory arthritis model. The majority of perisplenic arterial nerves are within close proximity of the lumen and are primarily sympathetic efferent fibers. Nerves in the mid-segment may be the preferred SDN target given their proximity to the artery and paucity of periarterial off-target organs. SDN appears safe and effective at reducing splenic NEPI levels.

TCTAP C-173 Splenic Artery Aneurysm

### Patient Initials or Identifier Number SD ### Relevant Clinical History and Physical Exam 30 years old asymptomatic gentleman presented with an incidentally detected large fusiform aneurysm arising from proximal splenic artery during an ultrasonography scan. Triphasic contrast-enhanced CT scan

Review of proximal splenic artery embolization in blunt abdominal trauma

The spleen is the most commonly injured organ in blunt abdominal trauma. Unstable patients undergo laparotomy and splenectomy. Stable patients with lower grade injuries are treated conservatively; those stable patients with moderate to severe splenic injuries (grade III-V) benefit from endovascular splenic artery embolization. Two widely used embolization approaches are proximal and distal splenic artery embolization. Proximal splenic artery embolization decreases the perfusion pressure in the spleen but allows for viability of the spleen to be maintained via collateral pathways. Distal embolization can be used in cases of focal injury. In this article we review relevant literature on splenic embolization indication, and technique, comparing and contrasting proximal and distal embolization. Additionally, we review relevant anatomy and discuss collateral perfusion pathways following proximal embolization. Finally, we review potential complications of splenic artery embolization.

Surgical resection of locally advanced paravisceral neuroganglioma

Background: Neurogangliomas are rare, benign tumors of neural crest origin most commonly seen in the mediastinum/retroperitoneum and can involve critical vasculature. They are indolent and slow-growing tumors that present with symptoms based on mass effect and location. A 29-year old male presented with 2 months of worsening abdominal pain, early satiety, and diarrhea. Initial outside imaging revealed an indeterminate abdominal mass with EUS biopsy consistent with neuroganglioma. Triple phase CT revealed a large (10 x 7 x 9 cm) abdominal mass that appeared to arise from the right diaphragmatic crus and involving the paravisceral arteries of the abdominal aorta. Methods: The mass spared the left gastric artery but circumferentially encased the common hepatic artery with extension to the proper hepatic/gastroduodenal artery bifurcation, and circumferential encasement of the proximal splenic artery and superior mesenteric artery origin from the aorta extending down to the middle colic artery take-off with sparing of distal superior mesenteric root branches. The mass abutted the body/tail of the pancreas and anteriorly displaced the main portal, splenic vein and distal superior mesenteric vein with narrowing and there was encasement of the coronary vein. The left renal vein was involved and two right renal arteries were abutted but left renal artery uninvolved. After multidisciplinary discussion with no other viable treatment options in a highly symptomatic patient with a paravisceral ganglioneuroma, surgical resection was recommended Results: The patient was taken to the operating room for attempted vascular-sparing resection with plan for en bloc multi-arterial resection and reconstruction. A midline laparotomy was performed, the left lateral bisector was mobilized from its diaphragmatic attachments and reflected medially. The omentum was taken off transverse mesocolon, lesser sac entered and gastro-hepatic ligament divided. The right and left colon were mobilized and full Kocher maneuver performed. The medial wall of IVC and left renal vein and right renal arteries were dissected from the mass arising from the right diaphragmatic crus. The distal CHA at the proper hepatic/gastroduodenal bifurcation was dissected free and GDA was ligated. The omentum was divided close to the spleen and short gastric vessels ligated. The spleen and distal pancreas were dissected,mobilized in a retrograde fashion along left kidney/adrenal gland andIMV was ligated. The left diaphragmatic crus was divided and left renal artery preserved. Dissection was carried onto the aorta and the origins of the variant visceral vessels were isolated The splenic artery required ligation at its origin but the CHA and SMA origins preserved. Splenectomy was performed preserving the distal pancreas.The distal uninvolved SMA from the mesenteric root was dissected identifying the middle colic artery. The tumor was divided over the course of the SMA distally to its origin from the aorta circumferentially dissecting it from the encased SMA ligating several lateral pancreaticoduodenal branches going to the uncinate of the pancreas preserving distal jejunal mesenteric branches. Similarly the mass was dissected where it was encasing the common hepatic from the proper hepatic to the CHA origin with circumferential dissection of the vessel. Tumor was adherent to the portal vein and pancreas. Conclusion: Ligation of various venous tributaries including coronary vein was performed and tumor was carefully dissected off the uncinate and the specimen removed en bloc. Despite ligation of short gastric arteries and GDA there was still adequate arterial gastric inflow via the preserved right and left gastric arcade and this was confirmed with intraoperative Doppler signals and ICG injection under SPY device revealing good perfusion. Ganglioneuromas are rare, benign tumors that can arise in challenging anatomic locations with no other effective options other than resection. In our case pathology revealed benign paravisceral ganglioneuroma. Tumors involving visceral aortic branches require careful preoperative planning, experience with advanced resection and anatomical dissection, and attention to anatomical variants that can assist with R0 resection with minimal morbidity.

