Splenic Artery Research Articles

BN SO31 - Pedicle First; a Paved Laparoscopic Approach for Huge Splenomegaly

Abstract Background Since its introduction for the first time by Delaitre et al1 in 1991, laparoscopic splenectomy (LS) has become the minimal invasive approach of choice for the management of the hematological splenic disorders2. Many agreed benefits have been achieved with this approach regarding the hospital stay, blood loss, duration of recovery, aesthetic results and quality of life; however, massive spleens remain a real technical challenge in front of achieving those benefits. The complex and non-typical variable configurations of the vascular system for the pancreatic body and tail which come from the splenic artery represents another faced point of anatomical complications3. Method From March 2020 to February 2024, a prospective study has included 30 patients presented with benign hematological disorders and massive splenomegaly (more than 20 cm longitudinal axis) who underwent laparoscopic splenectomy in our institution. Detailed data regarding their demographics, splenic size, operative time, blood loss, conversion rate, postoperative serum amylase and hospital stay were collected. Standardized anterior approach operative steps were adopted by the same surgeon for all patients with early control of the arterial system of the splenic circulation before mobilization (short gastric vessels and splenic artery 2 to 4 cm away from hilum). Results Thirty patients presented with huge splenomegaly have underwent laparoscopic splenectomy with a conversion rate of 6.6% (2 patients due to extensive perisplenic adhesions). The mean longitudinal splenic dimension was 24 ± 1.5 cm (range from 20 to 27 cm), mean operative time was 110 ± 16 minutes, mean operative blood loss was 160 ± 20 ml, mean hospital stay was 4 ± 1.5 days, postoperative rate of hyperamylasemia in 20% (asymptomatic 6 patients with no operative evidence of pancreatic injury), respiratory complications in 16.6 % (5 patients), and reactive thrombocytosis in 6.6% (2 patients). Conclusion Early laparoscopic control of the arterial system away from the splenic hilum can enable us to lessen the conversion rate for massive splenomegaly patients and achieve successfully the benefits of laparoscopy for those patients on the expense of the elevated postoperative hyperamylasemia rate.

EGS SO04 - Gastrodoudenal Artery Pseudoaneurysm Secondary to blunt abdominal trauma: A rare case report

Abstract Background Visceral artery pseudoaneurysms (VAPAs) are rare, potentially life-threatning aneurysms found in the celiac, superior, or inferior mesenteric arteries. They are most common in the splenic artery (60-70%), followed by hepatic arteries (20%) and celiac or mesenteric arteries (10%). Usually asymptomatic, VAPAs are often discovered incidentally during abdominal imaging. They pose a high risk of rupture and haemorrhage. Risk factors include iatrogenic injury and abdominal trauma. Traumatic VAPAs are extremely rare with unclear management guidelines. Treatment options vary from observation to endovascular therapy or surgical repair. This report presents a case of a gastoduodenal artery psuedoaneurysm due to blunt abdominal trauma. Method A case report: a 68-year-old male with a high BMI and atrial fibrillation managed with edoxaban, presented with severe upper abdominal pain following a fall. Initial examination and laboratory results suggested acute pancreatitis or cholecystitis, but a CT angiography revealed a GDA pseudoaneurysm with active extravasation. The patient was referred for urgent therapeutic embolization; however, the pseudoaneurysm had spontaneously thrombosed, precluding the need for embolization. The patient was managed conservatively, with close monitoring in the high dependency unit (HDU), analgesics, proton pump inhibitors, and mechanical venous thromboembolism prophylaxis. He remained hemodynamically stable and was discharged with instructions for follow-up care. Results GDA pseudoaneurysms are rare, accounting for 0.01-1% of all visceral artery aneurysms, with trauma being an exceptionally infrequent cause. The management of VAPAs, particularly in hemodynamically stable patients, can range from conservative observation to endovascular interventions. This case underscores the importance of a multidisciplinary approach involving surgery, interventional radiology, and vascular teams for optimal management. Conclusion Gastroduodenal artery pseudoaneurysms secondary to blunt abdominal trauma can be effectively managed conservatively in stable patients. Comprehensive history-taking, appropriate imaging, and multidisciplinary discussions are crucial for successful outcomes. Continued monitoring is essential to ensure patient safety and address potential complications.

