Jejunal Artery Research Articles

Dissection Around the Superior Mesenteric Artery (SMA) Using LigaSure Maryland During Left Posterior Approach for Pancreaticoduodenectomy.

R0 resection for pancreatic head cancer without exposing the tumor demands complete resection of “mesopancreas”. In other words, dividing the proximal jejunal artery and vein at their roots of the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) respectively during pancreaticoduodenectomy (PD) is absolutely essential. We present here our standardized dissection procedures around the SMA during the left posterior approach for PD. This procedure is safe and reproducible owing to the secure sealing performance of LigaSureTM Maryland.

Hexafurcated coeliac trunks, trifurcated common hepatic artery, and a new variant of the arc of Bühler.

The coeliac trunk (CT) is well-known as trifurcated into the left gastric (LGA), common hepatic (CHA) and splenic (SA) arteries. Scarce reports indicate that the CT could appear quadri-, penta-, hexa-, or even heptafurcated. Reports of CTs with six branches (hexafurcated CT) are few, less than ten. The hexafurcated CT variant was documented by a retrospective study of 93 computed tomography angiograms. Two hexafurcated CTs were found. In one case an arc of Bühler was added to the inferior phrenic arteries, LGA, CHA and SA. In the second case the dorsal pancreatic artery was added to the other five branches. That arc of Bühler descended in front of the aorta to connect with the origin of the third jejunal artery. The CHA in that second case was trifurcated into the left and right hepatic arteries, and the gastroduodenal artery; the proper hepatic artery was absent. Although the hexafurcated CT, as well as the trifurcated CHA, are rarely occurring and reported anatomic variants, this doesn't mean they could not be encountered during surgical or interventional procedures, which they would complicate if not recognised. Moreover, the arc of Bühler, the embryonic remnant, was not reported previously to insert into the CT as an additional branch of it.

Imaging-Guided Percutaneous Puncture and Embolization of Visceral Pseudoaneurysms: Feasibility and Outcomes.

Visceral artery pseudoaneurysms (VAPAs) are the most frequently diagnosed pseudoaneurysms (PSAs). PSAs can be asymptomatic or symptomatic. The aim of our study was to evaluate the safety and effectiveness of percutaneous embolization of VAPAs performed on patients with an unfeasible trans-arterial approach. Fifteen patients with fifteen visceral PSAs, with a median dimension of 21 mm (IQR 20–24 mm), were retrospectively analyzed. No patients were suitable for trans-arterial catheterization and therefore a percutaneous approach was chosen. During percutaneous treatments, two embolic agents were used, either N-butyl cyanoacrylate (NBCA) (Glubran II, GEM Milan, Italy) mixed with Lipiodol (Lipiodol, Guerbet, France) or thrombin. The outcomes of this study were technical success, primary clinical success, and secondary clinical success. In our population the 15 PSA were located as follows: 2 in the left gastric artery, 1 in the right gastric artery, 3 in the right hepatic artery, 2 in a jejunal artery, 1 in left colic artery branch, 1 in a right colic artery branch, 1 in the gastroepiploic artery, 1 in the dorsal pancreatic artery, 1 in an ileocolic artery branch, 1 in an iliac artery branch, and 1 in a sigmoid artery branch. 80% of PSAs (12/15) were treated with a NBCA:lipiodol mixture and 20% of PSAs (3/15) were treated with thrombin. Technical, primary, and secondary clinical successes were obtained in 100% of the cases. No harmful or life-threatening complications were observed. Minor complications were registered in 26.6% (4/15) of the patients. Percutaneous embolization of visceral PSA is a safe and effective treatment and should be considered as an option when the endovascular approach is unsuccessful or unfeasible.

Classification of the superior mesenteric artery.

The aim of this study was to characterize the branching pattern and morphology of the superior mesenteric artery (SMA), and also to create a new SMA classification, which seems necessary for clinicians performing surgery in this anatomical area. The anatomical variations in the branching patterns of the SMA were examined in 30 cadavers fixed in 10% formalin. Morphometric measurements were then obtained twice by two researchers. In the proposed classification system, Type I, characterized by all normal branches-inferior pancreatoduodenal artery, ileocolic artery, right colic artery, middle colic artery and intestinal arteries-occurred in 53.33% of the specimens. Type II, characterized by absence of the inferior pancreatoduodenal artery, was present in 26.67%. Type III, characterized by absence of the right colic artery, was present in 3.33%. Type IV, characterized by a common trunk for the inferior pancreatoduodenal artery and middle colic arteries, was observed in 3.33%. Type V, characterized by an aberrant hepatic artery and absence of the inferior pancreatoduodenal artery, was observed in 13.33%. The origin of the SMA was at the Th12/L1 level in 10% of cases, at L1 in 43.33%, at L1/L2 in 36.67%, and at L2 in 10%. The SMA is characterized by high morphological variability, the variants being associated with distinct clinical aspects. The introduction of a new, structured, anatomical classification seems necessary for all clinicians.

