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Laparoscopic distal pancreatectomy for pancreatic arteriovenous malformation complicated with portal hypertension


1 Gastroenterological Surgery, Spporo Kyoritsu Gorinbashi Hospital; Department of Gastroenterological Surgery II, Faculty of Medicine, Hokkaido University, Sapporo, Japan
2 Department of Gastroenterological Surgery II, Faculty of Medicine, Hokkaido University; Division of Minimally Invasive Surgery, Hokkaido University Hospital, Sapporo, Japan
3 Gastroenterological Surgery, Spporo Kyoritsu Gorinbashi Hospital, Sapporo, Japan
4 Gastroenterology, Spporo Kyoritsu Gorinbashi Hospital, Sapporo, Japan
5 Department of Gastroenterological Surgery II, Faculty of Medicine, Hokkaido University, Sapporo, Japan

Date of Submission28-Aug-2020
Date of Decision19-Oct-2020
Date of Acceptance29-Oct-2020
Date of Web Publication30-Mar-2021

Correspondence Address:
Takehiro Abiko,
Sapporo Kyoritsu Gorinbashi Hospital, 1-Chome, Kawazoe 1-Jo, Minami-Ku, Sapporo, 0050802 Hokkaido
Japan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmas.JMAS_193_20

  Abstract 

Pancreatic arteriovenous malformation (PAVM) is defined as a vascular anomaly with an abnormal anastomosis of the arterial and portal networks within the pancreas. Treatment modalities of PAVM include transarterial embolisation (TAE), irradiation and operation. Most patients treated with TAE alone will experience recurrence, so surgery is the best radical treatment. A female patient was admitted to our institution for the treatment of haematemesis. Examination revealed varices in the oesophagus and stomach, collateral circulation development caused by portal hypertension and PAVM of the pancreas. Surgical treatment was intended to reduce left portal hypertension. In this case, collateral circulation were considered dangerous points for unexpected bleeding. TAE was performed on the splenic artery before surgery to reduce blood flow in the areas with collateral circulation. En bloc resection of retroperitoneal tissue using the surgical procedure of radical antegrade modular pancreatosplenectomy was effective to minimise blood loss.


Keywords: Laparoscopic distal pancreatectomy, pancreatic arteriovenous malformation, portal hypertension, pre-operative transarterial embolisation, radical antegrade modular pancreatosplenectomy



How to cite this URL:
Abiko T, Ebihara Y, Takeuchi M, Sakamoto H, Takahashi M, Homma H, Hirano S. Laparoscopic distal pancreatectomy for pancreatic arteriovenous malformation complicated with portal hypertension. J Min Access Surg [Epub ahead of print] [cited 2021 Apr 20]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=312754



  Introduction Top


Pancreatic arteriovenous malformation (PAVM), first reported by Halpern et al.,[1] is defined as a vascular anomaly in the pancreas. Treatment modalities of PAVM include transarterial embolisation (TAE), irradiation and operation.

Intraoperative bleeding is the cause of difficulty in securing a dry field during laparoscopic surgery. Rezende et al. reported pre-operative TAE for patients with arteriovenous malformation (AVM) to help reduce the incidence of intraoperative bleeding.[2] Therefore, in this case, TAE was performed to the splenic artery. Radical antegrade modular pancreatosplenectomy (RAMPS) was valid for the resection of collateral circulation around the left renal vein, the Gerota fascia and the left adrenal gland.[3]


  Case Report Top


A female patient in her 50s was transferred and admitted to our institution for the treatment of haematemesis. An upper gastrointestinal endoscopy revealed varices in her oesophagus and oozing from the gastric mucosa. Endoscopic haemostasis was performed. Contrast computed tomography was performed to find the cause of the varices, which revealed cirrhosis, AVM of the pancreas and collateral circulation development caused by portal hypertension [Figure 1]. Liver function test revealed the following: ICG15R was 41% and Child–Pugh Score was B. A liver biopsy was performed and the cause of cirrhosis was primary biliary cholangitis.
Figure 1: Contrast computed tomography showing pancreatic arteriovenous malformation in the area of the pancreatic body ([a] about 25 mm in size) and tail ([b] about 35 mm in size) and also showing collateral circulation (c and d). Transarterial embolisation was performed to the splenic artery (e)

