Resection and reconstruction of pancreatic artery aneurysms
Some patients with the compression of the celiac trunk by the median arcuate ligament (MAL) suffer pancreatic artery aneurysms (PAAs) due to excessive blood flow from the superior mesenteric artery. These aneurysms are in peril because they are prone to rupture irrespective of size.

A 44-year-old man who was first diagnosed to have a visceral artery aneurysm with a diameter of 43 mm was accidentally found by ultrasound examination at a regular medical check-up. He was on anti-hypertensives and lipid-lowering drugs. There was no other remarkable past medical history. Contrast-enhanced CT revealed the compression of the celiac trunk by the MAL and a PAA originating from the first jejunal artery.

First, the patient underwent laparoscopic excision of the MAL in order to release the compression of the celiac trunk. The follow-up angiography revealed that the blood flow of the GDA was retrograde and that the arterial blood to the liver, the stomach, and the spleen were completely supplied by the SMA via the GDA. A stent was placed at the celiac trunk in an attempt to increase the blood flow of the celiac trunk. Coil embolization of the aneurysm was abandoned because of anatomical difficulties. The follow-up CT revealed the gradually growing PAA. The patient was finally willing to undergo resection and reconstruction of the aneurysm which seemed to rupture sooner or later.

The abdomen was entered by an upper midline incision. The aneurysm was located near the ligament of Treitz. The SMA, the IPDA, the J1, the proper hepatic artery (PHA), and the GDA were controlled with tapes. First, the GDA was clamped in order to test whether the hepatofugal flow from the celiac trunk was restored. Although the stent placed in the celiac trunk proved to be patent by the preoperative CT, the attempt was not successful. The retrograde blood flow from the SMA via the GDA proved to be vital to the liver, the stomach, and the spleen. Next, the J1 was clamped in order to test whether this artery could be sacrificed in an attempt to simply reconstruct the arteries by an end-to-end anastomosis. Because the color of the proximal jejunum was darkened after this artery was clamped, this artery could not be sacrificed. The aneurysm was resected just below the IPDA branch of the J1. The flow of the IPDA was restored by an end-to-side anastomosis between the IPDA and the J1, as previously reported. The anastomotic procedure was completely done on the left side of the SMA. The posterior walls were intraluminally sutured by a continuous 7-0 non-absorbable suture and the anterior walls were sutured by an over-and-over continuous 7-0 non-absorbable suture.

The operation time was 308 min. and the intraoperative blood loss was 220 ml. The postoperative course was uneventful and he was discharged from the hospital on postoperative day 7. His blood pressure was strictly controlled by anti-hypertensives. The follow-up CT 2 years and 9 months after the operation revealed no recurrence of aneurysms and the patent anastomosis.

Source:https://surgicalcasereports.springeropen.com/articles/10.1186/s40792-021-01247-y
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