HPB O04 - Human Splenic Ex-Vivo Perfusion Model: A Platform for Translational Basic Science Research

Abstract Background The function of the spleen has always been shrouded in mystery and since the Renaissance leading figures have attempted to understand its function. Vesalius questioned Galen and Marcello Malpighi (1628-1694) gave the first accurate description of the histology and the physiology. The spleen still poses unique challenges as invasive approaches may produce intraperitoneal bleeding, differences between human and animal spleens complicates comparative studies, and post-mortem examinations reveal only late-stage disease manifestations and functional studies are impossible. This study describes a human splenic ex-vivo perfusion model for translational research, using microbiological studies as markers of splenic physiological function. Method Patients with left-sided pancreatic cancers scheduled for distal pancreatic and splenic resection were identified from the Hepato-Pancreatic and Biliary MDT at the University Hospitals of Leicester NHS Trust. Patients were informed, consented, and the surgical approach remained standard, with splenic artery ligation deferred until specimen extraction. The artery was cannulated, and residual blood clots were cleared with Custodiol® HTK solution. The perfusion technique employs an extracorporeal circuit incorporateing anoxygenator and a heated water chamber maintaining a 37°C perfusate. The perfused spleen was infected with Streptococcus Pneumoniae strains, with regular biopsies and perfusate gas analysis performed. Results Since February 2023, nine spleens have been successfully perfused, with an average weight of 169.5 grams, cold ischemic time of 116 minutes, and warm ischemic time of 12.2 minutes. Pressure was maintained at 80 mmHg and hourly perfusate gas analysis demonstrated a mean pH of 7.1 and a gradual increase in lactate. Histopathological examination revealed clear distinctions between the lymphoid tissue and splenic red pulp, with intact central arterioles and healthy cell morphology at time 0 and after 6 hours of perfusion. Additionally, the perfused spleens cleared S. pneumoniae strains to below-detection levels. Conclusion Our work demonstrates that a stable human splenic ex-vivoperfusion model which maintains structural and physiological integrity can be achieved from tissue that would otherwise be discarded. The continued physiological function is confirmed by the clearance of S. pneumoniae. While currently employed for microbiological studies, this model has the potential to facilitate a wide range of different translational science studieswhile reducing the need for animal experimentation. The perfusion times employed for the present study were sufficient to demonstrate bacterial clearance which was the aim but there is capacity in the system to significantly prolong the duration.

Refractory gastrointestinal bleeding caused by splenic artery pseudoaneurysm rupture.

A 64-year-old man was admitted for hematemesis. Esophagogastroduodenoscopy revealed a gastric ulcer with a visible vessel on the posterior wall of the gastric body. After admission, the patient developed multiple episodes of massive hematemesis. During emergent esophagogastroduodenoscopy, he developed hemodynamic instability due to spurting bleeding. On day 18 of hospitalization, hemostasis was achieved using hemostatic forceps; however, contrast-enhanced computed tomography performed on the same day revealed a small splenic artery pseudoaneurysm (SAP) that had not been previously detected. To prevent fatal re-bleeding, interventional radiology was performed, and coil embolization was applied proximal to the pseudoaneurysm. The patient recovered without further hematemesis. One month later, exposed coils were observed from the healing ulcer, and celiac trunk angiography confirmed splenic artery thrombosis. Despite multiple attempts at endoscopic intervention, the patient developed recurrent hematemesis, suggesting that the gastric ulcer had eroded into the splenic artery, forming the SAP and causing significant hemorrhage. Although SAPs secondary to gastric ulcers are extremely rare, early recognition is critical because they carry a high risk of rupture and mortality. Endoscopic procedure alone may be insufficient, and an endovascular approach is a standard treatment to prevent life-threatening re-bleeding.

Laparoscopic total pancreatectomy with total mesopancreas dissection using counterclockwise technique and tail-first approach.

