Spleno-pancreatectomy En Bloc with Parcelar Gastrectomy for Splenic Artery Aneurysm – A Case Report and Literature Review

Discussion

Splenic artery aneurysms usually develop at the level of the main splenic artery trunk, before its bifurcation; in up to 75% of cases they are located in the distal third of the arterial trunk followed by the middle third of the artery (in up to 20% of cases) (7, 8). These vascular malformations rarely exceed 3 cm in diameter and are associated with other visceral aneurysms in up to 14% of cases (9). Depending on their structure, splenic artery aneurysms might be true lesions (if all the three layers of the arterial wall are affected) or pseudoaneurysms (if one or more vessel's layer lack) (10). Regarding the etiology, the most commonly incriminated causes for the development of a true splenic artery aneurysm include arterial or portal hypertension, cirrhosis, liver transplantation or pregnancy (9, 11). In the meantime, in cases developing pseudoaneurysmal dilatation of the splenic artery the most commonly incriminated pathogenic factor is represented by chronic pancreatitis; in such cases it is believed that the pancreatic enzymes released at the moment of each episode of pancreatitis will induce the fragmentation of the elastic layer of the vessel inducing in this way a pseudoaneurysmal dilatation (12).

Although the majority of patients with this pathology remain asymptomatic for a long period of time, the aneurysm being incidentally discovered during routine abdominal imaging, epigastric pain, anorexia or vomiting might be reported (10). A dramatic scenario in such cases is represented by the aneurysmal rupture, where at that moment the patient presents sharp abdominal pain and hemodynamic shock (13, 14). In such situations mortality rate reaches 25% of cases; therefore, it is strongly recommended that a therapeutic gesture is performed whenever a large splenic artery aneurysm is detected. Trastek et al. recommend that all aneurysms larger than 2 cm as well as those in which an increase during a follow-up period is reported to be treated; moreover, pregnant women or those who plan to become pregnant and who are diagnosed with an asymptomatic splenic artery aneurysm should be also submitted to a therapeutic maneuver regarding this vascular malformation (15).

Therapeutic options in such cases include a large variety of strategies including standard surgery (consisting of resection) or endovascular surgical procedures (such as percutaneous stent placement or percutaneous aneurysmal embolization). Although percutaneous maneuvers intend to be less invasive and assure a good preservation of the spleen, a significant rate of splenic infarcts or impaired splenic function has been reported (16). Percutaneous embolization of the splenic artery aneurysms was initially described by Probst et al. in 1978 and has been widely performed in asymptomatic patients presenting splenic artery aneurysms (excluding those in which the lesion is located in the splenic hylum) (17). However, this therapeutic strategy remains the option of choice in patients presenting high risk for a classic surgical approach, an important number of cases developing complications (such as coil migration, infarction, splenic abscess, aneurysmal recanalization or even aneurysmal rupture) (18); moreover, embolization might fail in cases presenting tortuous splenic arteries (10). Endovascular stent placement might be also tempted; however, the method has the same limitations as the embolization, size, localization and tortuosity of the splenic artery being sometimes responsible for the failure of this method (10). However, this method has a lower risk of splenic infarction (10).

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Figure 1.

Computed tomography (coronal view) revealing the presence of a splenic artery aneurysmal dilatation in close contact with the posterior gastric wall.

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Figure 2.

Computed tomography (axial view) revealing the presence of a splenic artery aneurysmal dilatation embedded by the pancreatic body and tail.

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Figure 3.

The final intraoperative aspect after removing the splenic artery aneurysm en bloc with distal pancreatectomy, splenectomy and parcelar gastrectomy. Forceps pointing the splenic artery stump.

In cases in which percutaneous endovascular techniques fail or cannot be applied, classic surgery remains the option of choice. The strong development of the vascular surgery techniques in patients presenting splanchnic arteries' malformations played a central role as part of the management of patients presenting visceral aneurysms (19-21). Moreover, surgical intervention is considered as the conventional treatment in most centers especially in patients presenting large symptomatic lesions (22). This is the explanation why surgery was proposed as the first intention treatment in our case (large aneurysm in a symptomatic patient).

In a large study conducted by the surgeons from Ohio regarding the therapeutic strategies in patients diagnosed with splenic artery aneurysms, 128 such cases were introduced (23). Among these cases open surgery was needed in 13 cases and consisted of aneurysmal resection or resection en bloc with splenectomy (in seven cases), aneurysmal ligation (in four cases) and arterial reconstruction (in two cases). Moreover, seven of the 13 cases were submitted to surgery for ruptured aneurysms, two of them dying due to the hemorrhagic shock. Other reported complications among surgically treated patients included postoperative bleeding requiring reoperation (in two cases), wound infection (in one case) and a pancreatic fistula (in one case). However, the postoperative length of hospital-stay was significantly longer among patients treated surgically when compared to those treated by an endovascular technique. This fact can be explained by the larger complexity of the cases treated by open surgery (23).

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Figure 4.

The specimen of splenic artery aneurysm en bloc with distal pancreatectomy, splenectomy and parcelar gastrectomy. On section the presence of intra-aneurysmal blood cloths can be observed.

A similar case to the one presented in the current article was the one reported by Yadav and co. in the International Journal of Surgery Case Reports in 2012 (24). The authors reported the case of a 58-year-old female who presented for the apparition of a pulsatile mass in the left upper abdomen which proved to be a 10.6/10.38 cm splenic artery aneurysm arising from the distal segment, while the pancreas presented no pathological aspect. The patient was submitted to open surgery, the aneurysm being removed en bloc with distal pancreatectomy and splenectomy. The macroscopic analysis of the specimen revealed the presence of a 12.7/11.8 cm aneurysm with clotted blood inside, while the histopathological studies confirmed that it was a true arterial aneurysm, all the three layers being revealed (24).

When it comes to the necessity of associating a pancreatic resection, it seems that this gesture is almost always imposed when the aneurysmal dilatation is embedded within the pancreatic parenchyma (25), as in our case. Once the decision of performing a concomitant pancreatic resection is made, the surgeon should be aware of the significantly increased risk of developing acute postoperative complications such as pancreatic fistulas or long-term complications such as diabetes mellitus (26). However, due to improvements in the surgical technique and postoperative management of cases necessitating pancreatic resections, the perioperative morbidity rate significantly decreased in the last decades conducting to the safe association of pancreatic resections for various pathological processes involving these viscera (26, 27, 28).