Prognostic impact of the distance from the root of splenic artery to tumor in the patients with pancreatic body or tail cancer

BACKGROUND

The impact of the distance from the root of splenic artery to tumor (DST) on the prognosis and optimal surgical procedures in the patients with pancreatic body/tail cancer has been unclear.

METHODS

We retrospectively analyzed 94 patients who underwent distal pancreatectomy (DP) and 17 patients who underwent DP with celiac axis resection (DP-CAR) between 2008 and 2018.

RESULTS

The 111 patients were assigned by DST length (in mm) as DST = 0: n = 14, 0

CONCLUSIONS

DST did not affect prognosis in patients with pancreatic body/tail cancer. Neoadjuvant therapy followed by DP may be desirable for patients with a DST = 0 tumor. For those with a 0 Collapse

Key Words

• Distal pancreatectomy
• Distal pancreatectomy with celiac axis resection
• Neoadjuvant therapy
• Pancreatic cancer
• Root of splenic artery

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MESH Headings

• Humans
• Splenic Artery/surgery
• Prognosis
• Retrospective Studies
• Neoplasm Recurrence, Local/pathology
• Celiac Artery/surgery
• Celiac Artery/pathology
• Pancreatic Neoplasms/pathology
• Pancreatectomy/methods

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Affiliation(s)

Takuya Minagawa Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan; Department of Hepato-Biliary-Pancreatic and Gastrointestinal Surgery, School of Medicine, International University of Health and Welfare, Chiba, Japan
Yukiyasu Okamura Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan; Division of Digestive Surgery, Department of Surgery, Nihon University School of Medicine, Tokyo, Japan.
Teiichi Sugiura Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
Takaaki Ito Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
Yusuke Yamamoto Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
Ryo Ashida Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
Katsuhisa Ohgi Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
Keiko Sasaki Division of Pathology, Shizuoka Cancer Center, Shizuoka, Japan
Katsuhiko Uesaka Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan

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A gastroduodenal artery that branched from the celiac artery in gastrectomy: A rare case of an anatomical variant

Understanding anatomical anomalies of the branch of the celiac artery for safe gastrectomy is important. We report a case of laparoscopic distal gastrectomy with D1+ lymph node dissection for early gastric cancer with a vascular anatomical anomaly of the celiac artery. A 45-year-old woman was referred to our hospital because of early gastric cancer. Computed tomography showed an anatomical variation of the gastroduodenal artery, which branched from the celiac artery. The celiac artery also branched into the left gastric artery, the splenic artery, and the common hepatic artery. Preoperative understanding of an unusual branch of the celiac artery enabled a safe laparoscopic surgery. There were no postoperative complications. The Adachi classification or Michel classification is used for an anatomical anomaly of the celiac artery, but to the best of our knowledge, this case has not been previously classified and is the first reported case.

Distal Pancreatectomy With En Bloc Celiac Axis Resection (DP-CAR) for Locally Advanced Pancreatic Cancer: A Safe and Effective Procedure

OBJECTIVE

To determine perioperative and oncologic outcomes after distal pancreatectomy with en bloc resection of the celiac axis (DP-CAR).

BACKGROUND

DP-CAR can be used in a selective group of patients to resect locally advanced pancreatic cancer involving the celiac axis or common hepatic artery without arterial reconstruction by preserving retrograde blood flow via the gastroduodenal artery to the liver and stomach.

METHODS

We analyzed all consecutive patients who had undergone DP-CAR between May 2003 and April 2022 at a tertiary hospital specialized in pancreatic surgery and present one of the largest single-center studies.

RESULTS

A total of 71 patients underwent DP-CAR. Additional venous resection (VR) of the mesenterico-portal axis was performed in 31 patients (44%) and multivisceral resection (MVR) in 42 patients (59%). Margin-free (R0) resection was achieved in 40 patients (56%). The overall 90-day mortality rate was 8.4% for the entire patient cohort. After a cumulated experience of 16 cases, the 90-day mortality dropped to 3.6% in the following 55 patients. Extended procedures with (+) additional MVR with or without (+/-) VR resulted in higher major morbidity (Clavien-Dindo ≥IIIB; standard DP-CAR: 19%; DP-CAR + MVR +/- VR: 36%) and higher 90-day mortality (standard DP-CAR: 0%; DP-CAR + MVR +/- VR: 11%). Median overall survival after DP-CAR was 28 months.

CONCLUSIONS

DP-CAR is a safe and effective procedure but requires experience. Frequently, surgical resection has to be extended with MVR and VR to accomplish tumor resection, which results in promising oncologic outcomes. However, extended resections were associated with increased morbidity and mortality.

A rare case of a combination of ectopic kidney and medial arcuate ligament syndrome: a case report

BACKGROUND

Ectopic kidney and median arcuate ligament syndrome are both rare conditions. The clinical presentation and diagnosis of these conditions are not well studied. There are no reports on the combination of these two rare conditions.

CASE PRESENTATION

We report a 24-year-old woman with fever, dysuria, urinary frequency and left flank pain for two days. The primary diagnoses in the clinic were left acute pyelonephritis and left hydronephrosis due to throbbing pain in the left costovertebral angle and pyuria. However, further computed tomography showed right ectopic pelvic kidney, left renal pelvis dilatation without definite ureteral lesion, good bilateral renal contrast enhancement, and compression of the celiac axis due to obstruction by the median arcuate ligament. Chronic abdominal symptoms were reported by the patient after repeat history taking. The patient's condition was fully explained and discussed with her and her family, but they refused further therapy. After the acute pyelonephritis began improving, the patient was discharged for follow-up at our outpatient clinic.

CONCLUSION

We present an extremely rare case of a combination of two rare conditions: ectopic kidney and median arcuate ligament syndrome. No study to date has reported on the relationship between the two diseases. Given the rarity of the two conditions, no evidence or even a hypothesis exists to explain the possible etiology of their combination. More reports are required to enhance the understanding of these rare conditions.

Insights from managing clinical issues in distal pancreatectomy with en bloc coeliac axis resection: experiences from 626 patients

BACKGROUND

Distal pancreatectomy with en bloc coeliac axis resection (DP-CAR) for pancreatic body cancer has been reported increasingly. However, its large-scale outcomes remain undocumented. This study aimed to evaluate DP-CAR volume and mortality, preoperative arterial embolization for ischaemic gastropathy, the oncological benefit for resectable tumours close to the bifurcation of the splenic artery and coeliac artery using propensity score matching, and prognostic factors in DP-CAR.

METHODS

In a multi-institutional analysis, 626 DP-CARs were analysed retrospectively and compared with 1325 distal pancreatectomies undertaken in the same interval.

