Comparison of distal pancreatectomy with celiac axis resection and sub-adventitial divestment technique for locally advanced or borderline resectable pancreatic body cancer / 中华外科杂志

Objective: To compare the outcomes of modified Appleby procedure and sub-adventitial divestment technique for locally advanced or borderline resectable pancreatic body cancer. Methods: A total of consecutive 58 patients(33 males and 25 females) who were diagnosed as locally advanced or borderline resectable pancreatic body cancer and underwent distal pancreatectomy at Pancreas Center, First Affiliated Hospital of Nanjing Medical University between September 2013 and May 2019 were retrospectively reviewed. The age(M(IQR)) was 62(9)years(range: 43 to 79 years). Thirty-one patients underwent distal pancreatectomy with celiac axis resection (DP-CAR) and 27 patients underwent distal pancreatectomy with sub-adventitial divestment technique(SDT). Perioperative parameters and follow-up data of these patients were analyzed. Quantitative data were compared with Wilcoxon test while categorical variables were compared with χ2 test or Fisher's exact test. Survival results were estimated by the Kaplan-Meier survival method with a Log-rank test. Results: There were no differences in age,gender,body mass index,abdominal symptoms,comorbidity or preoperative serum CA19-9 between two groups(all P>0.05). Obvious preoperative weight loss was more common in the group of SDT(48.1%(13/27) vs. 19.4%(6/31),χ²=5.431,P=0.020). Longer operative time(310(123) minutes vs. 254(137)minutes, Z=2.277,P=0.023),higher rate of combined organ resection(41.9%(13/31) vs. 14.8%(4/27),χ²=5.123,P=0.041) and longer postoperative hospital stay(15(10) days vs. 11(5)days,Z=2.292,P=0.022) were observed in the group of DP-CAR. Moreover,rate of overall morbidities was also higher (71.0%(22/31) vs. 29.6%(8/27),χ2=9.876,P=0.003),implicated by clinically relevant postoperative pancreatic fistula(61.3%(19/31) vs. 29.6%(8/27),χ2=5.814,P=0.020) in the DP-CAR group. Tumor size of the DP-CAR group was bigger(4.9(1.5)cm vs. 4.0(1.2)cm,Z=2.343,P=0.019) but no difference was seen between the DP-CAR group and SDT group in R0+R1(<1 mm) resection rate (84.0%(21/25) vs. 90.0%(18/20),P=0.678) and LNR(12.0(23.0)% vs. 9.0(18.0)%,Z=1.238,P=0.216),as well as median disease free survival(11.7 months vs. 11.4 months,Z=0.019,P=0.892) and median overall survival(16.3 months vs. 13.7 months,Z=0.172,P=0.679). Conclusions: Both DP-CAR and distal pancreatectomy with SDT are relatively safe and feasible for locally advanced or borderline resectable pancreatic body cancer. Compared with arterial resection,SDT may contribute to lower rates of postoperative complications and shorter duration of hospitalization,but no significant benefit is seen in long-term survival.

Disección espontánea del tronco celíaco. Una emergencia vascular inusual / Spontaneous dissection of the celiac trunk. An unusual vascular emergency

Introducción. La disección espontánea del tronco o arteria celíaca es una emergencia vascular abdominal inusual, con una incidencia desconocida. Actualmente no existen guías o consensos para su tratamiento, el cual va desde intervenciones vasculares mayores hasta la conducta expectante. Caso clínico. Paciente masculino de 42 años sin antecedentes patológicos, con dolor abdominal intenso de un mes de evolución. Ante la sospecha clínica de patología inflamatoria se realizó una tomografía computarizada abdominal con medio de contraste, en la que se observó una disección del tronco celíaco asociada a un infarto esplénico. Se realizó manejo endovascular de forma exitosa. Discusión. La disección espontánea del tronco celíaco es una patología infrecuente, que puede presentarse en pacientes con hipertensión arterial, tabaquismo, enfermedad ateroesclerótica y vasculitis. Los síntomas más comunes son el dolor abdominal asociado a náuseas y vómito. La sospecha clínica debe ser confirmada mediante estudios imagenológicos que orienten al tratamiento conservador, endovascular o quirúrgico, ante la sospecha de infarto intestinal o ruptura arterial. Conclusiones. La disección espontánea del tronco celíaco es una patología vascular inusual que puede relacionarse con una alta mortalidad. Es importante tener siempre presente la interrelación entre la anatomía vascular abdominal, la anamnesis y el examen físico como elementos claves para realizar este diagnóstico.

