Jejunal Artery Research Articles

Clinical application of inferior pancreaticoduodenal artery management in laparoscopic pancreaticoduodenectomy

Objective: To investigate the clinical effect of proper management of inferior pancreaticoduodenal artery (IPDA) in laparoscopic pancreaticoduodenectomy (LPD). Methods: This is a retrospective case series study. The clinical and pathological data of 70 patients who received LPD due to pancreatic head tumors, periampullary tumors, or distal common bile duct tumors in the Pancreatic Center of the Second Clinical College of Guangzhou University of Chinese Medicine from January to December 2022 were retrospectively collected. There were 47 males(67.1%) and 23 females(32.9%),aged (59.9±12.8)years(range:13 to 87 years).The procedure of IPDA exposure was as follows:a middle approach was utilized to expose the right half of superior mesenteric artery(SMA) and its right branches between the SMA and superior mesenteric vein(SMV) in superior colonic region. In the subcolonic region,SMA trunk exposure via dissection along the jejunal artery from feet to head and identification the association between IPDA and jejunal artery were prior to IPDA root ligation and dissection. The safety and efficacy of intraoperative IPDA handling were assessed based on surgical videos. Follow-up was carried out in outpatient clinic or by telephone, and outpatient follow-up was conducted once every 1 to 3 months after surgery. Results: The percentage of total LPD was 98.6%(69/70),with all patients achieving R0 resection. Nine cases(12.9%) were involved in combined vascular resection and reconstruction,with 1 case (1.4%) requiring additional upper abdominal incision for vascular and gastrointestinal reconstruction,while the remaining eight cases (11.4%) were completed laparoscopically. The operative time was (432.7±115.4)minutes(range:282 to 727 minutes), and the blood loss was (140.0±125.7)ml(range:20 to 800 ml). Only two patients(2.9%) received fresh frozen plasma transfusion,with an average volume of 650 ml. Reliable ligation and safe handling of the IPDA were achieved in 91.4%(64/70) of cases, with 8.6%(6/70) suffering from IPDA injury-related bleeding. No one was converted to opened surgery. Pathologically,the mean tumor size was (3.3±1.6)cm (range:1 to 7 cm),and the mean number of harvested lymph nodes was 17.0±7.3(range:0 to 46). Lymph node metastasis was observed in 13 cases (18.6%). Five cases (13.2%) developed grade B pancreatic fistula,while no grade C pancreatic fistula occurred. Other complications included bile leakage in one case(1.4%),delayed gastric emptying in two cases(2.9%), lymphatic leakage in 2 cases(2.9%),intra-abdominal infection in 9 cases(12.9%),and fat liquefaction of surgical incision in 1 case(1.4%). Two cases(2.9%) experienced postoperative intra-abdominal bleeding,one due to mesangial bleeding of lesser curvature of the stomach and the other due to oozing from the hepatic arterial sheath. These bleeding events were not concerned with IPDA. The average length of postoperative hospital stay was (15.2±4.6)days(range:9 to 28 days). Conclusion: Proper intraoperative management of IPDA in LPD might reduce IPDA-related bleeding during and after surgery and improve the safety of LPD.

A comprehensive morphometric analysis of superior and inferior mesenteric arteries using cadaveric dissection and MDCT angiography

BackgroundSuperior mesenteric artery (SMA) and inferior mesenteric artery (IMA) are vital vascular structures supplying the majority of the intestinal tract. Despite their clinical significance, comprehensive morphometric studies combining traditional cadaveric dissection with modern imaging techniques are scarce in literature. This study aimed to provide a detailed morphometric analysis of the SMA and IMA using both cadaveric dissection and multi-detector computed tomography (MDCT) angiography. MethodsThe study utilized a dual approach, combining cadaveric dissection (30 formalin-fixed cadavers) and MDCT angiography (images from 50 patients). Measurements including stem lengths, diameters at origin, and distances from the aortic bifurcation were taken, along with assessment of vertebral levels of origin and branching patterns. Data from both components were analyzed using descriptive statistics. ResultsKey findings for SMA include: Mean stem length: 3.19 ± 0.72 cm (cadaveric) vs. 2.53 ± 0.53 cm (MDCT); Mean diameter at origin: 0.93 ± 0.22 cm (cadaveric) vs. 0.57 ± 0.10 cm (MDCT); Most common vertebral level of origin: Upper border of L1 (78 % of cases); Branching pattern variations observed in 23.3 % of cadaveric specimens, which included the origin of the inferior pancreaticoduodenal artery from the first jejunal artery, a common trunk for right colic and ileocolic arteries, and absence of middle colic artery. For IMA: Mean stem length: 3.61 ± 1.29 cm (cadaveric) vs. 3.41 ± 0.69 cm (MDCT); Mean diameter at origin: 0.50 ± 0.11 cm (cadaveric) vs. 0.26 ± 0.05 cm (MDCT); Most common vertebral level of origin: Upper border of L3 (40 % of cases). No variations observed in branching pattern. ConclusionsThe detailed measurements, frequency of variations, and comparison between traditional and modern assessment techniques offer a nuanced understanding of mesenteric vascular anatomy. This study bridges the gap between classical anatomical knowledge and contemporary imaging capabilities, potentially improving surgical planning, interventional procedures, and radiological interpretation.