RESULTS

Ninety-day mortality was observed in 7 of 21 high-volume centres (1 or more DP-CARs per year) and 1 of 41 low-volume centres (OR 20.00, 95 per cent c.i. 2.26 to 177.26). The incidence of ischaemic gastropathy was 19.2 per cent in the embolization group and 7.9 per cent in the no-embolization group (OR 2.77, 1.48 to 5.19). Propensity score matching analysis showed that median overall survival was 33.5 (95 per cent c.i. 27.4 to 42.0) months in the DP-CAR and 37.9 (32.8 to 53.3) months in the DP group. Multivariable analysis identified age at least 67 years (HR 1.40, 95 per cent c.i. 1.12 to 1.75), preoperative tumour size 30 mm or more (HR 1.42, 1.12 to 1.80), and preoperative carbohydrate antigen 19-9 level over 37 units/ml (HR 1.43, 1.11 to 1.83) as adverse prognostic factors.

CONCLUSION

DP-CAR can be performed safely in centres for general pancreatic surgery regardless of DP-CAR volume, and preoperative embolization may not be required. This procedure has no oncological advantage for resectable tumour close to the bifurcation of the splenic artery, and should be performed after appropriate patient selection.

Pancreaticoduodenectomy combined gastroduodenal collateral reconstruction and preservation due to median arcuate ligament syndrome: technical notes with two surgical cases report (with video)

INTRODUCTION

Pancreaticoduodenectomy in patients with CA stenosis due to median arcuate ligament often required carefully collateral pathways management to avoid hepatic ischemic complications.

CASES PRESENTATION

Case 1: A 63-year-old man was referred to our department because of jaundice with distal common bile duct tumor. Pancreaticoduodenectomy with left posterior SMA first approach and circumferential lymphadenectomy was performed. Case 2: A 48-year-old man was referred to our department because of right-upper-quadrant abdominal pain with Vater tumor. Laparoscopic pancreaticoduodenectomy with left posterior SMA first approach and circumferential lymphadenectomy was performed. Postoperatively, in all two cases, three-dimensional reconstruction images showed developed collateral pathways around the pancreatic head, and the CA was stenosis in 75% and 70% due to MAL, respectively. Intraoperatively, in all two cases, we confirmed poor blood flow in the common hepatic artery (CHA) by palpation and observation. So that in the first case, we have decided to proceed a no-touch technique of GDA segmental resection en bloc with the tumor and reconstructed with an end-to-end GDA anastomosis; in the second cases, we have decided to proceed gastroduodenal collateral preservation. When preserving these collateral pathways, we confirmed that the PHA flow remained pulsatile as an indicator that the blood flow was adequate.

CONCLUSION

Celiac axis stenosis was a rare but difficult-to-managed condition associated with pancreaticoduodenectomy. Collateral pathways management depends on variety of collateral pathways.

Long-term survival after distal pancreatectomy with celiac axis resection and hepatic artery reconstruction in the setting of locally advanced unresectable pancreatic cancer

The long-term survival of patients with locally advanced, unresectable pancreatic cancer is extremely poor. We present our experience with a 67-year-old woman who had a 40-mm mass in the body of the pancreas. Tumor infiltration reached the gastroduodenal artery, celiac artery, common hepatic artery, and splenic artery. After 10 courses of FOLFIRINOX, 2 courses of gemcitabine plus nab-paclitaxel, and 6 courses of gemcitabine alone, we performed distal pancreatectomy with celiac axis resection and hepatic artery reconstruction. The bifurcation of the gastroduodenal artery and the proper hepatic artery had to be resected, after which we created 2 anastomoses: proper hepatic-to-middle colic artery, and second jejunal-to-right gastroepiploic artery. Histopathologic examination revealed an Evans grade IIb histologic response to prior treatment and verified the R0 resection status. The patient was discharged on postoperative day 30 after treatment of a grade B pancreatic fistula and is still alive, without recurrence, more than 5 years after initiation of treatment. This patient with locally advanced, unresectable pancreatic cancer achieved long-term survival through perioperative multidisciplinary treatment, including distal pancreatectomy with celiac axis resection and hepatic artery reconstruction. This aggressive procedure could be a treatment option for patients with locally advanced, unresectable pancreatic cancer.

[Comparison of distal pancreatectomy with celiac axis resection and sub-adventitial divestment technique for locally advanced or borderline resectable pancreatic body cancer]

Objective: To compare the outcomes of modified Appleby procedure and sub-adventitial divestment technique for locally advanced or borderline resectable pancreatic body cancer. Methods: A total of consecutive 58 patients(33 males and 25 females) who were diagnosed as locally advanced or borderline resectable pancreatic body cancer and underwent distal pancreatectomy at Pancreas Center, First Affiliated Hospital of Nanjing Medical University between September 2013 and May 2019 were retrospectively reviewed. The age(M(IQR)) was 62(9)years(range: 43 to 79 years). Thirty-one patients underwent distal pancreatectomy with celiac axis resection (DP-CAR) and 27 patients underwent distal pancreatectomy with sub-adventitial divestment technique(SDT). Perioperative parameters and follow-up data of these patients were analyzed. Quantitative data were compared with Wilcoxon test while categorical variables were compared with χ2 test or Fisher's exact test. Survival results were estimated by the Kaplan-Meier survival method with a Log-rank test. Results: There were no differences in age,gender,body mass index,abdominal symptoms,comorbidity or preoperative serum CA19-9 between two groups(all P>0.05). Obvious preoperative weight loss was more common in the group of SDT(48.1%(13/27) vs. 19.4%(6/31),χ²=5.431,P=0.020). Longer operative time(310(123) minutes vs. 254(137)minutes, Z=2.277,P=0.023),higher rate of combined organ resection(41.9%(13/31) vs. 14.8%(4/27),χ²=5.123,P=0.041) and longer postoperative hospital stay(15(10) days vs. 11(5)days,Z=2.292,P=0.022) were observed in the group of DP-CAR. Moreover,rate of overall morbidities was also higher (71.0%(22/31) vs. 29.6%(8/27),χ2=9.876,P=0.003),implicated by clinically relevant postoperative pancreatic fistula(61.3%(19/31) vs. 29.6%(8/27),χ2=5.814,P=0.020) in the DP-CAR group. Tumor size of the DP-CAR group was bigger(4.9(1.5)cm vs. 4.0(1.2)cm,Z=2.343,P=0.019) but no difference was seen between the DP-CAR group and SDT group in R0+R1(<1 mm) resection rate (84.0%(21/25) vs. 90.0%(18/20),P=0.678) and LNR(12.0(23.0)% vs. 9.0(18.0)%,Z=1.238,P=0.216),as well as median disease free survival(11.7 months vs. 11.4 months,Z=0.019,P=0.892) and median overall survival(16.3 months vs. 13.7 months,Z=0.172,P=0.679). Conclusions: Both DP-CAR and distal pancreatectomy with SDT are relatively safe and feasible for locally advanced or borderline resectable pancreatic body cancer. Compared with arterial resection,SDT may contribute to lower rates of postoperative complications and shorter duration of hospitalization,but no significant benefit is seen in long-term survival.

