Overview
Definition:
Right gastric artery aneurysm oversew is a surgical procedure to ligate (tie off) an aneurysm of the right gastric artery, a branch of the common hepatic artery supplying the lesser curvature of the stomach
This is typically performed when the aneurysm is symptomatic, at risk of rupture, or discovered incidentally during abdominal surgery.
Epidemiology:
Aneurysms of the right gastric artery are rare, with a low incidence
They can be associated with underlying conditions such as atherosclerosis, infection (mycotic aneurysm), trauma, or connective tissue disorders
There are no specific demographic predilections widely reported, but they are more common in older individuals with risk factors for vascular disease.
Clinical Significance:
Rupture of a right gastric artery aneurysm can lead to significant intra-abdominal hemorrhage, manifesting as acute abdominal pain, hemodynamic instability, and potentially shock
Prompt diagnosis and management are crucial to prevent life-threatening complications
Accurate surgical technique, such as oversewing, ensures definitive treatment and patient safety.
Clinical Presentation
Symptoms:
Abdominal pain, typically epigastric
Nausea and vomiting
Hematemesis (vomiting blood) or melena (black, tarry stools) if the aneurysm erodes into the stomach
Palpable abdominal mass in some cases
Symptoms of rupture: sudden onset severe abdominal pain, hemodynamic instability (hypotension, tachycardia), signs of hemorrhagic shock.
Signs:
Tenderness on abdominal palpation, particularly in the epigastric region
A pulsatile abdominal mass may be present
Signs of hypovolemia and shock in cases of rupture.
Diagnostic Criteria:
Diagnosis is primarily based on imaging
No specific clinical diagnostic criteria exist, but a high index of suspicion is warranted in patients presenting with unexplained abdominal pain and risk factors for vascular disease, or in those with signs of gastrointestinal bleeding or hemodynamic compromise.
Diagnostic Approach
History Taking:
Detailed history of abdominal pain characteristics, onset, duration, and aggravating/relieving factors
History of gastrointestinal bleeding, ulcers, or inflammatory bowel disease
Risk factors for atherosclerosis (hypertension, diabetes, hyperlipidemia, smoking)
History of trauma or recent infection
Family history of aneurysms
Assess for hemodynamic stability.
Physical Examination:
Thorough abdominal examination including inspection for distension or surgical scars, auscultation for bowel sounds, percussion, and palpation for tenderness, masses, or organomegaly
Assess for peripheral pulses and signs of shock.
Investigations:
Abdominal ultrasound: initial imaging modality, may detect pulsatile mass
CT angiography (CTA): gold standard for diagnosis, delineates aneurysm size, location, relationship to surrounding structures, and presence of extravasation
MRI angiography (MRA): alternative if CTA is contraindicated
Upper gastrointestinal endoscopy: to assess for concomitant gastric pathology or erosion
Routine blood tests: CBC, electrolytes, coagulation profile, renal function tests, liver function tests
Blood transfusion may be necessary for hemorrhage.
Differential Diagnosis:
Peptic ulcer disease with perforation or bleeding
Gastric malignancy
Pancreatitis
Biliary colic
Aortic aneurysm
Mesenteric ischemia
Other intra-abdominal masses.
Management
Initial Management:
Immediate resuscitation in case of rupture: intravenous fluid resuscitation, blood transfusion, hemodynamic monitoring
Analgesia
Placement of nasogastric tube
Surgical consultation for urgent intervention.
Medical Management:
Primarily supportive
Management of comorbidities like hypertension, diabetes, hyperlipidemia
Proton pump inhibitors if gastric erosion or ulceration is suspected
Antibiotics if a mycotic aneurysm is suspected.
Surgical Management:
Indications: Ruptured aneurysm, symptomatic aneurysm, or asymptomatic aneurysm >2-3 cm in diameter, or rapidly expanding
Procedure: Laparoscopic or open surgical exploration
For right gastric artery aneurysm, direct exposure of the artery is achieved
The aneurysm is carefully dissected free from surrounding tissues
Proximal and distal control of the artery is obtained
The aneurysm sac is oversewn with non-absorbable sutures (e.g., polypropylene) in a running or interrupted fashion to achieve hemostasis and obliteration of the lumen
In some cases, proximal ligation of the feeding artery may suffice if distal flow is not critical or collateral circulation is adequate
Careful hemostasis is paramount.
Supportive Care:
Postoperative ICU monitoring for hemodynamic stability
Pain management
Gradual reintroduction of oral intake
Deep vein thrombosis prophylaxis
Early mobilization
Close monitoring for signs of bleeding or infection
Nutritional support if indicated.
Complications
Early Complications:
Hemorrhage from suture line, incomplete ligation
Injury to adjacent organs (stomach, duodenum, pancreas)
Infection
Ischemic complications to the stomach (gastric infarction) if collateral flow is insufficient
Rebleeding.
Late Complications:
Recurrence if ligation is inadequate
Stricture formation in the gastric lumen if oversewing is too tight
Adhesions.
Prevention Strategies:
Meticulous surgical technique with adequate proximal and distal control
Careful dissection to avoid injury to surrounding structures
Use of appropriate suture material and technique for oversewing
Preoperative assessment of vascular anatomy
Adequate intraoperative imaging or intraoperative angiography if uncertainty exists.
Prognosis
Factors Affecting Prognosis:
Presence and severity of rupture at presentation
Patient's comorbidities and hemodynamic stability
Presence of infection
Technical success of the surgical repair
Adequate collateral circulation to the stomach.
Outcomes:
Successful oversewing of a non-ruptured right gastric artery aneurysm typically results in an excellent prognosis
Ruptured aneurysms, especially in hemodynamically unstable patients, carry a higher morbidity and mortality risk
Postoperative complications can significantly impact long-term outcomes.
Follow Up:
Routine clinical follow-up is recommended to assess for any late complications or recurrence
Imaging follow-up (e.g., ultrasound or CT scan) may be considered in select cases, particularly if there were concerns about technical adequacy of the repair or underlying vascular disease.
Key Points
Exam Focus:
Right gastric artery aneurysms are rare but potentially life-threatening
CTA is the gold standard for diagnosis
Surgical oversewing is the definitive treatment
Key complications include hemorrhage and gastric ischemia.
Clinical Pearls:
Maintain a high index of suspicion for atypical abdominal pain with vascular risk factors
Always achieve proximal and distal control before attempting to ligate or oversew vascular lesions
Thorough intraoperative assessment for bleeding is critical.
Common Mistakes:
Failure to consider aneurysm as a cause of unexplained GI bleeding or abdominal pain
Inadequate proximal and distal control leading to uncontrolled hemorrhage
Insufficient hemostasis after oversewing
Ignoring signs of gastric ischemia postoperatively.