Distribution pattern of the celiac, cranial mesenteric, and caudal mesenteric arteries to the gastrointestinal tract in the common marmoset (Callithrix jacchus).

Gastrointestinal diseases pose problems to captive common marmosets. Therefore, knowledge of the anatomy of the arterial supply to the gastrointestinal tract is an important prerequisite for implementing appropriate veterinary care. The common marmoset's intestinal tract has a well-developed cecum specialized for the fermentative digestion of tree gums. This specialized gastrointestinal tract may have a unique pattern of arterial distribution. This study aimed to elucidate the species-specific gastrointestinal tract arterial anatomy of the common marmoset. We traced the celiac, cranial mesenteric, and caudal mesenteric arteries in six male and nine female common marmosets using the latex injection method. We found that the celiac artery gave rise to the left gastric, common hepatic, splenic, and caudal pancreaticoduodenal arteries. In addition to these arteries, the celiac artery gave origin to the middle colic or jejunal arteries in seven or one cases, respectively. The branches of the cranial mesenteric artery consisted of 3-6 arteries, including the middle colic, caudal pancreaticoduodenal, jejunal, right colic, ileocolic, and ileal arteries, as well as a common trunk of the ventral cecal and ileal branches, and the dorsal cecal and colic branches. In four cases, the cranial mesenteric artery gave rise to the jejunal, ileocolic, and ileal arteries. In one of the 13 cases, the celiac and cranial mesenteric arteries formed a common trunk. The caudal mesenteric artery branched into the left colic, sigmoid, and cranial rectal arteries in all the cases. These findings provide an anatomical basis for gastrointestinal veterinary care of common marmosets.

Feasibility of middle colic artery as a landmark for superior mesenteric artery – first approach in laparoscopic pancreatoduodenectomy: a prospective study

BackgroundSMA-first approach in pancreatoduodenectomy (PD) has been widely applied in open surgery as well as laparoscopy. Finding the superior mesenteric artery (SMA), inferior pancreatoduodenal artery (IPDA), first jejunal artery (J1A) has become a great challenge in laparoscopic PD (LPD). Meanwhile, exposing the midde colic artery (MCA) might be a feasible approach to determine SMA, IPDA, and J1A. Our study aims to find the anatomical correlation between MCA and SMA, IPDA, J1A, especially in SMA-first approach LPD from the left.MethodsUncontrolled clinical trial with 33 patients undergoing LPD had preoperative contrast abdominal CT scan to analyze the anatomical relevance between MCA and SMA, J1A, IPDA. The operation was performed starting with exposing MCA in advance to find SMA, J1A and IPDA. The data was analyzed by SPSS 25.0.Results90.9% of MCA started at 12–3 o’clock from SMA, the mean distance from the SMA root to the MCA and J1A was 56.4 mm and 37.4 mm, respectively. The distance between SMA and J1A was 19 mm. 72.7% J1A started at 9–12 o’clock, 69.7% J1A and IPDA had a common trunk. 78.8% IPDA started at 3–6 o’clock. 100% of the cases had J1A controlled intraoperatively, 81.8% for IPDA when approached from the left, 3% had MCA injury. The mean time to approach from the left was 98 min, median blood loss was 100 ml.ConclusionExposing MCA first helps determine SMA, J1A and IPDA safely, efficiently and faciliates SMA-first approach LPD from the left and complete dissection of the mesopancreas and lymph nodes.

