Gastroepiploic Vein Research Articles

Pyloroantrectomy and Pedunculated Short Gastric-Tube Interposition in Esophageal Carcinoma Patients Associated With Early Gastric Adenocarcinoma

Gastric carcinoma is one of the most common secondary malignancies in esophageal cancer patients. We herein report our surgical procedure for esophageal reconstruction in esophageal cancer patients associated with synchronous or metachronous early gastric adenocarcinoma. Gastric adenocarcinoma was removed by pyloroantrectomy with preservation of the right gastroepiploic artery and vein, and a pedunculated short gastric tube was used as an esophageal substitute in a Roux-en-Y fashion. Surgical data of 6 esophageal cancer patients who underwent this type of surgery between 1993 and 2012 were analyzed. Three patients had synchronous early gastric carcinoma and the remaining 3 patients had metachronous early gastric adenocarcinoma. The gastric tube was easily pulled up to the neck and no problems occurred during this procedure. Postoperative complications, including leakage of esophagogastrostomy, acute respiratory failure, and diffuse peritonitis, were observed in 3 patients. No patients suffered from necrosis of the gastric tube. Although 3 patients died of other diseases, gastric cancer recurrence has not been observed to date. Despite the need for precaution to ensure technical safety, pyloroantrectomy and esophageal reconstruction using a pedunculated short gastric-tube are oncologically feasible as a potential curative surgery for esophageal cancer patients with early gastric adenocarcinoma.

Portal perfusion with right gastroepiploic vein flow in liver transplant

Background Liver transplantation in patients with liver cirrhosis, portal vein thrombosis, and cavernous transformation of the portal vein, is a complex procedure with high possibility of liver graft dysfunction. It is performed in 2–19% of all liver transplants, and has a significantly high mortality rate in the post-operative period. Other procedures to maintain portal perfusion have been described, however there are no reports of liver graft perfusion using right gastroepiploic vein.

Extra hepatic portal venous obstruction [EHPVO] with or without portal biliopathy – Intra operative portal pressure measurements: A comparative study

Introduction: While portal biliopathy [PB] is common in patients of EHPVO, clinical or biochemical, i.e. symptomatic PB is seen in only 20–30% of cases. We herein compare portal pressure in patients of EHPVO with or without portal biliopathy. Methods: Retrospective analysis of prospectively collected data of all patients with EHPVO who underwent elective PSRS where intra-operative pressures were available between January 2008 to December 2014. Patients were classified into two group: Group A: Portal Biliopathy [PB] and Group B: Non-Portal biliopathy[NPB]. Intra-operative pre and post shunt pressures in the gastro-epiploic vein recorded using transducers were analysed. Post surgical outcomes including resolution of PB and need for subsequent biliary intervention was assessed. Results: While 116 patients underwent PSRS for EHPVO during the study period, 55 patients in whom intraoperative pressure data were available formed the study group (NPB: 33 and PB: 22). Preshunt pressure(in mmHg) and mean decrement in NPB group was 31.3 ± 6.3 and 9.06 ± 4.55 respectively as compared to 29.9 ± 8.4 and 8.8 ± 6.07 in PB group [p = 0.4833 and p = 0.577]. During a median follow up of 48 months, 6 (27.3%) of 22 PB patients needed biliary intervention including bilioenteric bypass in 4 and endoscopic stenting in 2. Conclusion: Intra-operative portal pressures and post shunt decrement did not differ between the portal biliopathy and non-portal biliopathy groups.

Dynamic computed tomography findings of an accessory spleen in the pelvis: a case report.

