Multiple Aneurysms or Pseudoaneurysms of the Gastroepiploic Artery: An Anecdotal Cause of Hemoperitoneum

Gastroepiploic artery aneurysms and pseudoaneurysms pose diagnostic challenges due to their rarity and overlapping radiological features. This case report presents an 82-year-old woman with sudden-onset severe abdominal pain with computed tomography revealing hemoperitoneum and saccular dilations adjacent to the stomach's greater curvature, suggestive of vascular pathology. Selective abdominal arteriography confirmed three saccular dilatations in the gastroepiploic artery, which were managed successfully with coil embolization. The discussion emphasizes the importance of accurate diagnosis, distinguishing between aneurysms and pseudoaneurysms, and prompt intervention to mitigate the risk of hemorrhagic complications of either of them. The case underscores the significance of endovascular management in such rare and critical scenarios.

Minimally Invasive Partial Spleen Resection Preserving the Lower Pole in Children: A Technical Report on Feasibility and Safety

Background: Laparoscopic partial splenectomy is a surgical option for removing part of the spleen with a pathological mass in a way that ensures preservation of the spleen's physiological functions. We aimed to evaluate the efficacy and feasibility of this procedure, performed while preserving the blood supply from the left gastroepiploic artery, in children. Materials and Methods: Following institutional review board approval, this retrospective study was conducted on patients who, between January 2015 and December 2019, underwent laparoscopic partial splenectomy with preservation of blood supply from the left gastroepiploic vessels. In the article, we described patient indications for surgery, surgical technique, surgery time, complications, and follow-up outcomes. Results: Eleven patients (mean age: 12.3 ± 3.4 years) underwent laparoscopic partial splenectomy. Indications for surgery included nonparasitic cysts (n = 8), pseudocysts (n = 2), and hamartomas (n = 1). The mean benign mass diameter was 60 ± 22 mm. The mean operative time was 193.2 ± 55.1 minutes. The mean size of the retained lower pole was 31.1% ± 3.8%. There was no conversion to open splenectomy or any significant complication. The mean postoperative stay was 9 ± 0.7 days. No thrombosis of the splenic and portal veins was noted in the follow-up period, and no splenic remnant infarction occurred. Conclusions: Laparoscopic partial splenectomy with preservation of blood supply arising from the left gastroepiploic vessels seems to be safe in children. However, a larger study is needed to confirm our results.

Conduits' Biology Regulates the Outcomes of Coronary Artery Bypass Grafting

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Accelerated atherosclerosis is common when SVGs, but not arterial grafts, are used for myocardial revascularization during CABG.

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This review will provide an overview of the available data on the most commonly used conduits in CABG, highlighting the differences in their cellular biology, mechanical, biochemical, and vasoconstrictive properties.

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Clinical and scientific evidence support the use of arterial grafts over venous conduits at the time of CABG. These arterial conduits seem to be more protected toward the development of atherosclerosis. Exploring the molecular and cellular mechanisms, of the various cell populations within these conduits, will help unveil the pathways responsible for these protective effects.

Coronary artery bypass graft (CABG) is the gold standard for coronary surgical revascularization. Retrospective, prospective, and meta-analysis studies looking into long-term outcomes of using different conduits have pointed to the superiority of arterial grafts over veins and have placed the internal mammary artery as the standard conduit of choice for CABG. The superiority of the internal mammary artery over other conduits could be attributable to its intrinsic characteristics; however, little is known regarding the features that render some conduits atherosclerosis-prone and others atherosclerosis-resistant. Here, an overview is provided of the available data on the most commonly used conduits in CABG (internal mammary artery, saphenous vein, radial artery, gastroepiploic artery), highlighting the differences in their cellular biology, mechanical, biochemical, and vasoconstrictive properties. This information should help in furthering our understanding of the clinical outcomes observed for each of these conduits.

Minimally Invasive Multiple Coronary Artery Bypass Grafting with Composite Graft Using in situ Right Gastroepiploic and Radial Arteries

Minimally invasive surgery/coronary artery bypass grafting (MICS CABG) via left thoracotomy and multiple CABG is a reported alternative to the standard sternotomy approach. However, harvesting the right internal thoracic artery (RITA) under direct vision requires high surgical skill. We describe MICS CABG with the left internal thoracic artery (LITA) and a composite graft using the in situ right gastroepiploic artery (GEA) and radial artery (RA) to achieve complete coronary revascularization. No complications occurred, and postoperative computed tomography showed patency of all grafts. Our experience suggests that this composite graft can be used safely and effectively in MICS CABG for complete arterial revascularization without difficulty.

