Venous bypass grafting for celiac occlusion in radical pancreaticoduodenectomy.

Radical pancreaticoduodenectomy was performed for cancer of the head of the pancreas in a 65-year-old male patient with congenital celiac occlusion. Preoperative angiography revealed that the arterial flow to the liver, spleen, and stomach was supplied via the pancreaticoduodenal arcade and that the dorsal pancreatic artery arose from the superior mesenteric artery. In order to perform radical pancreatectomy with sufficient clearance of lymph nodes and soft tissues around the pancreas, the celiac arterial circulation was reconstructed. The restoration of flow was effected via a saphenous vein graft between the common hepatic artery and the aorta. Postoperative angiography demonstrated patency of the graft. The patient's postoperative course was uneventful.     

Successful transcatheter embolization of a pancreaticoduodenal artery aneurysm in association with celiac axis occlusion: a case report

We report a case of a pancreaticoduodenal artery (PDA) aneurysm in association with celiac axis occlusion. A 54 year-old female complaining of abrupt onset of abdominal pain was admitted to our hospital. On admission, abdominal CT examination revealed a hematoma in the retroperitoneal space. Selective superior mesenteric artery (SMA) angiography disclosed an aneurysm in the anterior inferior pancreaticoduodenal artery (AIPDA). The celiac axis was occluded and blood was flowing to the liver and spleen via the enlarged pancreaticoduodenal arcade from the SMA. Transcatheter embolization of the aneurysm was performed successfully. Up to 1996, there have been 37 reported cases of PDA aneurysm in association with celiac axis stenosis or occlusion, including this one. Transcatheter embolization was performed successfully in only 5 of these cases. The formation of this type of PDA aneurysm is thought to be a result of the increased blood flow in the pancreaticoduodenal arcade due to celiac axis stenosis or occlusion. The transcatheter embolization performed in our report produced a far greater blood flow, which may lead to further aneurysmal formation. Careful follow-up is therefore necessary.     

Celiac artery stenting: a new strategy for patients with pancreaticoduodenal artery aneurysm associated with stenosis of the celiac artery

We report a new strategy—celiac artery stenting—to relieve stenosis of the celiac arterial root. This was performed in two patients with pancreaticoduodenal artery (PDA) aneurysm associated with a stenotic celiac arterial root. The first patient was a 66-year-old man complaining of abrupt onset of upper abdominal pain. Abdominal computed tomography revealed a huge retroperitoneal hematoma behind the duodenum, and superior mesenteric artery (SMA) angiography demonstrated an aneurysm arising from inferior pancreaticoduodenal artery and celiac arteriography showed a stenotic celiac arterial root. Transcatheter embolization of the aneurysm was tried, but failed. Because of his unstable hemodynamics, emergent laparotomy with resection of the aneurysm was performed. Fourteen days after the operation, percutaneous transluminal angioplasty with celiac arterial stenting was done. The patient was discharged 2 days later, and has had no further bleeding episode for 3 years. The second patient was a 46-year-old woman, who also complained of acute upper abdominal pain. Abdominal computed tomography disclosed a huge retroperitoneal hematoma, and selective SMA angiography demonstrated an aneurysm arising from the inferior pancreaticoduodenal artery, and celiac arteriography showed a stenotic celiac arterial root. Because angiography showed no active bleeding from the aneurysm, percutaneous transluminal angioplastic stenting of the stenotic celiac artery was performed. She was discharged 5 days later and has had no further bleeding episode for 2 years. Celiac arterial stenting, as shown in our two patients, could be easily and safely employed in patients with PDA aneurysm associated with a stenotic celiac arterial root to release the stenosis of the celiac arterial root and to prevent further possible bleeding.     