Mesenteric sparing approach for advanced nodal extent in small intestinal neuroendocrine tumors. Is there a limit to the vascular resection in order to avoid creating a short small bowel syndrome? An anatomic research study.

By selectively perfusing the first three jejunal arteries (JA), we aim to assess the individual perfusion length of small bowel (SB) and its impact on nodal resection in stage III-up small-intestinal neuroendocrine tumors (SI-NET). Our anatomical research protocol implies a midline laparotomy and three measures of the SB length. We then perform a classical anterior approach of the superior mesenteric vessels. We carry on with the complete dissection and checking of the superior mesenteric artery (SMA) in order to identify the first three JA. Then we selectively perfuse each artery with colored latex solutions and measure the length of small bowel perfused respectively. We conducted our protocol on six cadaveric subjects. Mean(SD) SB length was 413(5.7), 535(13.2), 485(15), 353(25.1), 730(17.3) and 525(16° cm respectively from subject one to six. Most JA originated from the left side of the SMA. The first JA originated from its posterior wall in two subjects. Mean(SD) distance of origin of the first three JA was 4.6(1.3)cm, 6(1.1)cm and 7.1(0.9)cm respectively. Mean(SD) diameter of SMA was 10.8(3.3)mm. Mean diameter of the three first JA was 4(1.4)mm, 4(1.5)mm and 5(1.2)mm respectively. Mean(SD) SB length perfused by first and second JA was 224(14.9)cm, 175(8.6)cm, 238.3(7.6)cm, 84.3(5.1)cm, 233.3(5.8)cm and 218.3(10.4)cm respectively from subject one to six. We observed a trend suggesting that the first and second JA may sustain a SB length beyond the viable 1.5m limit, implying the feasibility of stage III-up SI-NET resection with just two JA.

Preliminary report on embolization with quick-soluble gelatin sponge particles for angiographically negative acute gastrointestinal bleeding

Prophylactic embolization is usually performed using gelatin sponge particles, which are absorbed within several weeks, for managing angiographically negative gastrointestinal bleeding. This study aimed to evaluate the safety and effectiveness of transcatheter arterial embolization (TAE) with quick-soluble gelatin sponge particles (QS-GSP) that dissolve in less than 4 h for treating angiographically negative gastrointestinal bleeding. We included ten patients (M:F = 7:3; mean age, 64.3 years) who underwent prophylactic TAE with QS-GSP for angiographically negative acute gastrointestinal bleeding between 2021 and 2023. The technical success rate of TAE, clinical outcomes focusing on rebleeding, and procedure-related complications were evaluated. The embolized arteries were the gastroduodenal (n = 3), jejunal (n = 4), and ileal (n = 3) arteries. QS-GSP (150–350 µm or 350–560 µm) were used alone (n = 8) or in combination with a coil (n = 1). A 100% technical success rate was accomplished. In 1 patient (10%), rebleeding occurred 2 days after prophylactic TAE of the gastroduodenal artery, and this was managed by repeat TAE. There were no procedure-related complications. The use of QS-GSP for prophylactic TAE appears to be safe and effective for controlling bleeding among patients with angiographically negative gastrointestinal bleeding. There were no cases of related ischemic complications of the embolized bowels likely attributable to recanalization of the affected arteries following biodegradation of QS-GSP.

Jejunal vein tributary analysis and intraoperative clamp testing in avoiding congestion after pancreatoduodenectomy.

Although venous drainage of the jejunal loop may be maintained after sacrifice of jejunal vein tributaries during pancreatoduodenectomy, risk of severe jejunal mesenteric congestion following division of these tributaries can be difficult to predict. This study considered how best to predict safety of jejunal vein tributary dissection. Preoperative imaging findings and results of intraoperative clamp tests of jejunal vein tributaries during pancreatoduodenectomy were analyzed in 121 patients with hepatobiliary and pancreatic disease to determine whether this information adequately predicted safety of resecting superior mesenteric vein branches. Jejunal vein tributaries caudal to the inferior border of the pancreatic uncinate process tended to be fewer when tributaries cranial to this landmark were more numerous. Tributaries cranial to the border drained a relatively wide expanse of jejunal artery territory in the jejunal mesentery. The territory of jejunal tributaries cranial to the inferior border of the pancreas did not vary according to course of the first jejunal vein branch relative to the superior mesenteric artery. One patient among 30 (3%) who underwent intraoperative clamp tests of tributaries cranial to the border showed severe congestion in relation to a venous tributary coursing ventrally to the superior mesenteric artery. Jejunal venous tributaries drained an extensive portion of jejunal arterial territory, but tributaries located cranially to the inferior border of the pancreas could be sacrificed without congestion in nearly all patients. Intraoperative clamp testing of these tributaries can identify patients whose jejunal veins must be preserved to avoid congestion.

