Emergency Surgery Unit, Cisanello Hospital, University of Pisa, Via Paradisa 2, Cisanello, 56021, Pisa, Italy.
Surg Endosc. 2018 Feb;32(2):1070-1071. doi: 10.1007/s00464-017-5737-0. Epub 2017 Aug 4.
Gastroepiploic arterial aneurysms (GEAA) represent a very rare disorder [1, 2]. The risk of GEAA rupture is high, and it is associated with a high mortality rate [3]. GEAAs are usually identified following rupture or are incidentally diagnosed. In emergency, an open surgical approach to treat GEAAs has been most frequently reported [4]. Alternatively, if the patient is hemodynamically stable, an angiography and embolization can be attempted. Herein we report the case of a patient presenting with two fissurated GEAAs that were successfully excised laparoscopically after failure of the endovascular approach.
A 83-year-old lady was admitted for acute epigastric pain. Upon admission, her general status was stable. The abdomen was soft and slightly painful at deep palpation in epigastrium, with no sign of peritonism. In her past medical history, she had a transient ischemic attack and atrial fibrillation episodes for which a pacemaker had been placed. Her blood examinations showed a slight anemia (hemoglobin 10.5 g/dl). An abdominal ultrasonography identified two solid, circular, nodules next to the gastric anterior wall that, in a following angio-TC, were diagnosed as two aneurysms of the gastro-epiploic arterial arcade (GEA), one measuring 17 mm × 13 mm, the other 39 mm × 33 mm. Both showed X-ray signs of impending rupture and intraluminal "thrombization". The patient underwent selective angiography, during which, after an attempt of common hepatic artery catheterism, a dissection and, consequently, an occlusion of the hepatic artery and the celiac trunk unfortunately occurred. Therefore, after a catetherism of the superior mesenteric artery, only a partial and incomplete embolization procedure was possible. As a matter, at the end of the angiographic procedure, reperfusion of the GEA coming from the splenic and hepatic artery was recognized. After 24 h, repeated abdominal CT scan with contrast showed the persistence of the aneurysms with no dimensional changes and the presence of a small active extravasation of contrast from the lateral aneurysm.
Laparoscopic surgical exploration was then warranted. Two voluminous GEA arcade aneurysms, very close to greater curvature of the stomach, were identified. After a cautious visceral dissection, the right and left gastroepiploic arteries were clipped and sectioned. Due to the presence of strength adhesions between the aneurysms and the greater curvature of the stomach, we decided to perform double aneurismectomy "en bloc" with the excision of the adjacent greater gastric curve by using an articulated laparoscopic stapler (Endo GIA™ 60 mm Articulating Medium/Thick Reload with Tri-Staple™ Technology, MEDTRONIC, Minneapolis, US). No intraoperative complications were reported. The patient was discharged in fifth post-operative day.
In case of failure of a non-surgical management of ruptured GEA aneurysms, the laparoscopic resection is a safe and effective procedure.
胃网膜动脉动脉瘤（GEAA）是一种非常罕见的疾病[1,2]。GEAA 破裂的风险很高，与高死亡率相关[3]。GEAA 通常在破裂后被发现，或偶然被诊断。在紧急情况下，最常报道的治疗方法是开腹手术[4]。或者，如果患者血流动力学稳定，可以尝试血管造影和栓塞。在此，我们报告了一例患者，该患者出现两个裂孔性 GEA，在血管内治疗失败后，成功地通过腹腔镜切除。
一名 83 岁女性因急性上腹痛入院。入院时，一般情况稳定。腹部柔软，在上腹部深触诊时略有疼痛，无腹膜炎迹象。在她的既往病史中，她曾有短暂性脑缺血发作和心房颤动发作，因此植入了起搏器。她的血液检查显示轻度贫血（血红蛋白 10.5 g/dl）。腹部超声检查发现胃前壁附近有两个实性、圆形的结节，在随后的血管造影 CT 中被诊断为胃网膜动脉弓（GEA）的两个动脉瘤，一个大小为 17mm×13mm，另一个为 39mm×33mm。两者均有 X 射线破裂迹象和管腔内“血栓形成”。患者接受了选择性血管造影术，在尝试进行肝总动脉导管插入术期间，发生了夹层，随后肝动脉和腹腔干不幸发生了阻塞。因此，在肠系膜上动脉导管插入术后，仅能进行部分和不完全的栓塞术。因此，在血管造影术结束时，发现来自脾动脉和肝动脉的 GEA 再灌注。24 小时后，再次进行腹部 CT 扫描，显示动脉瘤仍存在，无尺寸变化，外侧动脉瘤有小的造影剂外渗。
随后进行了腹腔镜手术探查。发现两个巨大的胃网膜动脉弓动脉瘤，非常靠近胃大弯。在进行小心的内脏解剖后，夹闭并切断了右胃网膜动脉和左胃网膜动脉。由于动脉瘤与胃大弯之间存在牢固的粘连，我们决定使用铰接式腹腔镜吻合器（Endo GIA™60mm 铰接式中/厚型再加载 Tri-Staple™技术，美敦力，明尼苏达州，美国）进行双动脉瘤切除术“整块”切除相邻的胃大弯。术中无并发症发生。患者在术后第五天出院。
如果破裂的 GEA 动脉瘤的非手术治疗失败，腹腔镜切除是一种安全有效的方法。