Retroperitoneal-first laparoscopic approach (Retlap)-assisted distal pancreatectomy with celiac axis resection (DP-CAR): A novel minimally invasive approach for achieving adequate dorsal surgical margin

BACKGROUND

Distal pancreatectomy with celiac axis resection (DP-CAR) is a procedure to secure a surgical margin for a locally advanced pancreatic body cancer that invades the celiac axis. However, in patients with cancer close to the root of the celiac axis, obtaining adequate surgical margins can be difficult because the tumor obstructs the field of vision to the root of the celiac axis. Previously, we described the retroperitoneal-first laparoscopic approach (Retlap) to achieve both accurate evaluation of resectability for locally advanced pancreatic cancer requiring DP-CAR [1] and adequate surgical margin for laparoscopic distal pancreatectomy [2]. In this video, we introduce Retlap-assisted DP-CAR as a minimally invasive approach for performing an artery-first pancreatectomy [3, 4] and achieving sufficient dorsal surgical margin (Fig. 1).

METHODS

Our patient is a 67-year-old man with a 55 × 29-mm pancreatic body tumor after chemotherapy. Preoperative computed tomography revealed a tumor close to the root of the celiac axis. Because the area of tumor invasion on preoperative images was near the root of the celiac artery, Retlap-assisted DP-CAR was performed to determine whether the celiac axis can be secured and obtain an adequate dorsal surgical margin (Fig. 2).

RESULTS

The operative time and estimated blood loss was 715 min and 449 mL, respectively. In spite of the advanced tumor's location and size, R0 resection was achieved in a minimally invasive way.

CONCLUSION

Retlap-assisted DP-CAR is not only technically feasible and useful for achieving accurate evaluation of resectability but also facilitates obtaining an adequate surgical margin.

The role of coeliac axis resection in resected ductal adenocarcinoma of the distal pancreas: A result of tumour topography or a prognostic factor?

BACKGROUND

Whether coeliac axis resection (CAR) results from tumour topography or a prognostic factor for distal pancreatic ductal adenocarcinoma (PDAC) remains unclear. We aimed to compare the clinicopathological data between distal pancreatectomy with en bloc CAR (DP-CAR) and distal pancreatectomy plus splenectomy (DP-S) and analyse the prognostic factors.

METHODS

We retrospectively analysed clinicopathological data from 102 patients who underwent distal pancreatectomy for PDAC and the factors affecting disease-free survival (DFS) and overall survival (OS). Of these patients, 45 and 57 underwent DP-CAR and DP-S, respectively.

RESULTS

DP-CAR was associated with more operative challenges than DP-S: more portomesenteric vein resections (48.9% vs. 14.0%), longer operations (320 vs. 242 min), and greater estimated blood loss (EBL) (600 vs. 200 ml). DP-CAR had larger tumours (5 vs. 4 cm), more perineural invasion (91.1% vs. 73.7%), and more microscopically positive surgical margins (20% vs. 3.5%), compared to DP-S. The major complication was clinically relevant postoperative pancreatic fistula (20.6%). The median DFS was 15.8 months and the median OS was 20.1 months. CAR was not associated with DFS or OS. EBL>700 ml, lymphovascular invasion (LVI), and adjuvant chemotherapy independently affected DFS and OS.

CONCLUSION

DP-CAR was associated with larger tumours and more surgical challenges but not with poorer DFS and OS than DP-S. CAR was more likely to result from tumour topography rather than from an adverse prognostic factor for resected distal PDAC. EBL>700 ml, LVI, and adjuvant chemotherapy were independent factors affecting the survival of patients with distal PDAC who underwent surgical resection.

Endovascular stent repair of celiac arterial aneurysm

The aim of this study was to evaluate the safety and clinical effectiveness of endovascular stent repair of celiac arterial aneurysm (CAA).From January 2015 to December 2018, 11 patients (7 males, 4 females with a mean age of 52.2 ± 7.9 years) underwent endovascular stent repair of CAA in our center. A covered stent was used to occlude the CAA neck. Follow-up was performed 2 weeks and 1, 3, 6, and 12 months following surgery and yearly thereafter. Rates of technical success, treatment-related complications, and long-term outcome were analyzed.Each patient was placed with 1 stent for repair of CAA. Stent was placed in the celiac and common hepatic arteries for 10 patients and was placed in the celiac artery for 1 patient. The duration of the procedure ranged from 50 to 75 minutes (mean 63.2 ± 7.2 minutes). The rate of technical success of the endovascular stent repair was 100%. No patient experienced CAA rupture or instant endoleak during or after stent insertion. Abdominal pain was relieved progressively after stent insertion. All patients were followed-up for 6 to 48 months (mean 22.4 ± 10.8 months). All patients were alive during the follow-up. No endoleaks were experienced during follow-up with 100% stent patency rate. No patient suffered splenic, hepatic, or bowel infarction during follow-up.Endovascular stent repair is a safe, simple, and effective treatment for patients with CAA.

Distal pancreatectomy with en-bloc celiac axis resection (DP-CAR) through retroperitoneal-first laparoscopic approach (Retlap): A novel strategy for achieving accurate evaluation of resectability and minimal invasiveness

BACKGROUND

Distal pancreatectomy with en-bloc celiac axis resection (DP-CAR) for borderline resectable pancreatic body cancer is increasingly being performed [1,2]. For survival benefits, obtaining margin-free resection (R0 resection) is crucial [3]. However, in patients with cancer abutting the root of the celiac axis and/or SMA, accurate resectability using preoperative imaging is difficult to judge [4]. Recently, we developed a novel strategy named "Retlap: Retroperitoneal-first laparoscopic approach" to achieve accurate evaluation of resectability and minimal invasiveness for difficult hepatopancreatobiliary malignancies and retroperitoneal tumors. Retlap enables direct evaluation of invasion of the roots of the celiac axis and SMA through the retroperitoneal approach.

METHODS

This video demonstrates the case of a 50-year-old man with a 47 × 36-mm pancreatic body tumor after chemoradiotherapy. Preoperative computed tomography revealed tumor abutting on the roots of the celiac axis and SMA. Changes in the surrounding tissues due to chemoradiotherapy prevented accurate determination of the tumor invasion extent via preoperative imaging; thus, Retlap was applied. Retlap enabled us to identify and secure the roots of the celiac axis and SMA easily despite the advanced tumor. After confirming resectability, DP-CAR was performed.