We report the case of a 60-year-old man with an accessory spleen in the pelvis. He visited our outpatient clinic because of abdominal discomfort. Computed tomography (CT) showed an enhanced mass (40 mm in diameter) in the pelvis. Preoperative diagnosis was difficult even after magnetic resonance imaging and colonoscopy. The patient underwent surgery for suspicion of a gastrointestinal stromal tumor or malignant lymphoma of the rectum. Intraoperative findings showed a mass in the pelvis and a long cord-like tissue reaching the mass and arising from the great omentum; the mass was excised. Histopathologic examination indicated that the mass was splenic tissue, and feeding vessels were found in the cord-like tissue, which were determined to be derived from the left gastroepiploic artery and vein. Thus, we diagnosed it as an accessory spleen in the pelvis. An accessory spleen is not rare and can occur anywhere in the abdominal cavity. However, an accessory spleen in the pelvis is an infrequent finding, and only 9 other cases of an accessory spleen in the pelvis have been reported. Therefore, it is very difficult to make a correct diagnosis preoperatively. However, 7 of the 9 cases (77.8 %) of a pelvic accessory spleen had vascular pedicles from the great omentum or splenic hilum as feeding vessels; hence, determining the feeding blood vessels on dynamic CT may be useful for diagnosing an accessory spleen in the pelvis. Additionally, if the accessory spleen is symptomatic or has a vascular pedicle, surgeons should attempt to resect the accessory spleen in the pelvis using minimally invasive laparoscopy.

Successful liver allograft inflow reconstruction with the right gastroepiploic vein

Portal vein thrombosis is a common complication in cirrhotic patients. When portal vein thrombectomy is not a suitable option, a large collateral vessel can be used for allograft venous inflow reconstruction. We describe an unusual case of successful portal revascularization using the right gastroepiploic vein. The patient underwent a cadaveric orthotopic liver transplantation with end-to-end anastomosis of the portal vein to the right gastroepiploic vein. Six months after liver transplantation the patient is well with good liver function. The use of the right gastroepiploic vein for allograft venous reconstruction is feasible and safe, with a great advantage of avoiding the need of venous jump graft.

Single-Stage, Dual Gastroepiploic Lymph Node Flaps for the Surgical Treatment of Lymphedema

BACKGROUND: Several donor sites have been described for lymph node flap (LNF) harvest from around the body. The gastroepiploic donor site has several advantages, including constant anatomy, large-caliber vasculature, and no reported associated iatrogenic lymphedema. The purpose of this case report was to review the technique of expanding the gastroepiploic donor site to two flaps (Figure 1), based on the right and left gastroepiploic artery and vein (RGEA/V and LGEA/V), for distal and proximal vascularized lymph node transfer for extremity lymphedema (Figure 2).Figure 1: Schematic drawing of the dual gastroepiploic lymph node flap, based on the right and left gastroepiploic artery and vein (RGEA/V and LGEA/V). Adjacent omental vessels are shown.Figure 2: Distal and proximal inset of the dual gastroepiploic lymph node flap in the lymphedematous extremity.METHODS: Prospective data was collected on our first case of dual gastroepiploic lymph node flaps. Demographic data, indication, and perioperative details were recorded. RESULTS: Our patient was a 65-year-old female with cervical cancer-related right lower limb ISL stage II lymphedema, with progressive limb enlargement and decreased mobility for three years. Comorbidities included obesity (BMI = 35.4kg/m2) and poorly controlled hypertension. Preoperative circumferential measurements were 66.6cm thigh/ 44.3cm calf / 25.3cm ankle / 24.5cm foot, versus 56.5/39/1.6/22.4 contralaterally. Circumferential differentiation calculations were 17.9%/13.6%/17.1%/9.4%, with an average circumferential differentiation of 14%. Tonicity was not measureable at the thigh and leg, versus 87 / 86 contralaterally. Preoperative lymphoscintigraphy showed obstructive right lower limb lymphedema with dermal backflow distal to the thigh. Both gastroepiploic lymph node flaps survived, and no reexploration was required. Operative time was 575 minutes, harvest time was 140 minutes with open approach, and ischemia time was 120 minutes. All microanastomoses were performed in end-to-end fashion with 10-0 nylon. The anastomoses were the RGEA to the medial plantar artery, with corresponding veins, and the LGEA to the medial sural artery, with corresponding veins. Local flaps and small skin grafts were used for closure, to allow monitoring. Primary wound healing was achieved and there were no perioperative complications. CONCLUSIONS: The single-stage, dual gastroepiploic lymph node flap is a safe and novel option for the surgical treatment of extremity lymphedema. Long-term follow-up and further studies are warranted to further evaluate the potential of this flap.

