Endoscopic Ultrasound-Guided Glue Embolization for Left Gastric Artery Pseudoaneurysm Presenting as Hemosuccus Pancreaticus After Failed Radiological Intervention

Hemosuccus pancreaticus is characterized by intermittent bleeding from the ampulla of Vater due to the rupture of a pseudoaneurysm. There are significant diagnostic and therapeutic challenges associated with this rare and potentially life-threatening condition. We present a rare case in an 18-year-old man who presented with recurrent episodes of hematemesis and melena due to hemosuccus pancreaticus as a result of a left gastric artery pseudoaneurysm. Initial radiological angioembolization failed because of median arcuate ligament syndrome, and endoscopic ultrasound-guided glue embolization was successfully performed. This case further reinforces the importance of endoscopic ultrasound-guided therapy in the management of pseudoaneurysm after failed radiological treatment.

Atypical variable origins of the left inferior phrenic artery and left gastric artery

OBJECTIVES

The current report describes the combined unusual origin of the left inferior phrenic and left gastric arteries observed during a routine dissection of the upper abdominal region.

BACKGROUND

The branches of the abdominal aorta are important vessels that supply blood to various organs and structures in the abdominal cavity. While there is typically a common pattern of branching, anatomical variations can occur, leading to differences in the branching patterns of the abdominal aorta.

METHODS

An accidental finding in an 80-year-old male cadaver within anatomical dissection was assessed.

RESULTS

We observed that the left inferior phrenic artery originated from the celiac trunk and gives off middle and superior suprarenal arteries, while the left gastric artery arose from the abdominal aorta independently.

CONCLUSION

The identification of anatomic vascular abnormalities of the abdominal aorta and its branches is clinically important in surgical and invasive arterial procedures and preoperative knowledge of vascular anomalies should prevent iatrogenic vascular trauma and complications during surgery (Fig. 3, Ref. 14).

Gastric Ulcer Secondary to Left Gastric Artery Thrombosis

Peptic ulcer disease (PUD) is a well-known and commonly encountered gastrointestinal (GI) pathology. Helicobacter pylori and nonsteroidal anti-inflammatory drug (NSAID) use are the cause of the majority of PUD cases, although other rare etiologies may be encountered. PUD is confirmed by endoscopic visualization of gastric ulcers, with radiographic imaging being less impactful in diagnosis. In this paper, we present a middle-aged patient who presented with PUD caused by thrombotic occlusion of the left gastric artery (LGA), with her diagnosis being made with computed tomography (CT) imaging prior to endoscopy. This case emphasizes the importance of radiographic imaging in the undifferentiated patient, as well as the unique role radiologists play in both discovering diagnoses and their etiologies.

Successful Treatment of a Left Gastric Artery Pseudoaneurysm by Image Guided Percutaneous Thrombin Injection

Visceral artery pseudoaneurysms are common complications of pancreatitis that carry a high mortality rate. The splenic artery is the commonest artery involved. Gastric artery pseudoaneurysms are less common with less than 50 cases reported in the literature. A 58-year-old female was referred to the Interventional Radiology department with a left gastric artery pseudoaneurysm secondary to acute pancreatitis. Initial Digital Subtraction Angiography revealed the pseudoaneurysm arising from the left gastric artery. Several attempts to cannulate the pseudoaneurysm were unsuccessful due to arterial spasm. Consequently, the left gastric artery proximal to the pseudoaneurysm was embolised with 300 microns of polyvinyl alcohol and two coils. 24 hours post-procedure, a computed tomography (CT) scan was performed which revealed a blush of contrast enhancement within the pseudoaneurysm sac, consistent with unsuccessful embolisation. Using a combination of ultrasound and cone beam CT guidance, a 22-gauge Chiba needle was advanced percutaneously via a transhepatic approach to the patent segment of the pseudoaneurysm. 2.5 ml of human thrombin was then injected directly into the pseudoaneurysm. Image guided injection of thrombin has become a well-recognised treatment for a variety of peripheral and visceral pseudoaneurysms and is often performed following a failed attempt of routine endovascular embolisation. We report the case of a patient affected by a pseudoaneurysm of the left gastric artery, treated with a CT guided percutaneous thrombin injection directly into the pseudoaneurysm. This demonstrates that percutaneous coagulation can be an adjunct or an alternative to endovascular embolisation.

Left Gastric Pseudoaneurysm in a Case of Chronic Pancreatitis: A Case Report With Review of Literature

Visceral artery pseudoaneurysms are common complications of pancreatitis that carry a high mortality rate. Early detection and treatment of the pseudoaneurysms should be done as they carry high mortality following rupture. The splenic artery is the commonest artery involved followed by gastroduodenal and pancreaticoduodenal arteries. Gastric artery pseudoaneurysms are less common with less than 50 cases reported in the literature till now. We describe a case of gastric artery pseudoaneurysm secondary to chronic pancreatitis in a patient who presented with intermittent GI bleeding and also describe the role of endovascular management in the treatment of the same.