Laparoscopic total pancreatectomy (LTP) is technically challenging and infrequently documented in the literature. In this paper, we present a new approach for performing fully LTP, a pancreatic tail-first approach with a counterclockwise technique, to accomplish total mesopancreas dissection and standard lymphadenectomy en bloc. Firstly, the tail and body of the pancreas without the spleen were dissected retrogradely, starting from the lower border of the body of pancreas and then from left to right. After that, a counterclockwise dissection of the tail and body of the pancreas was performed. The splenic artery and vein were divided at the terminal end of the pancreatic tail. The spleen was preserved. The entire body and tail of the pancreas were then pulled to the right side. This maneuver facilitated the isolation and dissection of arteries in the retropancreatic region more easily via laparoscopy, including the splenic artery, gastroduodenal artery, and supporting superior mesenteric artery first-approach. It also enabled total mesopancreas dissection. The inferior pancreaticoduodenal artery was resected last during this phase. The remainder of the dissection was like that of a laparoscopic pancreaticoduodenectomy with total mesopancreas dissection, involving two laparoscopic manual anastomoses. The operative time was 490 minutes and the total blood loss was 100 mL. Pathology revealed a low-grade intraductal papillary mucinous neoplasm extending from the head to the tail of the pancreas.

Short-term outcomes of a phase II trial of perioperative capecitabine plus oxaliplatin therapy for advanced gastric cancer with extensive lymph node metastases (OGSG1701).

The prognosis of advanced gastric cancer (GC) with extensive lymph node (LN) metastasis treated with surgery alone remains poor. We conducted a multicenter phase II study to evaluate the efficacy and safety of perioperative capecitabine plus oxaliplatin (CapeOx) therapy in patients with advanced GC with extensive LN metastases. Patients with histologically proven HER2-negative or unknown gastric adenocarcinoma with paraaortic LN (PALN) metastases and/or bulky LN metastases located at the celiac axis, common hepatic artery, and/or splenic artery were included in the study. Patients received three cycles of preoperative CapeOx every 3weeks, followed by five cycles of postoperative CapeOx after gastrectomy with D2 or D2 + including PALN dissection. The primary endpoint was the response rate (RR) according to the RECIST v1.0 criteria. Thirty patients from 14 institutions were enrolled from September 2017 to June 2022. Complete response, partial response, stable disease, and progressive disease occurred in zero, 20, eight, and one patient, respectively. One patient was not evaluated. The RR was 66.7% (90% confidence interval, 50.1-80.7%; one-sided P = 0.049). The preoperative chemotherapy completion rate and the curative resection rate were 96.7% and 93.3%, respectively. The minor (grade ≥ 1b) pathological RR was 66.7%. Grade 3 adverse events of preoperative chemotherapy included neutropenia in 3.3%, anemia in 6.7%, and anorexia in 10.0%. One treatment-related death occurred due to postoperative complications. Preoperative CapeOx chemotherapy showed a favorable RR, curative resection rate, and acceptable adverse events in patients with advanced GC with extensive LN metastasis. UMIN000028749 and jRCTs051180186.

Organ-preserving embolization of a giant splenic hemangioma in an adult

Splenic hemangioma is a rare benign tumor, often found incidentally. Large hemangiomas bear a high risk of spontaneous rupture, an acute condition often life-threatening that requires immediate intervention. The spleen’s vital role in immunity and blood filtration mandates organ-preserving management of conditions such as hypersplenism or large lesions such as hemangiomas. A 51-year-old patient was referred to our department for abdominal pain due to a giant spleen hemangioma (6,6 × 6,3 × 5,6) cm in size. The patient was treated with hemangioma embolization through the splenic artery branches that fed the lesion, without any complications. Two years post-embolization the patient mentioned no symptoms and the hemangioma was measured (3 × 2) cm.Background The patient was referred to our department due to the large size of the lesion and the patient’s preference to avoid surgery and maintain the spleen. Our case report aims to underline (a) the safety and feasibility of the protocol among interventional radiologists, surgeons, and patients, (b) the benefit of relieving symptoms without losing a vital organ, and (c) the lower complication rate and hospital days compared with surgery. There are few reported cases of embolization of large spleen hemangioma. While Choi et al. (BMC Pediatr. 2018 12;18(1):354) report a similar case in a child. This case report describes the procedure in a stable adult and provides a 2-year follow-up.Graphical

Retrospective Observational Study of the Management of Blunt Traumatic Splenic Injury 2017-2022 at Major Trauma Centres in England. What is the Current Role of Splenic Artery Embolisation?

