Silent time bomb: a case report of pancreatic head arteriovenous malformation presenting with obstructive jaundice

An Update of Treatment of Pancreatic Arteriovenous Malformations

Pancreatic arteriovenous malformation is a rare entity (0.9%). There are about 200 articles available in PubMed. This review article includes 86 published articles, with 117 cases published after 2000. The median age at diagnosis was 51, and most of the patients were male (87.0%). The symptoms included pain, bleeding, pancreatitis, ulcers in the duodenum or stomach, varix formation, jaundice, and ascites. The diagnostic modalities were angiography, contrast-enhanced CT, MRI, and/or Ultra Sound. The most common treatments were surgery and embolization. The clinical success rate of embolization reported was 57.7%. The tailored embolization based on each agio-architecture had a clinical success rate of 80%. If embolic therapy is ineffective, surgical intervention should be considered.

Arteriovenous malformation in the pancreatic head initially mimicking a hypervascular mass treated with duodenum-preserving pancreatic head resection: a case report

Background

The mainstay treatment for arteriovenous malformation in the pancreatic head (Ph-AVM) is standard pancreatectomy, especially pancreaticoduodenectomy (PD), or interventional endovascular treatment. We report the first case of Ph-AVM treated with duodenum-preserving pancreatic head resection (DPPHR) performed to preserve the periampullary organs.

Case presentation

A 59-year-old man presenting with back pain underwent contrast-enhanced computed tomography followed by angiography of the anterior superior pancreaticoduodenal artery. He was diagnosed with Ph-AVM and indicated for DPPHR with preservation of the periampullary organs; Ph-AVM’s benign nature seldom requires lymph node dissection. During the operation, the right colon was mobilized and the omental bursa was released to expose the periampullary structures. The pancreas was transected just above the superior mesenteric vein. The inferior pancreaticoduodenal artery and papillary arteries branching from the posterior superior pancreaticoduodenal artery were carefully preserved to maintain the blood flow to the lower bile duct and papilla of Vater. The remnant pancreas was reconstructed with pancreaticogastrostomy using the modified Blumgart method. Pathological examination of the resected specimen revealed an irregular course of the arteries and veins concomitant with marked dilation throughout the pancreatic head. The patient was pathologically diagnosed with Ph-AVM. He developed hematemesis caused by a rupture of the pseudoaneurysm on postoperative day 20 and underwent coil embolization. A bilio-enteric fistula and stenosis of the common bile duct were found and treated by placement of an endoscopic biliary stent. At the 8-month follow-up, the Ph-AVM had not recurred.

Conclusions

Compared to PD, DPPHR confers the clinical benefit of preserving the periampullary organs, although further studies are needed to confirm this. Therefore, the choice of this procedure should be based on the surgical morbidities and long-term outcome of the patient.