Aneurisma de artéria pancreatoduodenal inferior: tratamento endovascular / Inferior pancreaticoduodenal artery aneurysm: endovascular approach

Resumo Os aneurismas das artérias pancreatoduodenais constituem uma afecção rara. Seu diagnóstico é realizado, na maioria das vezes, em situações de emergência por complicações como a rotura, a qual está associada a altas taxas de mortalidade (21-26%). A embolização do saco aneurismático é o tratamento de escolha, devido à sua alta efetividade e menor mortalidade. Neste artigo, é apresentado e discutido um caso de aneurisma de artéria pancreatoduodenal inferior com diagnóstico obtido durante investigação de sintomas gastrointestinais. O tratamento instituído foi a embolização com micromolas, com completa exclusão do aneurisma e boa evolução clínica.

Abstract Aneurysms of the pancreaticoduodenal arteries are a rare condition. In the majority of cases, diagnosis is made in emergency situations due to complications such as rupture, which is associated with high mortality rates (21-26%). Embolization of the aneurysm sac is the treatment of choice, because of its high efficacy and lower mortality. This article presents and discusses a case of inferior pancreaticoduodenal artery aneurysm that was diagnosed during investigation of gastrointestinal symptoms. The treatment provided was microcoil embolization, with complete exclusion of the aneurysm and a good clinical course.

Malformación arteriovenosa pancreática como causa de pancreatitis aguda tratada por vía endovascular / Pancreatic arteriovenous malformation as cause of acute pancreatitis treated by endovascular access

La malformación arterio-venosa (MAV) en el páncreas es una anomalía anatómica poco frecuente que puede ser causa de pancreatitis aguda. Presentamos el caso de un paciente de 46 años cuyo diagnóstico se sospechó por los hallazgos de la tomografía computarizada con contraste endovenoso y por resonancia magnética y se confirmó mediante una arteriografía del tronco celíaco y de la arteria mesentérica superior. El tratamiento recibido fue por vía endovascular, aunque la otra opción válida para el tratamiento de esta enfermedad es la resección quirúrgica. El objetivo de esta comunicación es presentar un caso de pancreatitis aguda por MAV tratada por vía endovascular.

Arteriovenous malformation in the pancreas is a rare anatomic abnormality that may produce acute pancreatitis. The diagnosis was suspected by computed tomography with intravenous contrast and by magnetic resonance imaging and it was confirmed by arteriography of the celiac trunk and superior mesenteric artery. The treatment received was endovascular, although the other valid option for the treatment of this disease is the surgical resection. The objective of this communication is to present a case of acute pancreatitis due to arteriovenous malformation treated by endovascular approach.

Objective Assessment of Surgical Restaging after Concurrent Chemoradiation for Locally Advanced Pancreatic Cancer

The role of neoadjuvant chemoradiation therapy in locally advanced pancreatic cancer (LAPC) is still controversial. The aim of this study was to evaluate surgical downstaging after concurrent chemoradiation therapy (CCRT) for LAPC by measuring the objective changes after treatment. From January 2003 through July 2011, 54 patients with LAPC underwent neoadjuvant CCRT. Computed tomography findings of the tumor size, including major vessel invasion, were analyzed before and after CCRT. Among the total recruited patients, 14 had borderline resectable malignancy and another 40 were unresectable before CCRT. After CCRT, a partial response was achieved in four patients. Stable disease and further disease progression were achieved in 36 and 14 patients, respectively. Tumor size showed no significant difference before and after CCRT (3.6 +/- 1.1 vs. 3.6 +/- 1.0 cm, P = 0.61). Vessel invasion showed improvement in two patients, while 13 other patients showed further tumor progression. Thirty-nine patients with unresectable malignancy and 11 patients with borderline resectable malignancy at time of initial diagnosis remained unchanged after CCRT. Four patients with borderline pancreatic malignancy progressed to an unresectable stage, whereas one unresectable pancreatic malignancy improved to a borderline resectable stage. Only one patient with borderline resectable disease underwent operation after CCRT; however, curative resection failed due to celiac artery invasion and peritoneal seeding. The adverse events associated with CCRT were tolerable. In conclusion, preoperative CCRT in LAPC rarely leads to surgical downstaging, and it could lower resectability rates.