03:18 PM Abstract No. 250 Meta-analysis of intraprocedural comparative effectiveness of coils versus vascular plugs in proximal splenic artery embolization and associated patient radiation exposure

03:18 PM Abstract No. 250 Meta-analysis of intraprocedural comparative effectiveness of coils versus vascular plugs in proximal splenic artery embolization and associated patient radiation exposure

Laparoscopic treatment of symptomatic non-ruptered proximal and middle segment splenic artery aneurysm

Laparoscopic treatment of symptomatic non-ruptered proximal and middle segment splenic artery aneurysm

Splenic artery embolization with detachable balloons for hypersplenism.

ObjectiveThis study was performed to investigate the efficacy of proximal splenic artery embolization using detachable balloons for patients with hypersplenism and portal hypertension.MethodsTwelve patients diagnosed with hypersplenism with thrombocytopenia or leukocytopenia caused by portal hypertension were treated by proximal splenic artery embolization with detachable balloons and metallic fibered coils. All patients were followed for up to 6 months. Blood parameters, coagulation factors, and liver function indicators were measured. Enhanced computed tomography and abdominal ultrasonography examinations were also performed in advance to confirm the infarction area and evaluate the changes in spleen size.ResultsPostoperative angiography demonstrated complete embolization of the proximal splenic artery in all 12 patients. Thrombocyte and leukocyte counts rose significantly in all patients in 2 weeks and stayed significantly higher than those before embolization throughout the 6-month follow-up. The total bilirubin concentration and prothrombin activity recovered significantly and returned to normal levels 6 months later. Computed tomography revealed partial infarction and liquefaction of the splenic parenchyma in nine patients.ConclusionsProximal splenic artery embolization using detachable balloons could be considered a safe and effective therapeutic modality in alleviating hypersplenism secondary to portal hypertension.

Central Lymph Node Metastasis in Gastric Cancer Is Predictive of Survival After Preoperative Therapy

BackgroundIt is unclear how preoperative therapy for gastric cancer affects the metastasis rate of lymph nodes (LNs) and whether the location of positive LNs affects survival after preoperative therapy. Therefore, we determined the association between positive central lymph nodes (CnLNs) and disease stage and overall survival (OS). MethodsWe reviewed a prospectively maintained database to identify patients who had undergone resection of gastric adenocarcinoma at our institution from 2005 to 2015. CnLNs were defined as common hepatic, celiac, and proximal splenic artery LNs (stations no. 8, 9, and 11p). The frequency of CnLN metastases and risk factors affecting OS were examined. ResultsWe identified 356 patients. Preoperative therapy was administered to 66% of patients. D2 LN dissection was performed in 80% of patients, and the median number of LNs examined was 25 (IQR, 18–34). In 243 patients (68%), CnLNs had undergone separate pathologic examination; the CnLN-positive rate was 9.1% (22 of 243; station no. 8, 4.5%; no. 9, 2.1%; and no. 11p, 4.8%). CnLN metastasis was associated with shorter 3-year OS in patients with pN2/3 disease (33 vs. 62%; p=0.004). Among patients who had undergone preoperative therapy, ypT3–4 stage (HR 2.44; p=0.01) and positive CnLNs (HR 5.44; p<0.001) were negatively associated with OS by multivariate analysis. ConclusionsCnLN metastases are uncommon in gastric cancer and have an adverse effect on OS in patients who have undergone preoperative therapy. Larger multi-institutional studies are needed to determine whether CnLN positivity requires a separate staging category after preoperative therapy.

