Inferior Mesenteric Vein Research Articles

ANATOMICAL VARIANTS OF INFERIOR MESENTERIC VEIN ACCORDING ON THE DATA OF MULTISPIRAL COMPUTED TOMOGRAPHY

Knowledge of the variants of the anatomical variability of the liver vascular bed can be of critical importance in liver resection, liver transplantation, laparoscopic operations, resection of the pancreas, surgical treatment of portal hypertension The main vessels of the hepatic portal vein system are characterized by pronounced anatomical variability in the formation of the portal vein trunk, the greatest variability is characterized by inferior mesenteric vein. The aim of the investigation was to study the variant anatomy of the inferior mesenteric vein according to multispiral computed tomography. The material was 100 multispiral computed tomograms of the abdominal organs from the archive of the clinics of the Samara State Medical University for 2018-2019. For mathematical modeling and the creation of three-dimensional models based on tomograms of the vascular bed, plugins were used in the programs «Luch» and «Autoplan». Variants of the portal vein formation, the angle of inflow of the inferior mesenteric vein into the superior mesenteric and splenic veins, the distance from the point of confluence of the inferior mesenteric vein to the point of confluence with the portal vein were studied. The study revealed that the inferior mesenteric vein in 40% of cases flows into the splenic vein, in 39% - into the angle of confluence of the superior mesenteric and splenic veins, in 16% - into the superior mesenteric vein. In 5% of cases, the absence of the inferior mesenteric vein was revealed. The angle of fusion of the inferior mesenteric vein with the superior mesenteric vein was statistically significantly greater than the angle of fusion of the inferior mesenteric vein with the splenic vein. The angles were 76.36 ± 1.53 ° and 64.89 ± 3.52 °, respectively (p = 0.004). The length of the common trunk of the inferior mesenteric and splenic veins was significantly greater than the common trunk of the mesenteric veins and amounted to 16.98 ± 1.09 mm and 9.37 ± 0.65 mm (p = 0.001), respectively. Thus, the study showed a high degree of anatomical variability of the inferior mesenteric vein.

Precision vascular anatomy for minimally invasive distal pancreatectomy: A systematic review.

Minimally invasive distal pancreatectomy (MIDP) is increasingly performed worldwide; however, the surgical anatomy required to safely perform MIDP has not yet been fully considered. This review evaluated the literature concerning peripancreatic vascular anatomy, which is considered important to conduct safe MIDP. A database search of PubMed and Ichushi (Japanese) was conducted. Qualified studies investigating the anatomical variations of peripancreatic vessels related to MIDP were evaluated using SIGN methodology. Of 701 articles yielded by our search strategy, 76 articles were assessed in this systematic review. The important vascular anatomy required to recognize MIDP included the pancreatic parenchymal coverage on the root and the running course of the splenic artery, branching patterns of the splenic artery, confluence positions of the left gastric vein and the inferior mesenteric vein, forms of pancreatic veins including the centro-inferior pancreatic vein, characteristics of the left renal vein, and collateral routes perfusing the spleen following Warshaw's technique. Very few articles evaluating the relationship between the anatomical variations and surgical outcomes of MIDP were found. The precise knowledge of peripancreatic vessels is important to adequately complete MIDP. More detailed anatomic analyses and descriptions will benefit surgeons and their patients who are facing these operations.

Definition and characterization of the descending branch of the left colic artery.

The descending branch of the left colic artery (dLCA) is under-recognized and has not been clearly defined. The dLCA is often confused with the sigmoid artery (SA) originating from the left colic artery (LCA). We clarified the anatomical characteristics of the dLCA and searched for surrogate measures to identify it. Arterial phase, venous phase, and three-dimensional images of abdominal arteries were created in 411 patients using contrast-enhanced computed tomography (CT). We analyzed the branching patterns of the inferior mesenteric artery (IMA) based on CT. The dLCA was defined as the artery originating from the LCA that flows into the marginal artery along the descending colon. We tested three candidate diagnostic measures for the dLCA using positional relationships and the segment length of vessels. Arteries from the LCA were present in 360 patients, among which 459 dLCAs and 165 SAs were identified in 333 and 146, respectively. By the first measure of identifying the artery with its root lateral to the inferior mesenteric vein (IMV) as the dLCA, the sensitivity, specificity, and accuracy rate were 94%, 87%, and 92%, respectively. The second measure of identifying the artery with its root higher than the root of the IMA as the dLCA and the third of identifying the artery with its root located > 27.6mm from the root of LCA as the dLCA yielded lower accuracy rates (69% and 89%, respectively). Our study demonstrated that dLCAs are prevalent (93%) and may be easily found lateral to the IMV in clinical practice.