Introduction. Spontaneous dissection of the celiac artery or trunk is an unusual abdominal vascular emergency, with an unknown incidence. Currently there are no guidelines or consensus for its treatment, which ranges from major vascular interventions to expectant management. Clinical case. A 42-year-old male patient with no medical history, with intense abdominal pain of one month of evolution. Given the clinical suspicion of inflammatory pathology, an abdominal computed tomography with contrast was performed, in which a dissection of the celiac trunk associated with a splenic infarction was observed. Endovascular management was performed successfully. Discussion. Spontaneous dissection of the celiac trunk is an infrequent pathology, which can occur in patients with high blood pressure, smoking, atherosclerotic disease, and vasculitis. The most common symptoms are abdominal pain associated with nausea and vomiting. Clinical suspicion must be confirmed by imaging studies that guide conservative, endovascular or surgical treatment in the event of suspected intestinal infarction or arterial rupture. Conclusions. Spontaneous dissection of the celiac trunk is an unusual vascular pathology that can be associated with high mortality. It is important to always keep in mind the relationship between the abdominal vascular anatomy, anamnesis, and physical examination as key elements in making this diagnosis.

Evaluación anatómica del tronco celíaco y sus ramas en una muestra de población mestiza colombiana / Anatomical evaluation of the celiac trunk and its branches in a sample of Colombian mestizo population

RESUMEN: El tronco celíaco (TC) es la rama de la arteria aorta abdominal (AA) que aporta la irrigación a la porción distal del esófago, parte media del duodeno, al estómago, páncreas, bazo y suple adicionalmente al hígado; sus diferentes expresiones anatómicas son reportadas en los diferentes grupos poblacionales con incidencia variable. Se evaluó las características morfológicas del TC y sus ramas en 26 bloques del piso supramesocólico de cadáveres masculinos adultos no reclamados, del grupo poblacional mestizo, a quienes se les practico autopsia en el Instituto de Medicina Legal de Bucaramanga - Colombia. Se observo el tipo I del TC en 23 especímenes (88,4 %), del cual correspondió 16 muestras (61,5 %). Al subtipo Ia con bifurcación y formación de tronco hepatoesplénico. Hubo un caso (3,8 %) en donde las ramas del T se originaron de manera independiente de la AA. El TC presentó una longitud promedio de 18,6 DE 7,53 mm y un diámetro externo de 7 DE 1,24 mm. De las ramas del TC, la AE presentó un diámetro promedio de 5,89 DE 1,04 mm sin diferencias estadísticamente significativa con relación al diámetro de la AHC, pero si con relación al diámetro de la AGI (P= 0,70; p<0,001 respectivamente). La gran mayoría de la muestra avaluada muestra la presencia de tronco hepatoesplénico seguido de la trifurcación en una verdadera configuración de trípode. El conocimiento de los patrones de ramificación del TC debe ser tomado en cuenta por cirujanos gastroenterólogos, radiólogos intervencionistas y oncólogos para evitar complicaciones durante los procedimientos quirúrgicos abdominales.

SUMMARY: The celiac trunk (CT) is the branch of the abdominal aorta artery (AA) that provides irrigation to the distal portion of the esophagus, the middle part of the duodenum, the stomach, pancreas, spleen and additionally supplies the liver; its different anatomical expressions are reported in the different population groups with variable incidence. The morphological characteristics of the CT and its branches were evaluated in 26 blocks of the supramesocolic floor of unclaimed adult male corpses, of the mestizo population group, who were autopsied at the Institute of Legal Medicine of Bucaramanga - Colombia. Type I CT was observed in 23 specimens (88.4 %), of which 16 samples (61.5 %) corresponded. to subtype Ia with bifurcation and formation of the hepatosplenic trunk. There was one case (3.8 %) in which the branches of the CT originated independently of the AA. The CT had an average length of 18.6 SD 7.53 mm and an external diameter of 7 SD 1.24 mm. Of the CT branches, the splenic artery presented an average diameter of 5.89 SD 1.04 mm without statistically significant differences in relation to the diameter of the AHC, but if in relation to the diameter of the IGA (P = 0.70; p <0.001 respectively). The vast majority of the sample evaluated shows the presence of a hepatosplenic trunk followed by trifurcation in a true tripod configuration. Knowledge of CT branching patterns should be taken into account by gastroenterological surgeons, interventional radiologists, and oncologists to avoid complications during abdominal surgical procedures.

Latest Progresses in Surgical Treatment of Median Arcuate Ligament Syndrome / 中国医学科学院学报

Median arcuate ligament syndrome(MALS)is compression of the celiac trunk by the median arcuate ligament.Median arcuate ligament release is the corner stone for the surgical treatment of MALS.Open surgery,laparoscopic surgery,and robot-assisted surgery have been developed,among which laparoscopic surgery has been proposed as the preferred approach in view of its minimal trauma and short hospital stay.Auxiliary celiac plexus neurolysis could further alleviate the patient's discomfort.Moreover,vascular reconstitution is of vital importance in the case of persistent stenosis in the celiac artery despite of median arcuate ligament decompression.Vascular reconstruction has satisfactory long-term patency rate,while endovascular treatment is less invasive.This article aims to summarize the consensuses and advances and shed light on the surgical treatment of MALS.

