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Rinaldi LF, Brioschi C, Marone EM. Endovascular and Open Surgical Treatment of Ruptured Splenic Artery Aneurysms: A Case Report and a Systematic Literature Review. J Clin Med 2023; 12:6085. [PMID: 37763025 PMCID: PMC10531855 DOI: 10.3390/jcm12186085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 09/16/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Ruptured splenic artery aneurysms (r-SAA), although rare, are burdened by high morbidity and mortality, even despite emergent surgical repair. It is suggested that endovascular treatment can achieve reduction in peri-operative death and complication rates, as in other vascular diseases, but evidence of such benefits is still lacking in this particular setting. We report a case of an r-SAA treated by trans-arterial embolization and then converted to open surgery for persistent bleeding, and we provide a systematic review of current results of open and endovascular repair of r-SAAs. MATERIALS AND METHODS A 50-year-old male presenting in shock for a giant r-SAA underwent emergent coil embolization and recovered hemodynamic stability. On the following day, he underwent laparotomy for evacuation of the huge intraperitoneal hematoma, but residual bleeding was noted from the splenic artery, which was ligated after coil removal, and a splenectomy was performed. A systematic literature review of the reported mortality and complications of r-SAA undergoing open (OSR) or endovascular (EVT) treatment was performed using the main search databases. All primary examples of research published since 1990 were included regardless of sample size. The main outcome measures were mortality and reinterventions. Secondary outcomes were post-operative complications. RESULTS We selected 129 studies reporting on 350 patients-185 treated with OSR and 165 with EVT. Hemodynamically unstable patients and ruptures during pregnancy were more frequently treated with open repair. Overall, there were 37 deaths (mortality: 10.6%)-24 in the OSR group and 13 in the EVTr group (mortality: 12.9% and 7.8% respectively, p-value: 0.84). There were 37 reinterventions after failed or complicated endovascular repair -6 treated with endovascular re-embolization and 31 with laparotomy and splenectomy (22.4%); there were 3 (1.6%) reinterventions after open repair. Overall complication rates were 7.3% in the EVT group (n: 12) and 4.2% in the OSR group (n: 7), and did not require reintervention. No significant differences in overall complications or in any specific complication rate were observed between the two groups. CONCLUSIONS Current results of r-SAA treatment show equipoise terms of morbidity and mortality between open and endovascular repair; however, in case of hemodynamic instability and rupture during pregnancy, open surgery might still be safer. Moreover, endovascular repair is still burdened by a significantly higher rate of reinterventions, mostly with conversions to open surgery.
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Affiliation(s)
- Luigi Federico Rinaldi
- Vascular Surgery, Department of Integrated Surgical and Diagnostic Sciences, University of Genoa, 16132 Genoa, Italy
- Vascular Surgery, Ospedale Policlinico di Monza, 20900 Monza, Italy; (C.B.); (E.M.M.)
| | - Chiara Brioschi
- Vascular Surgery, Ospedale Policlinico di Monza, 20900 Monza, Italy; (C.B.); (E.M.M.)
| | - Enrico Maria Marone
- Vascular Surgery, Ospedale Policlinico di Monza, 20900 Monza, Italy; (C.B.); (E.M.M.)
- Vascular Surgery, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
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Malviya KK, Verma A. Importance of Anatomical Variation of the Hepatic Artery for Complicated Liver and Pancreatic Surgeries: A Review Emphasizing Origin and Branching. Diagnostics (Basel) 2023; 13:diagnostics13071233. [PMID: 37046451 PMCID: PMC10093498 DOI: 10.3390/diagnostics13071233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 04/14/2023] Open
Abstract
Knowledge of anatomical variations of the hepatic artery from its origin to intrahepatic segmentation is of utmost importance for planning upper abdominal surgeries including liver transplantation, pancreatoduodenectomy, and biliary reconstruction. The origin and branching pattern of the hepatic artery was thoroughly described by the classification of Michels and Hiatt. Some rare variations of the hepatic artery were classified by Kobayashi and Koops. By the use of the multidetector computed tomography (MDCT) technique, the branching pattern of the hepatic artery can be visualized quite accurately. Unawareness of these arterial variations may lead to intraoperative injuries such as necrosis, abscess, and failure of the liver and pancreas. The origin and course of the aberrant hepatic arteries are crucial in the surgical planning of carcinoma of the head of the pancreas and hepatobiliary surgeries. In liver transplant surgeries, to minimize intraoperative bleeding complications and postoperative thrombosis, exact anatomy of the branching of the hepatic artery, its variations and intrahepatic course is of utmost importance. This review discusses variations in the anatomy of the hepatic artery from its origin to branching by the use of advanced imaging techniques and its effect on the liver, pancreatic, biliary and gastric surgeries.