The Impact of Confluence Types of the Right Gastroepiploic Vein on No. 6 Lymphadenectomy During Laparoscopic Radical Gastrectomy.

This study investigated anatomical variations in the confluence types of the right gastroepiploic vein (RGEV) to improve knowledge regarding no. 6 lymphadenectomy for laparoscopic gastrectomy.The RGEV drainage patterns of 144 patients who were diagnosed with gastric cancer and underwent laparoscopic distal gastrectomy at our department from July 2010 to June 2011 were prospectively collected and retrospectively analyzed, and we compared the impact of different drainage patterns on no. 6 lymphadenectomy.The RGEV confluence types were classified into 6 categories in this study. Types I, II, and III, which were observed in 53 (36.8%), 27 (18.8%), and 21 (14.6%) cases, respectively, were the most frequently found during gastrectomy. All 3 of these types included a gastropancreatic trunk and were defined as the gastropancreatic group (GP group). In addition, 15 cases (10.4%) were categorized as type IV, 19 (13.2%) were categorized as type V, and 9 (6.3%) were categorized as type VI. These 3 types, which could form a gastrocolic trunk, were defined as the gastrocolic group (GC group). No significant differences were found with respect to the clinicopathological characteristics, postoperative morbidity, perioperative mortality, and 3-year overall survival rates after surgery between the 2 groups (all P > 0.05). However, the mean no. 6 lymph node (No. 6 LN) dissection time, the mean blood loss due to No. 6 LN dissection and the rate of infrapyloric vascular injury were significantly increased in the GC group compared with the GP group (all P < 0.05).The RGEV exhibits 6 types of drainage patterns, and the division points of this vein during laparoscopic gastrectomy depend on the different drainage patterns. For types IV, V, and VI, the surgeon should carefully vascularize and divide the RGEV above its confluences during surgery.

PTU-008 Is cranial to caudal approach a feasible technique for complete mesocolic excision (cme) in laparoscopic transverse colectomy?

<h3>Introduction</h3> Laparoscopic transverse colectomy (LTC) is one of the most challenging techniques because the region of its mesentery and lymph node (LN) dissection is controversial. In addition, anatomical anomalies are often observed in the root of middle colic artery (MCA), which is surrounded by critical vessels such as superior mesenteric vein (SMV), splenic vein (SPV) and inferior mesenteric vein (IMV). We believe that cranial to caudal approach is one of the answers against how to overcome the hurdle of CME and LN dissection in LTC because it’s relatively easy to discern the border of transverse colon mesentery from pancreas. Another is to clarify the dominantly feeding vessel and establish the interest region of lymphandectomy by using CT colonography and angiography preoperatively. <h3>Method</h3> First, we open the bursa omentalis widely through the gastrocolic ligament, and subsequently mobilise and take down the hepatic and splenic flexure. The anterior lobe of transverse mesocolon is then dissected at the inferior border of the pancreas with the so-called cranial to caudal approach. Right gastroepiploic vein (RGEV) is a landmark to reach SMV. Exposing pancreatic head and second potion of duodenum and blunt dissection are also important to take down hepatic flexure of transverse colon and detach mesentery of transverse colon. In the process, we transect one or two accessory right colonic vein (ARCV). With skeletonizing SMV to proximal side, merging of SMV, SPV and IMV are uncovered. We think it’s critical to harvest the lymph nodes completely in the region enclosed by SMV, SPV and IMV where there should be generally the root of MCA. CT angiography is a robust support to comprehensively recognise the vessel anatomical anomalies and dissected region of colon mesentery. Continuously, it’s possible to dissect the root of ileocolic and right colic vessels with skeletonizing ventral surface of SMA and SMV in this approach. <h3>Results</h3> We herein present our practical laparoscopic transverse colectomy with LN dissection in video as attatched to demonstrate our concept and strategy in this field. <h3>Conclusion</h3> We think that cranial to caudal approach is a feasible technique for complete mesocolic excision in laparoscopic transverse colectomy. <h3>Disclosure of interest</h3> None Declared.

