Intraductal papillary mucinous neoplasias (IPMNs) belong to a heterogeneous group of pancreatic cysts. IPMNs have the potential for malignancy and are considered as the most important precursors of ductal adenomas [1] [2]. Therefore, total pancreatectomy is indicated in mixed type TPMN, or if a proximal IPMN extends through the body and tail of the pancreas or diffusely involves the glands [3]. The procedure is widely described and the intention of the practice is to remove the pancreas, distal stomach, duodenum and spleen en bloc [4]. The left gastric artery is essential for the blood supply of the proximal remnant of the stomach.

We report herein a case with total pancreatectomy with accidental lesion of the left gastric artery, when the rest of the blood supply to the distal part of the stomach has been cut off. Laser Speckle Contrast Imaging (LSCI) technic was used to identify, and confirm the line for transection of the stomach.

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Figure 1. Macroscopic picture of the upper part of the stomach following the lesion of left gastric artery. The numbers indicate regions of interest (ROI´s) in the LSCI measurements. F and B = fundus and body of the stomach, respectively.

A 71-year-old woman, known with hypertension and kidney stone, was investigated for renovascular disease. A CT-scan identified two Branch Duct IPMNs (BD-IPMNs) with the presence of diffuse dilatation of the main pancreatic duct. The diagnosis of mixed type IPNM was made and the patient was recommended total pancreatectomy, which she accepted.

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Figure 2. Single flux-picture of the upper part of the stomach, where a transection line was identified. The numbers indicates ROI´s where blood-flux was determined. F and B = fundus and body of the stomach, respectively.

The operative procedure began with a thorough exploration of the abdomen to evaluate the presence of extra-pancreatic disease. With no sign of dissemination, standard surgical procedures were followed. After the blood supply to the distal part of the stomach was disconnected, a large lymph node was found around the common hepatic artery, and was removed. At this procedure, the left gastric artery, which was gracile in this case, was accidently cut over and the blood flow to the upper stomach manifestly stopped. However, the very top of the stomach seemed to be vital, and it was concluded that this portion of the stomach had its blood supply partly from the esophagus and partly from the splenic artery via short gastric branches. With the use of the Laser Speckle Contrast Imaging (LSCI) camera, coeval with the clinical signs assessed by the surgeon, a transection line was identified (figures 1, 2 & 3), and the surgical procedure continued. The cut-off flux of 250 perfusion units (PU) was chosen according to earlier measurements on vital anastomosis, made at our department. At the end of the surgery, the vitality of the gastrojejunostomy was again assessed with LSCI technic (figure 4 & 5), which showed good perfusion at the region of anastomosis. The postoperative period was complicated by leakage from the hepaticojejunostomy, which was treated with percutaneous drainage. No complications occurred at the gastrojejunostomy, where LSCI were used to identify microcirculation. The patient was discharged 30 days after the operation.

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Figure 3. Graphic output of continues fluxes at the ROI´s. Mean fluxes of the highlighted period are seen in the table. The marker indicates the start of apnea during the measurement. Pay attention to the significantly lower flux in ROI nr. 4.

Total pancreatectomy is a massive surgical intervention with potential intraoperative complications. A feared complication is a lesion of the left gastric artery, the main vessel with blood supply to the remnant upper part of the stomach. Any lesion of this artery may require resection of the whole stomach.

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Figure 4. Single flux-picture following construction of the gastrojejunostomy. F = fundus of the remnant stomach, J = jejunum. ROI´s 1, 2 and 3 indicate the line of anastomosis, ROI nr. 4 is the jejunum, and ROI nr. 5 is the remnant stomach.

It is widely accepted that local ischemia significantly increases the risk of leakage when gastrointestinal continuity is being reconstructed during surgery. Therefore, sufficient blood supply to the area of the anastomosis is of paramount concern. A device able to identify real-time blood supply prior to transection and to follow construction of anastomosis is desirable. LSCI is a relatively new technique for microcirculatory monitoring. To our knowledge, this is the first clinical description of the intra-abdominal, perioperative utility of the technique. When laser light encounters a surface of an object, a random interference effect develops, called laser speckle contrast. The speckle pattern changes according to the velocity of the object, and tissue perfusion may be assessed by measuring the concentration and velocity of blood cells. Depending on the distance between the LSCI-camera and the area of interest, a real-time and non-contact measurement can be made on a large field (0.5 cm x 0.7 cm up to 15 cm x 20 cm) with a depth of 1 - 1.5 mm. Several experimental studies have revealed the potential of the technique. A recent study demonstrated excellent intra- and inter-observer reproducibility, when LSCI was used to assess alterations in cutaneous microperfusion [5]. Furthermore, Sturesson et al. showed reproducible measurements of hepatic microcirculation in the rat, in accordance with previously published results [6].

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Figure 5. Graphic output of continues flux in the ROI´s seen in A. Mean fluxes of the highlighted period are seen in the table. The marker indicates the start of apnea during the measurement.

LSCI appears to be the new method of choice for real-time, continuous and non-contact monitoring of the microcirculation. The ability of the technique, to offer an intraoperative assessment of tissue perfusion, is in the early phase of being evaluated.