Variations in the configuration of the celiac trunk among South Africans: clinical relevance / Variaciones en la configuración del tronco celíaco en sudafricanos: relevancia clínica

SUMMARY: The celiac trunk is the first major unpaired branch of the abdominal aorta found at the twelfth vertebral level (T12). It gives off branches supplying the spleen, liver and the stomach. However, the branching patterns of the celiac trunk tend to vary by population throughout the world. We sought to investigate the branching patterns of the celiac trunk in a South African Caucasian sample. The celiac trunk was assessed by visual observation in 66 dissected bodies comprised of both males (n= 30) and females (n=36). These samples were obtained at the School of Anatomical Sciences, University of the Witwatersrand, Johannesburg. The celiac trunk arose directly from the abdominal aorta in all cases, with none connected to the superior mesenteric artery. We observed celiac trunk trifurcation in 84.84 % of the sample, although a celiac trunk with four branches was observed in 10.61 %. Bifurcation into the common hepatic and splenic arteries forming a hepatosplenic trunk (2 females) or into the left gastric artery and splenic artery forming a splenogastric trunk (1 male) was also observed. The results are largely comparable with other studies in Caucasians, showing a high rate of celiac trunk trifurcation (above 75 %). Our sample exhibited fewer variations than reported in previous studies worldwide. Therefore, a larger study with more samples may be required in the future to ascertain all the existing celiac trunk branching patterns in the South African Caucasian population.

RESUMEN: El tronco celíaco es la primera rama principal de la parte abdominal de la aorta en el nivel de la duodécima vértebra torácica (T12), con ramas que irrigan el bazo, el hígado y el estómago. Sin embargo a nivel mundial, las ramificaciones del tronco celíaco tienden a variar según la población. En este estudio se investigaron los patrones de ramificación del tronco celíaco en una muestra caucásica sudafricana. El tronco celíaco se analizó mediante observación visual en 66 cuerpos disecados compuestos por hombres (n = 30) y mujeres (n = 36). Estas muestras se obtuvieron en la Facultad de Ciencias Anatómicas de la Universidad de Witwatersrand, Johannesburgo. El tronco celíaco surgió directamente de la parte abdominal de la aorta en todos los casos, sin que ninguno estuviera unido a la arteria mesentérica superior. Se observó trifurcación del tronco celíaco en el 84,84 % de la muestra, aunque en el 10,61 % se observó un tronco celíaco con cuatro ramas. También se observó bifurcación en las arterias hepática y esplénica común formando un tronco hepatoesplénico (2 mujeres) o en la arteria gástrica izquierda y la arteria esplénica formando un tronco esplenogástrico (1 hombre). Los resultados son comparables con otros estudios en caucásicos que muestran una alta tasa de trifurcación del tronco celíaco (mayor al 75%). Nuestra muestra presentó menos variaciones que las reportadas en estudios previos. Por lo tanto, es posible que se requieran estudios más amplios con más muestras en el futuro, para determinar todos los patrones de ramificación del tronco celíaco en la población caucásica sudafricana.

Angiotomografía de la arteria cística en preoperatorio y comorbilidad en colecistectomía laparoscópica por colelitiasis / Angiotomography of the cystic artery in preoperative and comorbidity in laparoscopic cholecystectomy for cholelithiasis

La colecistectomía laparoscópica es el tratamiento de elección de la colelitiasis; sin embargo, se acompaña de comorbilidades y no está exenta de complicaciones mayores que pueden ser letales; la identificación del trígono cistohepático con disección y ligadura de la arteria cística son pasos obligatorios de la cirugía; la identificación de las variaciones de la arteria cística y los conductos biliares pueden minimizar las eventuales complicaciones. Al protocolo preoperatorio se implementó una angiotomografía con Tomógrafo Siemens Somatón Sensation ® de 64 cortes para identificar la arteria cística en pacientes con colelitiasis de la Unidad de Cirugía General del Hospital de Especialidades Teodoro Maldonado Carbo IESS de Guayaquil. Se escogieron 60 pacientes femeninos en forma aleatoria (edades 19-70 años, promedio 44,25 años) y la muestra se dividió en dos grupos de 30; al grupo estudio se aplicó angiotomografía hasta un mes antes de la cirugía y al grupo control se le aplicó el protocolo convencional. Se evaluó morbilidades relacionadas con: hemorragia operatoria por lesión de la arteria cística y en el posoperatorio: infección de herida operatoria, íleo y drenaje. La angiotomografía permitió identificar la arteria cística en el preoperatorio y contribuyó a disminuir comorbilidades que acompañan a la colecistectomía laparoscópica.