Should the left gastric artery lymph node be considered as the predictive lymph node for extra-gastric lymph node metastases?

Background

To validate the prognostic impacts of the left gastric artery lymph node (No. 7 LN) metastasis and investigate whether the No. 7 LN metastasis should be considered as the predictive LN for extra-gastric LN metastases.

Methods

Between January 2003 and December 2011, a total of 1,586 patients who underwent R0 gastrectomy were retrospected. Patients with LN metastases were divided into three groups: (I) patients with only peri-gastric LN metastases (peri-gastric group); (II) patients with peri-gastric and only No. 7 LN metastases (No. 7 group); and (III) patients with other extra-gastric LN metastases (extra-gastric group). Propensity score matching (PSM) was adopted to accurately evaluate prognoses of all patients after surgery.

Results

Of 1,586 patients, 235 (14.82%) were pathologically identified to present with the No. 7 LN metastases. Patients with the No. 7 LN metastases presented the significantly lower survival rate both before and after adjustment by pTNM stage, compared to those without the No. 7 LN metastases. Patients in the No. 7 group were identified to present the significant lower survival rate than those in the peri-gastric group, and to present the similar median overall survival (OS) to those in the extra-gastric group. In addition, patients with extra-gastric LN except No. 7 LN metastases failed to show any superiority of survival outcomes, compared with those with extra-gastric LN metastases including the No. 7 LN metastasis.

Conclusions

The No. 7 LN metastases had the crucial survival implications. Nevertheless, the No. 7 LN failed to be considered as the predictive LN for the extra-gastric LN metastases in gastric cancer (GC).

Bariatric Embolization: A Narrative Review of Clinical Data From Human Trials

Bariatric arterial embolization (BAE) is a novel technique that is investigated as an alternative, often supplementary, method for weight management. BAE reduces blood perfusion to the gastric fundus, and thus, reduces the production of appetite-inducing hormones. No randomized controlled trial has evaluated the efficacy of BAE to date. Available evidence from published studies include retrospective evaluations of patients undergoing left gastric artery embolization for gastrointestinal bleeding, and early prospective, single-arm clinical trials. Review of clinical data from human trials suggest an average weight loss of about 8-9 kg (ranging 7.6-22.0 kg), corresponding to 8-9% (ranging 4.8-17.2%) of the patients' baseline weight. Common complications include superficial gastric ulcers. Though uncommon, gastric perforation and splenic infarct are important major complication that may arise after left gastric artery embolization. Overall, BAE is an effective, relatively safe procedure that may be associated with clinically significant weight loss in patients with obesity.

Types of coeliac trunk branching including accessory hepatic arteries: a new point of view based on cadaveric study

BACKGROUND

The coeliac trunk (CT) is major visceral branch of the abdominal aorta. Familiarity with anatomic variations of the CT is relevant for planning radiological and surgical procedures. The aim of our research was determining variations of the CT, including the occurrence of accessory hepatic arteries (AHA).

MATERIALS AND METHODS

Forty cadavers were studied. Six patterns of CT branching were observed in this study. AHA were observed in 7 (17.5%) specimens. The most prevalent variation was normal trifurcation, accounting for 62.5% of cases. The rarest variation was absence of the CT, with an incidence of 2.5%. In this variant the left gastric artery, the common hepatic artery, and the splenic artery branched directly off the abdominal aorta.

RESULTS

The study material allowed to distinguish two CT branching patterns which, to the best of our knowledge, have not been reported before. It was a type with four branches originating from the CT: the left gastric artery, the common hepatic artery, the splenic artery, and right AHA. The other previously unreported pattern variant was the CT which gave off three branches: the common hepatic artery, the splenic artery and right AHA.

CONCLUSIONS

The average distance between the aortic hiatus and the coeliac trunk calculated for all the cadavers amounted to 54 ± 11.85 mm. The average distance between the CT and the superior mesenteric artery was 11.1 ± 7.7 mm.

Bariatric embolization: a new and effective option for the obese patient?

Obesity is a public health epidemic in the United States, which results in significant morbidity, mortality, and cost to the healthcare system. Despite advancements in traditional therapeutic options for the obese patients, there is a treatment gap for patients in whom lifestyle modifications alone have not been successful, but for whom bariatric surgery is not a suitable option. Areas covered: This treatment gap needs to be addressed and thus, complimentary or alternative treatments to lifestyle changes and surgery are urgently needed. Recent evidence suggests that embolization of the gastric fundus ('Bariatric Embolization'), which is predominantly supplied by the left gastric artery, may affect energy homeostasis by decreasing ghrelin production. The purpose of this special report is to discuss the background, rationale and latest data on this topic, as well as provide the latest data from the ongoing BEAT Obesity clinical trial. Expert commentary: A multipronged approach is essential in the treatment of obesity. Bariatric embolization looks to treat the hormonal imbalances which contribute to obesity. If proven successful in the long-term, bariatric embolization represents a potential minimally invasive approach to treat obesity offered by interventional radiologists.

