Endovascular treatment of arterial bleeding in patients with pancreatitis

Diffuse Peritonitis Caused by Splenic Abscess After Laparoscopic Sleeve Gastrectomy: A Case Report

A splenic abscess (SA) following sleeve gastrectomy (SG) is a rare manifestation of a gastric leak (GL). The clinical findings include fever, abdominal pain, leukocytosis, and an elevated C-reactive protein. A computed tomography scan is diagnostic and can show signs of GL, or diffuse peritonitis. Treatment can either be non-operative (including large-spectrum antibiotics and percutaneous drainage) or surgical (including splenectomy). We present the case of a 41-year-old female patient with SA, with septic shock and diffuse peritonitis, successfully treated with a splenectomy three months post-SG.

A rare presentation of a splenic abscess

Although the spleen is frequently enlarged in association with systemic infection, splenic abscesses are rare. They result from direct or hematogenous spread, or when a hematoma becomes infected. We present a case of the rare splenic abscess in a low-resource setting.

Efficacy of endovascular embolization of arterial pseudoaneurysms in pancreatitis: A systematic review and meta-analysis

BACKGROUND

There is a significant variability in the reported outcomes following endovascular embolization of arterial pseudoaneurysms in pancreatitis. The objective of this systematic review and meta-analysis is to evaluate the efficacy of endovascular embolization of pancreatitis-related pseudoaneurysms.

METHODS

Searches of MEDLINE, EMBASE, and SCOPUS databases were performed through July 1, 2019 in accordance with PRISMA guidelines. All studies with ≥10 patients reporting technical success, clinical success, complications, and mortality were included. Generalized linear mixed method with random effects model was used for assessing pooled incidence rates and corresponding 95% confidence intervals (CIs).

RESULTS

A total of 29 studies (n = 840 with 638 pseudoaneurysms) were included. The pooled incidence rates of pseudoaneurysms in acute and chronic pancreatitis were 0.05% and 0.03%, respectively (odds ratio, 0.91, 95% CI-0.24-3.43). The most common site of pseudoaneurysm was splenic artery (37.7%). The most common embolization agent was coil (n = 415). The follow up period was 54.7 months (range, 21 days to 40.5 months). Pooled technical success rate was 97% (95% CI-92-99%, I² 83%). Clinical success rates at ≤3 months, 3-12 months, and >12 months were 82% (95% CI-70-90%, I² 42%), 86% (95% CI-75-92%, I² 44%), and 88% (95% CI-83-91%, I² 0%), respectively. There was no significant difference in the technical or clinical success between acute and chronic pancreatitis on subgroup analysis. Mortality was lower in chronic pancreatitis (OR 4.27 (95% CI 1.35-13.53, I² 0%)). Splenic infarction was the most common complication (n = 47).

CONCLUSION

Endovascular embolization is associated with a high technical and clinical success.

Management of Splenic Abscess after Splenic Arterial Embolization in Severe Acute Pancreatitis: A 5-Year Single-Center Experience

Objective

To describe the management and prognosis of splenic abscess after splenic arterial embolization in severe acute pancreatitis (SAP) patients.

Methods

This is a retrospective observational study. From August 2012 to August 2017, SAP patients with infected pancreatic necrosis (IPN) who underwent splenic arterial embolization after massive hemorrhage of the splenic artery were screened and those who developed splenic abscess were included for analysis. The demographic characteristics, etiology, treatment of splenic abscess, and clinical outcomes of these cases were collected and analyzed.

Results

A total of 18 patients with splenic abscess formed after splenic arterial embolization were included for data analysis. The median age of the 18 patients was 46 years. The etiologies included biliary AP, hypertriglyceridemic AP (HTG-AP), and other causes. Ten patients underwent minimally invasive percutaneous drainage only for splenic abscess while the other eight patients received splenectomy. One patient died due to uncontrolled infection and another patient died due to massive bleeding, and the remaining sixteen patients survived.

Conclusion

The incidence of splenic abscess was high in patients requiring splenic arterial embolization due to massive bleeding. Our data showed that most splenic abscess could be successfully managed with minimally invasive interventions, and traditional splenectomy should serve as a backup treatment.

Safety and efficacy of angioembolisation followed by endoscopic ultrasound guided transmural drainage for pancreatic fluid collections associated with arterial pseudoaneurysm

BACKGROUND AND AIMS

Arterial pseudoaneurysms associated with pancreatic fluid collections (PFC's) are serious complication of pancreatitis. There is insufficient data on safety of endoscopic ultrasound (EUS) guided drainage in these patients.

AIM

To retrospectively analyze results of combination of angioembolisation followed by EUS guided transmural drainage of PFC's associated with pseudoaneurysms.

