Inferior Mesenteric Vein Research Articles

Filter-Assisted Shunt Embolization of Large Portosystemic Shunts: Technical Feasibility, Safety, and Outcomes.

To describe the feasibility and outcomes of filter-assisted shunt embolization in patients with acquired large portosystemic shunts. Two-center HIPAA compliant retrospective study of all patients who underwent filter-assisted shunt embolization between 03/2015-03/2021. Initial clinical evaluation, including demographic information, shunt sizing, and procedural details, was reviewed. Technical success was defined as successful occlusion of the targeted shunt. Eight patients (55 ± 10years/88% male) had a large acquired portosystemic shunt which was suitable for filter-assisted shunt embolization. Indications for the procedure: 3 = pre-transplantation optimization, 2 = overt hepatic encephalopathy (HE), 1 = post-transplant thrombosis, 1 = portal vein thrombosis and encephalopathy, 1 = encephalopathy and variceal bleeding. Portosystemic shunts occurred between splenic and renal veins, inferior mesenteric and gonadal veins, and coronary veins. Mean shunt diameter was 27 ± 5mm. The technical success of the procedure was 8/8 (100%). In 7 patients, a transjugular intrahepatic portosystemic shunt (TIPS) was also placed at the time of the shunt embolization due to either pre-transplant indication or sluggish portal flow. There were no intraprocedural complications from filter placement. 3 = currently listed for transplant, 2 = resolution of HE, 1 = made CMO, 1 patient with patent post-transplant vasculature. 1 = died as a complication related to TIPS placement (SIR Class F Complication). Filter-assisted shunt embolization is a technically feasible and safe technique to reduce or embolize large portosystemic shunts.

3D mesenteric angiogram-based assessment of Arc of Riolan crossing the inferior mesenteric vein: important considerations in high ligation during splenic flexure takedown in anterior resection

BackgroundRecent studies have described the finding of the Arc of Riolan (AoR) crossing the inferior mesenteric vein (IMV) seen during high ligation of IMV while performing minimally invasive colectomies. However, the AoR usually has a medial course, and this variant AoR anatomic course and the clinical importance of its preservation during splenic flexure takedown in anterior resection remains controversial.MethodsAfter institutional approval (QA-5775), radiological identification of and mapping of the vessel horizontally crossing the IMV under the pancreas, when present, was performed at a single institution (Westmead Hospital, New South Wales, Australia). One hundred consecutive computed tomographic (CT) mesenteric angiograms conducted in 2018 were reviewed retrospectively to determine the presence of a vessel horizontally crossing the IMV. 3D reconstructions were used to map out its course to understand its origin and full course. Baseline characteristics, including demographic and comorbidity data, were obtained from the medical record.ResultsOn 3D mesenteric angiogram reconstructions, a vessel crossing anterior to the IMV was present in 11 of 98 cases (11.2%). Two cases were excluded as the presence of this vessel was indeterminate. Eight of 11 patients (72.7%) were male, and the mean age was 49.3 years (range: 21–80 years). There was no statistically significant difference in age and comorbidities between the groups. Importantly, in all 11 cases, there was an arterial vessel crossing the IMV originating from the SMA and communicating with the IMA or a branch of the IMA, proving definitively that this vessel was by definition the AoR.ConclusionThis 3D mesenteric angiogram mapping study has shown definitively that the vessel horizontally crossing anterior to the IMV and inferior to the pancreas is an arterial vessel from the SMA to IMA, and by definition the Arc of Riolan. When present, identification and preservation of this collateral arterial vessel during splenic flexure takedown in anterior resection may be important in reducing the risk of post-operative bowel ischaemia.

Re-interpreting mesenteric vascular anatomy on 3D virtual and/or physical models, part II: anatomy of relevance to surgeons operating splenic flexure cancer