3:45 PM Abstract No. 18 Outcomes of proximal versus distal splenic artery embolization for traumatic and nontraumatic indications

3:45 PM Abstract No. 18 Outcomes of proximal versus distal splenic artery embolization for traumatic and nontraumatic indications

Abstract No. 431 A retrospective analysis of clinical outcomes in patients who underwent proximal versus distal splenic artery embolization for traumatic splenic injuries

The purpose of this study is to assess clinical outcomes of splenic angioembolization in patients with traumatic splenic injuries, and to further assess which technique is associated with improved clinical outcomes (proximal versus distal embolization). 200 patients with traumatic splenic injuries were admitted to a level I trauma center from 10/2010 to 9/2017. The management method was determine using a retrospective analysis. Procedural reports were reviewed to determine whether a proximal or distal technique was used for embolization. Then, chart review was performed to record clinical outcome parameters including major rebleeding (requiring splenectomy), minor rebleeding (not requiring splenectomy), infection, and splenic inarction. Also, the AAST splenic injury grades were recorded. Outcomes were then compared between proximal and distal embolization, and stratified based on the AAST grades. 50 patients underwent splenectomy. 20 patients underwent splenic angioembolization (12 proximal, 6 distal, and 2 combination of proximal and distal). 5 of the total 20 patients (20%) had major rebleeding requiring splenectomy. The rate of major rebleeding for proximal embolization was 17% versus 33% for distal embolization. Of the 5 patients with major bleeding 4 had grade IV-V injuries and 1 had grades I-III injuries. In addition, 1 of the patients who had major rebleeding underwent a combination of proximal and distal embolization. The rate of minor rebleeding for proximal embolization was 8% compared to 0% for distal embolization. The rate of infarction for patients who had proximal embolization was 17% compared to 30% for distal embolization. Also, 1 out 2 patients undergoing a combination technique for embolization had a splenic infract. The rate of infection was 20% for the distal technique versus 0% for the proximal technique. The rate of major rebleeding requiring splenectomy is not statistically different for patients undergoing distal embolization compared to proximal embolization. Minor complications were higher in patients undergoing distal embolization. This data also suggests AAST grades IV-V should go straight to splenectomy.