Vascularization of the gastrointestinal tract of the bottlenose dolphin (Tursiops truncatus, Montagu 1821).

Odontocetes primarily rely on fish, cephalopods, and crustaceans as their main source of nutrition. In the digestive system, their polygastric complex exhibits similarities to that of their closest terrestrial relatives such as cows, sheep, and giraffes, while the entero-colic tract shares similarities with terrestrial carnivores. The morphology, caliber, and structure of the odontocete intestine are relatively constant, and, since there is no caecum, a distinction between the small and large intestine and their respective subdivisions is difficult. To address this issue, we used the intestinal vascularization pattern, specifically the course and branching of the celiac artery (CA) and the cranial and caudal mesenteric arteries (CrMA and CdMA). A series of pictures and dissections of 10 bottlenose dolphins (Tursiops truncatus) were analyzed. Additionally, we performed a cast by injecting colored polyurethane foam in both arteries and veins to measure the caliber of the arteries and clarify their monopodial or dichotomous branching. Our results showed the presence of multiple duodenal arteries (DAs) detaching from the CA. The CrMA gave origin to multiple jejunal arteries, an ileocolic artery (ICA), and, in six cases, a CdMA. In four specimens, the CdMA directly originated from the abdominal aorta. The ICA gave rise to the mesenteric ileal branches (MIB) and mesenteric anti-ileal branches and the right colic arteries (RCA) and the middle colic arteries. From the CdMA originated the left colic and cranial rectal arteries (LCA and CrRA). The measurements revealed a mixed monopodial and dichotomous branching scheme. The analysis of the arteries and their branching gave us an instrument, based on comparative anatomy, to distinguish between the different intestinal compartments. We used the midpoint of anastomoses between MIB and RCA to indicate the border between the small and the large intestine, and the midpoint of anastomoses between LCA and CrRA, to tell the colon from the rectum. This pattern suggested an elongation of the duodenum and a shortening of the colic tract that is still present in this species. These findings might be related to the crucial need to possess a long duodenal tract to digest prey ingested whole without chewing. A short aboral part is also functional to avoid gas-producing colic fermentation. The rare origin of the CdMA on the CrMA might instead be a consequence of the cranial thrust of the abdominopelvic organs related to the loss of the pelvic girdle that occurred during the evolution of cetaceans.

Observing vessel stumps axially: A novel exoscope for end-to-end microvascular anastomosis

Although many free tissue transfers have been performed, free flap loss can still occur because of vascular compromise. To facilitate microsurgery, we invented the axial-view microscope (aMS), a new type of microscope that can axially visualize vessel stumps. The aMS was combined with an optical microscope, the so-called bird’s-eye-view microscope (bMS). Using our aMS, we observed the cross-sections of the following 12 arteries during vascular anastomosis: three deep inferior epigastric arteries, three suprathyroid arteries, two thoracodorsal arteries, two jejunal arteries, one lateral circumflex femoral artery, and one facial artery. For each artery, we measured the vessel height-to-width (H–W) ratio to determine the roundness of the vessel stump. Based on the aMS and bMS, the average H–W ratios were 0.877 ± 0.187 and 0.445 ± 0.172, respectively. The H–W ratio obtained using the aMS was significantly higher than that of the bMS (P < 0.001). Providing the surgeon with a bidirectional view of the vessel stump reduced blind spots at the anastomotic site. In this report, we describe our new microscope and associated clinical cases.