BackgroundThe splenic flexure is irrigated from two vascular areas, both from the middle colic and the left colic artery. The challenge for the surgeon is to connect these two vascular areas in an oncological safe procedure.Materials and methodsThe vascular anatomy, manually 3D reconstructed from 32 preoperative high-resolution CT datasets using Osirix MD, Mimics Medical and 3-matic Medical Datasets, were exported as STL-files, video clips, stills and supplemented with 3D printed models.ResultsOur first major finding was the difference in level between the middle colic and the inferior mesenteric artery origins. We have named this relationship a mesenteric inter-arterial stair. The middle colic artery origin could be found cranial (median 3.38 cm) or caudal (median 0.58 cm) to the inferior mesenteric artery. The lateral distance between the two origins was 2.63 cm (median), and the straight distance 4.23 cm (median). The second finding was the different trajectories and confluence pattern of the inferior mesenteric vein. This vein ended in the superior mesenteric/jejunal vein (21 patients) or in the splenic vein (11 patients). The inferior mesenteric vein confluence could be infrapancreatic (17 patients), infrapancreatic with retropancreatic arch (7 patients) or retropancreatic (8 patients). Lastly, the accessory middle colic artery was present in ten patients presenting another pathway for lymphatic dissemination.ConclusionThe IMV trajectory when accessible, is the solution to the mesenteric inter-arterial stair. The surgeon could safely follow the IMV to its confluence. When the IMV trajectory is not accessible, the surgeon could follow the caudal border of the pancreas.Graphical abstract

Therapy Effect of the Stable Gastric Pentadecapeptide BPC 157 on Acute Pancreatitis as Vascular Failure-Induced Severe Peripheral and Central Syndrome in Rats.

We revealed the therapy effect of the stable gastric pentadecapeptide BPC 157 (10 μg/kg, 10 ng/kg ig or po) with specific activation of the collateral rescuing pathways, the azygos vein, on bile duct ligation in particular, and acute pancreatitis as local disturbances (i.e., improved gross and microscopy presentation, decreased amylase level). Additionally, we revealed the therapy’s effect on the acute pancreatitis as vascular failure and multiorgan failure, both peripherally and centrally following “occlusion-like” syndrome, major intoxication (alcohol, lithium), maintained severe intra-abdominal hypertension, and myocardial infarction, or occlusion syndrome, and major vessel occlusion. The application-sacrifice periods were ligation times of 0–30 min, 0–5 h, 0–24 h (cured periods, early regimen) and 4.30 h–5 h, 5 h–24 h (cured periods, delayed regimen). Otherwise, bile duct-ligated rats commonly presented intracranial (superior sagittal sinus), portal and caval hypertension and aortal hypotension, gross brain swelling, hemorrhage and lesions, heart dysfunction, lung lesions, liver and kidney failure, gastrointestinal lesions, and severe arterial and venous thrombosis, peripherally and centrally. Unless antagonized with the key effect of BPC 157 regimens, reversal of the inferior caval and superior mesenteric vein congestion and reversal of the failed azygos vein activated azygos vein-recruited direct delivery to rescue the inferior-superior caval vein pathway; these were all antecedent to acute pancreatitis major lesions (i.e., acinar, fat necrosis, hemorrhage). These lesions appeared in the later period, but were markedly attenuated/eliminated (i.e., hemorrhage) in BPC 157-treated rats. To summarize, while the innate vicious cycle may be peripheral (bile duct ligation), or central (rapidly developed brain disturbances), or peripheral and central, BPC 157 resolved acute pancreatitis and its adjacent syndrome.

Ischemic Colitis induced by COVID-19: A Case Report

COVID-19 has been associated with coagulation disorders which add further to the morbidity and mortality caused by the disease itself. Ischemic colitis can result from hypercoagulable states. In this report we present a rare case of ischemic colitis induced by COVID-19 in 27-year-old male. Patient presented with severe generalized abdominal pain. CT abdomen showed filling defects, absent enhancement indicating venous bowel ischemia. CT-angiograph revealed complete thrombosis of portal, splenic, superior and inferior mesenteric veins. Patient was shifted to intensive care unit and kept nothing per orum. He was given Heparin, tramadol and paracetamol intravenously. COVID-19 Reverse transcription–polymerase chain reaction (RT–PCR) was positive. He was then given Favipiravir through nasogastric (NG) tube. On 4th day NG was removed and patient was subsequently discharged on 9th day. COVID-19 may lead to hypercoagulable states and gastrointestinal complications. COVID-19 patients with gastrointestinal symptoms should be evaluated carefully for possible ischemia.