Case report and systematic literature review of a novel etiology of sinistral portal hypertension presenting with UGI bleeding: Left gastric artery pseudoaneurysm compressing the splenic vein treated by embolization of the pseudoaneurysm

INTRODUCTION

A novel case is reported of upper gastrointestinal (UGI) bleeding from sinistral portal hypertension, caused by a left gastric artery (LGA) pseudoaneurysm (PA) compressing the splenic vein (SV) that was successfully treated with PA embolization.

CASE REPORT

A 41-year-old man with previous medical history of recurrent, alcoholic pancreatitis presented with several episodes of hematemesis and abdominal pain for 48 hours. Physical examination revealed a soft abdomen, with no abdominal bruit, no pulsatile abdominal mass, and no stigmata of chronic liver disease. The hemoglobin declined acutely from 12.3 to 9.3 g/dL. Biochemical parameters of liver function and routine coagulation profile were entirely within normal limits. Abdominal CT revealed a 5-cm-wide peripancreatic mass compressing the stomach and constricting the SV. Esophagogastroduodenoscopy showed blood oozing from portal hypertensive gastropathy, small nonbleeding gastric cardial and fundal varices, gastric compression from the extrinsic mass, and no esophageal varices. MRCP and angiography showed that the mass was vascular, arose from the LGA, compressed the mid SV without SV thrombosis, and caused sinistral portal hypertension. At angiography, the PA was angioembolized and occluded. The patient has been asymptomatic with no further bleeding and a stable hemoglobin level during 8 weeks of follow-up.

DISCUSSION

Literature review of the 14 reported cases of LGA PA revealed that this report of acute UGI bleeding from sinistral portal hypertension from a LGA PA constricting the SV is novel; one previously reported patient had severe anemia without acute UGI bleeding associated with sinistral portal hypertension from a LGA PA.

CONCLUSION

A patient presented with UGI bleeding from sinistral portal hypertension from a LGA PA compressing the SV that was treated by angiographic obliteration of the PA which relieved the SV compression and arrested the UGI bleeding. Primary therapy for this syndrome should be addressed to obliterate the PA and not the secondarily constricted SV.

Survival prognosis and clinicopathological features of the lymph nodes along the left gastric artery in gastric cancer: implications for D2 lymphadenectomy

The Japanese Gastric Cancer Treatment Guidelines (third edition) have assigned No. 7 station left gastric artery lymph nodes (LNs) to the D1 range of lymphatic dissection. We investigated the clinicopathological characteristics, survival impact, and appropriateness of ascribing No. 7 station LNs to D1 lymphadenectomy in gastric cancer. Patients (n=608) undergoing radical resection with No. 7 station LN dissection were recruited between January 1997 and June 2008. They were subdivided into four groups: N0, no LN metastasis; D1, LN without No. 7 station LN metastasis in the D1 lymphadenectomy region; No. 7, No. 7 station LN without LN metastasis in the D2 lymphadenectomy region; and D2, LN without No. 7 station LN metastasis in the D2 lymphadenectomy region. Of these, 17.2% (n=105) were positive for No. 7 LN metastasis, an important, independent prognostic factor associated with poor clinicopathological parameters, advanced tumor stage, and reduced survival. Tumor behavior in the No. 7 group was similar to that in the D2 group, but poorer than in the D1 group in terms of advanced tumor stage, with 5-year survival rates of 34.3%, 25.9% and 54.6%, respectively. Five-year survival rates in the No. 7 group were comparable to those in the D2 group (P>0.05), but significantly lower than in the D1 group (P<0.05). Logistic multivariate regression analysis established No. 3 and 9 station LN metastasis, node classification, and tumor-node-metastasis stage as independent risk factors for No. 7 station LN metastasis. Thus, No. 7 station LNs should be ascribed to D2 lymphadenectomy in gastric cancer.

Common stem origin of left gastric, right and left inferior phrenic arteries, in association with a hepatosplenomesenteric trunk, independently arising from the abdominal aorta: case report using MDCT angiography

We describe in this paper a rare case of a 45-year-old male with a common stem origin of the left gastric artery (LGA), right inferior phrenic artery (RIPA), and left inferior phrenic artery (LIPA), in association with the presence of a hepatosplenomesenteric trunk (HSMT) arising from the abdominal aorta (AA), as revealed by routine multidetector computed tomography (MDCT) angiography. The common stem origin of the LGA, RIPA, and LIPA had an endoluminal diameter of 3.3 mm, the LGA of 2.8 mm. The endoluminal diameter of the RIPA and LIPA was at the origin of approximately 1 mm, complicating selective chemoembolization of the liver parenchyma.