Anatomy of the pancreatic nerve plexuses and significance of their dissection

Although various therapeutic modalities for carcinoma of the pancreas are available, curative resection is the most important. Thus, the aim of surgery for carcinoma of the pancreas is local complete resection of the carcinoma. All of the important pancreaticoduodenal arcades of arteries, veins, and nerves are situated on the fusion fascia of Treits. The pancreatic parenchyma, extrapancreatic nerve plexuses, superior mesenteric artery (SMA), and portal vein are also covered within the fusion fascia and exist in the same area. Carcinoma of the head of the pancreas invades through the pancreatic parenchyma, following the arteries, veins, and especially nerves between the parenchyma and fusion fascia, and then spreads horizontally toward the SMA or celiac axis. The entire dissected end of the nerve plexus should be investigated during surgery using frozen specimens and confirmed to be negative for cancer. If the dissected end is positive for cancer, additional resection of the nerve plexus should be performed to achieve curative resection. It is not possible to investigate thoroughly whether the dissected end of the nerve plexus is positive or negative for carcinoma after surgery, since the end may be long and some specimens may be deformed by formalin fixation; thus it is difficult to identify the true surgically dissected end. The pancreaticoduodenal artery arises from the left side of the SMA and divides into two arteries: jejunal artery 1; and the inferior pancreaticoduodenal artery (IPDA), which runs behind and transversely to the right of both the anterior and posterior IPDA. A common origin of the anterior and posterior IPDA is found in 80% of cases. The postoperative course of patients with pancreatic head carcinoma with invasion of the perineural plexuses immediately behind the SMA is not as good as in that of patients without cancerous invasion, even if additional resection is performed so that the dissected end is confirmed to be negative during surgery. Nevertheless, intraoperative pathologic examination of the entire dissected end of the neural plexues remains necessary for curative R Zero resection.     

Successful treatment of pseudoaneurysms of celiac and superior mesenteric arteries by combined endovascular and surgical approach

Pseudoaneurysm after pancreas resection poses serious complications, including rupture and hemorrhage. Here we report a case of delayed massive hemorrhage from celiac and superior mesenteric arteries, which was successfully treated with a combined endovascular and surgical approach. The patient was a 52-year-old man who presented with pseudoaneurysms of the celiac and superior mesenteric arteries after distal pancreatectomy. Following the detection of sentinel bleeding from the abdominal drain, emergency angiography of the celiac and superior mesenteric arteries revealed stenosis of the celiac artery and pseudoaneurysms in the superior mesenteric artery. We occluded these lesions with a platinum coil, using an interventional radiological technique combined with bypass grafting between the abdominal aorta and the SMA, using the saphenous vein. However, re-bleeding into the abdominal cavity occurred from the proximal SMA pseudoaneurysm. We inserted an endoluminal stent-graft into the abdominal aorta and completed bypass grafting between the aorta and bilateral renal arteries. The hemorrhage ceased and the postoperative course was uneventful. The patient was discharged 34 days after the treatment (149 days after the initial operation). In conclusion, this combined endovascular and surgical approach is feasible and seems appropriate for pseudoaneurysms arising from proximal sites in visceral arteries.     

Surgical treatment of superior mesenteric artery dissecting aneurysm and simultaneous celiac artery compression

Spontaneous dissections of visceral arteries are rare, but when they do occur, they most commonly involve the superior mesenteric artery (SMA). We present a case of intestinal ischemia caused by a spontaneous dissection of the SMA in a patient with simultaneous celiac artery occlusion. The patient was a 45-year-old woman who presented with intestinal angina of sudden onset. Arteriography revealed the classic findings of SMA dissection and occlusion of the celiac artery. The patient underwent repair of both visceral vessels and made a full recovery. The 18 previously reported cases of isolated, spontaneous dissection of the SMA are reviewed. No previous case has been associated with celiac compression syndrome. The reported experience with symptomatic dissections of the SMA would suggest that prompt surgical repair is indicated and yields excellent results.     