[Additional vascularization of the omental flap using mammary-gastroepiploic bypass grafting in the treatment of deep sternal wound infection]

Incidence of postoperative sternomediastinitis depends on various risk factors and makes up 8%. Surgical debridement with local management of the wound are used to achieve wound sterility. In some cases, sternectomy or subtotal sternal resection are performed for total sternal osteomyelitis with osteoporotic bone and multiple fractures. This procedure results an extensive bone defect. The final stage is anterior chest wall reconstruction. The most popular method is wound closure with autologous muscle or omental flaps. The authors describe a patient with sternomediastinitis who underwent staged treatment. At the final stage, subtotal sternectomy with simultaneous omentoplasty were performed. Additionally, mammary-gastroepiploic bypass grafting with right internal mammary artery and right gastroepiploic artery was carried out for additional vascularization of the omental flap. We found no similar surgery for sternomediastinitis in the literature. Long-term treatment outcome was followed-up (>50 months of relapse-free period and good quality of life).

Harvest of the right gastroepiploic artery graft using a novel hybrid ultrasonic/bipolar energy device

BACKGROUND

The right gastroepiploic artery (RGEA) is a useful in-situ graft, and skeletonization is effective to prevent spasm and achieve good patency. To harvest the skeletonized RGEA easily, ultrasonic scalpel has been widely used, but the tip shape of conventional ultrasonic device was not optimal for this procedure. Recently, a novel hybrid ultrasonic/bipolar energy device (THUNDERBEAT Open Fine Jaw [TOFJ]) has been developed and is widely used in general surgery.

SURGICAL TECHNIQUE

The operator holds forceps in left hand and TOFJ in right hand, incises the anterior layer of the omentum, and extends the incision distally along the RGEA. The side branches and satellite veins were sealed and cut. Because the tip of the TOFJ is well-designed to easily grasp and peel off the tissue, there is no need to change instruments throughout the procedure. After the dissection was advanced distally, the proximal side was subsequently dissected.

CONCLUSIONS

This novel device is useful for harvesting skeletonized RGEA.

A new surgical procedure for synchronous esophageal squamous cell carcinoma and gastric adenocarcinoma: Case report: three cases reports

RATIONALE

The stomach is always used to reconstruct the upper digestive tract for esophageal cancer operation. However, problems arise when the esophageal cancer and gastric cancer present at the same time. No medical literature mentioned about this surgical procedure till now.

PATIENT CONCERNS

Majority of the patients had the sensation of obstruction when swallowing because of the esophageal tumor. Gastric adenocarcinoma was found when gastroscopy was performed.

DIAGNOSIS

Synchronous esophageal squamous cell carcinoma and gastric adenocarcinoma were confirmed by biopsy pathology.

INTERVENTIONS

We describe the new technique as: distal gastrectomy preserving the gastroepiploic vessels, Roux-en-Y gastrojejunostomy and thoracoscopic Ivor Lewis esophagectomy with chest anastomosis.

OUTCOMES

Three patients accepted the surgery and recovered well without any complications. The patients did not undergo any postoperative adjuvant therapy and was doing well without any recurrence till date (23 months, 12 months, 6 months separately).

LESSONS

This procedure was less invasive and easier to perform for synchronous early-stage gastric cardiac cancer and middle or lower third thoracic esophageal cancer. We recommend the indication as: esophageal tumor was located at least 27 cm away from the incisor teeth (for R0 resection during chest anastomosis, be sure no superior mediastinal lymph nodes metastasis were found preoperation), gastric tumor was located in the distal portion of the gastric tube and evaluated for clinical stage IA.

Spontaneous rupture of right gastroepiploic artery aneurysm: a rare cause of hemorrhagic shock. case report

CONTEXT

Aneurysms of the gastroepiploic arteries are seen only rarely. They are usually diagnosed during autopsy or laparotomy in patients with hemodynamic instability. Although the operation to treat this condition is relatively easy, delay in making the diagnosis affects the course of the disease.

CASE REPORT

A 57-year-old woman was admitted to the emergency department with abdominal pain and unconsciousness. A computed tomography scan showed extravasation of contrast agent at the headcorpus junction of the pancreas, and the patient underwent exploratory laparotomy under general anesthesia. During laparotomy, aneurysmatic rupture of the right gastroepiploic artery was detected. Control over bleeding was achieved by ligating the right gastroepiploic artery at its origin. The aneurysm was also resected and sent for pathological examination.

CONCLUSION

Especially in cases of unidentified shock, splanchnic artery aneurysms should be kept in mind. Moreover, in the light of the data in the literature, the possibility of death should be taken into account seriously and, if feasible, prophylactic aneurysmectomy should be performed.

Histomorphologic superiority of internal thoracic arteries over right gastroepiploic arteries for coronary bypass

OBJECTIVE

In this study, we compared the histologic and morphometric properties of both internal thoracic arteries and the right gastroepiploic artery (GEA) in patients undergoing coronary artery bypass grafting (CABG).