Laparoscopic cholecystectomy is the treatment of cholelithiasis of choice; however, it is accompanied by comorbidities and is not exempt from major complications that can be lethal; the identification of the cystohepatic trigone with dissection and ligation of the cystic artery are mandatory steps of surgery; the identification of the variations of the cystic artery and the bile ducts can minimize the possible complications. The preoperative protocol was implemented with an angiotomography with Siemens Somatón Sensation ® 64-slice Tomograph to identify the cystic artery in patients with cholelithiasis of the General Surgery Unit of the Teodoro Maldonado Carbo IESS Specialty Hospital of Guayaquil. 60 female patients were chosen at random (ages 19 -70 years, average 44.25 years) and the sample was divided into two groups of 30; Angiotomography was applied to the study group up to one month before surgery and the conventional protocol was applied to the control group. Morbidities related to: operative haemorrhage due to cystic artery and postoperative injury: operative wound infection, ileus and drainage were evaluated. Angiotomography allowed to identify the cystic artery in the preoperative period and contributed to decrease comorbidities that accompany laparoscopic cholecystectomy.

Anatomical variations of the superior mesenteric artery and its clinical and surgical implications in humans / Variações anatômicas da artéria mesentérica superior e suas implicações clínicas e cirúrgicas em humanos

ABSTRACT Introduction: Superior mesenteric artery (SMA) usually arises from the abdominal aorta, just below the celiac trunk and it supplies the midgut-derived embryonic structures. Anatomical variations in this vessel contribute to problems in the formation and/or absorption of this part of the intestine and its absence has been recognized as the cause of congenital duodenojejunal atresia. Objective: To analyze SMA anatomical variations in humans and the possible associated clinical and surgical implications. Methods: This is a systematic review of papers indexed in PubMed, SciELO, Springerlink, Science Direct, Lilacs, and Latindex databases. The search was performed by two independent reviewers between September and December 2018. Original studies involving SMA variations in humans were included. SMA presence/absence, level, place of origin and its terminal branches were considered. Results: At the end of the search, 18 studies were selected, characterized as for the sample, method to evaluate the anatomical structure and main results. The most common type of variation was when SMA originated from the right hepatic artery (6.13%). Two studies (11.11%) evidenced the inferior mesenteric artery originating from the SMA, whereas other two (11.11%) found the SMA sharing the same origin of the celiac trunk. Conclusion: SMA variations are not uncommon findings and their reports evidenced through the scientific literature demonstrate a great role for the development of important clinical conditions, making knowledge about this subject relevant to surgeons and professionals working in this area.

RESUMO Introdução: A artéria mesentérica superior (AMS), normalmente, tem sua origem a partir da aorta abdominal, um pouco abaixo do tronco celíaco e é responsável pela irrigação das estruturas derivadas, embrionariamente, do intestino médio. Variações anatômicas nesse vaso contribui para defeitos na formação e/ou absorção dessa parte do intestino e a sua ausência tem sido reconhecida como a causa da atresia duodenojejunal congênita. Objetivo: Analisar as variações anatômicas dela em humanos e as possíveis implicações clínicas e cirúrgicas associadas. Métodos: Trata-se de uma revisão sistemática de artigos indexados nas bases de dados PubMed, SciELO, Springerlink, Scienc Direct, Lilacs e Latindex. A busca ocorreu por dois revisores independentes entre setembro e dezembro de 2018. Foram incluídos artigos originais envolvendo as variações da AMS em humanos. Considerou-se para este estudo a presença/ausência da AMS, o nível, local de origem e seus ramos terminais. Resultados: Ao final da busca foram selecionados 18 artigos, caracterizados quanto à amostra, método para avaliar a estrutura anatômica e principais resultados. O tipo de variação mais comum foi aquele cuja AMS se originou da artéria hepática direita (6,13%). Dois estudos (11,11%) evidenciaram a artéria mesentérica inferior originando-se a partir da AMS, enquanto outros dois (11,11%) constataram ser ela compartilhada na mesma origem do tronco celíaco. Conclusão: Variações na AMS não são achados incomuns e seus relatos evidenciados através da literatura científica demonstram grande importância para o desenvolvimento de condições clínicas importantes, tornando o conhecimento sobre esse assunto relevante para os cirurgiões e profissionais atuantes nesta área.

Arc of Buhler: A lifesaving anatomic variation. A case report / Arco de Buhler: uma variação anatômica que salva vidas - relato de caso

Abstract The presence of malperfusion syndrome in cases of complicated acute type B aortic dissection is a negative predictive factor and urgent intervention is indicated. Anatomic variations, such as the Arc of Buhler, contribute anastomotic channels and can preserve the visceral blood supply. In this case report, we describe the overall management of a 54-year-old man who presented with a type B aortic dissection. Initially, conservative management was chosen, as indicated for an uncomplicated type B dissection, but the dissection deteriorated. Despite the fact that severe occlusion of the celiac artery was detected on Computed Tomography (CT) angiography, the Arc of Buhler anatomical variation was present, contributing adequate visceral blood supply. After considering this finding, the patient was treated effectively with thoracic endovascular aortic repair (TEVAR).