腹腔干、肠系膜上动脉共干部动脉瘤的切除和血管重建探讨

目的探讨腹腔干、肠系膜上动脉畸形共干部真性动脉瘤的切除以及血管重建的手术治疗方法。方法回顾性总结1998年2月至2006年4月6例患者临床资料,均在全身麻醉下行动脉瘤切除,肾下主动脉与肝动脉、脾动脉、肠系膜上动脉行转流手术5例,行主动脉肝动脉转流、肠系膜上动脉成形术1例。结果均获得临床治愈,随访观察2月~8年,无一例复发。结论腹腔干、肠系膜上动脉畸形共干部动脉瘤切除,主动脉与内脏动脉转流或重建是一种安全有效的治疗方法。     

Embolization of the Replaced Common Hepatic Artery Before Surgery for Pancreatic Head Cancer: Report of a Case

We report the case of a patient with pancreatic head cancer, whose replaced common hepatic artery (RCHA) arose from the superior mesenteric artery (SMA). We performed preoperative embolization of the RCHA, after which the liver blood flow was well maintained by the left gastric artery. The patient underwent a radical operation involving en bloc resection of the RCHA without any serious complications.     

Common hepatic artery aneurysm branching from the superior mesenteric artery. Report of a case

A 58-year-old man was notified as having a mass in the head of the pancreas at medical checkup on September 26, 2000. He was admitted to our department after being diagnosed as having an aneurysm in the common hepatic artery, branching from the superior mesenteric artery (SMA), based on selective SMA angiography. From an abdominal midline incision, we were able to reach his common hepatic artery aneurysm (CHAA) by mobilizing the pancreas through the route lateral to the greater curvature of the stomach. This aneurysm arose in the common hepatic artery immediately after branching from the SMA. After proximal and distal control of the SMA and common hepatic artery, the aneurysm was incised and the distal hepatic artery was anastomosed end to side to the SMA. The patient had an uneventful postoperative course.     

Mesenteric vascular problems. A 26-year experience.

Mesenteric vascular problems are infrequent, but may be catastrophic. During a 26-year period, 55 private patients were treated for the following disorders: (1) 12 patients with visceral artery aneurysms, (2) 8 with celiac compression syndrome, (3) 13 with chronic mesenteric ischemia, (4) 12 with acute mesenteric ischemia, and (5) 10 with mesenteric ischemia associated with aortic reconstructions. Splenic artery aneurysms were managed by excision and splenectomy, while celiac and hepatic had excision with graft replacement. Patients with celiac compression syndrome underwent lysis of the celiac artery. Two patients had compression of both celiac and superior mesenteric artery (SMA). One patient required vascular reconstruction of both arteries for residual stenoses. Patients having chronic mesenteric ischemia were treated with bypass grafts, with one death (7.7% mortality) and good long-term results. Those with acute mesenteric ischemia were treated by SMA embolectomy, bowel resection, or both, with a mortality of 67%. When associated with aortic reconstructions, mesenteric ischemia carried a mortality of 100% if bowel infarction occurred after operation, but when prophylactic mesenteric revascularization was performed at the time of aortic surgery, prognosis was greatly improved, with only one death among six patients. An aggressive approach including prompt arteriography with early diagnosis and surgical therapy is advocated for these catastrophic acute mesenteric problems.     

Right colectomy with simultaneous vascular reconstruction for celiac and superior mesenteric arterial occlusion

INTRODUCTIONIdentification of the primary feeding vessel and its removal with corresponding lymphatics is crucial for oncologic bowel resection for colon cancer. However, this notion would be challenged if we encountered abnormal mesenteric vascular anatomy. We report a case of colon cancer with abnormal mesenteric circulation, for whom we performed oncologic colectomy with vascular reconstruction.PRESENTATION OF CASEA 61-year-old man presented with obstructing transverse colon cancer. A contrast-enhanced computed tomography (CT) scan showed complete occlusion at the root of the superior mesenteric artery (SMA) and the celiac artery (CA), with evidently dilated marginal artery (MA). An X-ray angiography revealed retrograde arterial blood flow originating from the inferior mesenteric artery (IMA) via the MA, the SMA, and to the CA.At laparotomy, we found remarkably dilated MA with the mid-transverse colon cancer. There were no other communicating vessels between the IMA and the SMA. Right colectomy with proper lymph node dissection was completed, following vascular anastomosis between the MA to the SMA. His postoperative course was uneventful. A postoperative CT angiography showed revascularization of the areas where the SMA and the CA supplied.DISCUSSIONIn this patient, if the abberant mesenteric circulation remained unrecognized at the time of surgery, and the MA were divided without vascular reconstruction, severe ischemia and subsequent gangrene of large part of the visceral organs would have occurred.CONCLUSIONThis case illustrates the fundamental importance of assessment for vascular anatomy in patients undergoing oncologic abdominal surgery which associates with division of major mesenteric arteries.     