METHODS

We microscopically examined transverse sections of segments of both internal thoracic arteries and the right GEA obtained from 83 consecutive patients who underwent CABG.

RESULTS

There were no significant differences between the internal thoracic arteries. Significant differences were found between the left and right internal thoracic arteries and GEA in the intimal width (21.8, 21.5, and 71.7 μm, respectively; P < .01), intima-to-media ratio (0.286, 0.256, and 0.749, respectively; P < .01), and media width (148.5, 157.5, and 164.8 μm, respectively; P = .43). No atherosclerotic lesions, medial calcification, or intimal thickening were seen in the internal thoracic arteries; however, atherosclerotic lesions were seen in the GEA. The intima of the GEA was thicker than that of the internal thoracic arteries. Intimal thickening of the GEA, but not the internal thoracic arteries, was positively correlated with risk of arteriosclerosis. In patients with diabetes mellitus, dietary/drug therapy and insulin therapy were associated with GEA intimal thickness (P = .02 and .01, respectively).

CONCLUSIONS

The internal thoracic arteries have equivalent histologic and morphometric properties that differ from those of the GEA only in intimal width. The former had no intimal thickening, and is thus preferable to the GEA for CABG.

Lethal gastric hemorrhage from a caliber-persistent artery of the antrum - a branch of the right gastric artery

AIM

To present a rarely diagnosed case of gastric Dieulafoy lesion.

DESCRIPTION OF CASE

A 62-year-old male was hospitalized with hematemesis. Laparoscopic ligature of two gastric ulcers located in the antrum was performed but the upper gastrointestinal bleeding was not stopped. The patient was transferred to another surgical clinic and he underwent an emergency abdominal laparotomy with re-suture of gastric ulcers. Considering his general condition and another recurrent bleeding, he was transferred to our hospital and a total gastrectomy of necessity was performed. The patient died four days after surgery because of sepsis. At autopsy, we identified diffuse peritonitis, hypertrophic cardiomyopathy and chronic pancreatitis with expanded fibrotic areas. Histological examination of the surgical specimen showed oversized tortuous vessels in the gastric submucosal layer with expansion into mucosa. Some of the vessels presented acute and/or organized thrombi with recanalization, in the others, lipid-rich atherosclerotic plaques were observed. Based on these criteria, the 'caliber-persistent artery', also known as 'Dieulafoy's lesion', was diagnosed.

CONCLUSION

Dieulafoy's lesion should be suspected in every case of gastrointestinal bleeding in both adults and children.

Which is the best graft for the right coronary artery?

Bilateral internal mammary arteries directed to the left coronaries are gaining popularity; an increasing level of evidence nowadays supports this surgical strategy. On the other hand, composite right internal mammary artery, radial artery, and gastroepiploic artery targeting high-grade stenotic lesions in the right coronary artery system may confer improved mid- and long-term patency compared to long saphenous veins. This analysis looks into the evidence comparing data of the third best available conduit for grafting the right coronary artery, and by extrapolating this report, compares total arterial revascularization vs. conventional coronary artery bypass grafting.

The comparison of the responsiveness of human isolated internal mammary and gastroepiploic arteries to levcromakalim: an alternative approach to the management of graft spasm

AIMS

We studied the effectiveness of levcromakalim, a potassium channel opener (KCO), in the prevention and reversal of spasm in arterial grafts used in coronary artery bypass operations, namely, internal mammary artery (IMA) and gastroepiploic artery (GEA).

METHODS

Spasm was mimicked in vitro in arterial rings from 109 patients by increasing the vascular tension with noradrenaline, the thromboxane analogue U46619, endothelin-1 and K+.

RESULTS

GEA displayed considerably higher contractile force to these agents than IMA. Pretreatment with levcromakalim depressed significantly the maximal contractile responses (either absolute or relative) to noradrenaline and U46619 but did not affect those of endothelin-1 and K+ in both of the arteries. Sensitivities (to all agents, except to endothelin-1) decreased significantly after levcromakalim. In experiments evaluating the antispasmodic activity of levcromakalim, a higher relaxant capacity was observed in GEA than IMA (for K+ contraction; IMA: 31.32 +/- 3.83%, n= 13 vs GEA: 98.01 +/- 0.71%, n=7, P<0.05). This different activity of levcromakalim between two arterial grafts was apparent even when GEA rings were contracted to higher force (g) than that of IMA (for K+ contraction; GEA: 72.56 +/- 4.96%, n = 7). Responses to levcromakalim were similar in IMA and GEA when endothelin-1 was used as the spasmogenic agent (IMA: 80.98 +/- 4.85%, n=10 vs GEA: 91.93 +/- 3.17%, n=7, P>0.05).

CONCLUSIONS

Our results provide evidence that levcromakalim may have a therapeutic value in the treatment of spasm of coronary artery bypass grafts, especially GEA.