Resumo A presença da síndrome de má perfusão em casos de dissecção aórtica aguda do tipo B complicada é um fator preditor negativo, e uma intervenção urgente é indicada. As variações anatômicas, tais como o arco de Buhler, contribuem como canais anastomóticos e podem preservar o suprimento sanguíneo visceral. Neste relato de caso, descrevemos o manejo geral de um paciente do sexo masculino, de 54 anos, que apresentou uma dissecção aórtica do tipo B. Inicialmente, o manejo conservador foi escolhido, conforme indicado para dissecção do tipo B não complicada, mas a dissecção sofreu deterioração. Apesar de uma oclusão grave da artéria celíaca ter sido detectada na angiotomografia computadorizada, a variação anatômica do arco de Buhler estava presente, contribuindo para o suprimento sanguíneo visceral adequado. Após levar em consideração esse achado, o paciente foi tratado de forma efetiva com reparação endovascular da aorta torácica.

Vasculitis del tronco celíaco como presentación de arteritis de Takayasu / Vasculitis of the celiac artery as a presentation of Takayasu's arteritis

La arteritis de Takayasu es una vasculitis idiopática y granulomatosa crónica que se manifiesta en forma de panaortitis, de etiología desconocida, aunque se postula un origen autoinmune. Es progresiva y genera, tanto en adultos como en niños, estenosis segmentaria, oclusión, dilatación y/o aneurismas. La vasculitis aislada gastrointestinal sin afectación sistémica es rara. Este caso lleva a tener en cuenta la manifestación abdominal atípica de la arteritis de Takayasu en el diagnóstico diferencial de un síntoma frecuente, como la epigastralgia, y a destacar el rol que ocupan en la actualidad los métodos de imágenes no invasivos para su diagnóstico.

Takayasu arteritis is an idiopathic and chronic granulomatous vasculitis manifested in the form of panaortitis, of unknown etiology, even though an autoimmune origin is postulated. It is progressive and generates, in adults and children, segmental stenosis, occlusion, dilation and / or aneurysms. Isolated gastrointestinal vasculitis without systemic involvement is rare. This case leads us to take into account the atypical abdominal manifestation of Takayasu arteritis in the differential diagnosis of a frequent symptom, such as epigastralgia, and to highlight the role currently played by non-invasive imaging methods for its diagnosis.

Disección espontánea de arterias viscerales: reporte de una serie de casos / Spontaneous dissection of visceral arteries: a series of cases

Background: Spontaneous dissections of visceral arteries are rare and usually secondary to other disease. There is paucity of information about their natural course. Aim: To describe the imaging, clinical characteristics and follow-up of spontaneous visceral artery dissections diagnosed at our institution. Material and Methods: We report a series of 14 patients in whom a spontaneous dissection of a visceral artery was diagnosed on abdominal angio-CT between 2010 and 2018. Clinical features and evolution were recorded. Results: Isolated lesions of the celiac axis were the most common finding. Multiple territories were involved in 14% of cases. A dissection flap was observed in four cases, a hematoma-dissection complex in seven and an aneurysmal dilatation associated with the dissection in three. Of the 10 patients who were followed at our institution, 90% had stabilization or partial regression of the imaging findings. In the remaining case, new dissection events were observed. All cases were managed conservatively, and no death was reported. Conclusions: In this series of patients, spontaneous dissection of visceral arteries had a benign, favorable course, requiring only conservative management.

Pancreatectomía corpo-caudal con resección en bloque de tronco celíaco: reporte de 2 casos / Corporal caudal pancreatectomy with celiac trunk block resection: report of 2 cases

INTRODUCCIÓN: El adenocarcinoma de cuerpo y cola de páncreas corresponde a cerca de un tercio del total de cánceres pancreáticos. Evoluciona en forma silenciosa hasta alcanzar estadios avanzados, llegando a comprometer muchas veces grandes vasos como tronco celíaco y sus ramas, y la arteria mesentérica superior. La resolución quirúrgica parece ser la única alternativa en estos casos. OBJETIVO: Presentar dos casos de adenocarcinoma de cuerpo y cola de páncreas tratados en nuestro hospital con pancreatectomía corpo-caudal y resección en bloque de tronco celíaco (procedimiento de Appleby modificado). DISCUSIÓN: Este procedimiento ha demostrado aumentar la sobrevida de estos pacientes, además de generar un alivio inmediato y duradero del dolor. Sin embargo, corresponde a una intervención con una alta morbilidad, siendo la fístula pancreática y la gastropatía isquémica las complicaciones más frecuentes. La evaluación del flujo de los vasos colaterales es un paso crítico para evitar las complicaciones isquémicas. CONCLUSIONES: La pancreatectomía corpo-caudal con resección en bloque de tronco celíaco, es una alternativa factible en adenocarcinoma de cuerpo y cola de páncreas localmente avanzado. Su indicación debe ser cuidadosa debido a que corresponde a un procedimiento con alta morbilidad.