Variations in the vascular supply of pancreas and transverse colon: a case report / Variaciones en el suministro vascular de páncreas y colon transverso: reporte de un caso

During anatomical dissection of the abdominal cavity of an adult male corpse, a changing pattern of vascular supply of pancreas and of the transverse colon was observed. The inferior pancreatic artery and the middle colic artery arose from a common trunk of the superior mesenteric artery. Moreover, the lienal artery did not direct a dorsal branch to the neck of the pancreas, but rather sent two greater pancreatic arteries (proximal and distal) to the body of the gland and one caudal artery to the terminal portion of the pancreas. We also observed a large communicating branch between the proximal portion of the middle colic artery and the ascending branch of the left colic artery, previously described as artery of Moskowitz. Based on these data, clinical and surgical implications of these variations were highlighted.

Durante la disección anatómica de la cavidad abdominal del cadáver de un hombre adulto, se observó un patrón cambiante en el suministro vascular del páncreas y del colon transverso. La arteria pancreática inferior y la arteria cólica media surgían de un tronco común desde la arteria mesentérica superior. Además, la arteria esplénica no daba origen a la rama dorsal hasta el cuello del páncreas, más bien contaba con dos arterias pancreáticas mayores (una proximal y una distal) hasta la glándula, y una arteria caudal. También se observó una conexión entre la parte proximal de la arteria cólica media y el ramo ascendente de la arteria cólica izquierda lo que fue previamente definido como la arteria de «Moskowitz¼. Las implicaciones quirúrgicas de estas variaciones fueron destacadas en base a estos datos.

Imaging Spectrum after Pancreas Transplantation with Enteric Drainage

Since the introduction of pancreas transplantation more than 40 years ago, surgical techniques and immunosuppressive regiments have improved and both have contributed to increase the number and success rate of this procedure. However, graft survival corresponds to early diagnosis of organ-related complications. Thus, knowledge of the transplantation procedure and postoperative image anatomy are basic requirements for radiologists. In this article, we demonstrate the imaging spectrum of pancreas transplantation with enteric exocrine drainage.

Microscopic study of rat pancreas after sympathectomy

The aims of the study are to monitor the structural changes in the rat pancreatic tissue after surgical sympathectomy and assess its effect on the pancreatic endocrine function. Twelve animals were used in this study. All animals had surgical sympathectomy. The morphological changes of the islets of Langerhans and the pancreatic acini were studied under the light microscope, 2 and 3 weeks after surgery. Glucose tolerance test and fasting blood sugar levels were monitored at different intervals of time after sympathectomy. The microscopic examination of the pancreatic tissue after sympathectomy showed histological changes, in the form of general atrophy and pancreatic cell degeneration. Furthermore, the fasting blood glucose levels and the glucose tolerance tests were significantly increased. The results of this study demonstrated that the pancreatic function in rats is dependent on the sympathetic innervations,and the metabolic and histologicalabnormalities were observed after surgical sympathectomy. The structural changes in the pancreatic acini and the islets of Langerhans after vagotomy and sympathectomy may explain the failure of pancreatic cell transplantation and the metabolic abnormalities that accompany the neurogenic shockin humans

Anatomía vascular pancreática: análisis comparativo entre el patrón universal y una muestra original / Pedagogical design form teaching security and quality of medical assistance and allied disciplines at the school of medicine

La complejidad de la irrigación pancreática representa un constante desafío tanto para los cirujanos como para los médicos y estudiantes que se inician en el tema. Las descripciones clásicas presentan discrepancias que sumergen al lector en un mar de confusión. Dada la cualidad proteiforme del tema, el trabajo se centró en la confección de un esquema "patrón" de la irrigación pancreátrica a través de una revisión bibliograáfica, teniéndose en cuenta solo aquellos vasos que figuraban en la literatura médica con prevalencia superior al 50 %. Este esquema- constituido por 13 arterias- fue luego comparado con una muestra original de 22 disecciones anatómicas, confirmándose un 76,92% de semejanza. En base a los hallazgos realizados en las disecciones, sugerimos que la prevalencia de 3 de las 13 arterias debería ser revisada: la APU y los dos ramos que constituyen la arcada PD media.

The complexity concerning the pancreatic blood supply stands as a constant challenge for surgeons and even form those facing the first stages aboarding the subject. Classic descriptions show discrepancies that mislead the reader into a sea of confusion. Given the proteiform shape of this subject, our labour was centered in developing a pattern scheme of the pancreatic irrigation after a bibliographic review-taking into account only those vessels that figured in the medical literature with a prevalence surpassing 50 %. The final scheme containing 13 arteries was then compared with an original sample consisting in 22 anatomic dissections, confirming a correspondence of 76,92 %. In the light of the findings made in the dissections, we suggest that the prevalence of 3 of the 13 arteries should be revisited: the UPA and the two branches constituting the middle PD arcade.

