RUPTURE OF A PANCREATIC PSEUDOANEURYSM AS A CONSEQUENCE OF CHRONIC PANCREATITIS: CASE REPORT OF A SURGICAL EMERGENCY

Introduction: Pseudoaneurysms of the pancreaticoduodenal arcade are rare, accounting for approximately 2% of all visceral artery aneurysms. They typically arise as complications of chronic pancreatitis, peptic ulcer disease, trauma, pancreatic and biliary surgery, or pancreas transplantation. Diagnosis often occurs only after rupture, leading to life-threatening internal bleeding. Bleeding may occur within a pseudocyst, with blood passing through the Vater's papilla into the digestive tract, or may result in the formation of a retroperitoneal hematoma that can rupture into the abdominal cavity, causing hemoperitoneum. The cell-saver is a tool that can be utilized for intraoperative blood cell salvage and autologous transfusions. Case Report: Our patient, a 54-year-old male, an untreated alcoholic with no prior medical history or documented treatment, presented to the Clinic for Emergency Surgery at the University Clinical Center of Serbia with a sudden onset of upper abdominal pain. A quick ultrasound of the abdomen was performed, followed by an urgent CT scan of the chest and abdomen, revealing a hematoma extending from the right retroperitoneum and mesentery of the intestine, measuring


INTRODUCTION
Pseudoaneurysms of the pancreaticoduodenal arcade are rare occurrences, constituting approximately 2% of all visceral artery aneurysms (1).They typically manifest as complications of chronic pancreatitis, peptic ulcer disease, trauma, pancreatic and biliary surgeries, or pancreas transplantation (2).Often, these pseudoaneurysms remain undiagnosed until rupture, leading to life-threatening internal bleeding (3).Bleeding may occur within a pseudocyst, with blood passing through Vater's papilla into the digestive tract, or result in the formation of a retroperitoneal hematoma that can rupture into the abdominal cavity, causing hemoperitoneum (3,4).
Traditionally, blood transfusion has been a common therapeutic intervention for treating perioperative anemia and surgical blood loss.Anemia, whether acute or chronic, is associated with increased morbidity and mortality risk.To reduce the need for allogeneic blood transfusions, modern blood conservation principles have been developed, which include intraoperative blood cell salvage and autologous transfusion (5).This approach is particularly beneficial in cardiac and O N L I N E F I R S T orthopedic surgeries, as well as operations anticipated to involve significant blood loss exceeding 1000 ml.The process of blood cell salvage involves three phases: collection, washing, and reinfusion.Blood collection from the operative field necessitates the use of a specialized suction device with dual lumens, known as a Cell-saver.One lumen draws blood from the operative site, while the other adds a predetermined volume of heparinized saline.Anticoagulated blood is then filtered and collected in a reservoir.Following centrifugation, red blood cells (RBCs) are washed and filtered to remove impurities, resulting in a hematocrit of 50-80%.Autologous transfusion can occur within six hours of RBC collection (6).
Potential complications associated with cell salvage include non-immune hemolysis, air embolism, febrile non-hemolytic transfusion reactions, coagulopathy, contamination with drugs or infectious agents, and incomplete washing leading to contamination with cytokines, leukocytes, and microaggregates.However, these risks have diminished with technological advancements, staff training, and increased experience in the method (6,7).The primary benefit of this approach is the reduced need for allogeneic blood transfusions, which are associated with various complications, including increased mortality.
The 2009 AAGBI guidelines have identified indications for cell salvage use, including predicted blood loss exceeding 1000 ml or 20% of estimated blood volume.It is considered suitable for patients with low hemoglobin levels, increased bleeding risk, antibodies against RBC surface antigens, rare blood groups, or those who decline allogeneic transfusions (5)(6)(7).However, literature describing the use of Cell-saver in emergency surgeries of this nature is limited (8).
In this case report, we present the clinical and radiological features of an adult male patient who presented to our center as an emergency with hemoperitoneum secondary to a ruptured pancreatic pseudoaneurysm due to chronic pancreatitis.The patient underwent surgery within hours of admission, with perioperative Cell-saver utilization aimed at preventing additional blood loss and facilitating autologous transfusion.

CASE REPORT
Our patient is a 54-year-old male, an untreated alcoholic with no prior medical history or chronic therapy.He presented to the Clinic for Emergency Surgery at the University Clinical Center of Serbia in Belgrade in November 2023, complaining of sudden upper abdominal pain that had started three hours before admission.The patient denied nausea, vomiting, or changes in stool appearance, and he did not lose consciousness.On admission, he was conscious, oriented, but  O N L I N E F I R S T   We decided to proceed with an urgent exploratory laparotomy.During the operation, we discovered blood and coagulum in all peritoneal recesses, along with a hematoma in the right peritoneal space extending towards the mesocolontransversum and the mesentery of the small intestine, with rupture towards the peritoneal cavity (Figure 5).To access the pancreas, we performed a Cattell-Braasch maneuver.We observed active bleeding in the area of the pancreaticoduodenal arcade due to the rupture of the pseudoaneurysm (Figure 6).We achieved permanent hemostasis and utilized the Cell-saver throughout the operation to preserve the minute volume.The operation concluded with tamponade of the retroperitoneal space on the right.