RESULTS

The operative time and estimated blood loss were 841 min and 572 mL. A negative surgical margin using Retlap was confirmed in frozen sections and R0 resection was achieved with uneventful postoperative course.

CONCLUSION

Retlap was technically feasible and useful for achieving accurate evaluation of resectability and minimal invasiveness for DP-CAR. Retlap can help provide optimal outcomes in locally advanced pancreatic cancer cases.

Prognostic impact of celiac lymph node involvement in patients after frontline treatment for advanced ovarian cancer

INTRODUCTION

Completeness of cytoreduction is the most important prognostic factor in patients with advanced ovarian cancer (OC). Extensive upper abdominal surgery has allowed to increase the rate complete cytoreduction and the feasibility of resection of celiac lymph nodes (CLN) and porta hepatis disease in these patients has been demonstrated. The aim of our study was to assess the prognostic impact of CLN involvement in patients with primary advanced OC undergoing a complete cytoreductive surgery (CRS).

MATERIAL AND METHODS

We designed a retrospective unicentric study. We reviewed data from patients who underwent CLN resection with or without porta hepatis disease resection, within upfront or interval complete CRS in the frontline treatment of advanced epithelial OC between January 2008 and December 2015. Patients were classified in two groups according to CLN status. Univariate and multivariate analyses were conducted. Survival rates were estimated using Kaplan-Meier method.

RESULTS

Forty-three patients were included and positive CLN were found in 39.5% of them. The median disease-free survival in the group of patients with positive and negative CLN were 11.3 months and 25.8 months, respectively. In multivariable analysis, both CLN involvement and high peritoneal cancer index were independently associated with decreased disease-free survival. Computed tomography re-reading by an expert radiologist has good sensitivity for detection of positive CLN.

CONCLUSION

CLN involvement and high preoperative tumor burden are independently associated with decreased survival after complete cytoreduction for OC. CLN involvement is a marker of diffuse disease and an independent risk factor for early recurrent disease.

[Vasculitis of the celiac artery as a presentation of Takayasu's arteritis]

Takayasu arteritis is an idiopathic and chronic granulomatous vasculitis manifested in the form of panaortitis, of unknown etiology, even though an autoimmune origin is postulated. It is progressive and generates, in adults and children, segmental stenosis, occlusion, dilation and / or aneurysms. Isolated gastrointestinal vasculitis without systemic involvement is rare. This case leads us to take into account the atypical abdominal manifestation of Takayasu arteritis in the differential diagnosis of a frequent symptom, such as epigastralgia, and to highlight the role currently played by non-invasive imaging methods for its diagnosis.

Distal Pancreatectomy with Celiac Axis Resection (DP-CAR) for Pancreatic Cancer. How I do It

Approximately 30% of all pancreatic cancer patients have locally advanced (AJCC stage 3) disease. A sub-group of these patients-where the cancer only involves the celiac axis-may benefit from distal pancreatectomy with celiac axis resection (DP-CAR). Previous studies have shown that DP-CAR offers a survival benefit to a selected group of patients with otherwise unresectable pancreatic cancer, when performed by experienced pancreatic cancer treatment teams at high-volume centers. This article proposes a standardized approach to DP-CAR, including routine neoadjuvant (FOLFIRINOX) chemotherapy. This approach to selecting patients and performing DP-CAR has the potential to improve short-term outcomes and overall survival in selected patients, but it should be reserved for high-volume centers.

Interventional treatment of isolated dissection of the celiac artery: A case report and literature review

RATIONALE

Isolated dissection of the celiac artery (IDCA) is one of isolated visceral artery dissection, which can occur alone, and can also be complicated with superior mesenteric artery dissection and splenic artery pseudoaneurysm. This disease is very rare in clinic. The exact pathogenesis of IDCA remains unknown. At present, no consensus has yet been reached on the best treatment strategy for this rare disease. In the present study, the clinical data of one IDCA patient diagnosed and treated in our hospital was retrospectively analyzed, and related literatures were reviewed, in order to improve the understanding of the disease.

PATIENT CONCERNS

The patient was a 49-year-old male, who was admitted in our hospital because of "pain of subxyphoid area for one month". One month before, the patient presented with persistent pain in the subxyphoid area after he had a cold, on paroxysmal exacerbation occurred. After taking "stomach drug", the subjective symptoms eased slightly, but the disease attacked again two hours later.

DIAGNOSES

The patient was diagnosed with "isolated dissection of the celiac artery" by enhanced CT.

INTERVENTIONS

The patient was interventionally treated with bare stent implantation.

OUTCOMES

The symptom of the patient disappeared after interventional therapy.

LESSONS

In the present study, the clinical symptoms and treatment process of one patient with IDCA were described. The clinical symptoms of IDCA are often atypical, and its incidence is extremely low, therefore it is extremely easily misdiagnosed. The definite diagnosis depends on imaging examination. Interventional therapy is the first choice for treating this disease due to its advantages of small trauma and good curative effect.

Spontaneous dissection of the celiac artery in the young: a case report and systematic review of the literature

INTRODUCTION

The spontaneous isolated celiac artery dissection (siCAD) represents a challenging cause of abdominal pain and complete information regarding incidence, etiology and risk factors in the young is still lacking. In this study, we report a case of siCAD occurred in a young woman and we systematically searched for information on siCADs in literature databases.

METHODS

PubMed/Embase and Cochrane were searched for, using the following terms: Isolated celiac trunk dissection, isolated celiac artery dissection, celiac artery dissection, celiac trunk dissection, spontaneous isolated visceral artery dissection, spontaneous isolated dissection of visceral arteries, isolated celiac artery dissection in the young, isolated celiac trunk dissection in the young. Patients were included if they were younger than 50 years, if they had a spontaneous etiology and a selective involvement of the celiac artery (with or without involvement of its branches).

RESULTS

180 studies were found, and 18 remained after screening. Twenty-one patients (male = 19, female = 2) with siCADs were included. Mean age was 44.71 ± 3.61 years. Hypertension was the most prevalent comorbidity. All patients presented with abdominal pain, more often located in the epigastrium (n = 11). Almost all patients underwent CT to confirm the diagnosis. A conservative treatment was adopted in 13 patients while an invasive approach was adopted in 8 patients (endovascular approach in 7).

DISCUSSION

siCADs represent a rare but important cause of vascular dissection in the young. Uncomplicated cases can be safely treated with conservative strategies. The surgical or endovascular repair is indicated when dissections complicate or symptoms persist despite an adequate conservative treatment.