Re-interpreting mesenteric vascular anatomy on 3D virtual and/or physical models: positioning the middle colic artery bifurcation and its relevance to surgeons operating colon cancer

BackgroundThe impact of the position of the middle colic artery (MCA) bifurcationand the trajectory of the accessory MCA (aMCA) on adequate lymphadenectomy whenoperating colon cancer have as of yet not been described and/or analysed in theliterature. The aim of this study was to determine the MCA bifurcation position toanatomical landmarks and to assess the trajectory of aMCA.MethodsThe colonic vascular anatomy was manually reconstructed in 3D fromhigh-resolution CT datasets using Osirix MD and 3-matic Medical and analysed. CTdatasets were exported as STL files and supplemented with 3D printed models whenrequired.ResultsThirty-two datasets were analysed. The MCA bifurcation was left to thesuperior mesenteric vein (SMV) in 4 (12.1%), in front of SMV in 17 (53.1%) and rightto SMV in 11 (34.4%) models. Median distances from the MCA origin to bifurcation were3.21 (1.18–15.60) cm. A longer MCA bifurcated over or right to SMV, while a shorterbifurcated left to SMV (r = 0.457, p = 0.009). The main MCA direction was towards right in19 (59.4%) models. When initial directions included left, the bifurcation occurredleft to or anterior to SMV in all models. When the initial directions included right,the bifurcation occurred anterior or right to SMV in all models. The aMCA was foundin 10 (31.3%) models, following the inferior mesenteric vein (IMV) in 5 near thelower pancreatic border. The IMV confluence was into SMV in 18 (56.3%), splenic veinin 11 (34.4%) and jejunal vein in 3 (9.4%) models.ConclusionAwareness of the wide range of MCA bifurcation positions reported iscrucial for the quality of lymphadenectomy performed. The aMCA occurs in 31.3% modelsand its trajectory is in proximity to the lower pancreatic border in one half ofmodels, indicating that it needs to be considered when operating splenic flexurecancer.

Redefining the collateral system between the superior mesenteric artery and inferior mesenteric artery: a novel classification.

The aim of this study was to evaluate the arterial collateral vasculature between the superior mesenteric artery and the inferior mesenteric artery (IMA) from a surgical perspective. A total of 107 fresh adult cadavers (94 male) were studied with emphasis on the vascular anatomy of the left colon. Dissections were carried out mimicking the anterior resection technique. The vasculature of the left mesocolon and the collaterals between the superior mesenteric artery and the IMA with respect to their relationship to the inferior mesenteric vein (IMV) were assessed and classified. Collaterals were classified into three different groups: marginal anastomoses (via the marginal=pericolic artery), intermediate mesocolic anastomoses (parallel to the marginal artery but neither adjacent to the IMV nor close to the duodenum) and central mesocolic anastomoses (next to the IMV at the level of the duodenojejunal junction and the lower border of the pancreas). All patients had a marginal anastomosis. However, the marginal anastomosis, as the only anastomosis between the superior and inferior mesenteric arteries at the splenic flexure, was observed in 41 cases (38%). In addition to the marginal artery, intermediate mesocolic anastomoses were found in 49 (46%) and a central mesocolic anastomosis was observed in 17 (16%) of the 107 cases in the splenic flexure mesocolon. It is in this latter variant that collateral vessels can be compromised during ligation/transection of the IMV. This new classification can contribute to a precise mesocolic dissection technique and splenic flexure mobilization and help prevent ischaemic damage to the descending colon.