Cannulation Indocyanine Green Method for Strategic Management of Postoperative Arterial Thrombosis after Free Jejunal Flap Transfer

Summary: Indocyanine green (ICG) angiography is widely used in reconstructive surgery to confirm the perfusion of the flap. Here, we report a case in which the use of the “cannulation ICG method” was useful for strategic management of postoperative arterial thrombosis after free jejunal flap transfer. A 64-year-old woman underwent cervical esophagectomy followed by a free jejunal transfer. On postoperative day 3, ischemia of the free jejunum was suspected, and takeback was performed. In the reoperation, re-anastomosis of the artery was planned after the removal of arterial thrombus. However, before re-anastomosis, it was unclear whether there was venous thrombus and whether this jejunum flap was salvageable. To resolve these two questions, we performed the cannulation ICG method. In this method, we injected a mixture of 1.0 mL of ICG and 20 mL of blood into the jejunal artery via 24-gauge cannula. We then evaluated the perfusion of the jejunal flap and monitoring jejunum, and the patency of the venous anastomosis site using a near-infrared fluorescence imaging device (LIGHTVISION; Shimadzu Corporation, Kyoto, Japan). In this case, the whole jejunal flap (including the monitoring jejunum) and venous anastomosis site were highlighted. We determined that there were no venous thrombi and that the entire jejunum was salvageable. After the arterial re-anastomosis, ICG angiography showed good perfusion of the whole jejunum. The postoperative course was uneventful, and the free jejunal flap survived completely. The cannulation ICG method may be effective for determining the surgical method for reoperation due to arterial thrombosis after reconstruction of the free jejunum.

S2048 A Jejunal Artery Pseudoaneurysm Rupture into Pancreatic Pseudocyst: A Case Report

S2048 A Jejunal Artery Pseudoaneurysm Rupture into Pancreatic Pseudocyst: A Case Report

Laparoscopic dissection around the superior mesenteric artery by left posterior approach during pancreaticoduodenectomy.

In pancreaticoduodenectomy (PD), the approach to superior mesenteric artery (SMA) is a critical process that supports adequate surgical margins and radicality for pancreatic tumors. In most of the reports on laparoscopic PD, the right-sided approach in which the jejunum is pulled out to the right side for peri-SMA dissection is used, since the left side of the SMA is difficult to dissect, and the only way to do this is to dissect the vein first. We devised a method to simplify and safely perform peri-SMA dissection by reversing the process, starting from the left side of the SMA. The first step involves the mobilization of the pancreatic head, which allows for rotation around the SMA. The second step involves the dissection of the left side of the SMA and transection of the jejunum. The key point is to change the incision line between the anterior and posterior mesojejunum. The third process includes the inferior pancreatoduodenal artery (IPDA) and first jejunal artery (J1A) dissection, which can be easily performed from the left side because the SMA rotates by simply continuing the dissection along the previously exposed SMA, and the IPDA/J1A are safely dissected at the root because they are drawn to the left side. The remaining processes are performed on the right side. This method was performed in 16 cases, and in most cases IPDA/J1A were divided from the left side. The technique for SMA dissection from the left posterior side was described with illustrations and video. Our method allows safe oncologic dissection around SMA avoiding anatomical misorientation during laparoscopic PD.

In situ method for the determination of nutrient acquisition and its hormonal regulation in the spiral valve of two chondrichthyan fishes.

Chondrichthyans play an important role in nutrient cycling of many marine ecosystems, yet little is known about their nutritional physiology particularly relating to nutrient acquisition in the spiral valve intestine. This unique organ poses challenges for examining nutrient transport physiology using traditional reductionist methods owing to its scroll-like morphology. Thus, we established a method for the characterization of nutrient uptake rates in two representative chondrichthyans, the Pacific spiny dogfish (Squalus suckleyi) and the Pacific spotted ratfish (Hydrolagus colliei). We validated a dual-cannulation method wherein perfusate was circulated through the vasculature of the spiral valve via the anterior and posterior intestinal arteries, and [14C]glucose or [3H]oleic acid was accumulated from the static spiral valve lumen into the anterior and posterior intestinal veins. Radiotracer accumulated at a stable rate in the venous effluent in comparison with measures of mucosal disappearance. Interestingly, similar anterior and posterior glucose uptake was observed in dogfish, yet significantly more oleic acid was accumulated in the posterior veins of ratfish. Further validation of the preparation in dogfish demonstrated sodium dependence of glucose transport as well as an effect of bovine insulin administration to the arterial circulation. Each of these manipulations resulted in significant differences in glucose handling between the anterior and posterior veins, suggestive of heretofore unknown heterogenous functions along the intestine. This preparation demonstrates a new and reliable method for the measurement of nutrient acquisition and regulation thereof in a unique digestive organ. Furthermore, it presents avenues for investigation of differential functional along the spiral valve.NEW & NOTEWORTHY We describe a novel dual cannulation method for investigating radiolabeled nutrient uptake from a unique organ, the spiral valve. Furthermore, we identify functional differences in nutrient transport along the length of the spiral valve which consists of a homogenous gross morphology. Finally, this method reveals a useful way in which to manipulate the arterial supply to better understand postprandial physiology as it varies with metabolites and endocrine factors.