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Surgical treatment was planned to reduce left portal hypertension. Laparoscopic surgery was considered to reduce the invasiveness. It was suspected that bleeding from the collateral circulation development caused by portal hypertension would have deteriorated the visual field. Therefore, TAE was performed on the splenic artery before surgery to reduce blood flow to the collateral circulation [Figure 1]. Laparoscopic distal pancreatectomy was performed. The shunt vessels flowing into the left renal vein were processed, at first. The left adrenal gland and the Gerota fascia were also resected all at once to completely and safely resect the collateral circulation of the retroperitoneum [Figure 2]. The operation was completed laparoscopically. The operative time was 246 min and the amount of blood loss was 230 ml. The patient had an uneventful post-operative course and was discharged on the 22nd post-operative day. Thirteen months after the surgery, gastrointestinal bleeding had not recurred.
Figure 2: (a) The shunt vessels flowing into the left renal vein were processed, at first. (b) The Gerota fascia was peeled from the left kidney. (c) Complete and safe resection of the collateral circulation of the retroperitoneum

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  Discussion Top


A literature review, including 89 cases reported by Chou et al., revealed the characteristic of PAVM. In total, 76 patients (85.4%) were male and 13 (14.6%) were female. The median age was 50 years. Furthermore, Chou et al. reported that the most commonly associated complications of PAVM were bleeding (50.6%), pancreatitis (16.9%) and portal hypertension (6.7%).[4] The most common presenting symptom was gastrointestinal bleeding (47.2%), followed by epigastric pain (46.1%).[4] Although the patient was a female, her age, symptoms and clinical course were typical.

The treatments of PAVM include TAE, irradiation and operation. Recurrent bleeding after TAE alone has been reported;[5] therefore, surgery is a radical treatment. Chou et al. had reported that the most common treatment for PAVM was surgery (53.9%), including a combination of surgery and TAE (10.1%).[4] In this case, laparoscopic surgery was chosen to reduce the invasiveness for the patient. During laparoscopic surgery, it was suspected that bleeding from the collateral circulation would have particularly obstructed the visual field. To safely perform laparoscopic distal pancreatectomy, pre-operative TAE and en bloc resection of retroperitoneal tissue were considered.

Rezende et al. reported that pre-operative TAE reduced the incidence of intraoperative bleeding and improved the surgical outcomes.[2] In addition, recurrent bleeding was reported in up to 37% of patients who were waiting for surgery after successful TAE.[4] Therefore, TAE was performed on the splenic artery the day before surgery.

RAMPS is a surgical procedure for locally advanced cancer within the pancreatic body to permit the adjustment of the depth of the posterior extent of resection. RAMPS is an extended distal pancreatectomy including en bloc resection of the retroperitoneal organ.[3] In this case, the collateral circulation around the left renal vein, the Gerota fascia and the left adrenal could have caused the unexpected bleeding. Using the surgical procedure of RAMPS, that is en bloc resection of retroperitoneal tissue including the collateral circulation, was found effective in minimising blood loss.


  Conclusion Top


Reducing collateral blood flow by pre-operative TAE, and suppressing bleeding via en bloc resection of retroperitoneal tissue by applying RAMPS, has been found useful for safe laparoscopic surgery.

Acknowledgement

The authors declare that they have no competing interests relevant to this article. We would like to thank Editage (www.editage.jp) for English language editing.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Halpern M, Turner AF, Citron BP. Hereditary hemorrhagic telangiectasia. An angiographic study of abdominal visceral angiodysplasias associated with gastrointestinal hemorrhage. Radiology 1968;90:1143-9.  Back to cited text no. 1
    
2.
Rezende MB, Bramhall S, Hayes T, Olliff S, Buckels JA, Candinas D, et al. Pancreatic arteriovenous malformation. Dig Surg 2003;20:65-9.  Back to cited text no. 2
    
3.
Strasberg SM, Drebin JA, Linehan D. Radical antegrade modular pancreatosplenectomy. Surgery 2003;133:521-7.  Back to cited text no. 3
    
4.
Chou SC, Shyr YM, Wang SE. Pancreatic arteriovenous malformation. J Gastrointest Surg 2013;17:1240-6.  Back to cited text no. 4
    
5.
Katoh H, Tanabe T. Congenital arteriovenous malformation of the pancreas with jaundice and a duodenal ulcer: Report of a case. Surg Today 1993;23:1108-12.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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2004 Journal of Minimal Access Surgery
Published by Wolters Kluwer - Medknow
Online since 15th August '04