Proctalgia secondary to rectal arteriovenous malformation and inferior mesenteric vein stenosis in a patient post liver transplant

BackgroundChronic proctalgia can have a major impact upon quality of life. There are many potential aetiologies however, in some patients no cause can be identified.Case presentationWe present a patient post liver transplant with intractable proctalgia, despite multidisciplinary management including opioids, nerve blocks and surgical intervention. An underlying rectal arteriovenous malformation (AVM) was subsequently identified and successfully treated with embolotherapy. The onset of symptoms coincided with the development of inferior mesenteric vein stenosis, likely leading to engorgement of the malformation due to impaired venous outflow. Neovascularisation secondary to the liver transplant procedure may also have contributed to growth of the lesion.ConclusionThis is a rare presentation of rectal AVM. These lesions can be treated with minimally invasive embolisation/sclerotherapy and should be considered in cases of unexplained proctalgia.

Вариантная анатомия бассейна нижней брыжеечной вены

Aim of study. The inferior mesenteric vein has three variants of the ostium. Each variant of the inferior mesenteric vein ostium has its morphological peculiarities. According to literatures, the occurrence is different between the variants of the confluence. The aim of this study was to determine the morphometric characteristics of veins forming different variants of the inferior mesenteric vein ostium and the occurrence of the two formation types of this vein (the magistral one and the transitional one). Material and methods. Vessels (inferior mesenteric veins) of 53 male patients undergoing treatment in surgery departments of the Krasnoyarsk Regional Clinical Hospital No.1 were enhanced with contrasting agents, studied and analysed. The work was performed using 3D-models of the vascular bed of the portal system (GE Advantage Workstations, Siemens singo.via) based on MSCT of the abdominal cavity with bolus contrast enhancement using the Ultravist-370 agent. We applied an original method for manufacturing of corrosion preparations of vessels (RF Patent for an invention “method of manufacturing models of human rectal veins” No.2545921 dated 26.02.15) and studied morphological parameters using 85 vein models of the colon, the sigmoid colon and the rectum. Results. The occurrence rates are different for the variants of the inferior mesenteric vein confluence (serving as the root for the portal vein in 5.5%, as the tributary of the splenic vein in 17.5% and draining into the superior mesenteric vein in 77% of the cases). The length of the inferior mesenteric vein differs for its confluence variants and varies from 54.5mm to 108.5mm; the diameter varies from 4.0 to 7.2mm. The magistral formation type of the inferior mesenteric vein is revealed in 23% of the cases and is characteristic to its drainage into the splenic vein or to its immediate junction with the portal artery trunk. In 77% of the cases, its formation type is transitional. Conclusion. The knowledge on ostium formation variants of the inferior mesenteric vein, inflow of its roots, characteristics of branches of the studied vessel is necessary for surgeons performing operations on the upper part of the abdominal cavity and for radiologists interpreting the images obtained at the stage before the operative intervention

Total laparoscopic left hemicolectomy with preservation of inferior mesenteric artery and vein combined with natural orifice specimen extraction

Introduction: For left side colon cancer surgery, the roots of the inferior mesenteric artery and vein (IMA/IMV) are generally cut to perform the D3 lymph node dissection. In these cases, the extended resection of the colon would be required owing to the poor blood supply of the colon. In order to reduce the risk of distal bowel ischaemia and anastomosis leakage and preserve more normal sigmoid colon function, we aimed to introduce an innovative method to preserve the IMA/IMV and present its efficacy and safety. Materials and Methods: From January to February in 2019, two advanced colonic splenic flexure cancer (CSFC) patients received total laparoscopic left hemicolectomy with preservation of IMA/IMV combined with natural orifice specimen extraction surgery. The surgery followed the D3 lymph node dissection principle. Results: Two patients underwent a total laparoscopic surgery and no cases were converted to open or laparoscopic-assisted surgery. The mean time of operation was 148 min and mean blood loss was 50 ml. The harvested lymph nodes were 17 and 39 respective and the length of normal bowel both proximal and distal to the tumor more than 10 cm. The mean time of post-operative hospitalisation was 6 days. There were no cases of intra-or post-operative morbidity, or of bleeding owing to vessel injury. Conclusion: It is an efficient and safe technique to treat CSFC in a setting of surgeons experienced in laparoscopic colorectal surgery.

Functioning arterial or venous riolan arch in localized pancreatic cancer. how it can change tactics?