O N L I N E F I R S T
Postoperatively, the patient was managed in the ICU.After 30 hours, we performed a relaparotomy to remove the tampons from the abdominal cavity.Hemostasis was satisfactory, and there were no signs of ischemia or necrosis in the colon and small intestine, which were both fully vital and normally colored.The pancreas exhibited a harder consistency consistent with chronic pancreatitis.Throughout the postoperative period, the patient remained hemodynamically stable

O N L I N E F I R S T
and was discharged from the hospital in good general condition two weeks after the initial operation.
We obtained verbal and signed consent from the patient to publish this case report.
All procedures performed were in accordance with the 1964 Helsinki Declaration and its later amendments.O N L I N E F I R S T

DISCUSSION
The pancreaticoduodenal arcade is an arterial network in the area of the pancreas head, connecting the coeliac artery and superior mesenteric artery.False or pseudoaneurysms of the pancreaticoduodenal arcade are more common than true aneurysms in the latest literature (where all layers of the wall, including the epithelium, are present) (9).Pseudoaneurysms typically develop due to chronic inflammatory and/or infective processes of the duodenum (such as penetrating duodenal ulcer) and pancreas (like chronic pancreatitis) (9,10).Bleeding from this site represents a severe complication, occurring in approximately 4.6% of patients with chronic pancreatitis according to Bergert et al (11).Various endovascular strategies are constantly evolving for minimally invasive treatment solutions.While these solutions often lead to favorable outcomes, they require highly specialized facilities and a sufficient number of trained specialists, especially in emergency medical settings (12,13).Criteria such as the patient's hemodynamic stability and O N L I N E F I R S T correction of any pre-existing coagulopathy must be met to safely perform endovascular or minimally invasive procedures (10).
Our clinic is regarded as a reference center in the country for such cases and pathology, with a large number of skilled general and abdominal surgeons routinely performing a significant number of urgent laparotomies and explorative laparoscopies in patients with hemoperitoneum of any etiology.Based on our experience, in cases of patient hemodynamic instability, rapid drop in hemoglobin values during a short-term observation period, and any radiological signs of hemoperitoneum, we advocate for surgical intervention.
In conclusion, in any patient undergoing treatment for chronic pancreatitis who suddenly experiences hemodynamic instability with a drop in arterial pressure and hemoglobin and hematocrit values, a ruptured pseudoaneurysm of the pancreatic or peripancreatic region should be considered.Only timely diagnosis and prompt surgical treatment can lead to a successful outcome.
Effective cooperation between radiologists, anesthesiologists, and surgeons is essential for success.
The use of Cell-saver significantly aids in maintaining cardiac output and the patient's hemodynamic stability.*Accepted papers are articles in press that have gone through due peer review process and have been accepted for publication by the Editorial Board of Sanamed.The final text of the article may be changed before the final publication.Accepted papers can already be cited using the year of online publication and the DOI, as follows: the author's last name and initial of the first name, article title, journal title, online first publication month and year, and the DOI.When the final article is assigned to volumes/issues of the journal, the Article in Press version will be removed and the final version will appear in the associated published volumes/issues of the journal.The date the article was made available online first will be carried over.
extremely agitated, with paler discoloration of the skin and visible mucous membranes.Auscultation of the chest revealed a normal respiratory murmur, while abdominal examination showed tenderness in the epigastrium without peritoneal signs or hernias.Predilection hernia sites were without manifest herniation.Initial hemoglobin level was 138 g/L.Ultrasound examination revealed a suspicious break in the antropyloric part of the stomach wall and a septate, organized mass with a diameter of about 70 mm in the right hemiabdomen, suggestive of a pseudoaneurysm, septate dense collection, or other etiology.Given these findings, an urgent CT scan of the chest and abdomen was performed, which showed a hyperdense left lobe of normal-sized liver without focal changes.The trunk of the portal vein measured 10mm in diameter, with extension of a hematoma from the right retroperitoneum and mesentery of the intestine into the infrapancreatic region, with signs of active bleeding.The CT findings suggested bleeding from the origin of a branch of the pancreaticoduodenal arcade, likely the lower one, with a differential diagnosis of arteriovenous fistula, suspected tumor, or inflammatory type, more likely a pseudoaneurysm (Figure1-4).

Figure 1 .
Figure 1.Contrast-enhanced abdominopelvic CT, axial image, arterial phase: Huge retroperitoneal and mesenterial hematoma located on the right side with a pseudoaneurysm of the pancreaticoduodenal arcade (arrow).

Figure 2 .
Figure 2. Contrast-enhanced abdominopelvic CT, axial image, arterial phase: Huge retroperitoneal hematoma with contrast "blush" in the central region of the hematoma -a CT sign of active arterial bleeding (arrow).

Figure 3 .
Figure 3. Contrast-enhanced abdominopelvic CT, coronal reconstruction, venous phase: Huge retroperitoneal and mesenterial hematoma with pseudoaneurysm of pancreaticoduodenal arcade (arrow) and contrast "blush" in the central region of the hematoma (star).

Figure 5 .
Figure 5. Retroperitoneal hematoma with propagation in the mesocolon transversum and mesentery of the small intestine (arrow).