Principles and Surgical Techniques in the Management of Intraoperative Retroperitoneal Vascular Injury

Objective: To assess the surgical techniques and ideas in the treatment of the intraoperative retroperitoneal vascular injury. Methods: Between Oct 2017 and Dec 2019, 85 retroperitoneal tumor patients with retroperitoneal vascular injury intraoperatively in Changhai Hospital, Naval Medical University were analyzed retrospectively. Among them, the arterial injury occurred in 52 patients, the venous injury occurred in 49 patients, and 16 patients had both arterial and venous injuries. Main disease diagnosis, common types of vascular injury, different management methods, and results of vascular injury were analyzed. Results: The most common type of diagnosis is a retroperitoneal primary malignant tumor, followed by metastatic malignant tumor and retroperitoneal benign tumor. The most frequent injury arteries were the aorta (12 patients) and common iliac artery (12 patients), followed by the external iliac artery (6 patients) and superior mesenteric artery (6 patients). The most frequent injury vein was inferior vena cava (10 patients), followed by internal iliac vein (7 patients), external iliac vein (6 patients), inferior mesenteric vein (6 patients), and common iliac vein (4 patients). A total of 19 patients received artificial vessels replacements, including aortic replacement (4 patients), renal artery replacement (1 patient), superior mesenteric artery (2 patients), common iliac artery (5 patients), external iliac artery (3 patients), inferior vena cava (1 patient), Right renal vein (1 patient), common iliac vein (1 patient) and external iliac vein (1 patient). The remaining patients underwent ligation and sutures to achieve hemostasis. All patients attained hemostasis in the operating room and were admitted to medical wards or the medical ICU. After artificial vessels replacements, one patient died of DIC postoperatively, other patients had an uneventful perioperative course, no anastomotic bleeding was reported. Conclusion: In the management of intraoperative retroperitoneal vascular injury, it is important to assess the extent of injury, select reasonable remediation methods, and adopt artificial vessels replacements when necessary.

A study on spinal level, length, and branch type of the inferior mesenteric artery and the position relationship between the inferior mesenteric artery, left colic artery, and inferior mesenteric vein

BackgroundThis study was aimed to explore the clinical application of dual-energy computed tomography (DECT) monoenergetic plus (mono+) imaging to evaluate anatomical variations in the inferior mesenteric artery (IMA).MethodsThe clinical and imaging data of 212 patients who had undergone total abdominal DECT were retrospectively analyzed. The post-processing mono+ technique was used to obtain 40-keV single-level images in the arterial phase. Three-dimensional reconstruction was performed to evaluate the relationship between the IMA root position and the spinal level, IMA length, and IMA branch type, as well as the position of the left colic artery (LCA) and inferior mesenteric vein (IMV) at the IMA root level.ResultsThe IMA root was located at the L3 level in 78.3% of cases and at the L2/L3 level in 3.3%. The highest vertebral level of IMA origin was L2 (4.2%), and the lowest was L4 (7.1%). The distance from the IMA root to the level of the sacral promontory was 99.58 ± 13.07 mm, which increased with the elevation of the IMA root at the spinal level. Of the patients, 53.8% demonstrated Type I IMA, 23.1% Type II, 20.7% Type III, and 2.4% Type IV. The length of the IMA varied from 13.6 to 66.0 mm. 77.3% of the IMAs belonged to Type A, the adjacent type, and 22.7% to Type B, the distant type.ConclusionDECT mono+ can preoperatively evaluate the anatomical characteristics of the IMA and the positional relationship between the LCA and IMV at the IMA root level, which would help clinicians plan individualized surgery for patients.

