Patient Report

Yonago Acta Medica 2017;60:56–58

A Case of Unruptured Right Gastroepiploic Artery Aneurysm Successfully
Resected by Laparoscopic Surgery
Yuki Murakami, Hiroaki Saito, Shota Shimizu, Yusuke Kono, Hirohiko Kuroda, Tomoyuki Matsunaga, YojiFukumoto, Tomohiro Osaki and Yoshiyuki Fujiwara
Division of Surgical Oncology, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago 683-8503,
Japan

ABSTRACTA 50-year-old woman was admitted to our hospital toundergo surgery to remove a pituitary adenoma. Preoperative dynamic computed tomography revealed an incidental right gastroepiploic arterial aneurysm (GEAA).
After removal of the pituitary adenoma, we performeda laparoscopic right gastroepiploic aneurysmectomy.
The postoperative course was uneventful. Right GEAAs
should be treated at diagnosis owing to the high possibility of rupture. Laparoscopic right gastroepiploic aneurysmectomy is feasible and should be considered for thetreatment of right GEAAs.

ng/mL) and insulin-like growth factor-1 (853 ng/mL)levels, possibly due to overproduction by the pituitaryadenoma. The tumor markers carcinoembryonic antigen(CEA) and carbohydrate antigen 19-9 (CA19-9) wereboth within normal limits. Preoperative dynamic computed tomography revealed an incidental right GEAA
(Fig. 1).
The right GEAA was located in the proximal right
gastroepiploic artery and was 23 mm in diameter. Surgery was performed to remove the pituitary adenoma.
Sixty days after this operation, the patient was referredto our department for treatment of the right GEAA.
Because the aneurysm was not near the root of the right
gastroepiploic artery, we considered it possible to ligate
the GEAA proximally and distally, and excise it. This
right gastroepiploic aneurysmectomy was performed
laparoscopically. Under general anesthesia, the patient
was placed in the supine position with open spread.
After the pneumoperitoneum was established using theopen technique at the umbilicus, a ﬂexible electrolaparoscope was introduced through the umbilical port. Four
additional ports were placed in the upper abdominal
area (three 5-mm ports under the bilateral rib bow andthe right side of the umbilicus and a 12-mm port at theleft side of the umbilicus). The abdomen was insufﬂatedwith carbon dioxide to 8 mmHg. During laparoscopic
exploration, a 2-cm spherical mass was seen at the rightside of the greater omentum (Fig. 2).
After detaching the greater omentum using laparoscopic coagulation shears (LCS, Ethicon Endosurgery,Cincinnati, OH), the right gastroepiploic artery was exposed proximal and distal to the GEAA and clipped (Fig.
3).
The GEAA was then excised and removed throughthe umbilical trocar incision. The aneurysm was 2.2 × 1.9× 1.8 cm (Fig. 4).
Intraoperative blood loss was minimal and the operation took 101 min. Staining with Elastica van Gieson
confirmed that the tunica media were present, althoughdisrupted. Thus, the final diagnosis was a pseudoaneurysm. The postoperative course was uneventful, and thepatient was discharged on day 6.

Key words Abdominal visceral artery aneurysm; Gastroepiploic artery aneurysm; Laparoscopic surgery

Abdominal visceral artery aneurysms are relatively rare,
especially gastroepiploic arterial aneurysms (GEAAs).1
The risk of rupture of GEAAs is high and most GEAAs
are identified after rupture or as a result of secondary
complications. GEAA rupture is associated with a highmortality rate.2 Here, we report a rare case of a right
GEAA that was diagnosed preoperatively without any
complications and was treated successfully with laparoscopic surgery.
PATIENT REPORT
A 50-year-old woman was admitted to our hospital toundergo surgery to treat a pituitary adenoma. On physical examination, she showed an acromegaly-like facialappearance. She had never smoked or consumed alcohol.
She had mild hypertension that did not require medication. Blood tests revealed elevated growth hormone (25.8
Corresponding author: Hiroaki Saito, MD, PhD
sai10@med.tottori-u.ac.jp
Received 2016 November 11
Accepted 2016 December 14
Abbreviations: CA19-9, carbohydrate antigen 19-9; CEA, carcinoembryonic antigen; GEAA, gastroepiploic arterial aneurysm;
GDA, gastroduodenal artery; PDA, pancreaticoduodenal artery;
SAA, splanchnic artery aneurysm; SMA, superior mesenteric artery56

Laparoscopic surgery of right GEAAs

Murakami et al. Figure 3	

Murakami et al. Figure 4	

Fig. 1. 3D computed tomography angiography shows the 17-mmaneurysm in the right gastroepiploic artery.

