Video. Laparoscopic distal pancreatectomy and splenectomy for splenic artery aneurysm

Surgical resection of a ruptured transverse pancreatic artery aneurysm

Background

Visceral artery aneurysms are rare, but they may cause heavy bleeding and high mortality. In addition, aneurysms originating from the superior mesenteric artery (SMA) account for only 1% of visceral artery aneurysms. We report the rare case of a ruptured transverse pancreatic artery aneurysm originating from the SMA that required urgent surgical treatment.

Case presentation

A 66-year-old woman presented with acute back pain after lunch, and she was transported by ambulance. She had upper quadrant spontaneous pain and moderate tenderness, but no guarding or rebound pain. She had rheumatoid arthritis, and was taking 10 mg of steroids per day. Contrast-enhanced computed tomography demonstrated a retroperitoneal hematoma spreading to the ventral side of the left kidney and extravasation of contrast agent from a branch of the SMA. We diagnosed rupture of aneurysm. We conferred with our IVR team on treatment strategy for the ruptured aneurysm. In addition, we finally selected operation, since the branch of the SMA to the aneurysm was too thin and complex to conduct IVR. For this reason, we performed emergency simple aneurysmectomy of the transverse pancreatic artery. The postoperative course was relatively smooth.

Conclusion

Rupture of a transverse pancreatic artery aneurysm originating from the SMA is rare. However, when diagnosing patients with acute abdomen or back pain, we should consider rupture of a visceral artery aneurysm. Endovascular treatment may currently be common for ruptured visceral artery aneurysms, but we should flexibly treat them according to the patient’s condition and facility considerations.

A systematic review on clinical features and management of true giant splenic artery aneurysms

BACKGROUND

True giant splenic artery aneurysms (GSAAs) >5 cm are rare and present unique therapeutic challenges. The aim of this study was to evaluate the anatomic and clinical characteristics of these lesions and the current surgical and endovascular techniques available for their treatment.

METHODS

A systematic review of the literature from 2004 to 2018 and the personal experience of the authors with management of GSAAs are presented. A total of 92 GSAA cases were reviewed. Analyses were performed on anatomic and clinical features and management modalities and outcomes of GSAA, including reintervention, morbidity, and mortality.

RESULTS

GSAA presented at a mean age of 56.1 ± 17.3 years, with no sex predilection; 73% were symptomatic at presentation. Abdominal pain was the presenting symptom in >50% of cases; 34% percent were ruptured, with an overall mortality rate of 12.5%. This group often presented with gastrointestinal bleeding or hemodynamic collapse. The aneurysms were almost evenly distributed across the splenic artery and were not uncommonly associated with arteriovenous fistula formation (8.7%). There were 88 patients who had surgical (53.4%), endovascular (44.3%), or combination (2.3%) therapy. The most commonly performed procedure was aneurysmectomy and splenectomy with or without additional resection. Overall, surgical treatment had a lower morbidity (P = .041) than endovascular therapy and comparable reintervention and mortality rates.

CONCLUSIONS

GSAAs are uncommon vascular lesions, with distinct clinical features and aneurysm characteristics. Considering their high risk of rupture, timely diagnosis and management are essential to attain a satisfactory outcome. Surgery remains the standard treatment of these lesions. Endovascular intervention is a viable alternative in high-risk patients, particularly those with lesions <10 cm or with anomalous origin.

Different laparoscopic treatment modalities for splenic artery aneurysms: about 3 cases with review of the literature

INTRODUCTION

The first laparoscopic treatment of splenic artery aneurysm (SAA) was performed in 1993. Since then, many papers have been published mentioning different laparoscopic treatment modalities, including splenectomy, aneurysmectomy, ligation or even occlusion.

PATIENTS AND METHODS

An updated literature review of the English medical literature using the following MeSH, 'Lapaorscopic splenic artery aneurysm', 'laparoscopic aneurysectomy', 'Laparoscopic Splenic artery Aneurysm Ligation' and 'Laparoscopic Splenic artery aneurysm excision' was done. Also three cases performed at our institutions are discussed, in terms of techniques, morbidity, mortality and postoperative outcomes.

RESULTS

About eight case series and 16 case reports were retrieved from the literature. Different techniques were described by the authors, including splenectomy, aneurysmectomy, splenic aneurysm ligation or even occlusion. Few morbidity cases were reported and none of the authors has mentioned a single mortality case. In our three cases, the postoperative course was uneventful, with good long-term results.

CONCLUSIONS

Despite the variations in the adopted operative techniques, the laparoscopic approach seems to be harmless. However, no treatment algorithm or consensus has been published.

Treatment of distal splenic artery aneurysm by laparoscopic aneurysmectomy with end-to-end anastomosis: A case report

RATIONALE

Splenic artery aneurysm (SAA) is the most common visceral artery aneurysm, while most SAAs are treated by endovascular or open procedures.

PATIENT CONCERNS

Here we present a case of SAA treated by laparoscopic aneurysmectomy with end-to-end anastomosis.

DIAGNOSES

A 40-year-old woman was incidentally found to have an asymptomatic distal SAA. CT scan revealed the SAA to be located at the hilum of the spleen, with a maximal diameter of 2.7 cm.

INTERVENTIONS

To prevent sudden rupture, the patient received laparoscopic aneurysmectomy. During the operation, end-to-end anastomosis was also performed since a tortuous proximal splenic artery prevented delivery of the stent graft.

OUTCOMES

The patient was ambulated 12 hours after surgery and discharged 5 days later. Postoperative recovery was smooth without hemorrhage, infarction, infection, or splenic artery thrombosis. At 10-month follow-up,no hemorrhage, aneurysm recurrence, spleen infarction, splenic artery stenosis, or thrombosis had occurred.

LESSONS

Patients with distal SAA can be treated by laparoscopic aneurysmectomy with end-to-end anastomosis to preserve the spleen. The laparoscopic procedure is safe and feasible in the selected patients.

Laparoscopic surgery for the treatment of a ruptured aneurysm of the right gastric artery: a case report

Laparoscopic surgery for the treatment of a ruptured visceral artery aneurysm is recognized as a challenging procedure. Here, we describe our experience with laparoscopic surgery to treat a ruptured aneurysm of the right gastric artery. A 72-year-old woman was diagnosed with intra-abdominal hemorrhage caused by a ruptured aneurysm of the right gastric artery. Transcatheter arterial embolization failed because the right gastric artery could not be cannulated. Therefore, we performed laparoscopic surgery. Using laparoscopy, we detected that the bleeding from the aneurysm had ceased; thus, the planned procedure was successful. The operative time and intraoperative blood loss were 100 min and 5 mL, respectively. The patient was discharged 7 days after surgery. Laparoscopic surgery after the failure of transcatheter arterial embolization is a suitable and safe procedure for ruptured visceral artery aneurysms, provided the circulatory dynamics are stable as a result of the temporary cessation of bleeding from the ruptured aneurysm.