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Affiliation(s)
- Kapil Kumar Malviya
- Department of Anatomy, Institute of Medical Science, Banaras Hindu University, Varanasi 221005, Uttar Pradesh, India
| | - Ashish Verma
- Department of Radiodiagnosis and Imaging, Institute of Medical Science, Banaras Hindu University, Varanasi 221005, Uttar Pradesh, India
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Kato H, Asano Y, Ito M, Kawabe N, Arakawa S, Shimura M, Koike D, Hayashi C, Kamio K, Kawai T, Ochi T, Yasuoka H, Higashiguchi T, Tochii D, Kondo Y, Nagata H, Utsumi T, Horiguchi A. The usefulness of preoperative exocrine function evaluated by the 13C-trioctanoin breath test as a significant physiological predictor of pancreatic fistula after pancreaticoduodenectomy. BMC Surg 2022; 22:49. [PMID: 35148748 PMCID: PMC8832756 DOI: 10.1186/s12893-022-01500-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 01/27/2022] [Indexed: 11/10/2022] Open
Abstract
Background The association between pancreatic fistula (PF) after pancreaticoduodenectomy (PD) and preoperative exocrine function is yet to be elucidated. This study aimed to evaluate the association between the preoperative results of the 13C-trioctanoin breath test and the occurrence of PF, showing the clinical relevance of the breath test in predicting PF. Method A total of 80 patients who underwent 13C-trioctanoin breath tests prior to PD from 2006 to 2018 were included in this study. Univariate and multivariate analyses were conducted to reveal the preoperative predictors of PF, showing the association between 13C-trioctanoin absorption and PF incidence. Results Among 80 patients (age, 68.0 ± 11.9 years, 46 males and 34 females; 30 pancreatic ductal adenocarcinoma [PDAC]/50 non-PDAC patients), the incidence of PF was 12.5% (10/80). Logistic regression analysis results revealed that the frequency of PF increased significantly as the 13C-trioctanoin breath test value (Aa% dose/h) increased (odd’s ratio: 1.082, 95% confidence interval: 1.007–1.162, p = 0.032). Moreover, the optimal cutoff value of the preoperative fat absorption level to predict PF was 38.0 (sensitivity, 90%; specificity, 74%; area under the curve, 0.78; p = 0.005). Indeed, the incidence of PF was extremely higher in patients whose breath test value was greater than 38.0 (33%, 9/27) compared with that in patients with values less than 38.0 (1.8%, 1/53). Conclusions Favorable preoperative fat absorption evaluated using the 13C-trioctanoin breath test is a feasible and objective predictor of PF after PD.
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Affiliation(s)
- Hiroyuki Kato
- Department of Gastroenterological Surgery, Fujita Health University School of Medicine, Bantane Hospital, 3-6-10 Otobashi Nakagawa Ward, Nagoya, Aichi Prefecture, 454-8509, Japan.