Venous drainage from the tail of the pancreas to the lienal vein and its relationship with the distal splenorenal shunt selectivity / Drenagem venosa da cauda do pâncreas para a veia lienal e sua relação com a seletividade da anastomose esplenorrenal

PURPOSE: To identify the veins draining from the pancreatic tail to the lienal vein and its possible relationship with the loss of the distal splenorenal shunt selectivity. METHODS: Thirty eight human blocks including stomach, duodenum, spleen, colon and pancreas, removed from fresh corpses, were studied with the replenish and corrosion technique, using vinilic resin and posterior corrosion of the organic tissue with commercial hydrochloric acid, in order to study the lienal vein and its tributaries. RESULTS: The number of veins flowing directly to the splenic vein varied from seven to twenty two (14.52 ± 3.53). Pancreatic branches of the pancreatic tail flowing to the segmentary veins of the spleen were found in 25 of the anatomical pieces studied (65.79 percent). These branches varied from one to four, predominating one branch (60 percent) and two branches (24 percent). CONCLUSIONS: In 65.79 percent of the anatomical pieces studied, the veins of the pancreatic tail flowed in segmentary branches of the splenic vein. These branches could be responsible for the loss of distal splenorenal shunt selectivity. The complete disconnection of the pancreatic tail could increase the selectivity in this procedure.

OBJETIVO: Identificar as veias da cauda do pâncreas afluentes da veia lienal e a possível relação destes ramos com a perda de seletividade da derivação esplenorrenal distal. MÉTODOS: Foram estudadas 38 peças humanas, retiradas de cadáveres, contendo estômago, duodeno, baço, cólon e pâncreas, utilizando-se a técnica de repleção vascular com resina vinílica e posterior corrosão do tecido orgânico com o objetivo de se estudar o molde vascular da veia lienal e seus afluentes. RESULTADOS: O número de veias afluindo diretamente para a veia esplênica variou de sete a vinte dois (MA 14.52±3.53). Ramos pancreáticos da cauda do pâncreas afluindo para as veias segmentares do baço estavam presentes em 25 das peças estudadas (65,79 por cento). Estes ramos variaram de um a quatro, predominando um ramo (60 por cento) e dois ramos (24 por cento). CONCLUSÕES: Em 65,79 por cento das peças veias da cauda do pâncreas desembocavam em ramos segmentares da veia esplênica. Estes ramos poderiam ser responsáveis pela perda de seletividade da derivação esplenorrenal distal e a esqueletização completa da cauda do pâncreas poderia aumentar a seletividade neste procedimento.

Beneficial effects of n-acetyl cysteine on pancreas and kidney following experimental pancreatic ischemia-reperfusion in rats

OBJECTIVE: To evaluate the protective effects of N-acetyl cysteine on the pancreas and kidney after pancreatic ischemia reperfusion injury in a rat model. METHODS AND MATERIALS: Pancreatic ischemia reperfusion was performed in Wistar rats for 1 hour. Revascularization was achieved followed by 4 h of reperfusion. A total of 24 animals were divided into four groups: Group 1: sham; Group 2: pancreatic ischemia reperfusion without treatment; Group 3: pancreatic ischemia reperfusion plus N-acetyl cysteine intravenously; and Group 4: pancreatic ischemia reperfusion plus N-acetyl cysteine per os. Blood and tissue samples were collected after reperfusion. RESULTS: There were significant differences in amylase levels between Group 1 (6.11±0.55) and Group 2 (10.30±0.50) [p=0.0002] as well as between Group 2 (10.30±0.50) and Group 4 (7.82±0.38) [p=0.003]; creatinine levels between Group 1 (0.52 ± 0.07) and Group 2 (0.77±0.18) [p=0.035] as well as between Group 2 (0.77±0.18) and Group 3 (0.48±0.13) [p=0.012]; and pancreatic tissue thiobarbituric acid reactive substance levels between Group 1 (1.27±0.96) and Group 2 (2.60±3.01) [p=0.026] as well as between Group 2 (2.60±3.01) and Group 4 (0.52±0.56) [p=0.002]. A decrease in pancreatic tissue GST-á3 gene expression was observed in Group 2 in comparison to Group 1 (p =0.006), and an increase was observed in Groups 3 and 4 when compared to Group 2 (p= 0.025 and p=0.010, respectively). CONCLUSION: This study provides evidence that N-acetyl cysteine has a beneficial effect on pancreatic ischemia reperfusion injury and renal function in a rat model.

unusual cause of gastric outlet obstruction: a pancreaticoduodenal artery aneurysm

