Multiple episodes of postpancreatectomy hemorrhage resolved by endoscopy and ultrasound-guided percutaneous thrombin injection into a common hepatic artery aneurysm: a case report

Postpancreatectomy hemorrhage (PPH) is one of the most common complications after pancreatoduodenectomy (PD). It mainly includes gastrointestinal hemorrhage and abdominal hemorrhage. With the development of digestive endoscopy and ultrasonic/radiological interventional technology, hemostasis can be effectively performed by minimally invasive methods in many patients with PPH. This report describes the successful treatment of multiple episodes of postoperative hemorrhage after PD. The patient developed anastomotic hemorrhage after PD and was successfully treated by endoscopic hemostasis. However, he also developed intra-abdominal hemorrhage after PD caused by a pseudoaneurysm that had formed next to the common hepatic artery. We effectively performed hemostasis by injecting lyophilized thrombin powder into the pseudoaneurysm with ultrasound guidance, which is a rarely used method. This case indicates that digestive endoscopy provides great advantages in the treatment of gastrointestinal hemorrhage after PD. For patients who develop PPH with a pseudoaneurysm, interventional ultrasonography is an option if transcatheter arterial embolization or covered stenting fails.

Congenital Visceral Vascular Variation Causing Gastrointestinal Hemorrhage: A Case Report

Variations in the visceral vasculature are often encountered, but rarely cause clinical symptoms. We report a 12-year-old girl with portal hypertension caused by congenital variations in visceral vessels. The clinical manifestations included gastrointestinal hemorrhage and ascites. The common hepatic artery and splenic artery stem shared the same trunk from the aorta, and the common hepatic artery was directly connected with the main portal vein to form an arteriovenous fistula. In addition, the left hepatic artery and the left gastric artery shared a common trunk termed the “hepatic-gastric trunk” which originated from the anterior wall of the aorta, while the right hepatic artery originated from the superior mesenteric artery and supplied the right liver. The patient was treated with interventional embolization and remained in good condition throughout the follow-up and at the time of publication.

Abdominal hemodynamics in patients with visceroptosis

Background Abdominal circulation plays the important physiological role for structure and function of the digestive system, maintenance of nutrient homeostasis. Purpose To study the features of abdominal hemodynamics in patients with visceroptosis. Methods We studied 69 patients (mean age 22.28±3.7 years) with splanchnoptosis (visceroptosis) and 52 age- and sex- matched patients without splanchnoptosis (controls). Exclusion criteria: a history of digestive system surgery of taking blood circulation activating drugs. Doppler ultrasonography of the common hepatic artery, splenic artery, superior mesenteric artery, portal vein was performed on an empty stomach and 30 minutes after a food sample (standardized for proteins (14 g), fats (10 g) and carbohydrates (45 g)) using the Sonoace-8000 ultrasound scanner (Medison, South Korea). The data were analyzed using the Statistica-6 packages. Results There were no differences in hemodynamic parameters of fasting abdominal blood flow (ABF). After a food testing, in the postprandial period the ABF in all vessels in patients with splanchnoptosis was lower than in controls: the portal vein blood flow (BF) 1124,0 [1030,0–1419,0] ml/min vs 1373,0 [1136,0–1567,5] ml/min respectively (U=433,5; Z=−2,1; p=0,0342); the common hepatic artery BF 341,0 [295,0–394,0] ml/min vs 412,0 [331,0–521,0] ml/min respectively (U=335,0; Z=−2,3; p=0,0218); the splenic artery BF 396,0 [292,0–538,0] ml/min vs 502,0 [394,0–594,0] ml/min respectively (U=328,0; Z=−2,1; p=0,0399); the superior mesenteric artery BF 988,0 [837,0–1272,0] ml/min vs 1136,5 [992,0–1465,0] ml/min respectively (U=1625,5; Z=−2,2; p=0,0314). Changes in ABF were correlated with splanchnoptosis: the portal vein BF with any ptosis (rs=−0,21; p<0.05), the common hepatic artery BF with gastroptosis (rs=−0,38; p<0.05), the superior mesenteric artery BF with colonoptosis (rs=−0,86; p<0.05). The peripheral vascular resistance was correlated with the common hepatic artery BF (rs=−0,46; p<0.05), with the splenic artery BF (rs=−0,33; p<0.05) and with the superior mesenteric artery BF (rs=−0.79; p<0.05). Conclusions Patients with splanchnoptosis in the postprandial period have low volumetric BF in abdominal aorta vessels. This can be associated with the length of the mesenteric vessels, which undergoes the greatest changes in splanchnoptosis. Food testing reveals latent BF deficit in patients with splanchnoptosis. FUNDunding Acknowledgement Type of funding sources: None.

The Impact of Hepatic Arterial Variations and Reconstructions on Arterial Complications in Liver Transplantation

Background: The purposes of the study were to determine the variations in hepatic arterial supply, to delineate the optimal methods of arterial anastomoses and reconstructions in liver transplantation and to analyse the incidence of arterial complications. Methods: The surgical anatomy of the extrahepatic arterial vascularization was investigated retrospectively in 209 donors and patients who underwent liver transplantation at Fundeni Clinical Institute (Bucharest, Romania) from January 1, 2015 to December 31, 2017. The vascular anatomy of the hepatic grafts was classified according to Michels’ description and other rare variations. Results: Anatomical variants of the classical pattern were detected in 26.3% of the livers (n = 55). The most common variant was a replaced right hepatic artery arising from the superior mesenteric artery (n = 17; 8.13%), followed by a common hepatic artery from superior mesenteric artery (n = 6; 2.87%). Arterial reconstructions were reported in 97 cases (45.5%). In recipients, used sites were intermediate: common hepatic artery (CHA) in 73.8% (n = 158), distal: proper hepatic artery (PHA) or common hepatic artery/gastro-duodenal artery bifurcation (CHA/GDA bifurcation) in 16.4% (n = 35) and proximal: coeliac trunk-splenic artery-aorta (CT–SA–A) in 9.3% (n = 20) of patients. Most common reconstructions were short graft artery (CT) on the recipient CHA (n = 33, 34.02%) and long graft artery: complex reconstruction between CT and superior mesenteric artery (SMA) - accessory right hepatic artery (RHA) from SMA on CHA (n = 12, 12.37%) and right hepatic graft artery on PHA or CHA/GDA bifurcation (n = 16, 16.49%). Conclusion: The information about the different hepatic arterial patterns, as well as establishing specific methods for arterial anastomoses and reconstructions is important in the determination of better outcomes.