Laparoscopic management of hemosuccus pancreaticus from the left gastric artery pseudoaneurysm secondary to traumatic pancreatitis and open splenectomy

Abstract

Laparoscopic management of hemosuccus pancreaticus from the left gastric artery pseudoaneurysm secondary to traumatic pancreatitis and open splenectomyA 55-year-old male presented with complaints of mild epigastric pain radiating to the back for 2 years, with a history of melaena for the last 1 month that was associated with worsening of pain. He received 2 U of blood transfusions for this. This pain started 2 months after open splenectomy for blunt trauma abdomen. Oesophago-gastro-duodenoscopy demonstrated a globular bulge with normal overlying mucosa, along the posterior wall of the stomach, near the gastro-oesophageal junction (Fig. 1). A contrastenhanced computed tomography scan with angiography showed a 4.0 Â 3.2 Â 3.0 cm well-defined cystic lesion with hyperdense contents in the lesser sac, communicating with the pancreatic duct A pseudoaneurysm arising from the left gastric artery (LGA) was found within this cystic lesion (Fig. 2). Based on these findings, a diagnosis of hemosuccus pancreaticus (HP) was established.Catheter angiography of the celiac axis confirmed the presence of the LGA pseudoaneurysm. However, due to very acute take-off from the celiac trunk, super-selective cannulation of the LGA was not feasible after repeated attempts, and surgical intervention was planned. A 3D laparoscopic system (Olympus, Japan) was used for the procedure. Dense omental adhesions to the parietal wall due to prior splenectomy were gently taken down with a Harmonic scalpel (Johnsons, USA). The gastrohepatic ligament was frozen due to repeated attacks of pancreatitis. After careful dissection, the common hepatic artery was identified at the superior border of the pancreas, and was secured with a silicon vessel loop. The dissection was then gradually progressed towards the celiac trunk and the LGA take-off was identified, and the artery was isolated. The LGA was then secured with Hem-o-Lok clips (Teleflex, USA) at its origin and was divided (Fig. 3). The postoperative course was uneventful, and he was asymptomatic at the last (8 months) follow-up.Sandbloom first coined the term hemosuccus pancreaticus to describe bleeding into the pancreatic duct and subsequently to the gut, through the ampulla. 1 Bleeding into the pancreatic duct can occur from rupture of arterial aneurysms, rupture of pseudoaneurysms into pseudocysts and by iatrogenic means. Pseudoaneurysm occurs due to erosion of the vessel walls from the amylase-rich pancreatic fluid. It mainly arises from the splenic (60-65%), gastroduodenal (20-25%), pancreaticoduodenal arcade (10-15%) and the hepatic artery (5-10%). 2 Pseudoaneurysm arising from the LGA causing HP is rarely reported. We could find only one case report on this after a thorough search of the literature. 3 The clinical presentation is mostly with crescendo-decrescendo pain followed by haemorrhage, as in the index case. Our patient had a history of open splenectomy for blunt