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Acute upper digestive tract hemorrhage most often arises from gastric and esophageal vessels located in the mucosa or the submucosa. Rupture in the upper gastrointestinal tract is a classical but uncommon complication of arterial (mainly the abdominal aorta) aneurysms. Splenic artery aneurysm usually ruptures in the peritoneum, unless it is associa...
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Central pancreatectomy (CP) is a well-described procedure done for neck and proximal body tumors of the pancreas. It can be done for benign lesions where an adequate length of normal distal pancreas will be left leading to organ preservation. The currently described benefit of the procedure is decreased long-term morbidity due to retention of both...
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... Splenic artery pseudoaneurysm rupture is another potentially fatal complication, generally associated more with pancreatitis than PDAC. Splenic artery pseudoaneurysm rupture due to PDAC is rare, with only six case reports to date, when excluding iatrogenic and post-surgical cases [32][33][34][35][36][37]. Three were pancreatic body cancers and three were PTCs, of which two had SHI, while all cases were treated successfully with transcatheter arterial embolization (TAE). ...
Background:
Pancreatic tail cancer (PTC) frequently displays splenic hilar involvement (SHI), but its impact on clinical outcomes remains unclear. We investigated the clinical impact of SHI in patients with unresectable PTC.
Methods:
We retrospectively reviewed all patients with unresectable PTC who received first-line therapy at our institution from 2016 to 2020.
Results:
Of the 111 included patients, 48 had SHI at diagnosis. SHI was significantly associated with younger age, liver metastasis, peritoneal dissemination, larger tumor size, modified Glasgow prognostic score of 1 or more, splenic artery involvement, gastric varices, and splenomegaly. Shorter median overall survival (OS; 9.3 vs. 11.6 months, p = 0.003) and progression-free survival (PFS; 4.3 vs. 6.3 months, p = 0.013) were observed in SHI patients. Poor performance status of 1 or 2, tumor size > 50 mm, hepatic metastasis, mGPS of 1 or 2, and SHI (hazard ratio: 1.65, 95% confidence interval: 1.08-2.52, p = 0.020) were independent predictors of shorter OS. Splenic artery pseudoaneurysm rupture and variceal rupture were rare and only observed in cases with SHI.
Conclusions:
Splenic hilar involvement is associated with worse outcomes in pancreatic tail cancer.
... Only three case reports in the available literature have described a splenic artery aneurysm associated with pancreatic cancer [8][9][10]. Interestingly, a splenic artery aneurysm and pancreatic cancer were synchronously diagnosed in two of the three cases, although it is unclear whether the splenic artery aneurysm developed before or after the pancreatic cancer [8,9]. ...
... Only three case reports in the available literature have described a splenic artery aneurysm associated with pancreatic cancer [8][9][10]. Interestingly, a splenic artery aneurysm and pancreatic cancer were synchronously diagnosed in two of the three cases, although it is unclear whether the splenic artery aneurysm developed before or after the pancreatic cancer [8,9]. In the third case, the pseudoaneurysm developed secondary to a pancreatic pseudocyst and obstructive pancreatitis associated with pancreatic cancer [10]. ...
A 48-year-old man presented with epigastralgia and back pain. Radiological evaluation revealed a pancreatic tail tumor with contrast enhancement and an intratumoral fluid component involving the splenic artery and invading the left kidney. Endoscopic ultrasound-guided fine-needle aspiration biopsy revealed an adenocarcinoma, and based on invasion of the left kidney, the patient was diagnosed with unresectable pancreatic cancer with suspected peritoneal dissemination. Radiological evaluation performed after the administration of eight courses of gemcitabine combined with nab-paclitaxel revealed stable disease without distant metastases or peritoneal dissemination. We planned to perform radical resection; however, the patient developed a pseudoaneurysm of the splenic artery preoperatively and initially underwent preoperative coil embolization, followed by radical resection (distal pancreatectomy with combined left nephrectomy and partial resection of the colon and stomach), 11 days after embolization. Histopathological examination of the resected specimen confirmed R0 resection, and the splenic artery pseudoaneurysm associated with pancreatic cancer was attributed to tumor invasion of this vessel. He showed satisfactory postoperative recovery and was discharged on the 24th day after surgery with administration of S-1 adjuvant chemotherapy.