We present a rare case of gastric outlet obstruction due to compression of the duodenum by a pancreaticoduodenal artery [PDA] aneurysm 2.5 cm in diameter, in a 43-year-old man from Saudi Arabia who presented with persistent vomiting and epigastric pain. The initial investigations and blood works were negative, and esophagogastroduodenoscopy [EGD] was unremarkable. A CT abdomen demonstrated a mass around the duodenum and dilatation of the stomach, and CT angiography showed the PDA aneurysm. The patient was stabilized and then referred to a tertiary center for embolization. Our case demonstrates a diagnostic challenge that physicians may encounter in patients who present with vomiting and epigastric pain

Transplante de pâncreas e ilhotas em portadores de diabetes melito: [revisão] / Pancreas and islet transplantation in patients with diabetes mellitus: [review]

O transplante simultâneo de pâncreas/rim tem indicações específicas, riscos e benefícios. O procedimento, cada vez mais realizado, traz vantagens se comparado ao paciente em diálise, em relação à qualidade de vida, anos de vida ganhos e evolução das complicações crônicas. Se o paciente tiver a opção de realizar o transplante de rim com doador vivo, que apresenta sobrevida semelhante do enxerto e do paciente aos dez anos, o procedimento deverá ser considerado. O transplante de pâncreas após rim, quando efetivo, pode melhorar a evolução das complicações cardiovasculares, mas em contrapartida provoca maior mortalidade nos primeiros meses após a cirurgia. O transplante isolado de pâncreas também ocasiona a maior mortalidade pós-operatória, resultado da complexidade do procedimento e da imunossupressão. O transplante de ilhotas tem sua indicação para um seleto grupo de diabéticos com instabilidade glicêmica.

Pancreas and kidney transplants have specific indications, benefits and risks. The procedure has become more common and more often as long-term success has improved and risks have decreased. Compared with a patient being on dialysis, simultaneous pancreas-kidney transplant offers a distinct advantage when it comes to mortality, quality of life and diabetic complications. Since there can be a living-donor kidney transplant,, a possibly similar patient and graft survival by 10 years follow-up, this procedure should be considered. Pancreas after kidney transplants, when successful, can improve microvascular complications compared with kidney transplant alone, but immediate mortality may be higher. Solitary pancreas transplantation can improve the quality of life in selected patients, but it may also increase the immediate risk of mortality due to the complexity of the surgery and the risks of immunosupression. The results of Islet transplantation differ from the higher metabolic performance achieved by whole pancreas allotransplantation and its applicability is limited to selected adult diabetic patients.

Malformación arteriovenosa del páncreas: caso clínico / Pancreatic arteriovenous malformation: Report of one case

Las malformaciones arteriovenosas del páncreas (MAVP) son poco frecuentes y generalmente asintomáticas, por lo que existen escasos reportes en la literatura. Se pueden complicar con sangrado, dolor o hipertensión portal. El diagnóstico preciso se logra con la angiografía, que también puede ser usada como terapia inicial. El tratamiento definitivo es la cirugía. Se presenta el caso de un hombre de 35 años que consultó por dolor epigástrico intenso con escasa respuesta a analgésicos. El estudio con tomografía computada, resonancia y angiografía de abdomen mostró una MAVP. Se le realizó una pancreatoduodenectomía con desaparición de los síntomas en forma completa.

Pancreatic arteriovenous malformations are uncommon and generally asymptomatic. Their complications can be bleeding, pain or portal hypertension. Angiography gives the definitive diagnosis and also can be used as the initial treatment. Surgery is the definitive treatment. We report a 35 years old with epigastric pain. Abdominal CAT scan, magnetic resonance and angiography showed a pancreatic arteriovenous malformation. He was subjected to a pancreatoduodenectomy with complete resolution of symptoms.

Hemobilia from Pancreatic Arteriovenous Malformation: Successful Treatment with Transportal Coil Embolization of Draining Veins / 대한소화기학회지

Pancreatic arteriovenous malformations (AVM) are extremely rare diseases frequently complicated by gastrointestinal hemorrhage. While surgical resection of affected lesion is preferred for the treatment of pancreatic AVM, angiographic intervention can be used as an alternative treatment, especially in surgically high-risk patients. We experienced a patient with pancreatic AVM manifested by hemobilia and biliary sepsis. Superior mesenteric and common hepatic arteriography showed pancreaticoduodenal AVM composed of nidus supplied by numerous fine feeding arteries and of draining veins encircling the common bile duct (CBD). Hemobilia was controlled by transportal coil embolization of draining veins of AVM around the CBD. Herein, we report this case with the review of literatures.