Human portal system morphometry based on 3D computer aided modelling

There is no discussion about human portal system variability. Features of interposition, veins branching included in this system, stereometric and lineal characteristics define its development, stream and ways of operation interference for several surgery diseases, which all in all decides the end of surgery pathology. Morphometry study of portal system using computer-aided modelling and methods of computational anatomy has been performed. DICOM data segmentation was performed using Dragonfly software (Object Research Systems, Canada) at the Innovation Technology Management Resources of the Reaviz University. Using series with arterial and vein contrast, we performed the segmentation of contrasting vessels, obtained three-dimensional data topology in .obj format. Then we processed the obtained models using scripts prepared for the pythonOCC framework. We built the central lines of the vessels and formed the branching tree. Methods of computational hemodynamics were implemented using the Visual-CFD application for OpenFOAM environment (ESI, France). Veins forming the portal vein are presented by three systems; in every one of them there are scapi and affluxes, which are different in branching types and other morphological characteristics. The superior mesenteric vein, for instance, is characterized by interjacent branching type, has one scapus 93,5 (78,5; 119,5) mm in length and diameter 9,5 (6,5; 12,0) mm, going to portal vein under the corner 170,0 (160,0; 175,0)0, and formed by venous inflows of majority unpaired organs of upper and down floors in abdominal cavity. Affluxes of the superior mesenteric vein have almost the same diameter from 3,5 to 12 mm but the length. The shortest affluxes are jejunal ones (40,0 (38,5; 46,5) mm) and right gastroepiploic vein (45,0 (38,5; 53,5) mm), then iliac (50,0 (48,5; 53,5) mm), middle colonic (60,0 (58,5; 63,5) mm) and iliac colonic (70,0 (68,5; 78,5) mm) veins. The system of inferior mesenteric vein contains a lower number of veins going to its bed in comparison with vessels net of superior mesenteric vein. Magistral type of branching of inferior mesenteric vein is found in 23% of cases and in 77% of cases it has interjacent type of branching. In case of interjacent type of branching mesenteric vein goes to superior mesenteric vein between right colonic and jejuna veins. Inferior mesenteric vein of magistral type goes to splenic vein in most cases (as it is shown on picture 1) or it is independent afflux of portal vein. Its diameter is significantly less than diameter of superior mesenteric vein and makes 4,5 (2,0; 6,5) mm. The current research gives quantitative orienting points for main vein structures of portal vein system. The research results have allowed adding science materials about types of branching and morphological patterns of portal vein and its branching. Variations common for every system are preferably being used for regulation of the discussed subject in terms of tactic patients’ curing with syndrome of portal hypertension or at the step of pre surgical preparation.

Vascular Resection in Pancreatectomy-Is It Safe and Useful for Patients with Advanced Pancreatic Cancer?

Simple SummaryPancreatic ductal adenocarcinoma (PDAC) is a lethal disease with poor prognosis and increased incidence. Surgical resection R0 remains the most important treatment to prolong survival in PDAC patients. In borderline and locally advanced cancer, vascular resection and reconstruction during pancreatectomy enables achieving R0 resection. This study is a comprehensive review of the literature regarding the role of venous and arterial resection with vascular reconstruction in the treatment of pancreatic cancer.Pancreatic ductal adenocarcinoma (PDAC) is a lethal disease with poor prognosis and increased incidence. Surgical resection R0 remains the most important treatment to prolong survival in PDAC patients. In borderline and locally advanced cancer, vascular resection and reconstruction during pancreatectomy enables achieving R0 resection. This study is a comprehensive review of the literature regarding the role of venous and arterial resection with vascular reconstruction in the treatment of pancreatic cancer. The literature review is focused on the use of venous and arterial resection with immediate vascular reconstruction in pancreaticoduodenectomy. Different types of venous and arterial resections are widely described. Different methods of vascular reconstructions, from primary vessel closure, through end-to-end vascular anastomosis, to interposition grafts with use autologous veins (internal jugular vein, saphenous vein, superficial femoral vein, external or internal iliac veins, inferior mesenteric vein, and left renal vein or gonadal vein), autologous substitute grafts constructed from various parts of parietal peritoneum including falciform ligament, cryopreserved and synthetic allografts. The most attention was given to the most common venous reconstructions, such as end-to-end anastomosis and interposition graft with the use of an autologous vein. Moreover, we presented mortality and morbidity rates as well as vascular patency and survival following pancreatectomy combined with vascular resection reported in cited articles.

Functional side-to-side splenorenal shunts to treat extrahepatic portal vein thrombosis in children

BackgroundSurgical shunts are commonly used to manage complications resulting from extrahepatic portal vein thrombosis (EHPVT) in children. We describe a single-center experience utilizing a functional Side-to-Side Splenorenal Shunt (fSRS), created using either an enlarged inferior mesenteric vein (IMV) or left adrenal vein (LAV). MethodsPediatric patients with isolated EHPVT who were poor candidates for a Rex shunt and who underwent a fSRS procedure at our institution between 2003 and 2020 were reviewed. The pre/post shunt portosystemic gradient change, rates of early and late complications, postoperative shunt patency, and mortality were evaluated. ResultsTwelve EHPVT patients (mean age of 6.1 years) underwent a fSRS procedure. The mean portosystemic gradient change for the cohort was −11.7 mmHg (±4.9). There were no cases of recurrent variceal bleeding or episodes of shunt thrombosis reported after fSRS procedures. ConclusionsSurgical shunts continue to be an important adjunct in the treatment of complications related to EHPVT. The functional Side-to-Side Splenorenal Shunt is a safe alternative that is easy to perform, involves minimal dissection and requires only a single anastomosis.