Transcatheter arterial embolization followed by surgical laparotomy for hemorrhagic shock due to intestinal bleeding: a case report

BackgroundAcquired jejunal diverticula are relatively rare conditions. While mostly asymptomatic, they can occasionally cause life-threatening complications requiring surgical treatment. We herein report a case of hemorrhagic shock due to jejunal diverticulum with intestinal amyloidosis that was successfully managed via transcatheter arterial embolization (TAE) and surgery.Case presentationAn 80-year-old female presenting with hematochezia and hemorrhagic shock was transferred to our institution. Contrast-enhanced computed tomography revealed extravasation in the small bowel around the upper jejunum. Massive transfusion was performed with subsequently planning for TAE to control bleeding followed by surgical laparotomy to evaluate the ischemic intestine. First, the second jejunal artery was selectively embolized with a 1:3 mixture of N-butyl cyanoacrylate (NBCA) and iodize oil, after which laparotomy was performed. Multiple jejunal diverticula were detected near Treitz’ ligament, and an induration of NBCA was palpable in the nearby mesentery. The intraoperative diagnosis was massive bleeding from acquired jejunal diverticula for which jejunectomy including the nearby diverticulum was performed to prevent future bleeding. Her postoperative course was stable. Histological examination of the specimen revealed several false diverticula with intestinal amyloidosis.ConclusionHemorrhagic shock due to jejunal diverticulum with intestinal amyloidosis is extremely rare. Combined treatment of TAE and surgical laparotomy appears to be effective, because the bleeding point can be identified by palpation of the embolic material.

Endovascular treatment of delayed arterial bleeding after pancreatic surgery: single-center experience

To evaluate technical aspects and clinical results of transcatheter arterial embolization (TAE) for delayed postoperative arterial bleeding after pancreatic surgery. There were 821 pancreatectomies between 2012 and 2020. Delayed bleeding occurred in 106 (12.9%) patients; 74 patients were included in the study. Previous pancreatic head resection was carried out in 75.7% of cases, pancreatic body resection - in 17.6% of cases, pancreatic tail resection - in 6.8% of patients. Primary endpoint was technical success of TAE, secondary endpoints - complications after TAE, as well as recurrent bleeding after embolization. Angiography of celiac-mesenteric arterial system was performed in 74 patients (91 procedures). The most common sources of bleeding were gastroduodenal and superior mesenteric arteries (35.7%), jejunal arteries (13.1%), common hepatic artery (11.9%). Combination of embolization agents was applied for TAE (metal coils and non-calibrated PVA particles, 48.6%). In 11 (14.9%) patients, we applied stent-grafts. Technical success rate was 100%. Recurrent bleeding occurred in 13 (17.6%) patients. In-hospital mortality was 12.2% (n=9). TAE is an effective treatment procedure in patients with arrosive bleeding. This method is characterized by high technical efficiency and low in-hospital mortality, but it does not affect recurrence of bleeding.

Segmental Arterial Mediolysis: A Multiguised Vasospastic Arteriopathy with Collateral Mesangial Cell Hyperplasia and Cardiac Toxicity Generated by Norepinephrine and Hyperdense Adrenoceptors Alone or by Crosstalk with Other Pressor Agents.