A case of acquired hemophilia A after pancreaticoduodenectomy for distal cholangiocarcinoma.

Acquired hemophilia A (AHA) is a rare disease that results from factor VIII inhibitors causing abnormal coagulation, and certain cases may develop after highly invasive surgery. The present case study reports on a 68-year-old male patient who developed AHA after undergoing a subtotal stomach-preserving pancreatoduodenectomy for distal cholangiocarcinoma. The patient experienced complications after surgery, requiring reoperation on postoperative day (PD) 5 due to rupture of the Braun's enterostomy. On PD 6, angiography was performed after bleeding was detected in the jejunal limb, but hemostasis occurred spontaneously during the examination. Bleeding was observed again on PD 8 and direct surgical ligation was performed. On PD 14, bleeding recurred in the jejunal limb and angiography was performed to embolize the periphery of the second jejunal artery. During the procedure, the prothrombin time was normal, but only the activated partial thromboplastin time was prolonged. A close examination of the coagulation system revealed a decrease in factor VIII levels and the presence of factor VIII inhibitors, resulting in the diagnosis of AHA. Administration of steroids was initiated on PD 15 and, in addition to daily blood transfusions, activated prothrombin complex concentrate was administered to achieve hemostasis. The patient was discharged from the intensive care unit on PD 36 but later developed an intractable labial fistula due to suture failure at the gastrojejunostomy site. As the use of factor VIII inhibitors continued despite the administration of steroids, cyclophosphamide (CPA) pulse therapy was added at PD 58. However, CPA was ineffective and the administration of rituximab was initiated on PD 98. After 12 courses of rituximab, the patient tested negative for factor VIII inhibitors on PD 219. On PD 289, labial fistula closure was performed with continuous replacement of factor VIII and the patient was discharged on PD 342.

Left-sided major hepatectomy with en bloc resection of the hepatoduodenal ligament utilizing a liver-transection first approach: A video vignette

TechniqueHepatoduodenal ligamentectomy (HL) is a challenging surgery for advanced perihilar cholangiocarcinoma extensively invading the hepatoduodenal ligament1-3. A liver-transection first approach in HL is a no-touch technique wherein liver transection is performed first, and the affected liver and hepatoduodenal ligament are removed en bloc. This approach allows for the early assessment of resectability and feasibility of vascular reconstruction4. ResultsThis video shows a 57-year-old man with advanced intrahepatic cholangiocarcinoma in the left hepatic lobe, which had directly invaded the perihilar region and the hepatoduodenal ligament via lymph node metastasis. The lymph node was extensively invasive into both the proper hepatic artery and portal vein. The case was initially deemed unresectable, but after three months of chemotherapy, conversion surgery was considered feasible. The common hepatic artery and gastroduodenal artery and then the common bile duct and main trunk of portal vein were secured at the pancreatic superior border. Hepatic dissection was performed along the Cantlie line. The right Glissonean pedicle was secured, including the right hepatic duct, right hepatic artery and right portal vein, and the operation was deemed feasible. The portal vein was dissected and reconstructed using the right external iliac vein. The left and caudate lobe with the middle hepatic vein and hepatoduodenal ligament were resected en bloc. Subsequentially, the common hepatic artery and right hepatic artery were reconstructed using the jejunal artery. ConclusionThe liver-transection first approach allowed us to determine the resectability of en bloc resection of the hepatoduodenal ligament at an early stage of surgery.