| | - Yukio Asano
- Department of Gastroenterological Surgery, Fujita Health University School of Medicine, Bantane Hospital, 3-6-10 Otobashi Nakagawa Ward, Nagoya, Aichi Prefecture, 454-8509, Japan
| | - Masahiro Ito
- Department of Gastroenterological Surgery, Fujita Health University School of Medicine, Bantane Hospital, 3-6-10 Otobashi Nakagawa Ward, Nagoya, Aichi Prefecture, 454-8509, Japan
| | - Norihiko Kawabe
- Department of Gastroenterological Surgery, Fujita Health University School of Medicine, Bantane Hospital, 3-6-10 Otobashi Nakagawa Ward, Nagoya, Aichi Prefecture, 454-8509, Japan
| | - Satoshi Arakawa
- Department of Gastroenterological Surgery, Fujita Health University School of Medicine, Bantane Hospital, 3-6-10 Otobashi Nakagawa Ward, Nagoya, Aichi Prefecture, 454-8509, Japan
| | - Masahiro Shimura
- Department of Gastroenterological Surgery, Fujita Health University School of Medicine, Bantane Hospital, 3-6-10 Otobashi Nakagawa Ward, Nagoya, Aichi Prefecture, 454-8509, Japan
| | - Daisuke Koike
- Department of Gastroenterological Surgery, Fujita Health University School of Medicine, Bantane Hospital, 3-6-10 Otobashi Nakagawa Ward, Nagoya, Aichi Prefecture, 454-8509, Japan
| | - Chihiro Hayashi
- Department of Gastroenterological Surgery, Fujita Health University School of Medicine, Bantane Hospital, 3-6-10 Otobashi Nakagawa Ward, Nagoya, Aichi Prefecture, 454-8509, Japan
| | - Kenshiro Kamio
- Department of Gastroenterological Surgery, Fujita Health University School of Medicine, Bantane Hospital, 3-6-10 Otobashi Nakagawa Ward, Nagoya, Aichi Prefecture, 454-8509, Japan
| | - Toki Kawai
- Department of Gastroenterological Surgery, Fujita Health University School of Medicine, Bantane Hospital, 3-6-10 Otobashi Nakagawa Ward, Nagoya, Aichi Prefecture, 454-8509, Japan
| | - Takayuki Ochi
- Department of Gastroenterological Surgery, Fujita Health University School of Medicine, Bantane Hospital, 3-6-10 Otobashi Nakagawa Ward, Nagoya, Aichi Prefecture, 454-8509, Japan
| | - Hironobu Yasuoka
- Department of Gastroenterological Surgery, Fujita Health University School of Medicine, Bantane Hospital, 3-6-10 Otobashi Nakagawa Ward, Nagoya, Aichi Prefecture, 454-8509, Japan
| | - Takahiko Higashiguchi
- Department of Gastroenterological Surgery, Fujita Health University School of Medicine, Bantane Hospital, 3-6-10 Otobashi Nakagawa Ward, Nagoya, Aichi Prefecture, 454-8509, Japan
| | - Daisuke Tochii
- Department of Gastroenterological Surgery, Fujita Health University School of Medicine, Bantane Hospital, 3-6-10 Otobashi Nakagawa Ward, Nagoya, Aichi Prefecture, 454-8509, Japan
| | - Yuka Kondo
- Department of Gastroenterological Surgery, Fujita Health University School of Medicine, Bantane Hospital, 3-6-10 Otobashi Nakagawa Ward, Nagoya, Aichi Prefecture, 454-8509, Japan
| | - Hidetoshi Nagata
- Department of Gastroenterological Surgery, Fujita Health University School of Medicine, Bantane Hospital, 3-6-10 Otobashi Nakagawa Ward, Nagoya, Aichi Prefecture, 454-8509, Japan
| | - Toshiaki Utsumi
- Department of Gastroenterological Surgery, Fujita Health University School of Medicine, Bantane Hospital, 3-6-10 Otobashi Nakagawa Ward, Nagoya, Aichi Prefecture, 454-8509, Japan
| | - Akihiko Horiguchi
- Department of Gastroenterological Surgery, Fujita Health University School of Medicine, Bantane Hospital, 3-6-10 Otobashi Nakagawa Ward, Nagoya, Aichi Prefecture, 454-8509, Japan
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Pancreaticojejunostomy Conducive to Biological Healing in Minimally Invasive Pancreaticoduodenectomy. J Gastrointest Surg 2022; 26:1967-1981. [PMID: 35546220 PMCID: PMC9489565 DOI: 10.1007/s11605-022-05339-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/10/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pancreaticojejunostomy, an independent risk factor for pancreatic fistula, is the cause of several postoperative complications of pancreaticoduodenectomy. As suturing in minimally invasive surgery is difficult to perform, more simplified