Clinical Benefit of Preserving Inferior Mesenteric Vein in Laparoscopic Curative Resection for Descending and Splenic Flexure Colon Cancer: A Comparative Study of CT-based objective Evidence

Background: Although the presence of remnant long sigmoid colon after left hemicolectomy with inferior mesenteric vein (IMV) ligation is a major risk factor for venous ischemia, there is insufficient objective evidence to support the clinical benefit of IMV preservation in curative resection for distal transverse, descending and splenic flexure colon cancer. This study was to confirm the patency through CT after IMV preservation in laparoscopic left hemicolectomy for distal transverse, descending and splenic flexure colon cancer, and to analyze the clinical outcomes compared to the IMV ligation group.

Single-Incision Laparoscopic Complete Mesocolic Excision With Central Vascular Ligation for Descending Colon Cancer.

Single-incision laparoscopic complete mesocolic excision with central vascular ligation for descending colon cancer is technically challenging. Standardization of the surgical procedures is therefore needed. In a Trendelenburg position with left side elevated, the sigmoid mesocolon is mobilized using a medial-to-lateral approach, and the left colic artery and inferior mesenteric vein (IMV) are divided after radical lymphadenectomy along the inferior mesenteric artery, preserving the superior rectal artery. The descending mesocolon is mobilized from the retroperitoneal planes up to the dorsal surface of the pancreas using medial and lateral approaches. Next, changing the surgical position to a reverse Trendelenburg position with left side elevated, the omental bursa is opened, and the transverse mesocolon is separated from the inferior border of the pancreas. The splenocolic ligament and lateral attachment are then divided, matching the previous medial dissection of the retroperitoneum, and the splenic flexure is fully mobilized. The IMV is divided again at the inferior border of the pancreas. The left branch of the middle colic artery is also divided. Forty-seven consecutive patients with DCC underwent single-incision laparoscopic CME with CVL. One patient required an additional port. Median operative time, blood loss, and number of harvested lymph nodes were 240min (interquartile range [IQR], 195-257min), 5mL (IQR, 5-52mL), and 21 (IQR, 13-29), respectively. Morbidity rate was 5.9%. Median duration of hospitalization was 9days (IQR, 7-11days). Single-incision laparoscopic CME with CVL is safe and feasible for DCC.

ANATOMICAL VARIATIONS OF PORTAL VENOUS SYSTEM: IMPORTANCE IN SURGICAL CLINIC.

ABSTRACT - BACKGROUND:Knowledge of the portal system and its anatomical variations aids to prevent surgical adverse events. The portal vein is usually made by the confluence of the superior mesenteric and splenic veins, together with their main tributaries, the inferior mesenteric, left gastric, and pancreaticoduodenal veins; however, anatomical variations are frequent.AIM: This article presents a literature review regarding previously described anatomical variations of the portal venous system and their frequency.METHODS: A systematic review of primary studies was performed in the databases PubMed, SciELO, BIREME, LILACS, Embase, ScienceDirect, and Scopus. Databases were searched for the following key terms: Anatomy, Portal vein, Mesenteric vein, Formation, Variation, Variant anatomic, Splenomesenteric vein, Splenic vein tributaries, and Confluence.RESULTS: We identified 12 variants of the portal venous bed, representing different unions of the splenic vein, superior mesenteric vein, and inferior mesenteric vein. Thomson classification of the end of 19th century refers to the three most frequent variants, with type I as predominant (M=47%), followed by type III (M=27.8%) and type II (M=18.6%).CONCLUSION: Thomson classification of variants is the most well-known, accounting for over 90% of portal venous variant found in clinical practice, inasmuch as the sum of the three junctions are found in over 93% of the patients. Even though rarer and accounting for less than 7% of variants, the other nine reported variations will occasionally be found during many abdominal operations.