Probiotic treatment with Kefir reduces vascular oxidative stress while suppressing COX2 mediated relaxation in intestinal arteries of an animal model of menopause

Functional foods such as probiotics are known to have benefits in various diseases including metabolic disorders and cardiovascular disease (CVD). In women, CVD has been shown to be linked with their gut microbiota and hormones. Here, we have evaluated the effects of chronic Kefir, a fermented milk beverage in Russia, Central Asia, Middle East and Eastern Europe, on mesenteric artery, using an animal model of menopause focusing on the superoxide anion and COX2 pathways. Two-month-old female Wistar rats were ovariectomized and treated by gavage with Kefir (5 % w/v, 3 mL/kg/day) or milk (Control) during two months. After this period, third-order mesenteric artery segments were isolated and mounted in a myograph system for evaluation of concentration-response curves to acetylcholine. We performed western blot analyses and measured oxidative stress through dihydroethidium (DHE) staining. Kefir reduced vascular oxidative stress, despite not changing SOD2 levels. COX2 levels were not changed by kefir, despite an apparent tendency towards reduction. However, in the functional experiments, under incubation with a COX2 inhibitor, a suppression of this pathway was observed in the kefir group, which suggests an interaction between inflammatory pathways and oxidative stress in this model. The effect of acute incubation with a superoxide anion scavenger on vascular responsiveness was equal in both groups. Kefir reduces vascular oxidative stress levels while suppressing COX2-mediated relaxation in mesenteric vessels in an animal model of menopause; which appears to involve an interplay between these two factors.

Modified Intestinal Derotation Procedure with Reversed Kocherization to Facilitate Mesopancreas Excision During Pancreaticoduodenectomy.

Although intestinal derotation procedure has advantages of facilitating mesopancreas excision during pancreaticoduodenectomy, the wide mobilization takes time and risks injuring other organs. This article describes a modified intestinal derotation procedure in pancreaticoduodenectomy and its clinical impact on short-term outcomes. The modified procedure comprised the pinpoint mobilization of the proximal jejunum following reversed Kocherization. Among 99 consecutive patients who underwent pancreaticoduodenectomy between 2016 and 2022, the short-term outcomes of pancreaticoduodenectomy with the modified procedure were compared with those of conventional pancreaticoduodenectomy. The feasibility of the modified procedure was investigated based on the vascular anatomy of the mesopancreas. Compared with conventional pancreaticoduodenectomy (n = 55), the modified procedure (n = 44) involved less blood loss and shorter operation time (p < 0.001 and 0.017, respectively). Severe morbidity, clinically relevant postoperative pancreatic fistula, and prolonged hospitalization occurred less often with the modified procedure compared with conventional pancreaticoduodenectomy (p = 0.003, 0.008, and < 0.001, respectively). According to preoperative image findings, most (72%) patients had a single inferior pancreaticoduodenal artery sharing a common trunk with the first jejunal artery. The inferior pancreaticoduodenal vein drained into the jejunal vein in 71% of the patients. The first jejunal vein ran behind the superior mesenteric artery in 77% of the patients. By combining our modified intestinal derotation procedure with preoperative recognition of the vascular anatomy of mesopancreas, mesopancreas excision during pancreaticoduodenectomy can be performed safely and accurately.

Arterial branching pattern of the cranial mesenteric artery in the degu (Octodon degus)

BackgroundThe cranial mesenteric artery exhibits a species-specific ramification pattern that adapts to the morphology of the intestinal tract. The degu is a strictly herbivorous rodent with a well-developed large intestine with a spiral loop in the ascending colon; therefore, the cranial mesenteric artery likely demonstrates a degu-specific ramification pattern. Thus, we traced the cranial mesenteric artery to establish the detailed ramification pattern of the branches. MethodsEighteen male degus were injected with 0.3–0.8 ml of a latex mixture and water at a 1:1 ratio in conjunction with red acrylic paint coloring using a catheter inserted into the thoracic aorta. The cranial mesenteric artery was traced using a surgical microscope and photographed using a digital camera. ResultsThe arteries emerging from the cranial mesenteric artery exhibited frequent variations in number, distribution area, anastomosis pattern, and branching order. In the most frequent cases (22%), the cranial mesenteric artery sequentially gave rise to caudal pancreaticoduodenal, middle colic, right colic, jejunal, and ileocolic arteries. The right and middle colic arteries exhibited four different ramification patterns. In the most common cases (67%), the middle and right colic arteries emerged independently from the cranial mesenteric artery. The former was distributed to the transverse and descending colon, whereas the latter sent branches to the spiral loop of the ascending colon. ConclusionsThe complex ramification pattern of the right colic artery in the degu may be an adaptation to the characteristic running pattern of the ascending colon. Thus, we present the first comprehensive report of the arterial branching pattern of the cranial mesenteric artery in the degu.