Gastroesophageal varices (bleeding) and splenomegaly: the initial manifestations of some pancreatic body and tail carcinoma.

Gastroesophageal varices (bleeding) and splenomegaly: the initial manifestations of some pancreatic body and tail carcinoma.

Posterior ‘Superior Mesenteric Artery First’ Approach for Resection of Locally Advanced Pancreatic Cancer

En bloc resection of the superior mesenteric vein (SMV), portal vein (PV), and/or splenic vein (SV) with concomitant venous reconstruction is required in 11-65% of cases of locally advanced pancreatic cancer.1 Early retropancreatic dissection of the superior mesenteric artery (SMA) from behind the pancreatic head utilizing an 'artery first' approach has been reported to be an efficient and safe approach to pancreaticoduodenectomy when SMA involvement is suspected.2 Additionally, this technique has been shown to reduce blood loss and result in shorter PV clamp times.3 While there are multiple variations to 'artery first' resection,4 this video will illustrate the critical steps of using the 'posterior approach' in patients with locally advanced pancreatic cancer. This approach has the benefit of early identification of a replaced right hepatic artery, but may be difficult in obese patients or those with extensive peripancreatic inflammation. These difficulties may be overcome by utilizing an 'inferior supracolic (anterior) approach', but this necessitates early division of the pancreatic neck and stomach.5 METHODS: Select video clips were compiled from several pancreatoduodenectomies to demonstrate this technique. A variety of bipolar devices were utilized for dissection depending on surgeon preference. All patients were diagnosed with locally advanced pancreatic cancer by Americas Hepato-Pancreato-Biliary Association/Society of Surgical Oncology (AHPBA/SSO) consensus criteria, confirmed by biopsy, and completed neoadjuvant chemotherapy. Patients were restaged by pancreas protocol computed tomography scan at the end of chemotherapy and offered local resection if the tumor did not progress and they were medically fit. No Institutional Review Board approval was required. The operation begins by dividing the attachment of the transverse mesocolon to the right perinephric area and extending this down to the white line of Toldt, followed by a wide Kocher maneuver. The lateral attachments to the pancreatic head are then divided, thereby exposing the left renal vein. The lesser sac is entered directly over the uncinate, allowing for a full visceral rotation of the pancreatic head, and further facilitating exposure of the left renal vein. In the setting of malignancy, the SMA may now be palpated posterior to the pancreatic head and/or neck to confirm it is free of tumor. If tumor is invading the SMA, the pancreaticoduodenectomy is aborted prior to performing any gastrointestinal or pancreatic transections. If the SMA is free, the dissection is then carried on to the inferior aspect of the pancreatic neck. Here the SMV (jejunal and ileal branches), middle colic vein, and the gastroepiploic vein are identified and the latter is ligated and transected. Following this, dissection of the portal structures (hepatic arteries, gastroduodenal artery, common bile duct, and PV) is performed. The jejunum is then divided, the ligament of Treitz is taken down, and the jejunum is then mobilized to the patient's right side. This allows for clear visualization of the pancreatic head/uncinate/SMV relationship. At this point, proximal and distal control of the PV, SMV, and SV should be obtained using vessel loops or umbilical tape. The dissection then proceeds laterally along the SMA border (posterior to the pancreatic head). This is often facilitated by use of a bipolar sealing device due to a rich lymphovascular network. Once the lateral border of the SMA is clearly exposed, dissection along its longitudinal axis is performed utilizing the jejunum for traction. Following this dissection, larger vessels such as the inferior pancreaticoduodenal artery can be more readily identified and ligated to fully mobilize the pancreatic head. After the head is completely separated from the SMA, the neck is divided. This leaves the specimen attached solely by the PV and SMV, which greatly facilitates venous resection and reconstruction when necessary. The 'artery first' approach has been shown to be safe and feasible in pancreatic resections. This technique should be considered whenever tumor is thought to involve the SMV and/or PVs as a means to facilitate safe venous resection and reconstruction while preserving sound oncologic principles.