INTRODUCTION: Adenocarcinoma of the body and tail of the pancreas corresponds to about one third of all pancreatic cancers. It evolves silently to reach advanced stages, often involving large vessels such as the celiac trunk and its branches, and the superior mesenteric artery. Surgical resolution seems to be the only alternative in these cases. AIM: To present two cases of adenocarcinoma of the body and tail of the pancreas treated in our hospital with distal pancreatectomy and celiac trunk en block resection (modified Appleby procedure). DISCUSSION: This procedure has been shown to increase the survival of these patients, in addition to generating immediate and lasting pain relief. However, it corresponds to an intervention with a high morbidity, being the pancreatic fistula and the ischemic gastropathy the most frequent complications. The evaluation of the flow of the collateral vessels is a critical step to avoid ischemic complications. CONCLUSIONS: Distal pancreatectomy with en bloc resection of the celiac trunk is a feasible alternative in locally advanced adenocarcinoma of the body and tail of the pancreas. Its indication must be careful since is a procedure with high morbidity.

Prevalence of hepatic arterial variations with implications in pancreatoduodenectomy / Prevalência de variações arteriais hepáticas com implicações em pancreatoduodenectomia

ABSTRACT Background: Pancreaticoduodenectomy is the usual surgical option for curative treatment of periampullary cancer and carries a significant mortality. Arterial anomalies of the celiac axis are not uncommon and might lead to iatrogenic lesions or requiring arterial resection/reconstruction in a pancreatoduodenectomy. Aim: Determine the prevalence of arterial variations having implications in pancreatoduodenectomy. Methods: Celiac trunk and hepatic arterial system anatomy was retrospectively evaluated in 200 abdominal enhanced computed tomography studies. Results: Normal anatomy of hepatic arterial system was found in 87% of cases. An anomalous right hepatic artery was identified in 13% of cases. In 12 cases there was a substitute right hepatic artery arising from superior mesenteric artery and in two cases an accessory right hepatic artery with similar origin. A hepatomesenteric trunk was identified in seven cases and in five there was a right hepatic artery directly from the celiac trunk. All cases of anomalous right hepatic artery had a route was behind the pancreatic head and then, posteriorly and laterally, to the main portal vein before reaching the liver. Conclusions: Hepatic artery variations, such as anomalous right hepatic artery crossing posterior to the portal vein, are frequently seen (13%). These patients, when undergoing pancreatoduodenectomy, may require a change in the surgical approach to achieve an adequate resection. Preoperative imaging can clearly identify such variations and help to achieve a safer pancreatic head dissection with proper surgical planning.

RESUMO Racional: Pancreatoduodenectomia consiste no procedimento cirúrgico usual para tratamento curativo de neoplasias periampulares e apresenta mortalidade significativa. Variações arteriais do tronco celíaco não são incomuns e podem favorecer lesões iatrogênicas ou exigirem realização de ressecção/reconstrução arterial durante pancreatoduodenectomia. Objetivo: Determinar a prevalência de variações arteriais que apresentam implicações durante pancreatoduodenectomia. Métodos: A anatomia do tronco celíaco e sistema arterial hepático foi investigada retrospectivamente em 200 exames tomográficos contrastados do abdome. Resultados: Anatomia normal do sistema arterial hepático foi observada em 87% dos casos. Presença de uma artéria hepática direita anômala foi identificada em 13%. Em 12 casos houve uma artéria hepática direita substituta originária da artéria mesentérica superior, em dois uma artéria hepática direita acessória com origem similar. Tronco hepaticomesentérico foi identificado em sete casos e em cinco houve uma artéria hepática direita originária diretamente do tronco celíaco. Em todos casos de artéria hepática direita anômala seu curso foi por trás da cabeça do pâncreas e com trajeto passando posteriormente ao tronco da veia porta e após percorrendo sua face lateral direita antes de alcançar o fígado. Conclusões: Variações arteriais hepáticas, como artéria hepática direita anômala com trajeto posterior à veia porta, são frequentes (13%). Nestes pacientes, quando submetidos à pancreatoduodenectomia, pode ser necessária alteração na abordagem cirúrgica para ressecção adequada. Exames de imagem pré-operatórios podem claramente identificar estas variações e auxiliar na realização de dissecção segura da cabeça do pâncreas com adequado planejamento cirúrgico.

Variação anatômica do tronco celíaco e do sistema arterial hepático: uma análise por exames de imagem / Anatomical variations of the celiac trunk and the hepatic arterial system: an imaging analysis