The differential organogenesis and functionality of two liver-draining lymph nodes in mice

The liver is an immunological organ. However, fundamental knowledge concerning liver-draining lymph nodes (LNs), which have been newly identified in mice as the portal and celiac LNs, is still lacking. Here, we revealed that the portal LN and celiac LN drain liver lymph through different lymphatic vessels. Although both the portal LN and celiac LN possess typical structures, they have different cell compositions. Interestingly, these two LNs form at different times during fetal development. Moreover, the organogenesis of the celiac LN, but not the portal LN, is controlled by the transcription factor NFIL3. Furthermore, the portal LN and celiac LN also perform different functions. The celiac LN is the predominant site of liver antiviral immune responses, whereas the portal LN functions in the in situ induction of dietary antigen-specific regulatory T cells. In conclusion, the portal LN and celiac LN are two independent liver-draining LNs with different organogenesis histories and separate functions in maintaining immune homeostasis in the liver.

Intestinal brucellosis associated with celiac artery and superior mesenteric artery stenosis and with ileum mucosa and submucosa thickening: A case report

RATIONALE

Brucellosis is a multisystem infection found worldwide that has a broad range of characteristics, which range from acute fever and hepatomegaly to chronic infections that most commonly affect the central nervous system, cardiovascular system, or skeletal system. Gastrointestinal and splanchnic artery involvements in brucellosis are relatively uncommon.

PATIENT CONCERNS

We report a case of brucellosis in an adolescent presenting as intermittent abdominal pain, diarrhea, and fever, with intestinal tract involvement. And stenosis of the celiac artery and the superior mesenteric artery was found after exposed to risk factors of Brucella infection. Splanchnic vessels stenosis and an endothelial lesion may exacerbate the prevalent symptom of abdominal pain, as a form of colic pain, occurring after eating.

DIAGNOSES

The patient was diagnosed as brucellosis. The narrowing of the SMA and CA was suspected to be vasculitis secondary to the brucellosis.

INTERVENTIONS

The patient was treated with minocycline and rifampicin for 12 weeks totally.

OUTCOMES

The gastrointestinal manifestations of brucellosis recovered rapidly under intensive treatment. However, follow-up imaging revealed that the superior mesenteric artery and celiac artery stenosis was unimproved.

LESSONS

In brucellosis, gastrointestinal manifestations may be the only observable features of the disease. Splanchnic arterial stenosis is a rare complication of brucellosis. Sonography and computed tomography may be useful for both diagnosis and follow-up.

Median Arcuate Ligament Syndrome of Diaphragm - Literature Review and Case Report

OBJECTIVES

To report a case of median arcuate ligament syndrome (MALS) and to review current literature.

METHODS

Case report and literature review using PubMed with the terms "median arcuate ligament", "Dunbar syndrome" and "MALS treatment" as major topics. The bibliography of relevant articles has been checked to identify other significant papers.

RESULTS

Median arcuate ligament syndrome (MALS) or Dunbar syndrome is a rare clinical entity characterized by celiac trunk compression by median arcuate ligament and variable gastrointestinal symptoms. However, some degree of radiographic compression is observed in 10%-24% of asymptomatic patients, so MALS is a diagnosis of exclusion. Treatment options include release of median arcuate ligament (open, laparoscopic or robot-assisted) and open vascular reconstruction. Endovascular treatment is currently used only as adjuvant procedure after surgical release of median arcuate ligament. A 34-year-old woman, previously healthy, presented with a epigastric pain, mainly postprandial, for 6 months, associated to anorexia and unprovoked weight loss of 8kg over 3 months. Physical examination was normal. Other gastrointestinal pathologies were ruled out. Abdomino-pelvic computed tomography angiography revealed a focal 80% stenosis of proximal celiac trunk. An open decompression of the celiac trunk was performed. The postoperative period was uneventful and the patient was discharged 5 days later, with normal gastrointestinal transit and without abdominal pain recurrence.

CONCLUSION

MALS diagnostic and therapeutic approach must be patient focused, bearing in mind the multiple clinical presentation and treatment options. Open surgical decompression of median arcuate ligament is the base of treatment.

Unusual branching pattern of celiac trunk associated with supernumerary hepatic arteries and abnormal adrenal venous drainage - case study and review of the literature

Celiac artery (trunk) is one of the three major arteries which arise from abdominal aorta. It's variations not seem to be very uncommon. A routine dissection of a male cadaver at Department of Anatomy Jagiellonian University revealed unusual branching pattern of the celiac trunk with numerous supernumerary hepatic arteries. Additionally unusual venous drainage of the adrenal glands was found. A review of current literature has shown that a changed branching pattern may be important from clinical point of view, with special respect to endovascular procedures, laparoscopic surgery or radiology.

Type B Dissection Complicated with Subacute Visceral Ischemia

A 63-year old man presented with back pain and abdominal pain that worsened after eating. Contrast-enhanced computed tomography revealed type B aortic dissection. Arteriography 20 days after dissection revealed celiac trunk stenosis and the superior mesenteric artery did not arise from the true lumen. Saphenous vein bypass grafting from the right common iliac artery to the superior mesenteric and gastroduodenal arteries was performed. The postoperative course was uneventful and the abdominal symptoms completely disappeared.

Aneurysm of Pancreatic Artery in Association with Celiac Axis Stenosis: Report of a Case and Review of the Literatures

A 63-year-old Japanese woman with a history of pemphigus was referred to us for abnormal findings of dynamic abdominal CT where three aneurysms of splenic artery and pancreaticoduodenal artery, celiac axis compression, and gall stone. Superior mesenteric artery supplied hepatic arterial flow via pancreaticoduodenal artery. Avoiding transarterial embolization to prompt arterial ischemia of liver/pancreas head/duodenum, she laparotomically underwent cholecystectomy, splenectomy, transection of median arcurate ligament, and ligation of splenic and inferior pancreaticoduodenal artery all at once. Postoperative course was uneventful except drainage of abdominal abscess, and she remained well without aneurysm recurring 40 months post. Important point of treatment for pancreaticoduodenal artery aneurysm associated with celiac artery occlusion/stenosis is both preventive solutions for rupture of aneurysm and hepatic/duodenal/pancreatic arterial ischemia. Remaining main arterial supply for the liver via pancreaticoduodenal artery from superior mesenteric artery would prompt recurrent aneurysm of pancreaticoduodenal artery. When a clinician encounters a case of pancreatic aneurysm associated with celiac axis occlusion, the case should be treated using with multimodality such as interventional radiology, and vascular surgery.