An Alternative Technique in the Treatment of Celiac Axis Stenosis Diagnosed During Pancreaticoduodenectomy

Celiac compression is usually a benign condition, but when surgery necessitates division of collaterals from the superior mesenteric artery, it may cause life-threatening celiac organ ischemia. Celiac axis obstruction is found in 12.5% to 49.7% of patients during abdominal angiography. In such patients, the arterial blood supply to the stomach, spleen, and liver is sustained through extraordinarily welldeveloped pathways in the pancreas.Though collateral pathways may be sacrificed during pancreaticoduodenectomy, only a small proportion of patients develop hepatic, gastric and splenic ischemia during the procedure. If the appropriate angiographic studies have not been obtained before pancreatic resection, a test occlusion of the gastroduodenal artery, as recommended by Bull et al. [2], should precede its ligation. The hepatic arteries are palpated before and after the test occlusion. In the occasional patient in whom the pulse diminishes during occlusion or if there is evidence of upper abdominal visceral ischemia, revascularization of the celiac circulation may be required. Reestablishment of the celiac circulation may be accomplished by the use of a vein graft between the aorta and the celiac tributaries. This article describes an alternative technique for revascularization of the celiac circulation without the use of a venous graft.     

Celiac axis occlusion with replaced common hepatic artery and pancreatoduodenectomy

A rare case of intraductal papillary mucinous tumor of the pancreas associated with a replaced common hepatic artery and celiac axis occlusion, which was treated by pancreatoduodenectomy, is reported. In this patient, the celiac trunk was occluded at its root and the splenic and left gastric artery could be visualized serially via the enlarged collateral artery on superior mesenteric arteriography. At surgery, the collateral artery was carefully preserved and pancreatoduodenectomy was successfully performed without ischemia of the stomach, spleen, and remnant pancreas. Although celiac axis occlusion is an uncommon finding for patients undergoing pancreatoduodenectomy, we recommend performing celio-mesenteric angiography before pancreatoduodenectomy, and, at surgery, clamping of the gastroduodenal artery is required for patients with celiac axis occlusion.     

胰头部动脉优先离断在根治性胰十二指肠切除术中的运用

目的探讨胰头部动脉优先离断在肠系膜上静脉或门静脉受侵犯的胰头部恶性肿瘤行根治性胰十二指肠切除术中的运用价值。方法回顾性分析2012年1月至2013年5月华中科技大学同济医学院附属同济医院完成的58例胰头部恶性肿瘤行根治性胰十二指肠切除术患者的临床资料。58例患者术前薄层CT检查均显示肠系膜上静脉或门静脉受侵犯或受压,均行胰头部动脉优先离断的根治性胰十二指肠切除术,即在处理胰头部静脉血管之前优先离断胰头部的所有动脉供血,即三大动脉血管的分支,主要步骤包括：在十二指肠水平部或横结肠系膜根部暴露和悬吊肠系膜上动、静脉;解剖肝总动脉从而离断胃十二指肠动脉和胃右动脉,同时沿肝总动脉根部解剖腹腔动脉干上方;离断胰腺和脾动脉的胰头分支;沿暴露的肠系膜上动脉前方、右侧和后方解剖,完全离断胰头钩突部与肠系膜上动脉和腹腔动脉干间的神经结缔组织,与腹腔动脉干的上方贯通,此时可清楚地显示腹主动脉前方;最后通过预置的静脉血管阻断带安全剥离、切除或重建肠系膜上静脉或门静脉,完整切除肿瘤。结果术前影像学检查判断局部肿瘤可切除患者37例,可能切除患者21例。58例患者均顺利施行胰头部动脉优先离断的根治性胰十二指肠切除术,手术时间为4．5～8．1h,术中出血量为200—900mL,术中及术后胰腺钩突部无出血。行肠系膜上静脉侧壁部分切除修补术21例,肠系膜上静脉受累段切除端端吻合术10例,血管受压迫成功将肿瘤从血管上剥离行标准的胰十二指肠切除术27例。术后患者出血、胰液漏和胆汁漏的发生率分别为5．2％（3／58）、6．9％（4／58）和1．7％（1／58）。围手术期无患者死亡。结论胰头部动脉优先离断方式能保障肠系膜上静脉或门静脉受侵犯或受压的胰头部恶性肿瘤行根治性胰十二指肠切除术的安全性,减少术中出血。     