Introdução: As variações anatômicas das artérias hepáticas e do tronco celíaco são de grande importância para cirurgias laparoscópicas, transplantes hepáticos, intervenções radiológicas e tratamento de lesões abdominais. O grande aumento de intervenções minimamente invasivas deixou os atos cirúrgicos com menos espaço para o reconhecimento de estruturas anatômicas. Métodos: Foi realizado um estudo retrospectivo do banco de dados do Hospital São Vicente de Paulo durante o ano de 2016, analisando imagens abdominais de tomografia computadorizada com contraste e angiotomografias que envolvem a aorta abdominal e seus ramos ­ um total de 461 imagens foram analisadas. Resultados: Dos 461 pacientes analisados, 86,9% apresentaram a conformação usual do tronco celíaco ­ cuja anatômica é a origem tríplice com as artérias gástrica esquerda, esplênica e hepática comum e artéria mesentérica superior se originando sozinha da aorta abdominal. Dentre as anatomias anômalas (13%), o padrão mais comum desses ramos foi a presença em 4,5% de um tronco hepatomesentérico e um tronco gastroesplênico. No sistema arterial hepático a conformação mais prevalente foram as artérias hepáticas direita e esquerda sendo ramos da hepática próprias em 66,3%. Das alterações anatômicas (33,2%), as mais comuns foram a presença de uma artéria hepática esquerda acessória ramo da artéria gástrica esquerda (7,8%). Conclusão: Variações anatômicas do sistema arterial hepático e do tronco celíaco são prevalentes, podendo apresentar diversos arranjos organizacionais. (AU)

Introduction: Anatomical variations in the hepatic arteries and the celiac trunk are of great importance for laparoscopic surgeries, liver transplants, radiological interventions and treatment of abdominal injuries. A large increase in the number of minimally invasive interventions hampered the recognition of anatomical structures in surgical procedures. Methods: A retrospective study was performed using the 2016 São Vicente de Paulo Hospital database of contrast-enhanced abdominal computed tomography images and computed tomography angiographies showing the abdominal aorta and its branches. In total, 461 images were analyzed. Results: Of the 461 patients analyzed, 86.9% had usual conformation of the celiac trunk, which trifurcates into the left gastric artery, the common hepatic artery and the splenic artery, while the superior mesenteric artery originates alone from the abdominal aorta. Among the cases of anomalous anatomy (13%), the most common pattern in these branches was the presence of a hepatomesenteric trunk and a gastrosplenic trunk in 4.5%. In the hepatic arterial system, the most prevalent conformation was the right and left hepatic arteries being branches of the hepatic artery proper in 66.3%. Of all anatomical variations (33.2%), the most common were the presence of a left accessory hepatic artery of the left gastric artery (7.8%). Conclusion: Anatomical variations in the hepatic arterial system and the celiac trunk are common, having different structural arrangements. (AU)

Celiac artery compression: Dunbar syndrome / Síndrome da compressão da artéria celíaca (síndrome de Dunbar)

Celiac artery compression syndrome, also referred to as median arcuate ligament syndrome, celiac axis syndrome or Dunbar syndrome is a rare disorder consequent to extrinsic compression of the celiac trunk by the median arcuate ligament. Doppler ultrasound, multi-slice computed tomography angiography, magnetic resonance angiography, or invasive selective angiography can identify stenosis of the initial segment of the celiac artery and confirm diagnosis. Treatment options include open surgical or videolaparoscopic section of the median arcuate ligament and the fibers of the celiac plexus, or percutaneous transluminal angioplasty via an endovascular approach. We report herein an interesting case of a 38-year-old woman diagnosed with this rare condition and successfully treated with the surgical strategy

A síndrome da compressão da artéria celíaca, também denominada síndrome do ligamento arqueado mediano, síndrome do eixo celíaco ou síndrome de Dunbar, é uma doença rara causada pela compressão extrínseca do tronco celíaco pelo ligamento arqueado mediano. Ultrassonografia Doppler, angiotomografia computadorizada, angiorressonância magnética ou angiografia seletiva invasiva conseguem identificar a estenose do segmento inicial da artéria celíaca e confirmar o diagnóstico. As opções de tratamento incluem secção videolaparoscópica ou laparotômica (a céu aberto) do ligamento arqueado mediano e das fibras do plexo celíaco, assim como angioplastia transluminal percutânea. Relatamos o interessante caso de uma mulher de 38 anos de idade diagnosticada com essa rara condição e adequadamente tratada pela estratégia cirúrgica

Effect of taxifolin on oxidative gastric injury induced by celiac artery ligation in rats

Abstract Purpose: To examine the effect of taxifolin on I/R induced gastric injury in rats using biochemical and histopatholohical methods. Methods: Eighteen albino Wistar male rats equally grouped as; gastric I/R (I/R), 50 mg/kg taxifolin + gastric I/R (TAX+ I/R) and sham operation applied (SHAM). Ischemia induced for 1 hour, and reperfusion induced for 3 hours. Results: Oxidant parameters like, Malondialdehyde (MDA) and Hydroxyguanine (8-OHdG) were higher, whereas total glutathione (tGSH) was lower in the I/R group according to SHAM group, histopathological findings such as marked destruction, edema, and proliferated dilated congested blood vessels were observed severely in the I/R group, whereas there was not any pathological finding except mild dilated congested blood vessels in the TAX+ I/R group. Conclusion: The taxifolin can be clinically beneficial in the treatment of gastric injury due to I/R procedure.