Background: CT are obligatory before pancreatic surgery. Discovery of functioning arterial or venous Riolan arch (FRA) can have substantial influence on tactics. Aim: To assess importance of FRA discloser for decision making before pancreatic surgery. Patients: Retrospective analysis of 554 patients' consecutive preoperative CT data revealed arterial(n2) and venous(n5) FRA in 7 cases. Modification of treatment were assessed. Results: Arterial FRA was found in pancreatic body cancer(n2). 1.atherosclerotic occlusion of CA and SMA with symptomatic abdominal ischemia; 2.tumor involved CA on the background of endoluminally unreсonstructable SMA occlusion. In the first case CA stenting before distal pancreatectomy eliminated symptoms fully. In the second case after FOLFIRINOXn12 R0 DPCAR without SMA reconstruction was done because of good collateral supply. Uneventful postop period, discharge on days 10 and 13. Venous FRA in all the cases of PDAC of the head±body were the sign of full block of all SMV tributaries and already formed outflow through the splenic(SV) and/or inferior mesenteric(IMV) vein. In all these cases efficient neoadjuvant therapy and venous FRA were the weighty argument for pancreatic resection. Thrice it was done without venous reconstruction, twice with IMV transposition in SV, once with SMA resection. Uneventful postop period, discharge on days 10-19. One patient died 44 month (distant mets), the second died 19 months disease-free (MI), others alive 21,18,13,12 and 11 months after treatment. Conclusion: Delineation of FRA before pancreatic surgery is the indication for tactics change: endovascular treatment for arterial FRA and more aggressive surgery in case of venous FRA.

Hybrid Mini ALPSS as a Solution for a Complex Big Size Tumor

Introduction: ALPPS procedure is probably the last significative progress in the liver surgery. ALPPS didn´t more morbidity than classic approach 2-stage for colorectal liver metastases but its utility in another tumor is controverial. To reduce aggressiveness in the first surgical stage, Hybrid mini-ALPPS (intraoperative embolization portal, parenchymal transection and minimize liver mobilization) was developed with minimal cases reported. Our aim is to present the approach using Hybrid mini-ALPPS in a complex big size tumor. Methods: A 43 years old patient with a complex big liver tumor that involves the right hepatic lobe, medial sectory and Inferior cavus vein (IVC). The preoperative evaluation is concordant with resectable intrahepatic cholangiocarcinoma (ICC) with a future liver remnant (FLR) of 433cc (lower< 20%). Our video shows how first surgery time was performed thorugh a laparoscopic approach partial parenchymal transection (90%), with bipolar using Pringle technique and intraoperative embolization of the right hepatic vein though canulation of the inferior mesenteric vein (VMI). The second surgery time was performed after 2 weeks with a new manometry that shows an increase in FKR to 883cc (an increase in 204% of the FLR). Right trisectionectomy and resection of IVC tumor and diaphragm was performed. The 5th postoperative day is discherged in good condition with a slight increase in trasaminases levels. Conclusion: The Hybrid mini-ALLPS is a feasible technique and could be considered in complex big tumour not colorectal liver metastases when a short time solution of surgical problem is necessary for a mutidisciplinary team approach.

The Congenital Absence of the Portal Vein

Congenital absence of the portal vein (CAPV) is a rare defect often accompanied by other abnormalities such as heart defect, skeletal anomalies and / or liver tumors [1]. We describe here a case of CAPV revealed by an upper gastrointestinal tract hemorrhage in a child aged 02 years and 8 months. The esogatro-duodenal fibroscopy revealed the presence of Esophageal varices grade II, abdominal ultrasound revealed a large liver with no visualization of the spleen. Subsequent abdominal computed tomography revealed the presence of a spleno-mesaraic trunk measuring 7 mm in anteroposterior diameter receiving the inferior and superior mesenteric vein and a small splenic vein draining by dilated peri-gastric and peri-esophageal leads. Associated with splenic hypoplasia and portal trunk atresia. The rest of the malformative assessment was negative

Arc of Riolan-Dominant Colonic Perfusion Identified by Indocyanine Green After High Ligation of Inferior Mesenteric Artery: Critical in Preventing Anastomotic Ischemia.