PURPOSE: To compare the treatment and outcomes of blunt splenic injury (BSI) management strategy within Major Trauma centres in England between 2017 and 2022. Data was extracted from UK TARN (Trauma Audit Research Network) identifying all splenic injuries admitted to English Major Trauma Centres (MTCs) between 01/01/17 and 31/12/21. Mechanism, injuries, treatment and outcomes were compared between management strategies according to American Association of Surgery in Trauma (AAST) grade over the period. The main endpoints of splenic salvage rate, along with mortality and length of stay were compared between the treatment options. 3,723 patients sustained BSI; 2,906 (78.1%) were managed conservatively, 491 (13.2%) underwent embolisation while 326 (8.8%) underwent splenectomy. There were 1895 (50.9%) AAST grade 2 injuries, 1019 (27.4%) grade 3, 592 (15.9%) grade 4 and 247 (6.6%) grade 5. Embolisation was successful (i.e. no subsequent splenectomy) for 465/491 (94.7%). The length of stay of discharged patients in the splenectomy group was longer than in those receiving embolisation (p = 0.001) or conservative management (p < 0.001) (median (IQR) of 12 (7, 27), 10 (6, 19), 10 (6, 20) days, respectively). Mortality at 30days was not significantly different in those who underwent splenectomy (12.3%) compared to embolisation (8.6%) and conservative management (11.5%) (p = 0.129). Splenic embolisation results in a high rate of splenic salvage.

Ballooning and Bursting of Barrels and Pipes: A Rare Case of Suspected Vascular Ehlers–Danlos Disease

Vascular Ehler–Danlos disease (vEDS), a rare subtype of a rare disease, is a life-threatening disease, with an increased risk for spontaneous vascular or visceral rupture. These patients have fatal complications ranging from vascular aneurysms, dissection, and rupture of systemic vessels to frequent thromboembolic events, the common causes of death in these individuals with a shortened life span. In the present case, a 28-year-old male with history of shoulder dislocations and spontaneous colon perforation presented to the primary care clinic with right lower extremity swelling and pain. His history includes presentation to the emergency department with left lower leg swelling with compartment syndrome one year prior. A CT angiogram of lower extremities and abdomen revealed acute arterial extravasation of the left posterior tibial artery, indicating a ruptured aneurysm along with aneurysms of the splenic artery and left common iliac artery. He was treated with a saphenous vein graft, but was associated with post-operative complications that necessitated below-knee amputation. CT angiogram of his right leg revealed occlusion of the anterior tibial and peroneal arteries with aneurysms, and, ultimately, he was referred to a tertiary care center for aneurysm embolization. This case report emphasizes the frequent vascular complications encountered in vascular EDS patients, and thus advocates for close and regular monitoring for early referral and surgical management of their vascular anomalies. Finally, genetic counseling and screening of asymptomatic family members should be routinely implemented in these patients.

Successful laparoscopic arterial ligation of splenic artery aneurysm with a splenomesenteric trunk: a case report and literature review

BackgroundThe mortality rate of splenic artery aneurysm rupture is very high, and patients with aneurysms larger than 30 mm are recommended for treatment, regardless of the presence or absence of symptoms. We herein report a case of splenic artery aneurysm with an abnormal bifurcation that was treated with laparoscopic ligation of the splenic artery.Case presentationA 51 year-old Japanese male was referred to our hospital because a splenic artery aneurysm was noted on abdominal echocardiography during a medical examination. The splenic artery bifurcated from the superior mesenteric artery (SMA), and a 38-mm splenic artery aneurysm was found just after the bifurcation; thus, surgery was performed. Intraoperative angiography was performed, a balloon catheter was placed before the splenic artery bifurcation, and laparoscopic splenic artery ligation was performed to prepare for sudden bleeding. After ligation of the splenic artery, angiography was performed again to confirm the absence of the splenic artery aneurysm and that the peripheral splenic artery was visible through the peripheral collateral vessels. The patient was discharged on the fourth postoperative day, with good progress. Contrast-enhanced computed tomography performed 1 month postoperatively confirmed the disappearance of the splenic artery aneurysm, and the contrast-enhanced peripheral splenic artery was visible.ConclusionThis is the first report of a safe laparoscopic artery ligation procedure for a splenic artery aneurysm with an abnormal splenic artery bifurcation from the SMA, in which a balloon catheter was placed at the splenic artery bifurcation.