Fig. 2. Operative findings revealed a 2-cm round mass (arrow) at
the right side of the greater omentum.

Fig. 3. The right gastroepiploic artery was clipped and divided at
the proximal site of the right gastroepiploic arterial aneurysm.

Fig. 4. Surgical specimen shows an aneurysm of 2.2 × 1.9 × 1.8
cm.

DISCUSSION
Abdominal visceral artery aneurysms are a relatively
rare vascular disease. Stanley et al. reported the abdominal viscera aneurysms of 1,118 patients, including
splenic aneurysms (656 patients, 58.7%), hepatic arteryaneurysms (227 patients, 20.3%), superior mesentericartery (SMA) aneurysms (89 patients, 8.0%), and gastricand gastroepiploic artery aneurysms (53 patients, 4.9%).1
Abdominal visceral artery aneurysm has been associated with arteriosclerosis, congenital vascular abnormalities, infection, trauma, inﬂammation, vasculitis due tocollagen disease, and segmental arterial mediolysis.
Because rupture of abdominal visceral artery aneurysms is associated with a high mortality rate, the timingof treatment is extremely important. Despite this, there
is no consensus regarding the optimal timing for treating right GEAAs. Corey et al. previously determined
the natural history of 138 splanchnic artery aneurysms
and concluded that small splanchnic artery aneurysms(SAAs) (25 mm or less) in major arteries, such as theceliac artery, splenic artery, and common hepatic artery,are not prone to significant expansion and do not require
frequent surveillance imaging.2 Conversely, gastroduodenal aneurysms and aneurysms of the pancreaticoduodenal seem to behave in a different manner. It is
important to recognize that these aneurysms differ fromother types of SAAs in their potential for growth andrupture. It has been reported that size was not predictive57

Y. Murakami et al.

of rupture and that these aneurysms were strongly associated with rupture on univariate analysis.2 Ducasse etal. also reported that most ruptured pancreaticoduodenalarteries (PDAs) are < 10 mm.3 Because the right GEAA
is a branch of the gastroduodenal artery (GDA), it seems
necessary to treat at diagnosis, regardless of aneurysm
size.
There are endovascular therapy and surgical therapy
options for the treatment of abdominal visceral arteryaneurysms. Endovascular therapies include coil embolization and stent graft exclusion, and are effective for thetreatment of PDAs and GDAs. It has been reported that
more than 90% of patients with either PDAs or GDAs
were successfully managed by endovascular therapies,
with complete obliteration of the aneurysm sacs on follow-up imaging 30 days after the procedure.2 Therefore,
endovascular therapy is a considerable treatment option
for right GEAAs. However, complications sometimes
occur after an endovascular repair, including distal
thromboembolic events, non-target vessel embolization,coil migration, end-organ infarction, and intra-procedural aneurysm rupture.4–6 Splenic atrophy or infarct
has been reported in 20%–40% of cases following endovascular treatment of distal or hilar splenic artery aneurysms.7 Furthermore, embolization of the splanchnic
vessels is difficult because the anatomy is so variable.
Therefore, endovascular therapy should be performed by
an experienced radiologist.
Surgical resection of the aneurysm is another option
for the treatment of right GEAAs. When possible, theaneurysm should be ligated proximally and distally, andexcised. Unlike other abdominal visceral artery aneurysms, the gastroepiploic artery can be divided without
any functional disorder. Furthermore, recent advancesin laparoscopic surgery make it a viable technique forthe treatment of abdominal visceral artery aneurysms.
There are accumulating reports showing the successful
laparoscopic treatment of splenic artery aneurysms,
which is the most common abdominal visceral arteryaneurysm.8–11 On the other hand, to the best of ourknowledge, only three cases (including our case) of successful laparoscopic right gastroepiploic aneurysmectomy have been reported.12, 13 Laparoscopic procedures
are not complicated for the treatment of GEAAs andare less invasive compared with open surgery. Furthermore, aneurysmectomy is more effective treatment thanendovascular therapy.6 Therefore, laparoscopic right
gastroepiploic aneurysmectomy was performed for thetreatment of GEAAs in the current case.

In conclusion, right GEAAs should be treated at
diagnosis owing to the high possibility of rupture andassociated high mortality rate. Laparoscopic right gastroepiploic aneurysmectomy is feasible and should beconsidered for the treatment of right GEAAs.
The authors declare no conflict of interest.

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