Resection of the head of the pancreas in three patients with anomalous arrangement or occlusive diseases of the major abdominal visceral arteries

We resected the head of the pancreas in three patients with occlusive diseases or anomalous arrangement of the abdominal visceral arteries. The first patient who was diagnosed with cancer of the head of the pancreas; pancreatoduodenectomy (PD) was performed. Preoperative celiac angiography showed no significant occlusion of the celiac axis, while superior mesenteric arteriography visualized the common hepatic artery, with delayed retrograde filling. At the completion of the PD, an unsuspected atherosclerotic celiac occlusion was identified. Celiac reconstruction was performed. The second patient was diagnosed with cystadenoma of the head of the pancreas and had congenital ostial occlusion of the superior mesenteric artery (SMA), with dilated pancreaticoduodenal (PD) arcades as a celiacomesenteric collateral pathway. Duodenum-preserving resection of the head of the pancreas was performed, with preservation of the PD arcades. The third patient was diagnosed with cancer of the common bile duct, and exhibited a replaced common hepatic artery that arose from the SMA and formed PD arcades. PD was performed, with revascularization of the common hepatic artery. Following surgery, the three patients have done well for 18, 27, and 9 months, respectively. Careful preoperative investigation to identify abnormalities of the visceral arteries is necessary before resection of the head of the pancreas is performed.     

Distal pancreatectomy with resection of the celiac axis and reconstruction of the hepatic artery for carcinoma of the body and tail of the pancreas

Distal pancreatectomy with resection of the celiac axis can increase resectability of carcinoma of the body and tail of the pancreas. We performed reconstruction of the hepatic artery to avoid complications caused by a decrease in hepatic arterial flow. We carried out distal pancreatectomy with resection of the celiac axis for carcinoma of the body and tail of the pancreas in four patients. When pulsation in the proper hepatic artery was weak after occlusion of the celiac axis, we performed reconstruction of the hepatic artery, using the splenic artery, which had been taken beforehand from the resected specimen. In two patients, we performed reconstruction of the hepatic artery. These two patients underwent reconstruction of the portal vein combined with prolonged clamping of the portal vein. Levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were elevated just after the operation, but recovered to normal levels within 10 days. No complications related to hepatic ischemia were observed. These results suggested that reconstruction of the hepatic artery allowed us to safely perform distal pancreatectomy with resection of the celiac axis for carcinoma of the body and tail of the pancreas.     

Celiac axis occlusion of a patient undergoing pancreaticoduodenectomy after distal gastrectomy

In patients with celiac axis occlusion, performance of pancreaticoduodenectomy involves sacrifice of the gastroduodenal artery which results in a risk of hepato-pancreato-biliary and other organic ischemia. Celiac axis occlusion does not recently seem an uncommon finding in cases of pancreaticoduodenectomy but diagnosis of celiac axis occlusion may be difficult in patients with former abdominal surgery. The present case report shows a patient with pancreatic head adenocarcinoma, in whom a preoperative diagnosis of celiac axis occlusion was not proved because of displacement of the celiomesenteric arterial branches based on former distal gastrectomy with Kocher's maneuver. A 56-year-old man with malignant obstruction of the lower bile duct was referred to our hospital for undergoing pancreaticoduodenectomy. In his past history, the patient had undergone distal gastrectomy reconstructed with Billroth I method due to gastric ulcer. In preoperative abdominal angiography, the celiac axis was not detected at the normal position and was incorrectly recognized to be anomalously originated from the superior mesenteric artery. During surgery, hepatic arterial flow was markedly diminished by clamping of the gastroduodenal artery. Celiac axis occlusion was then proved and the thick and tight median arcuate ligament was detected. Hepatic arterial blood flow was recovered by a complete division of the median arcuate ligament. Postoperative course of the patient was uneventful. In cases of pancreaticoduodenectomy, careful preoperative angiographic diagnosis is needed for patients with celiac axis occlusion who have undergone former gastric surgery because the celio-mesenteric arterial branches have been displaced by Kocher's maneuver. The present report also demonstrates another patient with a typical celiac axis stenosis.     

Successful transcatheter arterial embolization of an inferior pancreaticoduodenal artery aneurysm associated with celiac axis stenosis

A case of inferior pancreaticoduodenal artery (IPDA) aneurysm associated with celiac axis stenosis was successfully treated using only transcatheter arterial embolization (TAE). A 57-year-old woman was urgently referred to our hospital with sudden abdominal pain; computed tomography revealed retroperitoneal hematoma due to bleeding from an aneurysm around the superior mesenteric artery (SMA). Selective angiography into the SMA showed an aneurysm derived from the IPDA posterior branch; the IPDA anterior branch was intact and contrast medium flowed into the common hepatic artery territory through the pancreatic arcade because of celiac axis stenosis. We subsequently performed TAE on the lesion. Arteriography after TAE showed that the aneurysm had disappeared and that the IPDA anterior branch was intact. She had no aneurysm recurrence for about two years after the treatment. We believe that TAE is effective even for a PDA aneurysm with celiac axis stenosis or occlusion. However, it is important to perform embolization precisely and over a long period.     