Fibromuscular Dysplasia of the Superior Mesenteric Artery-Case Report and Review of the Literature

Fibromuscular dysplasia is a multifactorial arteriopathy most commonly affecting the renal and carotid arteries. In this report we present a case of visceral artery involvement, causing occlusion of the superior mesenteric artery and celiac trunk and resulting in visceral ischemia. Treatment consisted of superior mesenteric artery reimplantation. Visceral artery FMD can present as occlusive or aneurysmal disease and treatment depends on patient characteristics and symptoms.     

Fibromuscular dysplasia of the superior mesenteric artery--case report and review of the literature

Fibromuscular dysplasia is a multifactorial arteriopathy most commonly affecting the renal and carotid arteries. In this report we present a case of visceral artery involvement, causing occlusion of the superior mesenteric artery and celiac trunk and resulting in visceral ischemia. Treatment consisted of superior mesenteric artery reimplantation. Visceral artery FMD can present as occlusive or aneurysmal disease and treatment depends on patient characteristics and symptoms.     

Aneurysms of anomalous splenomesenteric trunk: Clinical features and surgical management in two cases

Aneurysms of the splenic artery that anomalously arise from a splenomesenteric trunk are a rarity. Aneurysmal disease of visceral arteries is found in only 0.2% of the general population. The celiac trunk and superior mesenteric artery (SMA) are involved in less than 10% of all visceral aneurysms. Although rupture seems to occur in 20% to 22% of patients, the related mortality rate can rise as high as 100%. Anomalies of the celiac trunk and SMA, more common than previously claimed, include the splenic artery arising from the SMA, which occurs in only 1% of patients. We present two cases of young patients who had 4-cm aneurysms behind the pancreas that involved an anomalous splenic artery. The first patient required dissection of the entire splenopancreatic bloc through a transverse abdominal incision to excise the aneurysm and repair the SMA. The second patient was treated by the classic approach, through a median incision and by entering the mesenteric root. There do not seem to be reports of similar cases, except for two cases of aneurysms involving the celiomesenteric trunk. The cause of these aneurysms can be attributed to mesenchymal alterations during the embryonic formation of aortic collateral branches. A correct surgical approach to splanchnic aneurysms calls for awareness of potential vascular variations of the arteries and their collateral pathways. (J Vasc Surg 1996;24:687-92.)     

Significance of selective arteriographic patterns in the celiac axis and superior mesenteric artery in portal hypertension

Selective celiac and superior mesenteric arteriographies were performed in patients with portal hypertension. An arterioarterial (A-A) shunt between the superior mesenteric artery and the celiac axis via pancreatic arcades was found in fifteen of forty-three patients with associated massive splenomegaly. A mild A-A shunt disappeared after portacaval anastomosis alone, whereas a prominent A-A shunt was reduced but persisted. The persisting A-A shunt disappeared after splenectomy. These findings led us to suggest that the paucity of the blood flow in the common hepatic artery concomitant with increased splenic arterial flow to the massively enlarged spleen may result in a compensatory supply to the liver from the superior mesenteric artery via the shunt.     

Ischemic Gastropathy After Distal Pancreatectomy with Celiac Axis Resection

Purpose Stomach-preserving distal pancreatectomy with en bloc resection of the celiac, common hepatic, and left gastric arteries is a radical operation performed for locally advanced cancer of the pancreatic body. However, it is not known whether the collateral pathways that develop immediately from the superior mesenteric artery to the gastroduodenal and hepatic arteries provide sufficient blood flow to support the hepatobiliary system and the stomach. This article examines the ischemic gastropathy that can occur after this procedure and identifies the predisposing conditions.Methods Between 1997 and 2001, nine patients underwent stomach-preserving distal pancreatectomy with en bloc resection of the celiac, common hepatic, and left gastric arteries. Concomitant resection of the right gastric artery or gastroduodenal artery was performed due to cancer infiltration in three patients.Results Irregular, shallow, and wide ulcerations thought to be ischemic in origin developed in these three patients, but all the ulcerations healed in 1–2 weeks with antiulcer medication. None of the other six patients had evidence of gastric ischemia.Conclusions Ischemic gastropathy is rare after distal pancreatectomy with celiac axis resection alone; however, division of additional arteries supplying the stomach may predispose to ischemic gastropathy.     