Gastric conduit-preserving, radical pancreaticoduodenectomy with microvascular reconstruction for pancreatic head cancer after esophagectomy: report of a case

Pancreaticoduodenectomy is a radical treatment for pancreatic head cancer. However, it is sometimes difficult to perform pancreaticoduodenectomy, particularly in patients who have previously undergone esophagectomy with gastric conduit reconstruction. We herein describe a surgical technique for radical pancreaticoduodenectomy with microvascular reconstruction that preserves the gastric conduit. A 72-year-old male with a previous history of esophagectomy and gastric conduit reconstruction for esophageal cancer was referred to our hospital for surgical treatment of advanced pancreatic head cancer. After considering both the cancer curability and preservation of the gastric conduit, we performed a standard pancreaticoduodenectomy, and added a microvascular anastomosis of the gastroduodenal artery to the right gastroepiploic artery. In addition, we also performed reconstruction of the right gastroepiploic vein. This radical pancreaticoduodenectomy with microvascular reconstruction was safely and successfully performed, and it preserved the gastric conduit. The 6-month follow-up showed recurrence-free survival and a good quality of life.

Sixty-Four–Slice Computed Tomography Angiography of Perigastric Veins With Image Fusion

The objective of this study was to assess the efficacy and clinical value of 64-slice computed tomography angiography (CTA) with image fusion for demonstrating the perigastric venous anatomy. Twenty-six patients with gastric cancer underwent abdominal CTA examinations. Computed tomography angiography of stomach and perigastric veins and arteries were reconstructed and fused using volume-rendering technique. The inflow and courses of perigastric veins as well as the spatial relationship among the perigastric veins, arteries, and stomach were compared with surgery. Compared with surgical findings, the visualization rate of the 7 perigastric veins on CTA was 90.9% to 100%. There was a statistically significant decrease in number of short gastric veins identified on CTA compared with surgery (P = 0.004). There was no statistically significant difference between the 2 modalities in detecting other perigastric veins including the left gastric vein, right gastric vein, right gastroepiploic vein, left gastroepiploic vein, posterior gastric vein, and gastrocolic trunk (P = 0.317, P = 0.157, P = 1, P = 1, P = 0.317, P = 1, respectively). Sixty-four-slice CTA with image fusion clearly depicts most of perigastric veins and their relationship with the stomach and perigastric arteries. It can facilitate gastrectomy.

Isolated gastric variceal bleeding caused by splenic lymphoma-associated splenic vein occlusion

Isolated gastric varices (IGV) can occur in patients with left-sided portal hypertension resulting from splenic vein occlusion caused by thrombosis or stenosis. In left-sided portal hypertension, blood flows retrogradely through the short and posterior gastric veins and the gastroepiploic veins, leading to the formation of an IGV. The most common causes of splenic vein occlusion are pancreatic diseases, such as pancreatic cancer, pancreatitis, or a pseudocyst. However, various other cancers, such as colon, gastric, or renal cancers, have also been known to cause splenic vein occlusion. Our patient presented with a rare case of IGV bleeding induced by splenic lymphoma-associated splenic vein occlusion. Splenectomy, splenic artery embolization, and stenting of the splenic vein are the current treatment choices. Chemotherapy, however, is an alternative effective treatment for splenic vein occlusion caused by chemotherapy-sensitive tumors. Our patient responded well to chemotherapy with a cyclophosphamide, hydroxydaunorubicin, oncovin, and prednisolone regimen, and the splenic vein occlusion resolved after the lymphoma regressed.