Vaginal bleeding in a patient with type C liver cirrhosis without a past history of laparotomy: successful treatment with partial splenic artery embolization

A 47-year-old female patient with type C liver cirrhosis underwent endoscopic injection sclerotherapy for esophageal varices 13?years ago. The patient had no past history of hysterectomy or any other gynecological disorders. She was admitted to our hospital because of persistent vaginal bleeding and exacerbation of anemia. A contrast-enhanced computed tomography scan revealed marked dilation of not only the inferior mesenteric vein, but also the left ovarian vein, the uterine vein and the internal iliac vein. A celiac arteriography showed that the blood in the splenic vein was flowing almost totally hepatofugally into the dilated inferior mesenteric vein. An ovarian venography demonstrated knob-shaped dilation of the left ovarian vein draining into the left internal iliac vein. A proximally wedged left ovarian venography visualized the right ovarian vein and the right internal iliac vein with contrast medium via a palisade venous plexus from the dilated uterine and ovarian veins. Partial splenic embolization (PSE) was performed to increase platelet count and to reduce splenic venous blood flow into the ovarian vein. Following the PSE, the platelet count increased, and the blood flow in the dilated ovarian vein and uterine vein diminished. In addition, the portal blood flow became hepatopetal, and remarkably increased. There has as yet been no case report in which vaginal bleeding developed in women with liver cirrhosis without any past history of hysterectomy or other gynecological disorders. The present case report may be warranted in view of the rarity of the condition.     

Arterial anomaly of crucial importance in resection of head of pancreas

In a patient with pancreatic cancer, an arterial anomaly was observed that apparently consisted of the congenital absence of the celiac axis and the replacement of the pancreaticoduodenal arcade by an anomalous vessel. The complete or near-complete arterial flow to the liver and spleen depended upon this anomalous prepancreatic vessel that arose from the superior mesenteric artery. The anomaly was demonstrated preoperatively by arteriography. At laparotomy, the anomalous artery was prominent, lying across the surface of the head of the pancreas. Unrecognized, its operative interruption might have threatened the life of the patient. Resection of the head of the pancreas would have required restoration of the arterial flow, preferably by vascular grafting. The anomaly appears to be different from those previously described.     

Stent implantation for iliac compression syndrome with acute deep vein thrombosis: a case report

An 80-year-old woman presented with left lower limb pain and swelling with tenderness over the great saphenous vein. Venography revealed thrombus in the lower leg vein and occlusion of the femoral vein. A temporary vein filter was placed below the renal vein and catheter intervention was performed. The wire was carefully advanced from the left femoral vein to the vena cava. Hard resistance was felt at the proximal iliac vein. After balloon dilation, intravascular ultrasonography showed a very flat lumen at the occlusion site. Stent implantation was performed followed by anticoagulation therapy. Venography at 3 months follow-up showed a widely opened iliac vein. Angiography showed the occlusion site was the crossing point of the right iliac artery and left iliac vein. Stenting for iliac compression syndrome is effective to maintain patency of the vein.     

Pancreaticoduodenal artery aneurysms associated with celiac axis stenosis due to compression by median arcuate ligament and celiac plexus

Celiac axis stenosis is frequently associated with pancreaticoduodenal artery aneurysms. Although the cause of stenosis was not clear in most of the reported cases, compression of the median arcuate ligament of the diaphragm was found to be responsible for the stenosis in 7 of 42 reported cases of this type of aneurysm. We report a case of aneurysm caused by compression of the median arcuate ligament of the diaphragm and celiac plexus. An asymptomatic 43-year-old Japanese man was admitted with a low echoic lesion in the uncus of pancreas. Computed tomographic scan and angiogram revealed stenosis of the celiac axis and two aneurysms in the inferior posterior pancreaticoduodenal artery. The celiac plexus and median arcuate ligament were divided surgically and normal flow was reestablished in the celiac axis. One of the aneurysms was resected and the afferent artery of the other aneurysm was ligated. In the setting of pancreaticoduodenal artery aneurysm associated with celiac axis stenosis, management of stenosis should be considered in addition to local treatment of the aneurysm. In this context, division of median arcuate ligament and celiac plexus or aorto-celiac bypass may normalize the flows in the pancreaticoduodenal arcade and could be effective in preventing aneurysm reformation. (Received May 12, 1997; accepted Sept. 26, 1997)     

Spasm of left main coronary artery.