Detailed analysis of extra-pancreatic nerve plexus invasion in pancreatic body carcinoma analyzed by 50 consecutive series of distal pancreatectomy with en-bloc celiac axis resection

BACKGROUND/AIMS

Advanced pancreatic body carcinoma frequently accompany extra-pancreatic nerve plexus (PL) invasion, one of the poor indicator of patient prognosis. The present study aimed to reveal the progress of the PL invasion from cancer of the pancreas body toward the root of the celiac artery (CA) and superior mesenteric artery (SMA) followed by investigation of the relevance of diagnostic accuracy.

METHODOLOGY

Resected specimens from 50 consecutive patients who underwent distal pancreatectomy with en bloc celiac axis resection (DP-CAR) were pathologically analyzed for the direction of PL invasion. Diagnostic accuracy on CT imaging were also investigated.

RESULTS

Thirty seven of the 50 patients (74%) were positive for PL invasion around the CHA, SPA, CA and SMA. In terms of the diagnostic accuracy, positive predictive values for the PL invasion were 35%, 36%, 43% and 81% for the SPA, CHA, CA and SMA, respectively. Among 21 patients and 23 patients with PL invasion around CHA and SPA, 13 and 6 patients also accompanied PL invasion around CA, respectively.

CONCLUSIONS

Carcinoma of the pancreatic body is found to frequently accompany PL invasion around CA. Under the limitation of low diagnostic accuracy, DP-CAR might be feasible operation that increases the possibility of R0 resection.

Celiac trunk and branches dissection due to energy drink consumption and heavy resistance exercise: case report and review of literature

Higher doses and consumption of energy drinks leads to cardiovascular effects and potential consequences. Principal components found in energy drinks such as caffeine, guarana and taurine has been related to dilatation, aneurysm formation, dissection and ruptures. There is no evidence showing an integration of these components and its effects in endothelium and aortic walls due to higher levels of pressure during exercises. We report a case of a 44 years male with celiac trunk and branches dissection due to long-term consumption of energy drinks and intense exercise routine. Our proposition relates cell and vessel walls alterations including elasticity in endothelial wall due to higher blood pressure, resistance by intense exercise routine and long-term consumption of energy drinks.

[A case of salvage surgery for gastric wall recurrence of esophageal cancer after chemoradiotherapy]

The patient was a 69-year-old man. He underwent chemoradiotherapy for advanced esophageal cancer, and achieved a complete response. However, 16 months after chemoradiotherapy, lymph nodes metastases were detected along the celiac artery. He underwent chemotherapy followed by radiotherapy. Positron emission tomography (PET)-computed tomography (CT) at 3 months after radiotherapy showed new uptake of fluorodeoxyglucose (FDG) at the cardiac region of the stomach. Endoscopy revealed a tumor that was diagnosed as squamous cell carcinoma by biopsy. Under the diagnosis of gastric intramural recurrence of esophageal cancer, he was referred to our hospital. Proximal gastrectomy and resection of lymph nodes along the celiac artery were performed. The patient is alive without recurrence 1 year after surgery. Metachronous gastric intramural recurrence of esophageal cancer is very rare. We report this case with a review of the literature.

Utility of endoscopic ultrasound (EUS)-guided fine-needle aspiration for peri-arterial soft tissue cuffs without identifiable pancreas mass on CT and EUS: a prospective comparative study

Pancreatic cancer may present as a peri-arterial soft tissue cuff (PSTC) around the superior mesenteric artery or celiac axis without an identifiable pancreatic mass. We evaluated the diagnostic yield of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in patients with a PSTC without definite pancreas involvement and those with a typical pancreatic mass. The patients who underwent EUS-FNA of a PSTC without pancreatic involvement were prospectively enrolled. The patients who underwent EUS-FNA for a pancreatic mass were recruited as a control group. A total of 224 patients underwent 247 EUS-FNAs. Among the 13 patients with a PSTC, 11 were positive for malignancy as determined by EUS-FNA, with 5 diagnosed after the first session and 6 after the second session. The diagnostic yield of PSTCs by EUS-FNA was significantly lower than that for typical pancreatic masses (65% vs. 87%, p = 0.02). An on-site cytopathologist and repeated EUS-FNA are recommended to improve the diagnostic accuracy of this disease entity.

Endovascular pseudoaneurysm repair after distal pancreatectomy with celiac axis resection

Erosive hemorrhage due to pseudoaneurysm is one of the most life-threatening complications after pancreatectomy. Here, we report an extremely rare case of rupture of a pseudoaneurysm of the common hepatic artery (CHA) stump that developed after distal pancreatectomy with en block celiac axis resection (DP-CAR), and was successfully treated through covered stent placement. The patient is a 66-year-old woman who underwent DP-CAR after adjuvant chemoradiotherapy for locally advanced pancreatic body cancer. She developed an intra-abdominal abscess around the remnant pancreas head 31 d after the surgery, and computed tomography (CT) showed an occluded portal vein due to the spreading inflammation around the abscess. Her general condition improved after CT-guided drainage of the abscess. However, 19 d later, she presented with melena, and CT showed a pseudoaneurysm arising from the CHA stump. Because the CHA had been resected during the DP-CAR, this artery could not be used as the access route for endovascular treatment, and instead, we placed a covered stent via the inferior pancreaticoduodenal artery originating from the superior mesenteric artery. After stent placement, cessation of bleeding and anterograde hepatic artery flow were confirmed, and the patient recovered well without any further complications. CT angiography at the 6-mo follow-up indicated the patency of the covered stent with sustained hepatic artery flow. To our knowledge, this is the first reported case of endovascular repair of a pseudoaneurysm that developed after DP-CAR.

[Surgical management of a spontaneous dissection of the celiac axis caused by fibromuscular dysplasia. First clinical report]

The clinical case of a 46 years old male is reported, who complained of a sudden and sharp epigastric pain, with no other accompanying symptoms or signs. The patient was evaluated in the emergency department of a local hospital and the clinical and laboratory analysis excluded the occurrence of a common acute abdominal pathology. A CT and an angio CT study disclosed a spontaneous dissection and aneurismal dilatation of the celiac axis, along its extension. The patient underwent surgical management, consisting in the resection and prosthetic replacement of the celiac axis and the pathological studies of the specimen revealed a fibromuscular dysplasia, which seems to be, according to the literature, an exceptional situation, never reported before, thus justifying its publication and dissemination.

[Successful treatment of a case of advanced sigmoid colon cancer with occlusion of the common celiacomesenteric trunk]

A 74-year-old man was admitted to our hospital with abdominal pain and bloody stool. The patients' history showed that he had had occlusion of the proximal common trunk of the celiac artery (CA) and the superior mesenteric artery (SMA). The inferior mesenteric artery (IMA), and the marginal artery of the colon had developed well. It was assumed that almost the entire visceral blood might be supplied by the IMA to the CA and the SMA. Our investigation revealed that the patient had advanced cancer of the sigmoid colon, which had caused intestinal obstruction. Sigmoidectomy was performed with care to avoid injuring the IMA and the marginal arcade artery. Normal hemodynamics were successfully established followed by sigmoidectomy, and cure was obtained in this patient.