Spontaneous rupture of a splenic artery aneurysm with hemoperitoneum; case presentation

Spontaneous rupture of a splenic artery aneurysm with hemoperitoneum; case presentation

Our Experience with the Low-Profile Braided Occluder: A Case Series of Splenic Artery Embolization in Three Trauma Patients

AbstractThe spleen is the most injured intra-abdominal organ, with splenic injuries constituting 42 to 49% of all abdominal injuries. Due to this vulnerability and the fact that splenic ruptures can potentially result in life-threatening hemorrhage, finding quick and efficient ways to control splenic bleeding in a trauma setting can improve patient outcomes. Recently, the U.S. Food and Drug Administration cleared the low-profile braided occluder (LOBO; Okami Medical, Aliso Viejo, California, United States), a vascular occlusion system designed to rapidly occlude vessels by using a high-density, uniform small pore structure. We present a small case series describing the use of the LOBO device for proximal splenic embolization in three trauma patients. Our report suggests that the LOBO device is safe and efficient for proximal splenic artery embolization as all three of our patients had a successful outcome with no complications; furthermore, we believe using the LOBO device may enhance patient and provider safety by decreasing fluoroscopic time and radiation dose, though further studies are needed to support this.

The safety and feasibility of laparoscopic partial splenectomy: analysis of perioperative indications from different vascular subtypes and improvement of surgical approach.

While laparoscopic splenectomy (LS) has been widely used in benign splenic tumor, more concerns have been raised for postoperatively short-term and long-term complications. Laparoscopic partial splenectomy (LPS) is a surgical option, to preserve splenic function, and reduce postoperative complications. The aim of our study was to retrospectively identify the safety and feasibility of LPS compared with LS in patients with splenic benign tumor. From 2014 to 2024, a total of 165 patients diagnosed with occupational splenic lesions underwent splenectomy, of whom 87 underwent LPS and 78 underwent LS. We compare the perioperative parameters and long term follow up between these two groups. The etiology of splenic space-occupying lesions was nonparasitic splenic cysts, followed by splenic lymphangioma and splenic hemangioma. Of the patients with LPS, 55 underwent conventional surgery with blockage of the splenic arterial branch and resection along the ischemic line (RAIL), and 32 underwent with our modified total splenic blood supply blockade followed by resection alone the tumor edge (RATE). The tumor size, the operative time and estimated blood loss were comparable between the LPS and LS groups. One patient developed abnormal signs during the LPS procedure and was promptly referred for LS. The LPS group had fewer pancreatic leakage, incision infection, and pulmonary infection. As for different vascular types, patients with LS under all branches of the splenic artery had a longer time to resume postoperative feeding. As for the comparison of RAIL and RATE, estimated blood and operative time were significantly reduced in patients receiving RATE. Postoperative complications were the same in patients underwent each surgical procedures. LPS is a viable approach for patients with splenic benign tumor. We introduce the tumor artery supply types to indicate the resection region. Our RATE technique has proven to be clinically effective and safety.

Interventional Management of Visceral Artery Aneurysms: Simple to Complex

AbstractVisceral artery aneurysms (VAAs) are uncommon but potentially life-threatening vascular disorders that can involve the celiac, superior, and inferior mesenteric arteries or their branches. They are often asymptomatic but can present with vague abdominal pain, secondary effects, or signs of hemorrhage. The most common site of involvement is the splenic artery, followed by the hepatic artery, the celiac axis, and mesenteric arterial branches. VAAs can be classified into two types: true aneurysms (TAs) and pseudoaneurysms (PSAs). Imaging, particularly multidetector computed tomography angiography, is the cornerstone in diagnosing VAAs. Treatment decisions are based on the risk of rupture and clinical deterioration in a patient with a VAA. The endovascular approach remains the mainstay in the treatment of VAAs. As a general guideline, PSAs, even when asymptomatic, should always be treated. TAs are treated based on their size and location. Deconstructive and reconstructive strategies are the standard treatment options for any VAA, and assessing the vascular anatomy and collateral circulation is paramount for treatment decisions.