Pancreatic capillary blood flow during caerulein-induced pancreatitis evaluated by a laser-doppler flowmeter in rats

Purpose: The pancreatic capillary blood flow (PCBF) was studied to determine its alterations during caerulein-induced pancreatitis in rats. Methods: Twenty rats were divided in groups: control and caerulein. A laser-Doppler flowmeter to measure PCBF continuously was used. Blood pressure (BP) and heart rate (HR) were monitored. Serum biochemistry analyses were determined. Histopathological study was performed. Results: The PCBF measured a mean of 109.08 ± 14.54 percent and 68.24 ± 10.47 percent in control group and caerulein group, respectively. Caerulein group had a mean decrease of 31.75 ± 16.79 percent. The serum amylase was 1323.70 ± 239.l0U.I-1 and 2184.60 ± 700.46U.I-1 in control and caerulein groups, respectively. There was a significant difference in the PCBF (p<0.05) and serum amylase (p<0.05) when compared to control and caerulein groups. Although micro and microvacuolization were seen in 30 percent in caerulein group, no significant difference was seen between the groups. Conclusion: A decrease in the PCBF may be one of the leading events and it is present before histopathological tissue injury had been established in this model of acute pancreatitis.

Reactive oxygen species inactivation improves pancreatic capillary blood flow in caerulein-induced pancreatitis in rats

Purpose: Reactive oxygen species (ROS) inactivation was studied to determine alterations in the pancreatic capillary blood flow (PCBF) during caerulein-induced pancreatitis in rats. Methods: A laser-Doppler flowmeter to measure PCBF and N-t-Butyl-Phenylnitrone (PBN) compound to inactivate ROS were used. Forty rats were divided in groups: 1) control; 2) caerulein; 3) PBN; 4) caerulein+PBN. Serem biochemistry and histopathological analyses were performed. Results: PCBF measured a mean of 109.08 ± 14.54 percent, 68.24 t 10.47 percent, 102.18 ± 10.23 percent and 87.73 ± 18.72 percent in groups 1, 2, 3 and 4, respectively. PCBF in groups 2 and 4 decreased 31.75 ± 16.79 percent and 12.26 ± 15.24 percent, respectively. Serum amylase was 1323.70 ± 239.10 U/l, 2184.60 ± 700.46 U/1, 1379.80 t 265.72 U/1 and 1622.10 ± 314.60 U/1 in groups 1, 2, 3 and 4, respectively. There was a significant difference in the PCBF and serem amylase when compared groups 2 and 4. Cytoplasmatic vacuolation was present in groups 2 and 4. Otherwise, no qualitative changes were seen. Conclusion: ROS inactivation improves PCBF and minimizes the serem amylase increase during caerulein-induced pancreatitis. ROS effect may be one of the leading causative events in this model of acute pancreatitis.

A Case of Multiple Bleeding Pseudoaneurysms Complicating Acute Pancreatitis / 대한소화기학회지

Arterial pseudoaneurysm is rare but potentially a catastrophic complication of pancreatitis because it can cause massive gastrointestinal bleeding. Since surgical treatment of arterial pseudoaneurysm has a high mortality, percutaneous angiographic embolization of bleeding artery has recently been advocated as the alternative therapy. Acute hemorrhage into the peritoneal cavity or pseudocyst complicating chronic pancreatitis was frequently reported. However, multiple pseudoaneurysmal hemorrhage without pseudocyst complicating acute pancreatitis are extremely rare. Here, we present a case of multiple pseudoaneurysmal hemorrhage secondary to acute pancreatitis, which were managed successfully by percutaneous angiographic embolization.

Tomografía computada helicoidal bifásica del páncreas: estudio cuantitativo del realce del páncreas y vasos peripancreáticos / Bifasic helical computed tomography of the pancreas

La Tomografía computada helicoidal (TCH) es actualmente el principal método de diagnóstico de las enfermedades pancreáticas. Para el cáncer de páncreas, han sido recomendados protocolos bifásicos con adquisición de imágenes durante las fases arterias y venosa luego de la inyección del contraste. En este estudio se evaluaron 45 pacientes en quienes se practicó una TCH bifásica del páncreas: adquisición durante la Fase Arterial (FA) en 20-40 s durante la Fase Venosa Portal (FVP) en 60-80 s luego del inicio de la inyección del contraste (140 ml a 3 ml por s. Se analizó cuantitativamente el realce del páncreas, de arterias y venas peripancreáticas). El realce pancreático y el venoso fueron significativamente superiores en la FVP. El realce arterial fue significativamente superior en la FA pero satisfactorio durante la FVP. En conclusión, con nuestra técnica de inyección de contraste la adquisición de imágenes durante la fase arterial es innecesaria