Diverticulitis complicated by colovenous fistula formation and pylephlebitis

Acute diverticulitis is associated with a range of complications including fistula formation. Colovenous fistula formation, where there is a fistula between the inferior mesenteric vein and colon, is an extremely rare and serious complication of diverticulitis. Pylephlebitis, which is defined as infective suppurative thrombosis of the portal vein, is another uncommon complication of any intra-abdominal source of infection, including diverticulitis. Both complications are independently associated with significant morbidity and mortality. We report a case of a patient with acute diverticulitis who subsequently developed both colo-venous fistula and pylephlebitis and was successfully managed conservatively.

Features of morphometric parameters of vessels in the human portal venous system identified by multislice computed tomography

The aim of this study was to identify the morphometric features of the human portal venous system by means of multislice computed tomography (MSCT).Materials and methods. A contrast X-ray study of the portal vein was carried out in 53 men who were treated in the surgical departments of the Krasnoyarsk Regional Hospital No. 1. The average age of the patients was 54.9 ± 1.7 years (36–71 years). Measurements were performed on 3D models of the vascular bed in the portal venous system (GE Advantage Workstation and Siemens singo.via workstations). Branching patterns, length, diameter, angle of the portal vein formation relative to the midline of the human body, and angles of formation of the vessels forming the portal vein in the frontal plane were evaluated.Results. Variations in the morphometric parameters of the intrahepatic vessels of the portal vein are obvious, although the branching patterns are not diverse and are reduced to one type – the magistral pattern (according to V.N. Shevkunenko). The veins that form the portal vein are represented by three systems, each of which has a stem and tributaries that differ in branching patterns and other morphological characteristics.Conclusion. The findings of the study made it possible to supplement the scientific materials regarding branching patterns and morphological characteristics of the portal vein and its tributaries as well as to use the morphometric characteristics of the superior and inferior mesenteric and splenic veins to resolve the issues of surgical intervention on the abdominal organs.

Isolated Giant Mesenteric Vein and Anomalous Inferior Mesenteric Vein Insertion in the Presence of Cirrhosis – A Cadaveric Case Report

The inferior mesenteric vein is one of the tributaries of the portal vein which receives blood from the large intestine, sigmoid colon and the rectum. It usually connects with the splenic vein before draining into the portal vein. It may however show variations such as joining the superior mesenteric vein directly or to the confluence of the superior mesenteric vein and splenic vein. Varices of the inferior mesenteric vein can be seen in the presence of portal hypertension due to various reasons and this can be isolated or in association with other portosystemic collaterals. We report a case of a giant isolated inferior mesenteric vein with an anomalous insertion. The inferior mesenteric vein was seen to be connected to the superior mesenteric vein before draining into the portal vein. Further, on the distal end it was seen to be connected to the left renal vein, which in turn had dilated and enlarged. The left testicular vein was observed draining in to the inferior mesenteric vein but was not enlarged. The superior mesenteric vein, splenic vein and portal vein were not enlarged or varicosed even though the liver showed features of cirrhosis with no obvious signs of splenic enlargement. This report contributes to enhance the knowledge on a rare anatomical connection between portal system and the systemic circulation and will be important to surgeons operating in this area.

ЭМБОЛИЯ БАРИЕМ ВОРОТНОЙ ВЕНЫ И ПЕЧЕНИ

Background. An upper and lower gastrointestinal (GI) series is an available and informative diagnostic test. Side effects are extremely rare. Objective. To present a case description of portal vein and liver barium embolism with a fatal outcome and explain the mechanism of its occurrence. Material and methods. The clinical manifestations, laboratory and instrumental findings, as well as autopsy of a female patient who died after lower GI radiography were analyzed. Results. To exclude intestinal obstruction, the patient underwent a barium follow through. Three days later, during X-ray computed tomography, barium and gas were detected in the inferior mesenteric vein, portal vein and its intrahepatic branches. During colonoscopy, diverticula of the sigmoid colon were detected, but the localization of the intestinalvenous fistula wasn’t determined. Conservative surgery failed and the death occurred 15 days after radiography. Conclusions. The autopsy revealed that the site of entry for the development of barium embolism as well as for gas, were diabrotic veins in peridiverticular abscesses localized in pericolic tissue.