Spleen-Preserving Laparoscopic Distal Pancreatectomy for Insulinoma in a Child

Introduction: Insulinomas are rare insulin-secreting neoplasms. Ten percent occur in the setting of multiple endocrine neoplasia-type 1 (MEN-1). This video presents the technical details of a spleen-preserving laparoscopic distal pancreatectomy in a child. Nowadays, the adoption of this approach is limited. Our aim is to bring this procedure closer to routine clinical practice. Operative Technique: A 13-year-old girl with neuroglycopenic symptoms for 6 months was referred to our institution for evaluation and management. The work-up demonstrated hyperinsulinemic hypoglycemia, a 3 cm lesion of the tail of the pancreas, a prolactinoma, and adenomas of two parathyroid glands (MEN-1). A four-trocar laparoscopic distal pancreatectomy was performed with the surgeon between the legs. We started with the division of the gastrocolic ligament using a 5 mm tissue-sealing device to enter the lesser sac. The stomach was retracted cephalad, allowing for a better exposure of the pancreatic tail. The peritoneum on the lower pancreatic margin was incised to get access to the retroperitoneal area. Retropancreatic attachments were dissected. With dissection advanced, the pancreas could be lifted up. The insulinoma became visible on the posterior margin and was well delimited with intraoperative palpation. The next step was dissection of the splenic vein on the superior border, embodied by the tail of the pancreas. Approaching small pancreatic vessels originating in the splenic vein is better performed with a hook monopolar electrocautery. We continued freeing toward the body of the pancreas. The peritoneum around the proximal splenic artery was also incised with the hook. If bleeding from the splenic vein is encountered, compression and application of fibrin sealant could provide hemostasis. A bleeding short vessel could be isolated, ligaclipped, oversewn, or coagulated. If bleeding is impossible to control, it is still possible to spare the spleen according to Warshaw's method (the splenic vessels are ligated and spleen becomes dependent on the short gastric vessels). Once the splenic vessels were retracted and the dissection completed, the umbilical 5-mm port was converted to a 12-mm port. The EndoGIA™ linear stapler was introduced and transection of the pancreas was performed using two 30 mm cartridges. The end of the proximal pancreas was over sewn to prevent pancreatic leak. The specimen was extracted in a retrieval bag through the umbilical port. A drain was left in situ. Results: The postoperative course was uneventful. No postoperative diabetes was observed and no treatment for hypoglycemia was necessary. Early oral feeding on postoperative day 2 was well tolerated. The drain was removed and the patient was discharged home in a good condition at postoperative day 5. Histology analysis confirmed the full resection of the intrapancreatic insulinoma but also revealed a second tumor more distally on the pancreatic tail. The patient remains asymptomatic 20 months after surgery. Conclusions: Spleen-preserving laparoscopic distal pancreatectomy is a feasible, effective, and safe procedure. Distal pancreatectomy is preferred to tumorectomy to avoid incomplete resection in cases of multifocal disease. Laparoscopy gives an excellent view of small vessels and has all the advantages of the mini-invasive surgery. Spleen preservation avoids the overwhelming postsplenectomy infection. No competing financial interests exist. Runtime of video: 5 mins 9 secs

Interventional Treatment for Hepatic Artery Thrombosis after Liver Transplantation

PurposeTo evaluate short-term and long-term effectiveness of interventional treatment for hepatic artery thrombosis (HAT). Materials and MethodsFrom March 2003 to October 2015, 34 patients (32 male and 2 female; mean age, 45 y; range 7–64 y) with HAT were identified 0–21d (mean 6.5 d ± 6.0) after liver transplantation and underwent interventional treatments. Technical success, clinical success, complications, hepatic artery patency, and survival time were assessed. ResultsAll 34 patients underwent urokinase thrombolytic treatment. The mean dosage of urokinase was 1,250,000 U ± 1,000,000 (range, 350,000–9,000,000 U). Thrombolysis treatment required 5–120 h (mean 50 h ± 31) for completion. In 21 patients, stents were also implanted during thrombolytic treatment. In 3 patients with splenic artery steal syndrome, proximal splenic artery embolization was performed during thrombolytic treatment. The technical and clinical success rate was 91% (31/34), with treatment failure in 3 children. Hemorrhage was observed in 11 cases. Local necrotic foci in the transplanted liver were found on CT in 5 patients. Complications associated with the interventional procedures occurred in 2 patients. Patency rates of the hepatic artery at 1 y, 2 y, 3 y, and 5 y were 96%, 93%, 83%, and 83%. Overall survival rate at 1 y, 2 y, 3 y, and 5 y were 82%, 73%, 57%, and 57%. ConclusionsInterventional treatment can achieve satisfactory short-term and long-term effectiveness for adult HAT.

Radical Lymph Node Dissection Along the Proximal Splenic Artery During Laparoscopic Gastrectomy for Gastric Cancer Using the Left Lateral Approach.

Recent technical improvements allow safe laparoscopic lymph node dissection (LND) in gastric cancer.1 , 2 In suprapancreatic LND, careful LND around the celiac artery (CA) is essential. From a patient's right side, deep LND is performed around the right side of the CA after dissecting around the common hepatic artery (CHA). For LND around the left side of the CA on the same operative axis as the right side, we developed a new procedure for LND along the proximal splenic artery (SA), performed from the patient's left side. After LND around the CHA and right side of the CA from the patient's right side, the surgeon then moves to the patient's left side. The anterior pancreatic fascia is cut at the middle point of the SA to discern the dorsal layer of the LN along the SA, such as the splenic vein. LND is performed by preserving the posterior pancreatic fascia around the SA in a left-to-right direction. Finally, the LNs around the left side of the CA are deeply dissected. We performed this procedure on ten patients between April 2016 and January 2017; no operative complications were reported in grade II or higher cancer patients.3 After exposing the dorsal landmark, LNs around the proximal SA and left side of the CA were removed in all patients. This procedure enables early identification of the dorsal layer and deep LND around the left side of the CA, keeping this layer. The left lateral approach is useful for radical LND along the proximal SA.