A Ruptured Pancreaticoduodenal Artery Aneurysm Repaired by Combined Endovascular and Open Techniques

Aneurysms of the pancreaticoduodenal arteries (PDA) are rare, accounting for <2% of all visceral aneurysms. An association with celiac artery stenosis has been reported. Many present with rupture, and a high mortality can be expected. Treatment is therefore challenging. Arterial ligation, anuerysmectomy, or bypass has been the mainstay of treatment. We recently treated a patient (who had no celiac axis) with a ruptured PDA aneurysm with combined open and endovascular techniques. A 46-year-old man was transferred to our hospital with a 1-day history of abdominal pain and syncope. On admission, an abdominal and pelvis computerized tomographic (CT) scan identified a large mesenteric hematoma, a 1.9 cm PDA aneurysm, and an occluded celiac axis. Mesenteric angiography revealed no active aneurysm leak and a stenotic superior mesenteric artery (SMA) origin. All hepatic blood flow originated from the stenotic SMA via markedly enlarged PDA collaterals. The patient was brought to the operating room, where absence of the celiac axis was confirmed. An aorto-to-proper hepatic and SMA bypass was performed using a bifurcated polyester graft. The next day, the patient was brought to the angiography suite, where the PDA aneurysm was coiled. Postprocedure CT scans confirmed thrombosis of the aneurysm. Ruptured mesenteric artery aneurysms are a challenging problem for the vascular surgeon. PDA aneurysms are rare and often occur in an unfavorable location. There appears to be an association with anatomic anomalies of the mesenteric circulation. Prompt invasive and noninvasive diagnostic studies aid in the definitive management of this often fatal problem. Combined endovascular and open techniques can be used for successful treatment.     

Endovascular Repair of a Thoracoabdominal Aortic Aneurysm Involving the Celiac Artery and the Superior Mesenteric Artery

We present a successful endovascular repair of a thoracoabdominal aortic aneurysm (TAAA) involving the celiac artery and the superior mesenteric artery. After the intentional occlusion of the celiac artery, an Inoue stent graft with a side arm to the superior mesenteric artery was implanted. Management of the visceral arteries in the endovascular repair of TAAA was highlighted.     

Ruptured superior mesenteric artery aneurysm occurring in association with a heterotopic pancreas: Report of a case

Aneurysmal disease of the visceral arteries is found in only about 0.2% of the population, and the celiac trunk and superior mesenteric artery (SMA) are involved in less than 10% of all visceral aneurysms. We present herein the case of a 71-year-old woman who suffered rupture of a SMA aneurysm. Histological examination of the periarterial tissues which existed next to the aneurysm revealed a heterotopic pancreas. To the best of our knowledge, no other case of an SMA branch aneurysm presenting in association with a heterotopic pancreas has ever been described in either the Japanese or English literature. This is the first report to indicate that a heterotopic pancreas is a likely incidental factor predisposing to visceral aneurysms.     

En bloc resection including the superior mesenteric artery and vein of locally advanced pancreatic carcinomas

Curative resection has been shown to be one of the key factors affecting the survival of patients with carcinomas of the head of the pancreas. However, local recurrence is very common, and Esposito and colleagues stated that: "Most pancreatic cancer resections are R1 resections." In 2002, we developed a new method for en bloc resection of the pancreatic head including the superior mesenteric artery (SMA) and vein (SMV) for pancreatic head carcinoma with portomesenteric invasion, called "augmented regional pancreatoduodenectomy (ARPD)." The technical and general eligibility criteria for ARPD are: 1) presumed achievement of R0 status; 2) tumor infiltration proximal to the SMV and SMA; and 3) tumor respecting the hepatic artery, splenic artery, and celiac trunk and neither hepatic nor paraaortic nodal metastasis. Between 2002 and 2010, 17 patients underwent ARPD in our institution. Postoperative death occurred in 2 patients. One death occurred after full-dose radiotherapy and the other after rupture of an aortic aneurysm. The surgical margins (R0) were histologically negative in 14 patients (82%). The overall 5-year survival probabilities were 24% in R0. Three patients survived more than 5 years. The ARPD procedure has advantages in obtaining sufficient margins at the uncinate and posterior site in patients with pancreatic head carcinoma.