Arc of Riolan is a collateral mesenteric vessel observed in up to 17.8% of individuals1 bridging the superior mesenteric artery (SMA) and inferior mesenteric artery (IMA) systems perfusing the descending colon besides the marginal artery. Proximal perfusion of the anastomosis after the high division of the IMA during left-sided colorectal resections is maintained by the marginal artery, but in some, this may be absent or small-caliber at the Griffiths point.2 Identification and preservation of the arc of Riolan has been associated with a decrease in acute anastomotic ischemia events requiring resection and Hartmann's procedure, although not totally eradicated the number of anastomotic leaks requiring lesser interventions.1 This video shows the vascular supply of the left colon during a robotic ultra-low anterior resection for low rectal cancer. The arc of Riolan is identified and preserved at its usual anatomical position during the isolation and division of the inferior mesenteric vein inferior to the pancreas, lengthening the descending colon for a tension free anastomosis. The arc of Riolan is temporarily occluded with an endoscopic vascular clamp after the IMA's high division. 4mg of intravenous indocyanine green (ICG) is infused to visualize the perfusion of the descending colon for 3 minutes, which is ICG's half-life.3 The fluorescence image of the descending colon is noted to be less than expected and another 3mg of ICG is infused after unclamping the arc of Riolan, revealing a visibly higher fluorescent descending colon confirming the dominant perfusion from this vessel. ICG has clearly demonstrated the arc of Riolan's dominance in perfusing the left colon. Armed with prior knowledge, its preservation can be a critical step in preventing anastomotic ischemia after IMA's high ligation in patients with potentially weak marginal artery, whilst division of a non-dominant arc of Riolan makes splenic flexure mobilization technically less challenging. See Video Abstract at http://links.lww.com/DCR/B439.

An unusual cause of lower gastrointestinal bleeding

AbstractAcute lower gastrointestinal (GI) bleeding refer to blood loss of colon origination. The cause of lower GI bleeding may include vascular (ulcer, angiodysplasia, ischemic, or radiation), anatomic (diverticulum), inflammatory (ulcerative colitis, Crohn's disease), infectious, or neoplastic. Mesenteric venous thrombosis is responsible for 5% to 15% of all mesenteric ischemic events, and the involvement of the inferior mesenteric vein (IMV) is rare. A 70‐year‐old man who presented with episodes of bloody diarrhea. Colonoscopy revealed diffuse hyperemic changes in the rectum and sigmoid colon. A contrast‐enhanced computed tomography showed diffuse, circumferential wall thickening of the descending colon, sigmoid colon, and rectum as a result of thrombosis in the IMV. Anticoagulant was administered and there was no further bloody diarrhea. Mesenteric venous thrombosis is a rare cause of lower GI bleeding. However, it may be kept in mind in high risk populations such as malignancy, prothrombotic states, inflammatory bowel disease, recent abdomen injury or surgery, and diabetes mellitus.

Sequential CT arterioportography-arteriosplenography depicts individual haemodynamic changes in children with portal hypertension without cirrhosis

We evaluated sequential computed tomography (CT) arterioportography-arteriosplenography for the assessment of venous pathways in children with portal hypertension without cirrhosis. Institutional Review Board approval was obtained for this retrospective, single-centre study. CT was performed after contrast application via catheters placed in the superior mesenteric artery (CT arterioportography) and the splenic artery (CT arteriosplenography) consecutively. Venous pathways in 22 children were evaluated. In all patients, the detailed haemodynamic consequences of portal hypertension could be characterised. The supply of varices at different locations could be assigned to the superior mesenteric vein or splenic vein system. Retrograde blood flow through the splenic vein and inferior mesenteric vein, portosystemic shunting, and patency of splanchnic veins were determined. CT arterioportography-arteriosplenography allowed a complete evaluation of individual haemodynamic pathways in children with portal hypertension.

The extracorporeal circulation with transdiaphragmatic approach in living-donor liver transplantation for hepatoblastoma with atrial extension of tumor thrombus

Background: Surgical intervention for hepatoblastoma (HB) with tumor thrombi extending into the inferior vena cava (IVC) and the right atrium (RA) might require careful planning of the surgical procedures, including vascular reconstruction and extracorpo real circulation. Methods: We herein report a successful case of living-donor liver transplantation (LDLT) for HB with atrial extension of a tumor thrombus by extracorporeal circulation with a transdiaphragmatic approach. Results: The patient was a 5-year-old boy with PRETEXT IV HB with a tumor thrombus that extended into the IVC and the RA. After four cycles of chemotherapy (PHITT group D: high-risk protocol) and resection of bilateral lung metastases, the size of the primary HB tumor decreased. As the tumor extension from the left hepatic vein to the RA had decreased but was still present, we performed LDLT with tumor thrombectomy. The central part of the diaphragm was sagittally incised to expose the suprahepatic IVC and the RA. Venovenous bypass was achieved from the right femoral vein and inferior mesenteric vein to the RA. En bloc re section of the native liver with the tumor thrombus was then performed. Hepatic vein anastomosis was made between the newly created orifice on the IVC and the graft left hepatic vein. The duration of LDLT was 10 hours and 44 minutes (extracorporeal cir culation time, 78 minutes). Conclusions: Pediatric liver transplantation for HB with the extension of tumor thrombi into the RA under extracorporeal circu lation is a feasible option and allows for the expansion of the indications for transplantation for children with unresectable liver tumors.