Lymph node metastasis in gastric cancer: Location of positive station to predict survival after preoperative therapy.

166 Background: We sought to determine the association between the identification of positive lymph nodes on D2 lymph node dissection (LND) with stage and outcomes, in the era of preoperative treatment for gastric cancer. Methods: We reviewed data from a prospectively maintained database of gastric cancer patients who underwent resection of gastric or gastroesophageal cancer at our institution from 2005-2016. Central lymph nodes (CnLN) were defined as common hepatic, celiac, and proximal splenic artery lymph nodes (stations #8, 9, and 11p). Risk factors for CnLN metastases, and overall survival (OS) were examined. Results: We identified 356 patients, median age was 64 years (IQR 54-71) and 59% were male. Preoperative therapy was given in 66% of patients. D2 LND was performed in 80% of patients, and the median number of LN examined was 25 (IQR 18-34). Most patients (N = 244, 68%) had separately-examined CnLN in pathology and the median number of examined LNs was higher in this group (27 vs 19; p &lt; 0.001). The CnLN positivity rate was 9.1% (22/244; #8: 4.8%, #9: 6.1%, and #11p: 4.8%), which was higher in advanced pT stage patients (pT0 - 3%, pT1 - 0%, pT2 - 6%, pT3 - 18%, pT4 - 13%; p = 0.001). If we assume that D2 LND was not performed on these patients, a total of 7 (3%, 7/244) patients would have had pN stage down-migration (6 with N1 to N0, 1 with N2 to N1). Of the 22 CnLN-positive patients, 10 (45%) had pN1, 2 (9%) had pN2, and 10 (45%) had pN3 stages. On multivariate analysis, EUS N stage (positive) was associated with positive CnLNs (OR 2.86 [95%CI 1.08-7.58]). Among 342 patients who had R0 resection, the median follow-up was 3.6 years, and the median OS was 11.6 years. Among patients who received preoperative therapy, pT3/4 stage (HR 2.44 [1.27-4.69]; p = 0.01) and positive CnLN (HR 5.44 [2.36-12.52]; p &lt; 0.001) were negatively associated with OS by multivariate analysis. Conclusions: CnLN metastases are uncommon in gastric cancer, and are associated with an adverse impact on OS. However, long-term survival is still possible in patients with positive CnLN whom underwent a D2 lymph node dissection. Larger multi-institutional studies are needed to determine if CnLN positivity requires a separate staging category.

This Aimless Cobra Spits Blood: A Dieulafoyʼs Lesion as the Cause of Massive Hematemesis

Introduction: Dieulafoy's lesion is a tortuous, dilated aberrant submucosal artery that can erode through the mucosa and rupture spontaneously to cause severe gastrointestional bleeding. The lesion is most commonly found in the proximal stomach along the lesser curvature within 6 cm of gastroesophageal junction. It has up to 80% mortality rate because of its tendency to cause intermittent but severe bleeding and diagnostic challenges.Table 1: Neuroendocrine Tumor Characteristics on Surgical PathologyFigure 1Figure 2Case: A 39-year-old Hispanic male presented with sudden onset of melena and painless massive hematemesis. He was a nonsmoker and nonalcoholic with no history of NSAID use. His past medical history was significant for GERD and similar complaints of melena and hematemesis 8 years previously. Extensive prior investigations including CT abdomen and pelvis, esophagogastroduodenoscopy (EGD) and nuclear medicine scan failed to reveal the source of bleeding. He was hemodynamically stable at the time of presentation but his hemoglobin dropped from a baseline of 13 to 8. EGD showed mild reflux esophagitis, acute duodenitis, and gastric varices in the fundus of the stomach. CTA showed a small tangle of abnormally enlarged tortuous bleeding vessels along the posterior cardia of stomach with the absence of early venous return, suggestive of multiple Dieulafoy's lesions. IR-guided mesenteric angiogram was subsequently performed with successful embolization of multiple Dieulafoy's lesions arising from the proximal splenic artery and coursing through the region of the gastric cardia and fundus. The patient had an uneventful recovery and he was discharged home. He did not have recurrence of bleeding and his hemoglobin was within the normal limits at a 3 month follow-up visit.Figure 3Discussion: Diagnosis of Dieulafoy's lesion presents a formidable challenge for physicians and radiologists. Endoscopy is the diagnostic modality of choice but it is often unrevealing due to small size of the Dieulafoy's lesion, normal appearance of surrounding mucosa and intermittent bleeding patterns. These lesions have been known to be mistaken for other entities such as arteriovenous malformations, aneurysms, Mallory-Weiss tears and gastric varices, such as in our case. Contrast-enhanced CT and angiography can be helpful in cases where initial endoscopy fails to reveal the diagnosis of Dieulafoy's lesion and can offer minimally invasive therapeutic alternatives to surgical resection through selective arterial embolization.