Strengthening the Description of Superior Mesenteric Artery Occlusions in Acute Mesenteric Ischaemia: Proposition for an Anatomical Classification

The aim of this study was to propose computed tomography angiography (CTA) based anatomical segmentation of the superior mesenteric artery (SMA), in order to standardise the reporting of occlusive lesions in acute mesenteric ischaemia (AMI). A retrospective CTA evaluation of patients with occlusive AMI admitted between 2016 and 2021. After the screening of 468 patients, 95 were included. The SMA was segmented into proximal (S1, ostium to the inferior pancreaticoduodenal artery), middle (S2, from the inferior pancreaticoduodenal to the ileocolic artery), and distal (S3, downstream the ileocolic artery) sections. The jejunal arteries were labelled J1 to J6, and the middle, right, and ileocolic arteries C1, C2, and C3. Two radiologists independently applied the proposed segmentation to a cohort of patients with occlusive AMI to describe occlusive lesions. Intra- and inter-rater agreement was assessed with kappa statistics. Occlusions involved one segment in 50 (53%) patients (S1, n= 27 [28%]; S2, n= 12 [13%]; S3, n= 11 [12%]); two segments in 37 (39%) patients (S2/S3, n= 31 [33%]; S1/S2, n= 3 [3%]; S1/S3, n= 3 [3%]); and all three segments in eight patients (S1/S2/S3, 8%). The median number of jejunal arteries was four (interquartile range 3, 4.5). C1 and C2 were present in 93 (98%) and 23 patients (24%), respectively. Almost perfect intra-rater agreement was obtained for S1 (91% agreement, κ= 0.82, 95% confidence interval [CI] 0.72 - 0.92); substantial agreement was obtained for S2 (90% agreement, κ= 0.80, 95% CI 0.68 - 0.92) and S3 (86% agreement, κ= 0.72, 95% CI 0.58 - 0.86). Almost perfect inter-rater agreement (with the second junior reading) was obtained for S1 (97% agreement, κ= 0.95, 95% CI 0.89 - 1.0), S2 (91% agreement, κ= 0.82, 95% CI 0.72 - 0.92), and S3 (agreement 96%, κ= 0.91, 95% CI 0.83 - 0.99). A standardised CTA based anatomical segmental description of SMA occlusive lesions in AMI is proposed; it provided substantial to almost perfect intra- and inter-rater agreement for most anatomical segments.

Covered stent placement for gastroduodenal artery stump hemorrhage after pancreaticoduodenectomy: long-term patency and risk factor of stent failure.

To evaluate the long-term outcomes of covered stent placement in patients with gastroduodenal artery (GDA) stump hemorrhage after pancreaticoduodenectomy (PD) and to identify risk factors of stent failure. Covered stent was placed in total of 21 patients for GDA stump hemorrhage after PD from September 2012 to March 2021. Technical and clinical success, complications, and stent patency were retrospectively evaluated. Nine relevant variables were analyzed to determine risk factors for stent failure. In 20 of 21 patients (95.2%), the GDA stump was completely excluded with covered stent placement. Immediate hemostasis was achieved in the 20 patients and rebleeding from jejunal artery occurred in one patient which was successfully embolized one day after the stent placement. There was no procedure-related complication or early mortality (<30 days). During follow-up period (median 655.5 days), stent thrombosis was found on CT in 10 patients (50.0%, 10/20) without any laboratory or CT abnormalities. One thrombosed stent migrated into the jejunum 20 months after placement. The six-month, one-year, and two-year stent patency were 81.9%, 52.9%, and 37.8%, respectively (median 620 days). The recurrence of primary malignancy was associated with stent failure (HR 5.70; 95% CI 1.18-27.76, p = 0.03). Covered stent placement is an effective and safe management of postoperative GDA stump hemorrhage. Stent failure occurred frequently (50%) but did not cause liver ischemia. Stent failure was associated with recurrence of primary malignancy. 1. Covered stent placement is an effective and safe management of postoperative GDA stump hemorrhage.2. Stent failure occurred frequently (50%) but did not cause liver ischemia.3. Stent failure was associated with recurrence of primary malignancy.