A 46-year-old male patient with atypical angina pectoris appeared to have an important elongated stenosis of the left main coronary artery on coronary arteriography, and slight irregularities in the left anterior descending, circumflex, and right coronary arteries. A saphenous vein bypass graft to the left anterior descending artery was performed, and this relieved the patient's symptoms. Postoperative coronary arteriography demonstrated a widely patent left main coronary artery and graft. The original narrowing of the left main coronary artery was probably caused by spasm and the source of the patient's anginal symptom.     

Spasm of left main coronary artery.

A 46-year-old male patient with atypical angina pectoris appeared to have an important elongated stenosis of the left main coronary artery on coronary arteriography, and slight irregularities in the left anterior descending, circumflex, and right coronary arteries. A saphenous vein bypass graft to the left anterior descending artery was performed, and this relieved the patient's symptoms. Postoperative coronary arteriography demonstrated a widely patent left main coronary artery and graft. The original narrowing of the left main coronary artery was probably caused by spasm and the source of the patient's anginal symptom.     

Pancreatic islet cell tumor presenting as bleeding gastric varices secondary to splenic vein occlusion

Summary This is a report of a patient with a nonfunctioning islet cell tumor of the distal pancreas presenting with a 12-month history of recurrent upper gastrointestinal bleeding. The presence of bleeding gastric varices secondary to occlusion of the splenic vein by tumor was established by endoscopy and selective celiac arteriography. Partial pancreatectomy and splenectomy was performed successfully and bleeding from gastric varices has not recurred over a 12-month period postoperatively.     

Significance of intraoperative monitoring of arterial blood flow velocity and hepatic venous oxygen saturation for performing minimally invasive surgery in a patient with multiple calcified pancreaticoduodenal aneurysms with celiac artery occlusion

Even for patients with multiple pancreaticoduodenal aneurysms, successful treatment with noninvasive operative procedures can be employed, if intraoperative devices are considered. A 73‐year‐old man, without any symptoms, was admitted to our hospital and had computed tomography (CT) scanning to examine his liver for hepatitis C virus (HCV). Selective superior mesenteric artery (SMA) angiography confirmed multiple aneurysms in the anterior inferior pancreaticoduodenal artery (AIPDA), one aneurysm in the posterior inferior mesenteric artery (PIPDA), and another in the occluded celiac trunk, all with severe calcification. All of the aneurysms were thought to communicate with each other. With the celiac artery occlusion, the right hepatic artery (RHA) was revealed to be supplied by collateral arteries from the aneurysms in the AIPDA, and the left hepatic artery was shown to be supplied by collaterals from the left gastric artery. Intraoperative Doppler echography, at the time of the clamping of both IPDAs, demonstrated a marked decrease of blood velocity in all aneurysms (before clamping, >50 cm/s; after, <10 cm/s), although loss of pulsation and a marked decrease of flow in the RHA were inevitable. Therefore, each of these two IPDAs were ligated on the proximal side to the aneurysm, thus preserving the blood flow of the pancreas head fed by the PIPDA; bypass grafting from the AIPDA to the RHA, using the great saphenous vein, was done at the same time. After the creation of an anastomosis, the hepatic venous oxygen saturation (ShvO2) increased from 38% (at the time of ligation of the IPDAs) to 57% under ventilation. The patient's postoperative clinical course was uneventful. We describe and discuss our successful noninvasive operative management of multiple pancreaticoduodenal aneurysms, done while monitoring the blood flow and ShvO2, with some consideration of the literature.     