Exploring Central Vascular Anatomy With Axial Computed Tomography During Surgery for Sigmoid Colon and Rectal Cancer: New Insights Into the Anatomical Relationship Between the Inferior Mesenteric Artery and the Duodenum

Background: In some individuals, the inferior mesenteric artery (IMA) originates from the aorta above the lower edge of the duodenum. This anatomical feature has rarely been reported but may be important in guiding central vascular ligation and lymph node dissection in colorectal surgery. This retrospective study aimed to explore the anatomical relationship between the IMA and the duodenum and evaluate its potential impact on the efficacy of D3 lymph node dissection.Methods: A total of 439 patients undergoing laparoscopic colorectal surgery at the Department of General Surgery, Qilu Hospital of Shandong University, were retrospectively enrolled. Clinical data from axial computed tomography (CT) scans were collected and analysed.Results: In 27.69% of patients, the IMA originated at or above the lower edge of the duodenum (median distance: −8 mm). These patients were characterised by a shorter superior mesenteric artery to aortic bifurcation distance, a superiorly located IMA origin, and a greater distance between the IMA and both the left colic artery and the inferior mesenteric vein. The number of harvested lymph nodes was not significantly associated with the distance between the IMA and the duodenum (P = 0.858).Conclusions: Preoperative axial CT scans can provide a great deal of information regarding central vascular anatomy in the context of sigmoid colon and rectal cancer surgery. Nearly one-third of patients have the IMA originating at or above the duodenum. Whether this anatomical feature affects D3 lymph node dissection warrants further investigation.

Stable Gastric Pentadecapeptide BPC 157 Therapy for Primary Abdominal Compartment Syndrome in Rats.

Recently, the stable gastric pentadecapeptide BPC 157 was shown to counteract major vessel occlusion syndromes, i.e., peripheral and/or central occlusion, while activating particular collateral pathways. We induced abdominal compartment syndrome (intra-abdominal pressure in thiopental-anesthetized rats at 25 mmHg (60 min), 30 mmHg (30 min), 40 mmHg (30 min), and 50 mmHg (15 min) and in esketamine-anesthetized rats (25 mmHg for 120 min)) as a model of multiple occlusion syndrome. By improving the function of the venous system with BPC 157, we reversed the chain of harmful events. Rats with intra-abdominal hypertension (grade III, grade IV) received BPC 157 (10 µg or 10 ng/kg sc) or saline (5 ml) after 10 min. BPC 157 administration recovered the azygos vein via the inferior–superior caval vein rescue pathway. Additionally, intracranial (superior sagittal sinus), portal, and caval hypertension and aortal hypotension were reduced, as were the grossly congested stomach and major hemorrhagic lesions, brain swelling, venous and arterial thrombosis, congested inferior caval and superior mesenteric veins, and collapsed azygos vein; thus, the failed collateral pathway was fully recovered. Severe ECG disturbances (i.e., severe bradycardia and ST-elevation until asystole) were also reversed. Microscopically, transmural hyperemia of the gastrointestinal tract, intestinal mucosa villi reduction, crypt reduction with focal denudation of superficial epithelia, and large bowel dilatation were all inhibited. In the liver, BPC 157 reduced congestion and severe sinusoid enlargement. In the lung, a normal presentation was observed, with no alveolar membrane focal thickening and no lung congestion or edema, and severe intra-alveolar hemorrhage was absent. Moreover, severe heart congestion, subendocardial infarction, renal hemorrhage, brain edema, hemorrhage, and neural damage were prevented. In conclusion, BPC 157 cured primary abdominal compartment syndrome.

Portal Perfusion Through the Splenic Vein During Liver Procurement.

Livers procured via donation after cardiac death have produced good outcomes. Some centers use only aortic perfusion; others add portal perfusion. We report a series of organ procurements in which portal perfusion was performed via cannulation of the splenic vein instead of the inferior mesenteric vein in 4 donors after cardiac death and 2 donors after brain death. After declaration of death, donors were brought to the operating room and prepared and draped. During procurement, first the aorta was cannulated, and then the atrium or inferior vena cava was opened and perfusion was started.The spleen was mobilized, the splenic vein was dissected out and cannulated, and portal perfusion was performed with 2 L of University of Wisconsin solution. Five liver allografts were transplanted: 3 at our center, and 2 at outside centers. One liver from a donor after cardiac death was declined because of a high fat content. All 5 transplanted grafts showed good initial function; there was no sign of primary nonfunction, and no vascular or biliary complications developed. For livers from donors after cardiac death, cannulation of the splenic vein was easier than access via the inferior mesenteric vein. For donors after brain death, we also found this technique was suitable for livers with intra-abdominal adhesions or a small inferior mesenteric vein. Graft outcomes in this series were excellent.