Segmental arterial mediolysis (SAM), an uncommon vasospastic arteriopathy occurring in the muscular arteries innervated by the peripheral sympathetic nervous system, usually presents with catastrophic abdominal and retroperitoneal hemorrhages in elderly patients. SAM is initiated by the coupling of norepinephrine to plastically derived hyperdense foci of alpha-1 adrenergic receptors on the sarcolemma of arterial muscle. This ligand is created by stimuli signaled by iatrogenic sympathomimetic agonists, some beta-2 agonists, or an excessive release of adrenal catecholamines. Coupling of this ligand with cytoplasmic heterotrimeric Gq protein excessively signals a cascade of biochemical events generating two principal lesions of injurious-phase SAM—the shearing of the outer media from the adventitia and an overload of cytoplasmic calcium ions toxic to mitochondria causing mediolysis and/or apoptosis. The massive hemorrhages are caused by ruptured gap aneurysms created by the transmedial loss of the medial muscle. A norepinephrine-directed reparative response rapidly develops either resolving angiographic injurious lesions or creating a body of vascular disorders, the new guises of SAM with ischemic clinical profiles. These present in the epicardial, vertebral, intestinal, and retroperitoneal arteries, often in younger females as fibromuscular dysplasia, dissecting hematomas, and persistent aneurysms. Norepinephrine can crosstalk with other pressor agents to create SAM lesions—serotonin with idiopathic pulmonary hypertension and persistent pulmonary hypertension in the newborn, histamine in spontaneous coronary artery dissections with eosinophilia, and endothelin-1 in a field effect generated by SAM that creates venous fibromuscular dysplasia. Norepinephrine also participates in the collateral development of mesangial hyperplasia with focal segmental glomerulosclerosis and myocardial mediolysis and apoptosis in subjects with markedly elevated heart rates. Conclusion. Norepinephrine coupling with plastically elevated alpha-1 adrenoceptor or other pressor agents generates SAM, a histologically recognizable vasospastic arteriopathy, that with repair is transformed into several different standardized arterial diseases that alter SAM's clinical profile from a hemorrhagic to an ischemic disorder.

What Should We Cover Beyond Gross Disease With Radiation Therapy for Localized Pancreatic Ductal Adenocarcinoma (PDAC): Proposal of an Innovative and Standardized Clinical Tumor Volume (CTV) for PDAC of the Head – The Triangle

<h3>Purpose/Objective(s)</h3> Although overshadowed by metastatic failure, patients (pts) with locally advanced pancreatic adenocarcinoma (LAPC) who undergo resection after neoadjuvant therapy (NAT) also experience high rates of locoregional failure (LF). Prior data from our institution indicate LF developed in > 30% of LAPC pts resected after NAT with multi-agent chemotherapy (MA-CT) and RT from 2016-2019 despite an R0 rate of 88%. In this cohort, gross disease and involved vessels were the target, raising the question whether field design modification could reduce LF. Indeed, elective treatment of tissue at risk of harboring microscopic residual disease after resection may be critical, but consensus regarding what constitutes the CTV for NAT does not exist. In the surgical literature, support is growing for extended dissection of the "Heidelberg Triangle" (HT), tissue between the celiac artery (CA), superior mesenteric artery (SMA), common hepatic artery (CHA), and portal vein (PV) that contains key perineural and lymphatic tracts at risk of harboring subclinical disease. Whether this concept can be applied to CTV field design is unclear. In investigation, we mapped LF locations in LAPC pts to assess if the LF distribution matches the anatomy of the Triangle volume (TV). <h3>Materials/Methods</h3> A total of 21 consecutive LAPC pts with involvement of the head or neck at diagnosis treated at our institution with MA-CT and stereotactic body radiation who developed LF after resection were reviewed. The TV starts superiorly at the CA take-off point, extends along the CA to the trifurcation, then extends laterally along the CHA and stops at the proximal proper HA. At this lateral boundary, the PV is also included and the TV extends posteriorly to the aorta along the inferior vena cava, including the SMA take-off until the crossing of the left renal vein. From the lateral boundary of the PV, the volume descends to the superior mesenteric vein (SMV) and covers the groove between the SMA-SMV. The inferior boundary is the branching of the first jejunal artery (JA) from the SMA. Descriptive statistics were generated to report the frequency of LF in relation to the TV and the frequency of critical vasculature involvement. <h3>Results</h3> In 21 consecutive pts, the median TV was 80.2 ± 30.1 cubic centimeters (cc) (27.7-110.3 cc). The LF centroid was located within the TV in 20 pts (95.2%). The SMA from take-off to the JA branch-point was the most common vessel involved at diagnosis (85.7%) and at failure (80.1%) with the next four being the CA (66.7%, 57.1%), SMV (61.9%, 66.7%), CHA (61.9%, 38.1%), and PV (38.1%, 47.6%). <h3>Conclusion</h3> The TV nearly universally encapsulates LF location and could serve as the basis for CTV design in the neoadjuvant setting. Future studies should investigate the feasibility of therapeutic dosimetry to this volume and ultimately whether treatment of the TV reduces LF.