Tips of laparoscopic pancreaticoduodenectomy: superior mesenteric artery first approach (with video)

In previous reports of laparoscopic pancreaticoduodenectomy, the Kocher maneuver with a wide mobilization of the right colonic flexure is carried out in the early phase, and dissection of the superior mesenteric artery is performed in the last phase of resection. This report describes laparoscopic superior mesenteric artery first approach, in which the superior mesenteric artery is dissected in the early phase of resection. Through the ligament of Treitz, the retroperitoneum is widely opened and the superior mesenteric artery is isolated just superior to the left renal vein. The periarterial connective tissue and nerve plexuses surrounding the superior mesenteric artery are dissected longitudinally to identify the inferior pancreaticoduodenal artery, which is then tied and divided. The superior mesenteric artery first approach and early ligation of the inferior pancreaticoduodenal artery is considered to be a feasible, safe, and effective method for performing pure laparoscopic pancreaticoduodenectomy.     

Celiac artery aneurysm: a case report

Aneurysm of the celiac artery is an uncommon clinical problem; fewer than 180 cases have been reported in the world medical literature. Most patients are symptomatic at the time of diagnosis. However, occasionally such aneurysms are detected incidentally during diagnostic imaging for other diseases. We present the case of a 72-year-old man who had an asymptomatic celiac artery aneurysm detected by computed tomographic angiography after endoluminal exclusion of an infrarenal aortic aneurysm. The patient underwent successful resection of the aneurysm and revascularization of the aorta-common hepatic and splenic arteries with use of an autologous saphenous vein graft.     

A case of hepatic artery embolization and partial arterialization of the portal vein for intraperitoneal, hemorrhage after a pancreaticoduodenectomy

We report a case of hepatic artery embolization and partial portal vein arterialization for the treatment of a delayed massive hemorrhage after a pancreaticoduodenectomy. A 70-year-old male underwent a pancreaticoduodenectomy for the treatment of lower bile duct cancer. A slight discharge of pancreatic juice was recognized early during the postoperative period. A delayed massive hemorrhage occurred on postoperative day 34, resulting in hypotensive shock. Angiography and computed tomography examinations revealed bleeding from a pseudoaneurysm at the stump of the gastroduodenal artery and portal vein compression by the hematoma. Embolization of the stump of the gastroduodenal artery resulted in the total occlusion of the hepatic artery. We performed a partial portal vein arterialization via side-to-side anastomosis of a branch of the ileal artery and vein. The partial portal oxygen pressure increased from 70 mmHg to 90 mmHg. A liver abscess was recognized two weeks after the arterialization, but was successfully treated by percutaneous transhepatic drainage. The patient was discharged from hospital in good condition on postoperative day 69. Whether the partial portal vein arterialization was effective is unclear, but partial portal vein arterialization should be considered as an option in cases of total hepatic artery occlusion with impairment of portal blood flow.     

Total gastric necrosis due to aberrant arterial anatomy and retrograde blood flow in the gastroduodenal artery: a complication following pancreaticoduodenectomy

Patients with coeliac artery occlusion often remain asymptomatic due to the rich collateral blood supply (pancreaticoduodenal arcades) from the superior mesenteric artery. However, division of the gastroduodenal artery (GDA) during pancreaticoduodenectomy may result in compromised blood supply to the liver, stomach and spleen. Postoperative complications associated with this condition are rarely reported in the literature. We report two cases of coeliac artery occlusion encountered during pancreaticoduodenectomy, one of which was complicated by hepatic ischaemia and total gastric infarction postoperatively. Based on our experience and review of the literature, a management algorithm for coeliac artery stenosis encountered during pancreaticoduodenectomy is proposed.     

Spontaneous rupture of intrahepatic artery aneurysm with complicated vascular anomalies

An 18-year-old man developed a sudden onset of upper abdominal pain with vomiting. Ultrasound and computed tomographic (CT) scans revealed the spontaneous rupture of an intrahepatic artery aneurysm with subcapsular hematoma. A celiac arteriogram demonstrated a ruptured intrahepatic artery aneurysm in the right lobe of the liver, right extrahepatic artery aneurysm, obliteration of gastroduodenal artery, and abnormal flow pattern of the splenic artery. Portal vein phase, using superior mesenteric arteriography, showed portal vein varices and obliteration of the portal trunk. A right hepatic lobectomy was performed. The cut surface of the resected liver revealed a ruptured intrahepatic artery aneurysm with massive hematoma.