True pancreaticoduodenal aneurysms with celiac stenosis or occlusion

BACKGROUND

Pancreaticoduodenal artery (PDA) aneurysms are rare, representing only 2% of all visceral artery aneurysms. True PDA aneurysms associated with celiac stenosis or occlusion make up an even smaller subset of this group. No relationship between aneurysm size and the likelihood of rupture of PDA aneurysms is apparent. PDA aneurysm rupture is associated with a mortality rate upwards of 50%; therefore, accepted practice is treatment upon diagnosis. There is debate in the literature on whether the treatment of coexisting celiac axis stenosis is necessary for the prevention of recurrence.

DATA SOURCES

Literature relating to PDA aneurysms associated with celiac stenosis or occlusion was identified by performing a PubMed keyword search. References from identified articles were also assessed for relevance. The current literature was then reviewed and summarized.

CONCLUSIONS

Characteristics of this patient population are identified. Based on current evidence, our best practice recommendation for the treatment of coexisting celiac axis stenosis is provided.

A morphological study of celiac, superior mesenteric and inferior mesenteric arteries in atherosclerosis

BACKGROUND

Depolymerisation of acid-mucopolysaccharides results in the loss of metachormasia of the ground substance followed by visible fibre crumbling, complete dissolution and replacement by lipid droplets and cholesterol. The objective of this study was to assess the distribution of different atherosclerotic lesions in celiac, superior mesenteric and inferior mesenteric arteries relation to age and sex.

METHODS

A prospective descriptive observation study was conducted at Mortuary of King Edward Medical University Lahore, and Department of Pathology Allama Iqbal Medical College Lahore. A total of 30 human autopsies were carried out. Celiac, Superior mesenteric and inferior mesenteric arteries were taken out and opened length-wise. One to four areas of tissue were taken from each artery for histological examination. Slides were prepared from each paraffin block. Sections were stained with haematoxylin and eosin. Special stains were performed on sections to display each component of atherosclerosis.

RESULTS

The fibrolipid plaques were seen in 6 cases. The complicated lesions were present in 5 cases. Of these, 4 showed ulceration and 1 showed thrombus formation. The calcified lesions were observed in 5 cases. The morphological changes in media and elastica were present in 4 cases. In superior mesenteric artery fatty streaks were present in 8 cases. The fibrolipid plaques were confirmed in 5 cases. Three cases showed ulceration, 1 case showed intimal vascularisation, haemorrhage, and thrombus formation. The calcified lesions were present in 2 cases. The morphological changes in media and elastica were seen in 4 cases in anterior mesenteric artery. Fatty streaks were present in 8 cases. The fibrolipid plaques were grossly observed in 6 cases. The complicated lesions were present in 4 cases; of these, 3 cases showed ulceration, and 1 showed intimal vascularisation and haemorrhage along with thrombus formation. The calcified lesions were present in 3 cases. The morphological changes in media and elastica were present in 4 cases.

CONCLUSION

This data indicates the incidence of ischemic changes in abdominal viscera due to atherosclerotic narrowing.

[A case of pancreatic cancer with celiac trunk and common hepatic artery invasion successfully resected after gemcitabine+S-1therapy]

We present a case of a 59-year-old female who was admitted to our hospital for upper abdominal pain. She was diagnosed with pancreatic body carcinoma by computed tomography and magnetic resonance imaging. We started gemcitabine+S-1 chemotherapy because the tumor had invaded the celiac trunk, common hepatic artery, superior mesenteric vein, and splenic vein. We reduced the S-1 to 100mg/body after the third course of gemcitabine(1, 000mg/m2 on days 1 and 8, every 21 days)+S-1(120mg/body on days 1-14, every 21 days)because of side effects. The tumor became smaller, and the celiac trunk and common hepatic artery were released. Thus, we conducted a distal pancreatectomy with a D2 lymph node dissection.

Spontaneous celiac artery dissection case report and literature review

Symptomatic spontaneous celiac artery dissection is a rare condition that is being detected more often with the use of advanced imaging techniques. There is no consensus as to whether surgical or endovascular treatment is more appropriate.We describe the case of a 41-year-old hypertensive woman who presented with the sudden onset of sharp, persistent, right-upper-quadrant abdominal and epigastric pain. Magnetic resonance angiography of the abdomen revealed celiac artery dissection, with a flap compressing the lumen approximately 17 mm from the artery's origin at the aorta. Because of the patient's persistent epigastric pain, endovascular celiac artery stent implantation was performed with the use of 2 overlapping balloon-expandable stents. Twelve months after the procedure, the patient remained asymptomatic, and the stents were patent. This case and others in the medical literature suggest that endovascular treatment can be feasible in symptomatic patients with isolated spontaneous celiac artery dissection.

[The diagnosis and treatment of isolated celiac and superior mesenteric artery dissection: 2 cases report and literature review]

OBJECTIVE

To investigate the diagnosis and treatment of isolated celiac artery (CA) dissection and superior mesenteric artery (SMA) dissection.

METHODS

Integrating clinical data of 119 cases with isolated dissection of the visceral arteries (IDVA) reported in literature and 2 patients with spontaneous isolated dissections of both CA and SMA treated in the Third Affiliated Hospital of Sun Yat-sen University, the diagnosis and treatment of IDVA were analyzed retrospectively.

RESULTS

Among 119 cases reported in the literature, 69 cases were symptomatic. All of the cases were diagnosed by contrast-enhanced abdominal CT or MRI. After IDVA was discovered, surgical treatment and endovascular stent placement was performed in 8 and 5 patients respectively, although the remaining 106 patients were managed conservatively with good results. In our 2 cases, the diagnosis of CA and SMA dissection was established by contrast-enhanced CT and confirmed by conventional angiography. One patient was treated with anticoagulation and antihypertension, and the other patient was treated with endovascular stenting. Both of the patients didn't have discomfort during the follow-up period of 12 and 3 months respectively.

CONCLUSIONS

Contrast-enhanced abdominal CT is the main tool for detection of IDVA. Most of the patients with IDVA can be managed conservatively, but close surveillance with imaging studies is necessary for early recognition of dissection progression. Patients with persistent or relapsed symptoms, and dissection progression, should undergo surgical or endovascular treatment.

Resectability and operative morbidity after chemotherapy in neuroblastoma patients with encasement of major visceral arteries

BACKGROUND/PURPOSE

Image-defined vessel encasement is a significant risk factor for surgical complications and incomplete resection for intermediate-risk tumors. We sought to examine the impact of vessel encasement on complications or resectability in intermediate-risk or high-risk patients after neoadjuvant chemotherapy.