Symptomatic Isolated Celiac Artery Dissection following Blunt Trauma

An isolated splanchnic artery injury due to blunt trauma occurs rarely because abdominal vascular injuries are typically associated with injuries to the surrounding abdominal structures, including solid organs or hollow viscus. Of the major abdominal vessels, the celiac artery is the least commonly injured by penetrating or blunt abdominal trauma. Furthermore, a celiac artery dissection due to blunt trauma is rarely reported and there is no clearly defined treatment method, even though endovascular and conservative treatments are accepted widely. On the other hand, endovascular treatment can be challenging if the celiac artery dissection involves its main branch, including the proper hepatic artery, left gastric artery, and splenic artery. This case study presents the treatment experience of a celiac artery dissection involving its main branch following dorsal blunt trauma. Furthermore, conservative treatment is proposed as a treatment option for this rare injury.

Ruptured Suprarenal Abdominal Aortic Pseudoaneurysm with Superior Mesenteric and Celiac Arteries Occlusion, Revealing Behçet’s Disease: A Case Report

Behçet’s disease (BD) is a multisystemic, chronic autoimmune inflammatory vasculitic disease with an unknown etiology. Although the literature reports that vascular involvement occurs in 7% to 38% of all BD cases, the arteries are rarely involved; however, arterial involvement is usually associated with significant mortality and morbidity. We report the case of a young female patient who presented to the emergency department with severe abdominal pain and a history of weight loss. The patient was evaluated using computed tomography angiography, which revealed a ruptured suprarenal aortic pseudoaneurysm with occlusion of both the superior mesenteric and celiac arteries. Urgent surgery was performed with aortic repair with an interposition graft and superior mesenteric artery embolectomy. The patient’s clinical history and radiological imaging findings were strongly suggestive of the diagnosis of BD with vascular involvement.

Merits of and Technical Tips for Supra-Mesenteric Aortic Cross Clamping

Supra-celiac aortic cross clamping is often utilized during aortic reconstruction for aneurysmal/occlusive disease involving the pararenal aorta. However, this may be accompanied a myriad of complications related to hemodynamic disturbances, cardiopulmonary compromise and hepatic ischemia. Supra-mesenteric aortic cross clamping may be an excellent option in selected patients with suitable anatomy to minimize or avoid these complications. Herein, the merits of and technical tips for supra-mesenteric aortic cross clamping are discussed.

Isolated Spontaneous Celiac Artery Dissection as a First Manifestation of Systemic Lupus Erythematosus / 전남의대학술지

No abstract available.

Morfometría y variantes anatómicas del tronco celíaco en población mexicana / Morphometry and anatomical variants of the celiac trunk in Mexican population

RESUMEN: Las variantes anatómicas del tronco celíaco (TC) son relevantes en el ámbito quirúrgico e intervencionista. Existen diferentes estudios a nivel mundial que han demostrado las variaciones que puede presentar el TC tanto en longitud como en estructura; dichos estudios han sido realizados predominantemente en población asiática y europea. Por lo anterior, realizamos un estudio que caracterizó esta estructura y que sea referente para la población mexicana. Se analizó una muestra de 50 especímenes cadavéricos humanos embalsamados de origen mexicano. El promedio de longitud del TC a su primera rama fue de 12,44 mm; de su origen a la segunda rama fue de 17,07 mm; y hasta la tercera fue de 19,15 mm. En la muestra de estudio se encontraron variantes en el 20 % de los especímenes, de éstos el 14 % presentaron variantes morfométricas en cuanto a longitud y 6 % en estructura. Respecto a las variantes morfométricas, destacó la presencia de un TC de 3 mm de longitud. En cuanto a las variantes morfológicas dos individuos presentaron un tronco gastro-esplénico con tronco hepato-mesentérico; y el tercero un tronco bifurcado hepato-gástrico con la arteria esplénica naciendo de la arteria hepática común. Éste último no reportado en la literatura.

SUMMARY: Anatomical variants in the celiac trunk (CT) are important in surgical and interventional fields. Studies worldwide have demonstrated length and structure variations in the celiac trunk. These studies have predominantly been carried out in Asian and European population. Therefore, we considered it necessary to realize a study to describe this structure and serve as a reference in the Mexican population. A sample of 50 human cadaveric specimens of Mexican origin was analyzed. The average length of the celiac trunk from its origin to its first branch was 12.44 mm, to the second branch was 17.07 mm, and to the third branch was 19.15 mm. In the studied sample, variants were found in 20 % of the specimens, 14 % of these presented morphometric variations in terms of length, and 6 % in terms of structure. In reference to the morphometric variants, the presence of one 3 mm length CT was noteworthy. Morphological variants were found in two specimens presenting a gastro-splenic trunk with a hepatomesenteric trunk, and a third specimen with hepatogastric bifurcated trunk, with the splenic artery originating from the common hepatic artery was observed. No reports were found in the literature concerning the latter.