Percutaneous Ultrasound-Guided Superior and Inferior Mesenteric Vein Access for Portal Vein Recanalization-Transjugular Intrahepatic Portosystemic Shunt: A Case Series.

ObjectiveTo describe the technique and outcomes of mesenteric access under ultrasound guidance to perform portal vein recanalization–transjugular intrahepatic portosystemic shunt (PVR-TIPS).MethodsFour patients (3 male: 1 female, mean age: 46.2 years; range 38–64 years) with portal vein thrombosis (PVT) and cavernous transformation were eligible for PVR-TIPS. Due to inaccessible splenic vein (one patient with history of splenectomy and 3 patients with unavailable splenic vein during the procedure), noninvasive direct puncture of superior (n = 3) and inferior (n = 1) mesenteric vein was conducted under ultrasound guidance to obtain access for PVR-TIPS.ResultsTrans-mesenteric access and PVR-TIPS were successful in all patients at first attempt. No immediate complication was observed following the procedures. Follow-up imaging with computed tomography (CT) scan and Doppler ultrasound revealed patent TIPS and portal venous vasculature in all patients.ConclusionPercutaneous noninvasive transmesenteric access is a feasible approach for PVR-TIPS in patients with inaccessible splenic veins.Level of evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.Electronic supplementary materialThe online version of this article (10.1007/s00270-020-02713-0) contains supplementary material, which is available to authorized users.

Evaluation of vascular anatomy for colon cancer located in the splenic flexure using the preoperative three-dimensional computed tomography angiography with colonography.

The aim of this study is to reveal the vascular branching variation in SFC(splenic flexure cancer) patients using the preoperative three-dimensional computed tomography angiography with colonography (3D-CTAC). We retrospectively analyzed patients with SFC who underwent preoperative 3D-CTAC between January 2014 and December 2019. Among 1256 colorectal cancer (CRC) patients, 96 (7.6%) manifested SFC. The arterial branching from the superior mesenteric artery (SMA) was classified into five patterns, as follows: (type 1A) the left branch of middle colic artery (LMCA) diverged from middle colic artery (MCA) (N = 47, 49.0%); (2A) the LMCA diverged from the MCA and the accessory middle colic artery (AMCA) (N = 26, 27.1%); (3A) the LMCA independently diverged from the SMA (N = 16, 16.7%); (4A) the LMCA independently diverged from the SMA and AMCA (N = 3, 3.1%); (5A) only the AMCA and the LMCA was absent (N = 4, 4.1%). Venous drainage was classified into four patterns, as follows: (type 1V) the SFV flows into the inferior mesenteric vein (IMV) then back to the splenic vein (N = 50, 52.1%); (2V) the SFV flows into the IMV then back to the superior mesenteric vein (SMV) (N = 19, 19.8%); (type 3V) the SFV independently flows into the splenic vein (N = 3, 3.1%); (type 4V) the SFV is absent (N = 24, 25.0%). 3D-CTAC could reveal accurate preoperative tumor localization and vascular branching. These classifications should be helpful in performing accurate complete mesocolic excision and central vessel ligation for SFC.

Complex Liver Transplantation Using Venovenous Bypass With an Atypical Placement of the Portal Vein Cannula.