methods are needed to guarantee a safe pancreatic anastomosis. The concept of "biological healing" proposed in recent years has changed the conventional understanding of the anastomosis, which recommends rich blood supply, low tension, and loose sutures in the reconstruction of the pancreatic outflow tract. METHODS A literature search was conducted in PubMed for articles on pancreaticojejunostomy published between January 2014 and December 2021. After following a due selection process, several techniques developed in accordance with the concept of biological healing that were found suitable for minimally invasive surgery and their related clinical outcomes were described in this review. RESULTS The incidence of clinically relevant pancreatic fistula associated with the presented techniques did not exceed 15.9%, indicating superior results compared to Cattell-Warren double-layer duct-to-mucosa anastomosis (incidence: approximately 20%). The features and drawbacks of these approaches have been enumerated from the viewpoint of biological healing. CONCLUSIONS This review described several modified pancreaticojejunostomy techniques with the advantages of a simplified procedure and a lower incidence of pancreatic fistula. Surgeons can choose to apply them in clinical practice to improve patient prognosis.
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Takayama T, Fujita A, Sugihara T, Fujisaki A, Yamazaki M, Kameda T, Kamei J, Ando S, Kurokawa S, Fujimura T. Natural history of asymptomatic renal artery pseudoaneurysm after robot-assisted partial nephrectomy. Transl Androl Urol 2021; 10:3555-3565. [PMID: 34733652 PMCID: PMC8511543 DOI: 10.21037/tau-21-384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/15/2021] [Indexed: 11/06/2022] Open
Abstract
Background We assessed the natural history of renal artery pseudoaneurysm (RAP) after robot-assisted partial nephrectomy (RAPN). Methods From May 2016 to September 2020, 106 patients underwent RAPN for renal tumors at our institution. Among 100 patients, excluding 6 who were ineligible for contrast-enhanced computed tomography (CE-CT), 4 underwent renal artery selective embolization (RAE), of which 2 cases were emergency RAE within 7 days after RAPN and the other 2 were prophylactic RAE 8 or more days after RAPN. In 98 patients examined for the clinical course of asymptomatic RAP managed by surveillance, excluding the 2 who underwent emergency RAE, routine CE-CT was performed at 7 days, 1 month and 3 months after RAPN. Factors influencing the occurrence of RAP among these 98 patients, including the 2 who underwent emergency RAE and excluding the 2 who underwent prophylactic RAE, were analyzed by logistic regression analysis. Results Median [interquartile range (IOR), range] observation period, age, radiographic tumor size, and maximum diameter of RAP were 20.8 (23.9, 3.0–57.6) months, 63 (18, 22–84) years, 23 (11, 9–48) mm, and 6.6 (5.2, 3.0–16.0) mm, respectively. CE-CT detected 28 RAPs in 23 (23.0%) of 100 patients by 7 days after RAPN and routine CE-CT detected 25 RAPs in 21 (21.4%) of 98 patients excluding 2 who underwent emergency RAE at 7 days after RAPN. RAP was diagnosed by routine CE-CT in 21 (21.4%), 1 (1.0%), and 0 (0%) patients at 7 days, 1 month, and 3 months after RAPN, respectively. In univariate analysis, age [odds ratio (OR) 0.144: 69–84 vs. 22–56 years old, P=0.0179], R.E.N.A.L [radius (tumor size as maximal diameter), exophytic/endophytic properties of tumor, nearness of tumor deepest portion to collecting system or sinus, anterior/posterior descriptor and location relative to polar line] nephrometry score (OR 1.374, P=0.0382), warm ischemic time (OR 1.085, P=0.0393), and renorrhaphy time (OR 1.055, P=0.0408) were significantly associated with the occurrence of RAP. In multivariate analysis, only age (OR 0.124, P=0.0148) was a significant factor. Conclusions Asymptomatic RAP up to 15 mm in diameter resolved spontaneously 3 months after RAPN. Young age (under 56 years) may be a factor in the development of RAP.