X-ray Endovascular Embolization for Splenic Artery Aneurysm Complicated by Intestinal Bleeding

Introduction. Splenic artery aneurysms refer to the most common visceral artery aneurysms. However, they are diagnosed quite rarely, since about 80% of them appear asymptomatic. Clinically, splenic artery aneurysms manifest themselves through their complications, including hemorrhage into pancreatic cysts or intra­abdominal bleeding due to their rupture, leading to lethality up to 8.5%. Other complications of splenic artery aneurysms appear extremely rare. The gold standard for the diagnosis of splenic artery aneurysms refers to digital subtraction angiography that enables their exact localization to be determined and aneurysm embolization to be performed. Materials and methods. In the period from 2015 to 2023, we observed 51 patients who underwent endovascular interventions on the splenic artery for hypersplenism (n = 32) and aneurysms (n = 19). In most cases, the aneurysms were asymptomatic. The paper presents a rare clinical case of splenic artery aneurysm complicated by recurrent intestinal bleeding. Results and discussion. Examination (EGD, CS) did not detect the source of recurrent intestinal bleeding. Contrast CT revealed a splenic artery aneurysm. Celiac angiography detected a large aneurysm (52×41 mm) of the splenic artery, closely adjacent to the lower horizontal branch of the duodenum. Endovascular embolization of the splenic artery was performed proximal to the aneurysm, resulting in complete occlusion of blood flow through the splenic artery and aneurysm. No repeated episodes of intestinal bleeding were observed after the intervention, thereby indicating the effectiveness of hemostasis. No signs of splenic ischemization were detected by clinical and examination data due to the preservation of blood flow through short splenic vessels. Conclusion. Endovascular embolization of the splenic artery is found to be an effective treatment for its complicated aneurysms.

7799 Nesidioblastosis Concurrent with Anatomically Confirmed Metastatic Gastric Cancer

Abstract Disclosure: Y. Cho: None. K. Jo: None. J. Han: None. S. Moon: None. E. Kim: None. Background: Nesidioblastosis is a rare condition that should be considered in cases of pancreatogenic hyperinsulinemic hypoglycemia without evidence of insulinoma on imaging. We present the first case of nesidioblastosis concomitant with anatomically confirmed metastatic gastric cancer of the pancreas. Case Report A 57-year-old male presented with recurrent episodes of loss of consciousness and hypoglycemia, with a glucose level of 26 mg/dl upon arrival at the emergency room. Despite a history of advanced gastric cancer and previous chemotherapy, the patient had not been diagnosed with diabetes and was not taking medications associated with hypoglycemia. Four months prior, he underwent total gastrectomy. The fasting plasma glucose levels was 38 mg/dl, accompanied by C-peptide levels of 6.10 ng/mL, insulin levels exceeding 1000 uIU/ml, and proinsulin levels at 8.8 pmol/L. The insulin antibody level was more than 100%, and the highest cortisol level reached 15.60 ug/dL during the rapid ACTH stimulation test. The patient's postprandial 2-hour glucose level reached 233 mg/dl during the 75g glucose tolerance test. Imaging studies, including whole-body PET CT and abdominal CT, showed no evidence of suspected metastatic lesions, and the pancreas appeared normal on MRI. Endoscopic ultrasound could not be performed due to anatomical changes following the surgery. A selective arterial calcium stimulation test demonstrated a substantial over twofold increase in insulin concentrations in the gastroduodenal artery, splenic artery, and superior mesenteric artery. The patient received methylprednisolone 125 mg once daily but insulin levels remained elevated, exceeding 1000 uIU/ml, requiring continuous dextrose infusion. Octreotide therapy was initiated, resulting in an improvement in insulin levels to 589 uIU/ml, although discontinuation of dextrose fluid remained unfeasible. After consultation with the surgeon, a open subtotal pancreatectomy was performed, allowing discontinuation of dextrose on the second post-surgery day, with improved glucose and insulin levels. Histological examination showed three clusters of atypical cells with perineural infiltration. Immunostaining indicated negative synaptophysin and positive CK20, suggesting possible gastric cancer metastasis, consistent with prior gastrectomy findings. Moreover, an increased number of variable-sized Langerhans islets exhibited positive insulin and glucagon immunostaining within the islets, indicative of nesidioblastosis. Conclusion: Nesidioblastosis should be considered in cases of unexplained post-surgery hypoglycemia following metastatic gastric cancer treatment. Furthermore, given the potential link with metastatic gastric cancer, which may elude detection via imaging alone, aggressive surgical intervention should be contemplated as a nesidioblastosis treatment strategy. Presentation: 6/3/2024