Resection and reconstruction of pancreatic artery aneurysms caused by the compression of the celiac trunk by the median arcuate ligament: a report of two cases

BackgroundSome patients with the compression of the celiac trunk by the median arcuate ligament (MAL) suffer pancreatic artery aneurysms (PAAs) due to excessive blood flow from the superior mesenteric artery. These aneurysms are in peril because they are prone to rupture irrespective of size. Here, we present two cases of resection and reconstruction of PAAs caused by the compression of the celiac trunk by the MAL.Case presentationPatient 1 was a 44-year-old man who was first diagnosed to have a visceral artery aneurysm with a diameter of 4 cm accidentally found by ultrasound examination at a regular medical check-up. Contrast-enhanced CT revealed the compression of the celiac trunk by the MAL and a PAA originating from the first jejunal artery. First, laparoscopic excision of the MAL followed by a stent placement into the celiac trunk was performed. Although the stent was patent, the PAA still grew. The patient underwent resection and reconstruction of the PAA. Reconstruction of the pancreatic arterial arcade was needed because clamping of the inferior pancreaticoduodenal artery (IPDA) resulted in disappearance of the hepatic arterial blood flow. The follow-up CT 2 years and 9 months after the operation revealed no recurrence of aneurysms and the patent anastomosis. Patient 2 was a 68-year-old man who presented with an epigastric pain. Contrast-enhanced CT revealed the compression of the celiac trunk by the MAL and a PAA approximately 6 cm in diameter originating from the IPDA. The PAA was surrounded by a relatively low-intensity area, suggesting impending rupture of the PAA. The patient underwent resection and reconstruction of the PAA under an emergency situation. Reconstruction of the pancreatic arterial arcade was needed because clamping of the inflow IPDA resulted in disappearance of the hepatic blood flow. The follow-up CT 1 year and 8 months after the operation revealed no recurrence of aneurysms and the patent anastomosis.ConclusionsAlthough long-term follow-up is needed, resection and reconstruction is one of the therapeutic choices for PAAs caused by the compression of the celiac trunk by the MAL in order to prevent catastrophic aneurysm rupture.

Precision anatomy for safe approach to pancreatoduodenectomy for both open and minimally invasive procedure: A systematic review.

Minimally invasive pancreatoduodenectomy (MIPD) has recently gained popularity. Several international meetings focusing on the existing literature on MIPD were held; however, the precise surgical anatomy of the pancreas for the safe use of MIPD has not yet been fully discussed. The aim of this study was to carry out a systematic review of available articles and to show the importance of identifying the anatomical variation in pancreatoduodenectomy. In this review, we described variations in surgical anatomy related to MIPD. A systematic search of PubMed (MEDLINE) was conducted, and the references were identified manually. The search strategy yielded 272 articles, with 77 retained for analysis. The important anatomy to be considered during MIPD includes the aberrant right hepatic artery, first jejunal vein, first jejunal artery, and dorsal pancreatic artery. Celiac artery stenosis and a circumportal pancreas are also important to recognize. We conclude that only certain anatomical variations are associated directly with perioperative outcomes and that identification of these particular variations is important for safe performance of MIPD.

Extraordinary first jejunal arterial variation associated with annular pancreas undergoing pancreaticoduodenectomy for pancreatic cancer: a case report

PurposeAnnular pancreas encountered in adults and jejunal arterial variations are rare. Anatomical variations can cause conflicts between oncology and surgical safety.MethodsCase report of a 68-year-old man suffering from vomiting because of an annular pancreas and a ductal adenocarcinoma of the pancreas head invading the second portion of the duodenum.ResultsContrast-enhanced computed tomography showed multiple arterial variations describing the absence of the coeliac trunk such that the left gastric artery (LGA), splenic artery and superior mesenteric artery (SMA) were arising separately from the aorta. The accessory left hepatic artery arose from the LGA; and both the common hepatic artery and combined trunk of the replaced right hepatic artery with the higher replaced first jejunal artery separately arose close to the root of the SMA. The patient underwent curative pancreaticoduodenectomy which achieved 3 years of recurrence-free survival.ConclusionThis was an extraordinary case of annular pancreas with first jejunal arterial variation detailing an embryological interpretation as well as considerations for balancing short- and long-term outcomes.