Omental vascular pedicle sign: Multidetector CT finding useful for diagnosis of an omental mass

To describe multidetector CT findings of "omental vascular pedicle" sign. "Omental vascular pedicle" sign was defined as dilated omental vein associated with a mass located in omentum and was observed in 7 patients (5 women, 2 men). Mean age was 45 years. CT examinations and patient records were retrospectively reviewed. CT images were obtained by 16-MDCT (n = 1) and 64-dual source MDCT (n = 6). Curved planar and volume rendered images were reconstructed from axial images. Diameter of omental vein and drainage site were recorded. Images were evaluated by 2 radiologists in consensus. Pathologic diagnosis of patients with "omental vascular pedicle sign" was omental angiosarcoma (n = 1), endometrial adenocarcinoma (n = 2), ovarian serous adenocarcinoma (n = 2), mixed gonadal tumor (n = 1), malignant peripheral sheath tumor (n = 1). In 5 patients, omental vein drained into splenic vein and in 2 patients it drained into right gastroepiploic vein. Mean size of omental masses associated with omental vascular pedicle was 7.1 × 4.5 cm (range 15 × 11 cm to 2.7 × 1.6 cm). Mean diameter of omental vein was 3.1mm (range 6-1.5mm). Diameter of the omental vein increased with the increasing size of omental masses and Pearson's correlation coefficient was 0.99. "Omental vascular pedicle sign" can be helpful to objectively diagnose omental masses in patients with primary and metastatic omental tumors.

En-Bloc Free Gastroepiploic Artery Graft Provides a Good Long-Term Patency Rate

For coronary artery bypass grafting, the use of free gastroepiploic artery is unpopular because of its tendency to vasospasm. We assessed the en-bloc free gastroepiploic artery graft, which has the gastroepiploic vein anastomosed to the right atrial appendage to prevent graft spasm, and compared it to the skeletonized free gastroepiploic artery graft. A retrospective review was conducted in 57 patients who received en-bloc grafts and 29 who had skeletonized grafts. Kaplan-Meier analysis demonstrated the superiority of the en-bloc free gastroepiploic artery graft with an 80-month patency rate of 96.6% compared to 66.7% with skeletonized grafts. We selected 13 cases from each group, using propensity-score matching, and compared the long-term patency rates. Propensity-score matched analysis showed 80-month patency rates of 100% for en-bloc grafts and 60% for skeletonized grafts. Coronary artery bypass using free gastroepiploic artery grafts with venous drainage seems to provide good long-term results.