6538 Find me if you can! A Case of a "Well Placed Solitary Insulinoma" in "The Center" of an SACST

Abstract Disclosure: R. Kennedy: None. D.A. D'Alessio: None. A.V. Vella: None. Introduction: Selective arterial calcium stimulation testing (SACST) can be utilized in patients to localize solitary insulinomas when imaging is non diagnostic. While a heterogenous stimulation pattern suggests NIPHS, or multiple insulinomas this case uniquely demonstrates such a pattern with a solitary insulinoma. Clinical Case: The patient is a 48 year old female who presented to the emergency department (ED) for bizarre behavior which resolved with a sweetened drink. Serum glucose was 62 mg/dL, she was treated with IV dextrose and was discharged from the ED. She was referred to outpatient endocrinology for further evaluation where continuous glucose monitoring confirmed predominantly fasting hypoglycemia. Adrenal insufficiency was excluded. She was admitted for a 72 hour inpatient fast where the patient achieved hypoglycemia within 24 hours, with glucose 46 mg/dL (associated with neuroglycopenic symptoms), beta hydroxybutyrate &amp;lt; 0.18 mmol/L, insulin 3.9 mcIU/mL, proinsulin 157pmol/L, c-peptide 1.4 ng/mL and a glucose rise greater than 25mg/dL after glucagon administration. Sulfonylurea screen and insulin antibodies were negative; IGF1 within normal limits. These labs were consistent with hyperinsulinemic hypoglycemia. An MRI pancreas however did not reveal an insulinoma. The patient therefore underwent a SACST, demonstrating a 10 fold response in the territory of the gastroduodenal artery and splenic artery, as well as a 3 fold response in the superior mesenteric artery. This heterogenous pattern in addition to the marked response in each arterial territory raised the possibility of multiple insulinomas. However as there were no tumors present on imaging, medical management was initiated with close follow up. She was trialed with months of somatostatin analogs and diazoxide with minimal improvement in the frequency and severity of her hypoglycemia. About a year after her initial diagnosis, repeat abdominal imaging (CT and MRI) revealed an 8 mm arterial hyper-enhancing lesion in the body of the pancreas concerning for neuroendocrine tumor. Repeat SACST was performed, this time showing a greater than 10 fold response in all three arterial territories. Angiography showed a tumor blush that was visible when each of the three major arteries were injected sequentially. She underwent laparoscopic pancreatic enucleation. The lesion was located on the body of the pancreas, with histology confirming an insulinoma. The patient responded promptly post operatively; her symptoms resolved without further need of medical management. Conclusion: Our case shows that the interpretation of an SACST should take into account the arterial anatomy before ascribing a non-focal response to multiple territories of insulin hypersecretion. Presentation: 6/1/2024