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Affiliation(s)
- Tatsuya Takayama
- Department of Urology, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Akifumi Fujita
- Department of Radiology, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Toru Sugihara
- Department of Urology, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Akira Fujisaki
- Department of Urology, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Masahiro Yamazaki
- Department of Urology, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Tomohiro Kameda
- Department of Urology, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Jun Kamei
- Department of Urology, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Satoshi Ando
- Department of Urology, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Shinsuke Kurokawa
- Department of Urology, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Tetsuya Fujimura
- Department of Urology, Jichi Medical University, Shimotsuke, Tochigi, Japan
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Finch LM, Baltatzis M, Byott S, Ganapathy AK, Kakani N, Lake E, Cadwallader R, Hazar C, Seriki D, Butterfield S, Jegatheeswaran S, Jamdar S, de Liguori Carino N, Siriwardena AK. Endovascular Hepatic Artery Stents in the Modern Management of Postpancreatectomy Hemorrhage. ANNALS OF SURGERY OPEN 2021; 2:e038. [PMID: 37638254 PMCID: PMC10455063 DOI: 10.1097/as9.0000000000000038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 01/08/2021] [Indexed: 11/26/2022] Open
Abstract
Background Postoperative hemorrhage is a potentially lethal complication of pancreatoduodenectomy. This study reports on the use of endovascular hepatic artery stents in the management of postpancreatectomy hemorrhage. Methods This is a retrospective analysis of a prospectively maintained, consecutive dataset of 440 patients undergoing pancreatoduodenectomy over 68 months. Data are presented on bleeding events and outcomes, and contextualized by the clinical course of the denominator population. International Study Group of Pancreatic Surgery terminology was used to define postpancreatectomy hemorrhage. Results Sixty-seven (15%) had postoperative hemorrhage. Fifty (75%) were male and this gender difference was significant (P = 0.001; 2 proportions test). Postoperative pancreatic fistulas were more frequent in the postoperative hemorrhage group (P = 0.029; 2 proportions test). The median (interquartile range [IQR]) delay between surgery and postoperative hemorrhage was 5 days (2-14 days). Twenty-six (39%) required intervention comprising reoperation alone in 12, embolization alone in 5, and endovascular hepatic artery stent deployment in 5. Four further patients underwent more than 1 intervention with 2 of these having stents. Endovascular stent placement achieved initial hemostasis in 5 of 7 (72%). Follow-up was for a median (IQR) of 199 days (145-400 days) poststent placement. In 2 patients, the stent remained patent at last follow-up. The remaining 5 stents occluded with a median (IQR) period of proven patency of 10 days (8-22 days). Conclusions This study shows that in the specific setting of postpancreatoduodenectomy hemorrhage with either a short remnant gastroduodenal artery bleed or a direct bleed from the hepatic artery, where embolization risks occlusion with compromise of liver arterial inflow, endovascular hepatic artery stent is an important hemostatic option but is associated with a high risk of subsequent graft occlusion.
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Affiliation(s)
- Louise M. Finch
- From the Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Minas Baltatzis
- From the Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Sam Byott
- Vascular Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | | | - Nirmal Kakani
- Vascular Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Edward Lake
- Vascular Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Rosemary Cadwallader
- Vascular Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Can Hazar
- Vascular Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Dare Seriki
- Vascular Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Stephen Butterfield
- Vascular Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Santhalingam Jegatheeswaran
- From the Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Saurabh Jamdar
- From the Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Nicola de Liguori Carino
- From the Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Ajith K. Siriwardena
- From the Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, United Kingdom
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
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