A Rare Cause of Life-Threatening Hematemesis

Question: A 46-year-old woman with renal cell carcinoma (RCC) in the left kidney underwent surgical intervention for complete nephrectomy 2 years ago. She had a 3-day history of melena and presented at the emergency room with acute vomiting containing fresh blood. Physical examination revealed pale conjunctivae and tachycardia without abdominal tenderness. Laboratory studies confirmed normocytic anemia (hemoglobin, 6.8 g/dL), thrombocytopenia (platelet count, 82,000/mm3), prerenal azotemia (blood urine nitrogen, 48 mg/dL; creatinine, 1.8 mg/dL), occult blood (4+) in stool samples, and normal liver function (aspartate aminotransferase, 24 U/L; alanine aminotransferase, 26 U/L). Panendoscopy (Figure A) revealed convoluted vessels protruding into the gastric fundus with a cluster-of-grapes-like appearance and multiple cherry-red spots on the overlying mucosa. Abdominal sonography (Figure B) showed a large, heterogeneous, hypoechoic lesion in the left renal fossa. Multidetector-row computed tomography (MDCT) scan (Figure C) was then performed. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Panendoscopy revealed an isolated gastric varices (GV) with stigmata of bleeding at the fundus of the stomach. MDCT scan disclosed the recurrent RCC (10 × 8 × 7 cm3) that compressed the SV (Figure C) resulting in left-sided portal hypertension (LSPH). The portal veins and superior mesenteric vein were patent and not encased. The diagnosis was recurrent RCC-related LSPH with GV bleeding. LSPH arising from isolated obstruction of the SV, such as thrombosis or stenosis often resulted from pancreatic pathology, is a rare clinical event that may lead to isolated GV bleeding. In patients with SV obstruction, splenic blood flows retrogradely through the short, posterior gastric and gastroepiploic veins resulting in the formation of GV. Isolated GV at the gastric fundus had been observed in only 1% of patients with portal hypertension and were more common in patients with LSPH.1Ryan B.M. Stockbrugger R.W. Ryan J.M. A pathophysiologic, gastroenterologic, and radiologic approach to the management of gastric varices.Gastroenterology. 2004; 126: 1175-1189Abstract Full Text Full Text PDF PubMed Scopus (264) Google Scholar Various malignant neoplasms other than pancreas, including colon cancer, gastric cancer, lymphoma, oat cell carcinoma, renal cancer, and retroperitoneal liposarcoma, have been rarely reported as the causes of SV obstruction.2Seyfettin K. Şahin Ç. Osman Y. et al.Left-sided portal hypertension.Dig Dis Sci. 2007; 52: 1141-1149Crossref PubMed Scopus (102) Google Scholar RCC leading to hematemesis because of bleeding from an isolated GV has been scarcely reported in literature.3Joya Seijo M.D. del Valle Loarte P. Marco Martinez J. et al.Sinistral portal hypertension with bleeding gastric varices as initial manifestation of renal cell carcinoma.An Med Interna. 2004; 21: 283-284PubMed Google Scholar However, recurrent RCC as the cause of isolated GV has not been reported yet. Further evaluations for LSPH need to be investigated in patients with GV bleeding who have a normal liver function and unexplained splenomegaly. Management of LSPH depends on the underlying cause. Splenectomy, splenic artery embolization, and stenting of the splenic vein are effectively therapeutic choices for patients of LSPH associated with GV.1Ryan B.M. Stockbrugger R.W. Ryan J.M. A pathophysiologic, gastroenterologic, and radiologic approach to the management of gastric varices.Gastroenterology. 2004; 126: 1175-1189Abstract Full Text Full Text PDF PubMed Scopus (264) Google Scholar Our patient underwent targeted therapy for the RCC, and the shrunken tumor mass observed on the follow-up MDCT scan was measured 7 × 5 × 4 cm3. The patient survived from this episode of life-threatening hematemesis and did not show any recurrence of GV bleeding at the 6-month follow-up.

Analysis of anatomic variants of mesenteric veins by 3-dimensional portography using multidetector-row computed tomography

Background It is important to be aware of mesenteric venous variants to perform peripancreatic surgery. We investigated the usefulness of 3-dimensional (3-D) portography. Methods Vessels were reconstructed using computer software in 102 patients undergoing multidetector-row computed tomography (MDCT) scheduled for gastrointestinal or hepatobiliary-pancreatic surgery. Results The superior mesenteric vein (SMV) was composed of single and double trunks around the splenoportal confluence in 78 and 24 patients, respectively. The inferior mesenteric vein joined the splenic vein (68.5%), SMV (18.5%), and splenoportal confluence (7.6%). The left gastric vein joined the splenic vein (46.3%), portal vein (39.0%), and splenoportal confluence (14.7%). Seventy-nine patients showed a gastrocolic trunk, mostly composed of the right gastroepiploic vein and veins from the colonic hepatic flexure. Intraoperative findings were identical to 3-D diagnosis in 68 gastrectomized and 9 pancreatectomized patients. Conclusion Although mesenteric venous tributaries are complex, 3-D portography is helpful for surgeons to safely perform peripancreatic surgery.