METHODS

Retrospective analysis of data base of eight patients (all males; mean age: 36.9 + 9.2 years; age range: 26-51 years) who underwent angioembolisation of pseudoaneurysm followed by EUS guided transmural drainage of the PFC's.

RESULTS

The median size of PFC was 6.5 cm (range 5-14 cm) with 7 patients having acute pancreatitis and one patient having idiopathic chronic pancreatitis. The etiology for acute pancreatitis was alcohol in 5 patients, trauma and gall stones in one patient each. Six patients had walled off pancreatic necrosis (WOPN) and 2 had pseudocysts. The pseudoaneurysm was located in splenic artery (5 patients), gastro-duodenal artery (2) and short gastric artery (1). All patients underwent successful digital subtraction angiography followed by angioembolisation. EUS guided transmural drainage was successfully done through stomach in 7 patients and via duodenum in one patient. The PFC's resolved in 3.9 + 2.5 weeks with no recurrence of either PFC or bleed over a follow up period of up to 24 months. No significant complications were observed in any patient.

CONCLUSIONS

Arterial pseudoaneurysms associated with PFC's can be successfully and safely treated with combination of initial radiological obliteration of the pseudoaneurysm followed by EUS guided transmural drainage.

Endovascular Treatment of Visceral Artery Pseudoaneurysms in Patients with Chronic Pancreatitis: Our Single-Center Experience

BACKGROUND

To analyze our experience in endovascular treatment as first-line approach for severe and acute hemorrhage in patients with chronic pancreatitis.

METHODS

From 2010 to 2016 at our institution, 12 males (mean age 66 years) with bleeding pseudoaneurysms (PSAs) underwent urgent visceral angiography and endovascular treatment. All patients had chronic pancreatitis. True visceral artery aneurysms and PSAs arising after surgery were excluded from the study.

RESULTS

Pancreatitis was caused by alcohol abuse in 9 (9/12, 75%) patients and biliary lithiasis in 3 (3/12, 25%). Involved arteries were gastroduodenal (5/12, 50%), splenic (2/12, 16%), common hepatic (2/12, 16%), middle colic (1/12, 9%), and celiac trunk (1/12, 9%). All patients underwent computed tomography angiography (CTA) scan and visceral angiography followed by endovascular treatment using different devices. Technical success rate was 100%. Bleeding was stopped in all patients, and no one required reembolization. No major complications occurred. There were 2 complications associated with the endovascular procedure: in one case, a coil migration and in another case, in-stent restenosis at 6 months. Follow-up included CTA performed during hospitalization and at 6 months after the procedure.

CONCLUSIONS

Our experience confirms the role of CTA and visceral angiography as diagnostic and therapeutic tool, respectively.

Superselective transcatheter arterial embolization in patients with acute peripancreatic bleeding complications: review of 44 cases

PURPOSE

To evaluate the efficacy of superselective transcatheter arterial embolization (TAE) in the treatment of acute peripancreatic bleeding complications.

METHODS

During a 9-year period, 44 patients with acute bleeding of the peripancreatic arteries underwent TAE in our institution. Thirty-eight patients were treated using microcatheters and 6 patients with a diagnostic catheter. Embolic agents included coils (n = 38), polyvinyl alcohol (PVA) particles (n = 2), isobutyl cyanoacrylate (n = 2), coils plus PVA particles (n = 1), and coils plus isobutyl cyanoacrylate (n = 1). Outcome measures included technical success, clinical success, and the rate of complications.

RESULTS

Identified bleeding sources included gastroduodenal artery (n = 14), splenic artery (n = 9), pancreaticoduodenal artery (n = 6), common hepatic artery (n = 5), superior mesenteric artery branches (n = 4), proper hepatic artery (n = 3), and dorsal/transverse pancreatic artery (n = 3). Technical success with effective control of active bleeding was achieved in 41/44 patients (93 %). Clinical success attributed to TAE alone was documented in 40/44 patients (91 %). The rate of major complications was 2 % including death in one patient.

CONCLUSIONS

Superselective TAE allows effective, minimally invasive control of acute peripancreatic bleeding complications with a low rate of therapeutically relevant complications.

Non-surgical management of pancreatic pseudocysts associated with arterial pseudoaneurysm

BACKGROUND

Pseudoaneurysms associated with pancreatic pseudocysts are different from simple, isolated pancreatic pseudoaneurysms and there is paucity of published data on their non surgical treatment.

AIM

To retrospectively analyze results of combination of angioembolisation or thrombin injection followed by endoscopic transpapillary drainage for management of pseudoaneurysms associated with pancreatic pseudocysts.