Background:
Ruptured splenic artery aneurysms (r-SAA), although rare, are burdened by high morbidity and mortality, even despite emergent surgical repair. It is suggested that endovascular treatment can achieve reduction in peri-operative death and complication rates, as in other vascular diseases, but evidence of such benefits is still lacking in this particular setting. We report a case of an r-SAA treated by trans-arterial embolization and then converted to open surgery for persistent bleeding, and we provide a systematic review of current results of open and endovascular repair of r-SAAs.
Materials and methods:
A 50-year-old male presenting in shock for a giant r-SAA underwent emergent coil embolization and recovered hemodynamic stability. On the following day, he underwent laparotomy for evacuation of the huge intraperitoneal hematoma, but residual bleeding was noted from the splenic artery, which was ligated after coil removal, and a splenectomy was performed. A systematic literature review of the reported mortality and complications of r-SAA undergoing open (OSR) or endovascular (EVT) treatment was performed using the main search databases. All primary examples of research published since 1990 were included regardless of sample size. The main outcome measures were mortality and reinterventions. Secondary outcomes were post-operative complications.
Results:
We selected 129 studies reporting on 350 patients-185 treated with OSR and 165 with EVT. Hemodynamically unstable patients and ruptures during pregnancy were more frequently treated with open repair. Overall, there were 37 deaths (mortality: 10.6%)-24 in the OSR group and 13 in the EVTr group (mortality: 12.9% and 7.8% respectively, p-value: 0.84). There were 37 reinterventions after failed or complicated endovascular repair -6 treated with endovascular re-embolization and 31 with laparotomy and splenectomy (22.4%); there were 3 (1.6%) reinterventions after open repair. Overall complication rates were 7.3% in the EVT group (n: 12) and 4.2% in the OSR group (n: 7), and did not require reintervention. No significant differences in overall complications or in any specific complication rate were observed between the two groups.
Conclusions:
Current results of r-SAA treatment show equipoise terms of morbidity and mortality between open and endovascular repair; however, in case of hemodynamic instability and rupture during pregnancy, open surgery might still be safer. Moreover, endovascular repair is still burdened by a significantly higher rate of reinterventions, mostly with conversions to open surgery.
Background:
Splenic artery aneurysm (SAA) and pseudoaneurysm are rare vessel's lesions. Pseudoaneurysm is often symptomatic and secondary to pancreatitis or trauma. True SAA is the most common aneurysm of visceral vessels. In contrast to pseudoaneurysm, SAA is usually asymptomatic until the rupture, with high mortality rate. The clinical onset of SSA's rupture is a massive life-threatening bleeding with hemodynamic instability, usually into the free peritoneal space and more rarely into the gastrointestinal tract.
Case summary:
We describe the case of a 35-year-old male patient, with negative past medical history, who presented to the emergency department for massive upper gastrointestinal bleeding, severe anemia and hypotension. An esophagogastroduodenoscopy performed in emergency showed a gastric bulging in the greater curvature/posterior wall with a small erosion on its surface, with a visible vessel, but no active bleeding. Endoscopic injection therapy with cyanoacrylate glue was performed. Urgent contrast-enhanced computed tomography was carried out due to the clinical scenario and the unclear endoscopic aspect: The radiological examination showed a giant SAA which was adherent to posterior stomach wall, and some smaller aneurysms of the left gastric and ileocolic artery. Because of the high risk of a two-stage rupture of the giant SAA with dramatic outcome, the patient underwent immediate open surgery with aneurysmectomy, splenectomy and distal pancreatectomy with a good postoperative outcome.
Conclusion:
The management of a ruptured giant SAA into the stomach can be successful with surgical approach.