Fetal topohistology of the mesocolon transversum with special reference to fusion with other mesenteries and fasciae

The developing mesocolon transversum was investigated using hematoxylin and eosin-stained semiserial sections derived from 17 human fetuses between 12 and 30 weeks of gestation. The mesocolon was attached to the mesoduodenum and greater omentum until 12 weeks. However, the fetal duodenal attachment appeared not to correspond to the right colic flexure in adults. The greater omentum and mesocolon were likely to be irregularly folded at the attachment site possibly because the developing transverse colon "ran into" and pushed up the greater omentum and pancreatic head. Lymphatic vessels invaded the indistinct fusion plane to destroy the primary configuration. Moreover, the mesocolon seemed to "seize" or take-over some parts of the splenic side of the greater omentum, but the thick gastric side containing the right gastroepiploic artery and vein remained along the greater curvature. Until 20 weeks, the left colic flexure was fixed to the pancreatic tail, and near the flexure the mesocolon also fused with the renal fascia. The left splenic end of the greater omentum was folded and fused together to form a thick ligament-like structure, i.e., the gastrocolic ligament. In addition, near the duodenojejunal junction, a peritoneal bridge was often seen containing the inferior mesenteric artery or vein. Although surgeons generally believe that the mesocolon can be gently detached from the greater omentum, the fusion plane in adults appears to be the result of secondary modification and simplification by vascular development.

Laparoscopically harvested omental flap: results for 96 patients

Recent advances in endoscopic surgery have allowed laparoscopic harvesting of the omental flap with minimal deformity of the donor site. This study aimed to assess the safety and long-term complication rate for laparoscopic harvest of the omental flap (LHOF). From April 2002 to December 2008, 96 patients underwent LHOF for immediate reconstruction after breast cancer surgery. All the patients were evaluated for operating time, length of hospital stay, and the short- and long-term complications associated with LHOF. The omental flap was harvested successfully in 95 of 96 cases, and the total success rate for harvesting of the omental flaps was 99% without conversion to open surgery. The median operative time for harvesting of the omental flap was approximately 1 h. Five cases of partial graft necrosis (5.2%) and two cases of vascular injury (2.1%) to the gastroepiploic artery and vein occurred, and the graft survival rate was 96.8% (93 of 95 cases). Laparoscopy-associated complications occurred in eight cases (8.3%), including one incisional hernia. As a safe and minimally invasive procedure, LHOF has a low incidence of short- and long-term complications. This technique can expand the indications and usefulness of the omental flap.

Recanalized umbilical vein conduit for meso-Rex bypass in extrahepatic portal vein obstruction

Meso-Rex bypass is used to treat patients with clinically important extrahepatic portal vein obstruction (EHPVO). Usually, an autologous left internal jugular vein graft is used to bypass the portal blood circulation from the superior mesenteric vein to the left portal vein. Other vascular conduits have included the autogenous saphenous vein, splenic vein, right gastroepiploic vein, and inferior mesenteric vein. A total of 20 umbilical veins with attached livers were harvested from 20 deceased liver donors. Umbilical veins were dilated mechanically and checked for patency and communication with the left portal vein. Vein length and diameter after dilatation were recorded. Cross-sections of 15 recanalized umbilical veins were processed by routine histologic examination and stained with hematoxylin and eosin, as well as processed by immunohistochemistry for CD31 and factor VIII antigens. Subsequently, 3 children with EHPVO underwent this modified meso-Rex bypass using the umbilical vein as a vascular conduit. The mean length of harvested umbilical veins was 15 cm (range, 7-21); the mean length of recanalized and usable umbilical veins was 10 cm (range, 5-15). Recanalization was successful in 16 (80%) of the 20 donor umbilical veins. The mean diameter of the umbilical veins after serial dilatation and recanalization was 1.2 cm (range, 1-2). In 11 (73%) of the 15 recanalized vein specimens, the lumen was lined by endothelial cells. In 2 children, the vascular conduit was constructed entirely with native umbilical vein. In the remaining child, 3 cm of umbilical vein was preserved and anastomosed to a mobilized inferior mesenteric vein due to inadequate length. All 3 children had patent bypass and resolution of clinical manifestations of portal hypertension at a mean follow-up of 21 months. Meso-Rex bypass may prove to be a definitive treatment for patients with EHPVO. The use of native umbilical vein as a vein conduit achieved decompression of the splanchnic venous system and should be considered a natural alternative to other interposition vein grafts.