METHODS

Eight patients (all males; mean age ± SD: 31.2 ± 6.1 years; age range: 21-38 years) underwent radiological management of the pseudoaneurysm followed by endoscopic drainage of the pseudocysts.

RESULTS

All patients had pseudocysts (median size 4 cm) with underlying chronic pancreatitis. All patients had abdominal pain on presentation and 7/8 (87.5%) patients had presented with overt gastrointestinal bleeding. The size of the pseudoaneurysms varied from 1 to 4 cm. Two patients were treated with percutaneous thrombin injection whereas six patients underwent digital subtraction angiography and angioembolisation. All patients underwent successful endoscopic transpapillary drainage through the major (5) or minor papilla (3) and resolution of pseudocysts was noted within 6 weeks (median 4 weeks). No significant complication of the procedure was noted in any of the patients.

CONCLUSIONS

Pseudoaneurysms associated with pancreatic pseudocysts can be successfully and safely treated with a combination of radiological obliteration of the pseudoaneurysm followed by endoscopic transpapillary drainage.

Successful arterial embolization of a giant pseudoaneurysm of the gastroduodenal artery secondary to chronic pancreatitis with literature review

We report a case of an uncommon giant pseudoaneurysm of the gastroduodenal artery secondary to chronic pancreatitis. It presented with a perfused volume of 17.3 cm(3) close to the branch-off of the right hepatic artery. Superselective transcatheter embolization including interlocking detachable coils and a mixture of Ethibloc and Lipiodol was our technique of choice. Following the procedure, the patient was in hemodynamically stable condition. At that time, he was free of any clinical symptoms and showed no further signs of bleeding or ischaemia. Additionally, we present an overview of the relevant literature.

Successful arterial embolization of a giant pseudoaneurysm of the gastroduodenal artery secondary to chronic pancreatitis with literature review

We report a case of an uncommon giant pseudoaneurysm of the gastroduodenal artery secondary to chronic pancreatitis. It presented with a perfused volume of 17.3 cm(3) close to the branch-off of the right hepatic artery. Superselective transcatheter embolization including interlocking detachable coils and a mixture of Ethibloc and Lipiodol was our technique of choice. Following the procedure, the patient was in hemodynamically stable condition. At that time, he was free of any clinical symptoms and showed no further signs of bleeding or ischaemia. Additionally, we present an overview of the relevant literature.

Coil migration--a rare complication of endovascular exclusion of visceral artery pseudoaneurysms and aneurysms

INTRODUCTION

We describe a case of metallic, angiographic coil migration, following radiological exclusion of a gastroduodenal artery pseudoaneurysm secondary to chronic pancreatitis.

PATIENTS AND METHODS

A 55-year-old man presented to the out-patient clinic with chronic, intermittent, post-prandial, abdominal pain, associated with nausea, vomiting and weight loss. He was known to have chronic pancreatitis and liver disease secondary to alcohol abuse and previously underwent angiographic exclusion of a gastroduodenal artery pseudoaneurysm. During subsequent radiological and endoscopic investigation, an endovascular coil was discovered in the gastric pylorus, associated with ulceration and cavitation. This patient was managed conservatively and enterally fed via naso-jejunal catheter endoscopically placed past the site of the migrated coil. This patient is currently awaiting biliary bypass surgery for chronic pancreatitis, and definitive coil removal will occur concurrently.

CONCLUSIONS

Literature review reveals that this report is only the eighth to describe coil migration following embolisation of a visceral artery pseudoaneurysm or aneurysm. Endovascular embolisation of pseudoaneurysms and aneurysms is generally safe and effective. More common complications of visceral artery embolisation include rebleeding, pseudoaneurysm reformation and pancreatitis.

Pancreatic pseudocyst with pancreatolithiasis and intracystic hemorrhage treated with distal pancreatectomy: a case report

Introduction

Hemorrhage from pancreatic pseudocyst is one of the serious complications of chronic pancreatitis. We experienced intracystic hemorrhage from a huge pancreatic pseudocyst and successfully treated it with distal pancreatectomy.

Case presentation

A 65-year-old-man with a history of alcohol abuse was admitted to our hospital for abdominal pain and was diagnosed as having chronic pancreatitis with pancreatolithiasis and pseudocyst in the pancreatic tail. The pancreatic pseudocyst increased in size gradually for 4 month observation period. For intracystic hemorrhage we performed an urgent distal pancreatectomy with splenectomy. Postoperative course was good and the elevated serum amylase level decreased to the normal range.

Conclusion

Prolonged observation resulted in intracystic hemorrhage. Drainage or surgery in adequate time is important for the management of pancreatic pseudocysts to prevent complications.