In liver transplantation (LT) medical literature, venovenous bypass (VVB) with the interposition of a venous graft attached to the inferior mesenteric vein (IMV) or to the splenic vein (SV) has not been reported previously. Here, we report the decompression of the portomesenteric compartment in 2 patients with complex cases of orthotopic LT. A femoroaxillary percutaneous VVB was installed prior to abdominal opening to decompress massive collateral veins in the abdominal wall. In the first patient, the IMV was connected to a donor vein graft with a lateroterminal anastomosis, and the distal part of the vein graft was cannulated and connected to the VVB. In the second patient, because of the excessive size of the spleen, it was necessary to perform a splenectomy to gain sufficient space in the abdomen to implant the new liver. The SV was connected to a donor vein graft with a terminoterminal anastomosis, and the distal part of the vein graft was cannulated and connected to the VVB. In both patients, the decompression of the portomesenteric compartment was crucial to reduce portal hypertension and to access the hepatic hilum, where the dissection was very complex due to previous major surgeries. In conclusion, VVB with the interposition of a venous graft attached to the IMV or to the SV during LT is a safe and simple technique, and it may be useful for patients needing VVB with no standard access to the portal compartment, particularly in the case of severe portal hypertension and re‐LTs.

Diameter of Superior Rectal Vein - CT Predictor of KRAS Mutation in Rectal Carcinoma.

BackgroundThe purpose of this study was to investigate the feasibility of CT parameters to predict the presence of KRAS mutations in rectal cancer patients. The relationship between the presence of a KRAS mutation and pathological findings was evaluated simultaneously.MethodsEighty-nine patients (29 females, 60 males, age 27–90, mean 59.7±12 years) with pathologically proven rectal cancer were enrolled. A KRAS mutation test was completed following surgery. Parameters evaluated on CT included the tumor location, the diameter of the superior rectal vein (SRV) and inferior mesenteric vein (IMV), the presence of calcification, ulceration, lymph node enlargement (LNE), distant metastasis, tumor shape (intraluminal polypoid mass, infiltrative mass, or bulky), circumferential extent (C0–C1/4, C1/4–C1/2, C1/2–C3/4, or C3/4–C1), enhanced pattern (homogeneous or heterogeneous), CT ratio, and the length of the tumor (LOT). Pathological findings included lymphovascular emboli, signet ring cell, peripheral fat interval infiltration, focal ulcer, lymph node metastasis, tumor pathological type, and differentiation extent. The correlations between KRAS status and CT parameters, and KRAS status and pathological findings were investigated. The accuracy of CT characteristics for predicting KRAS mutation was evaluated.ResultsA KRAS mutation was detected in 42 cases. On CT image, the diameter of the SRV was significantly increased in the KRAS mutation group compared to in the KRAS wild-type group (4.6±0.9 mm vs 4.2±0.9 mm, p=0.02), and LNE was more likely to occur in the KRAS mutation group (73.3% vs 26.7%, p=0.03). There was no significant difference between the KRAS mutation group and the KRAS wild-type group on the other CT parameters (location, IMV, calcification, ulcer, distant metastasis, tumor shape, enhanced pattern, circumferential extent, CT ratio, and LOT). In the pathological findings, a KRAS mutation was more likely to occur in the middle differentiation group (p=0.03). No significant difference was found between the KRAS mutation group and the KRAS wild-type group in the presence of lymphovascular emboli, signet ring cell, peripheral fat interval infiltration, focal ulcer, lymph node metastasis, and tumor pathological type. With the best cut-off value of 4.07 mm, the AUC of the SRV to predict a KRAS mutation was 0.63 with a sensitivity of 76.2% and a specificity of 48.9%.ConclusionIt was feasible to use the diameter of the SRV to predict a KRAS mutation in rectal cancer patients, and LNE also can be regarded as an important clue on preoperative CT images.

Dacron Y Prosthesis for Quick Restoration of Portal Vein Circulation After Pancreaticoduodenectomy

In pancreatic cancer resection, when primary portal vein reconstruction (PVR) fails, small bowel oedema will increase until a new, successful PVR is performed. To decrease venous occlusion time, a quick interposition grafting procedure is proposed. The picture shows a bifurcated prosthesis bridging the gap between the distal vein inflow (superior mesenteric vein [SMV], first jejunal branch [JB1], and inferior mesenteric vein [IMV]) and the proximal portal vein (PV) outflow. SMV to right (R) Dacron limb and PV to Dacron body end to end anastomoses are performed initially, partially restoring the venous circulation (left limb clamped), while the common JB1 and IMV trunk to left (L) Dacron limb end to end anastomosis is performed last.Image 1