Endovascular Repair of Concomitant Celiac and Splenic Artery Aneurysms Using a Combination of Coil Embolization and Aortic Cuff Stent Graft

Visceral artery aneurysms comprise a small portion of all peripheral vascular aneurysms. Of these, the splenic artery is most commonly affected, while celiac artery involvement is rare. Repair is recommended for symptomatic aneurysms or those exceeding two centimeters in diameter. Most reported repairs for celiac artery aneurysms involve surgical excision with or without bypass grafting, but endovascular treatments are becoming more common. We present a case of a 75 year-old male with proximal celiac and distal splenic artery aneurysms treated with combined percutaneous coil embolization and aortic cuff stent graft placement. The splenic aneurysm sac and proximal splenic artery were coil embolized. Attempts to place a covered stent across the celiac artery aneurysm were unsuccessful from both femoral and brachial approaches. We then coil embolized the celiac artery distal to the aneurysm but proximal to the gastroduodenal branch. Coils were also placed into the celiac artery aneurysm sac and left gastric artery. There was insufficient neck length to place coils into the proximal celiac artery. Consequently, an aortic cuff stent graft was deployed across celiac artery origin to obliterate the inflow. There was no liver dysfunction afterwards due to retrograde flow through a patent gastroduodenal artery.

Primary surgery or radiological intervention for bleeding due to vascular complication following pancreatitis

Aim: The bleeding due to vascular complications following pancreatitis is a unique problem, difficult to manage with high morbidity and mortality. There are no definte guidelines to deal these complications. The aim of this study is to form a management algorithim for these bleeding complications. Methods: Between August 2013–August 2015, 18 patients (17 male, 1 female) (average age 41 years) were included. The factors analyzed were clinical presentation, source of bleeding, mode of investigation, and management. The etiology of pancreatitis was acute 6, acute on chronic 7, Chronic 3, Postoperative 1 and Post traumatic 1. Regarding symptoms 18 had abdominal pain, Haematemesis 9, malena 7, Both 6, haematochezia 2, haemoptysis 1. Regarding presentation, bleeding into the stomach 4, pancreatic duct 6, intracystic haemorrage 4, intercostal bleeding 1 and intraperitoneal 4. Ten patients had pseudoaneurysm. They were managed with Radiological intervention, surgical management or both. 5 had radiological intervention, 13 had surgical intervention, 4 had previous endotherapy. The patients requiring surgeries following endotherapy 4, angiointervention 3.Three require redo surgery. Results: There were 5 mortality in patients with delayed referral, redo surgery, previous endotherapy and failed angioembolization. Conclusion: Surgery for Distal splenic artery aneurysm were technically easier than proximal .Surgeries in the form of Ligation of aneurysmal sac alone and Direct opening of aneurysm sac produce worst outcome. Improper drainage of pancreatic collection following pancreatic surgery lead to infective complications and bleeding Radiological intervention has to attempted if bleeding source from Proximal splenic artery, GDA, Superior and Inferior pancreaticoduodenal arteries and unusual locations like Inferior phrenic and Intercostal vessels.