METHODS

We retrospectively reviewed 207 consecutive patients with circumferential encasement of the renal vessels, celiac axis, and/or superior mesenteric artery (SMA) who underwent resection between 1991 and 2009. Specifically, we evaluated resection rates, complications, and outcome.

RESULTS

Median age at diagnosis was 3.0 years, and 79% of patients had stage 4 disease. Of known MYCN status, 23.4% had MYCN amplification. Vessel encasement included renal vessels, celiac axis, or SMA alone in 107, 7, and 4 patients, respectively. Both the renal vessels and celiac axis were encased in 5 patients, renal vessels and SMA in 7 patients, and celiac axis and SMA in 14 patients. Sixty-three patients had all 3 vessels encased. The gross total resection (GTR) rate was 94%. No operative or postoperative deaths occurred. The overall complication rate was 34.8% (n = 72). Overall 5-year survival (± SEM) was 67.4% (± 7.4%).

CONCLUSION

Encasement of major visceral arteries in patients with neuroblastoma who have received chemotherapy does not preclude gross total resection.

Anatomical variations of the hepatic portal vein associated with incomplete celiac trunk

An association of two anatomical variations was revealed in a 65-year-old male cadaver: the first variation concerns the forming of the trunk of the hepatic portal vein, while the second concerns the branches of the celiac trunk. In this case, the inferior and superior mesenteric veins form a common trunk that is further united with the splenic vein and gives rise to the hepatic portal vein. At the same time, the existence of an incomplete (branched) celiac trunk was revealed, the hepatosplenic trunk from which the common hepatic artery and the splenic artery arise; the left gastric artery arises separately at 0.5 cm superolaterally from the origin of the celiac trunk. Familiarity with this anatomical variation provides useful information for abdominal surgery procedures.

Hemosuccus pancreaticus associated with segmental arterial mediolysis successfully treated by transarterial embolization

CONTEXT

Hemosuccus pancreaticus, a rare cause of intermittent upper gastrointestinal bleeding, is usually caused by the rupture of an aneurysm associated with chronic pancreatitis. Segmental arterial mediolysis is a rare non-arteriosclerotic, non-inflammatory vascular disease characterized by vacuolization and lysis of the arterial smooth muscle cells. Segmental arterial mediolysis often causes intra-abdominal hemorrhage through aneurysm rupture. To our knowledge, hemosuccus pancreaticus associated with segmental arterial mediolysis has not previously been reported.

CASE REPORT

A 59-year-old man had suffered from recurrent episodes of epigastric pain and melena. Laboratory data showed mild anemia and an elevated serum amylase level. Upper gastrointestinal endoscopy revealed bloody pancreatic juice exuding from the papilla of Vater. There were no findings suggestive of chronic pancreatitis, such as pancreatic calcification, irregularity of the pancreatic duct and atrophy of the pancreas. Contrast-enhanced computed tomography revealed a large fusiform aneurysm of the middle-distal splenic artery, and dissection of the proximal splenic artery and celiac artery. Leakage of contrast medium from the aneurysm into the main pancreatic duct was also evident. Angiography clearly revealed a fusiform aneurysm of the splenic artery. This was managed successfully by transarterial coil embolization and the patient has subsequently shown no recurrence of epigastric pain or melena.

CONCLUSION

Segmental arterial mediolysis is a very rare cause of hemosuccus pancreaticus not associated with chronic pancreatitis. Transcatheter arterial embolization is useful for treatment of ruptured aneurysm associated with segmental arterial mediolysis.

[Distal pancreatectomy with splenectomy and en bloc resection of the celiac trunk for locally advanced cancer of the pancreatic body with infiltration of the celiac trunk]

BACKGROUND

Locally advanced cancer of the body of the pancreas with infiltration of the celiac trunk and its branches is often considered an unresectable disease. Distal pancreatectomy with resection of the celiac trunk was described as a new concept for the curative treatment of these tumors.

CASE REPORT

The case of a 61-year-old female patient is reported, who underwent distal pancreatectomy with splenectomy and resection of the celiac trunk for locally advanced cancer of the pancreatic body with infiltration of the celiac trunk. The celiac trunk was embolized preoperatively in order to assure arterial perfusion of the liver.

CONCLUSION

Distal pancreatectomy with en bloc resection of the celiac trunk offers a high resectability rate and thus a curative option for locally advanced cancer of the pancreatic body with vascular invasion. The optimization of patient selection and the development of effective adjuvant chemotherapy could significantly improve the survival of patients subjected to this operation.

[Prenatal diagnosis of retroperitoneal neuroblastoma. Case report]

Neuroblastoma is the foremost malignant neoplasm of the fetus and neonate. It is a tumor of the sympathetic nervous system that originates from the neural crest which etiology is largely unknown. Due to its general variability in outcome, neuroblastoma has long been considered one of the most enigmatic of cancers. Although technological advances in ultrasonography have possible intrauterine detection, prenatal diagnosis is still a rare event. This kind of tumor has a high morbidity and mortality rate due to the metastatic risk. Early detection of the tumor is critical to improve outcome. We report a case of retroperitoneal neuroblastoma diagnosed at 32 week of gestation.

Successful pancreaticoduodenectomy with immediate vascular reconstruction in a patient with cancer of the pancreatic head and celiac artery stenosis. A case report

CONTEXT

Celiac artery stenosis is observed in a significant percentage of individuals in the general population. Although usually clinically silent and insignificant, due to the presence of extensive collaterals between the celiac artery and the superior mesenteric artery, celiac artery stenosis may be associated with potentially catastrophic ischemic complications in patients undergoing pancreaticoduodenectomy, due to the abrupt interruption of the collateral pathways. Therefore, revascularization may be indicated in selected patients with celiac artery stenosis undergoing a PD.

CASE REPORT

We present a patient with celiac artery stenosis diagnosed intraoperatively during a PD, who underwent vascular reconstruction at the time of the PD. In the immediate postoperative period, he developed hepatic ischemia due to stenosis at the anastomosis of the stent with the hepatic artery. He was subsequently treated successfully with the endovascular placement of a stent. In retrospect, a careful reevaluation of the preoperative abdominal CT scan showed the stenosis at the origin of celiac artery.

CONCLUSION

A careful evaluation of abdominal CT scan is required to preoperatively identify this not uncommon vascular obstructive disease, especially in asymptomatic patients. Otherwise, the astute surgeon should suspect celiac artery stenosis based on intraoperative findings/changes immediately following ligation of the gastroduodenal artery during a PD.