8179 Complicated Pancreatitis Unveiled: A Case Of Untreated Primary Hyperparathyroidism

Abstract Disclosure: A. Rehan: None. H. Al Jumaili: None. J. Lim: None. Introduction: Acute pancreatitis (AP) triggered by hypercalcemia stemming from primary hyperparathyroidism (PHPT) is an infrequent occurrence, with a prevalence of about 1.5-7%. The proposed mechanism involves deposition of calcium in the pancreatic ducts and activation of pancreatic enzymes. While a causal connection between AP and PHPT has been described, it remains controversial. Calcium levels are thought to play a major role in determining the severity of the pancreatitis. Additionally, it is thought that genetic mutations may contribute to the development of AP in PHPT. Here, we report a case of necrotizing pancreatitis in a patient with untreated PHPT. Clinical Case: Patient is a 59-year-old male with a medical history of hypertension, nephrolithiasis and PHPT secondary to parathyroid hyperplasia (scheduled for parathyroidectomy) who presented with abdominal pain, nausea, vomiting and was found to have AP. He reported no history of alcohol use, trauma or insect bites. His workup was unrevealing for cholecystitis, choledocholithiasis or hypertriglyceridemia. He represented with calcium level of 16 mg/dL (NR 8.7-10.1) due to PHPT. PHPT was deemed the likely cause of AP. Course was further complicated by necrotizing pancreatitis and pseudocyst. A few months later, patient started having coffee ground emesis, worsening epigastric pain and weight loss of 60 lbs due to poor oral intake. CT abdomen/pelvis showed walled off pancreatic necrosis with peripancreatic stranding and concern for gastric outlet obstruction. EGD with PEG-J placement was done with plans for future endoscopic drainage. Few weeks after, he had another bout of worsening abdominal pain. Labs at the time showed corrected calcium between 11-13 mg/dL, PTH 147 pg/ml (NR 5-44), phosphorus 1.6 mg/dL (NR 2.5-4.5), vitamin D 25 hydroxy 19.5 ng/ml (NR 22-110). His condition became more complex with a hemorrhagic walled off pancreatic necrosis and splenic artery pseudoaneurysm requiring ICU care. The repeated escalation of symptoms resulted in multiple delays for the scheduled parathyroidectomy. Patient was started on treatment with Cinacalcet and vitamin D while in the hospital. Due to constraints in resources, he was unable to continue Cinacalcet outpatient. He subsequently was able to undergo parathyroidectomy with pathology showing benign adenoma. Conclusion: Hypercalcemic hyperparathyroidism causing AP, although rare, is often severe and poses a greater risk of complications making it important to be aware of this association, especially when more common causes have been excluded. Imaging techniques like cervical ultrasound, CT, and scintigraphy using 99mTc-Sestambi should be utilized to confirm suspicion. Surgical resection is the mainstay treatment, and having a multidisciplinary team with gastroenterologists, endocrinologists, and surgeons helps improve outcomes. Presentation: 6/2/2024

A Dedicated Algorithm for Endovascular Approach as a First-Line Treatment Option for Visceral Artery Aneurysms

Few data are reported in literature about visceral artery aneurysms (VAAs) management. The aim of the present study was to analyze VAAs management in a single institution, with a dedicated algorithm for endovascular approach as the first line treatment. A single-center retrospective cohort study was performed. Patients with a VAA submitted to either endovascular repair or open surgery from 2016 to 2023 were included. A dedicated algorithm was used to evaluate the endovascular approach feasibility assessing on the preoperative computed tomography angiography the following parameters: (a) the tortuosity of the involved artery (<150°), (b) the healthy arterial diameter (>4mm), (c) the VAA proximity to the hilum and/or the presence of a bifurcation of the aneurysmatic artery, and (d) the circumferential calcium presence. An endovascular approach was chosen if (a) and (b) criteria were satisfied without (c) and (d) ones. Otherwise, it was deemed a challenging anatomy, and an open surgical treatment was considered. In the absence of (a) and/or (b) criteria open surgery was the preferred option. Thirty-one asymptomatic aneurysms (28 patients) were treated electively. The most frequent VAA location was the splenic artery (18 cases; 58%), followed by the renal arteries (6 cases; 19%), the common hepatic artery (5 cases; 16%), the gastroepiploic artery (1 case, 3.2%) and the pancreatoduodenal artery (1 case; 3%). Twenty-two aneurysms (71%) were initially treated by an endovascular approach (stent-graft deployment and/or transcatheter embolization) with 3 (13%) of them needing a surgical conversion. Nine aneurysms (29%) were submitted directly to a surgical treatment (aneurysm resection with or without interposition bypass) with no peri-operative and long-term complications. Technical success was 90.3%. Endovascular management as a first line approach is safe and effective in most cases. A preoperative dedicated algorithm is useful to identify suitable cases. Open surgery can be considered an alternative option in specific challenging anatomical situations or in case of endovascular failure.

S3820 Rare Presentation of Isolated Gastric Varices Secondary to Chronic Splenic Artery Calcification

S3820 Rare Presentation of Isolated Gastric Varices Secondary to Chronic Splenic Artery Calcification