Small Intestine Artery False Aneurysm Embolization

Bleeding from an aneurysm of a small intestine artery is a formidable complication, the treatment remains a difficult problem. In this case, aneurysm embolization is indicated. The aim of the article is to describe the role of embolization in the treatment of bleeding in an elderly patient, to analyze the efficacy and risk. The advantage of the intervention is minimal invasiveness and low blood loss. The presented observation showed the effectiveness of endovascular embolization in the rupture of a pseudo-aneurysm.

Simulated twin-phase pancreatic CT generated using single portal venous phase dual-energy CT acquisition in pancreatic ductal adenocarcinoma.

To evaluate the diagnostic performance of a simulated twin-phase pancreatic protocol CT generated from a single portal venous phase (PVP) dual-energy CT (DECT) acquisition in patients with pancreatic ductal adenocarcinoma (PDAC). In this retrospective study, we included 63 patients with PDAC who underwent pancreatic protocol (pancreatic phase [PP] and PVP) DECT. Two data sets were created from this original acquisition-(1) Standard protocol (50keV PP/65keV PVP) and (2) Simulated protocol (40keV/65keV PVP). Using a 5-point scale, three readers scored image quality, tumor conspicuity, and arterial involvement by the PDAC. Signal-to-noise ratio (SNR) of the pancreas and tumor-to-pancreas contrast-to-noise ratio (CNR) were calculated. Qualitative scores, quantitative parameters, and radiation dose were compared between standard and simulated protocols. No significant difference in detection rate of PDAC was seen between the standard (58/63, 92.1%) and simulated protocols (56/63, 88.9%) (P = 0.76). Subjective scoring for arterial involvement for celiac (P = 0.86), superior mesenteric (P = 0.88), splenic (P = 0.86), common hepatic (P = 0.52), gastroduodenal (P = 0.95), first jejunal (P = 0.48) arteries, and aorta (P = 1.00) were comparable between two protocols. The image quality (P = 0.14), the SNR of the pancreas (P = 0.15), and CNR (P = 0.54) were comparable between two protocols. The projected mean dose-length product (DLP) (629.6 ± 148.3mGy cm) in the simulated protocol showed a 44% reduction in radiation dose compared to the standard protocol (mean DLP, 1123.3 ± 268.9mGy cm) (P < 0.0001). Low keV images generated from a PVP DECT acquisition allows creation of a twin-phase pancreatic protocol CT with comparable diagnostic accuracy for detecting PDAC with significant reduction in radiation dose. Reduced radiation dose is desirable in surveillance and screening for pancreatic diseases.

Liver Transection-First Approach in Hepatopancreatoduodenectomy for Hilar Cholangiocarcinoma: A Safe and Secure Technique for the Early Assessment of Curable Resection and Vascular Reconstruction.

Hepatopancreatoduodenectomy (HPD) is often indicated in the resection of cholangiocarcinoma but is associated with high mortality.1-3 From a risk-benefit perspective, HPD can be justified only when curative resection is achievable.4-6 METHODS: A liver transection-first approach is a surgical technique in which liver transection precedes pancreatoduodenectomy (PD) and skeletonization of the hepatoduodenal ligament in HPD. This approach enables an early assessment of resectability and curability. A 64-year-old with jaundice had a tumor located mainly in the proximal bile duct, spreading from the confluence of hepatic ducts (dominant in the left hepatic duct) to the intrapancreatic bile duct. The right hepatic artery and portal vein existed in close proximity to the tumor. HPD (left hemi-hepatectomy and subtotal stomach-preserving PD) with vascular resection was performed. After liver transection along the Cantlie line, the right Glissonean pedicle was collectively secured inside the liver. The right hepatic artery, right portal vein, and right hepatic duct (RHD) were isolated, and the feasibility of vascular reconstruction was confirmed. After the RHD was divided and the negative margin was confirmed, we proceeded to perform PD. The portal vein was reconstructed between the right portal vein and the portal vein trunk. The right hepatic artery was anastomosed to the second jejunal artery of the jejunal loop with the right gastroepiploic artery as an interposition graft. The liver transection-first technique in HPD facilitates early assessment of curability and resectability as well as a safe and secure manipulation and reconstruction of the hepatic artery and portal vein.

S2872 A Case of CMV Enteritis Resulting in Severe Obscure GI Bleeding

INTRODUCTION: Small bowel (SB) bleeding accounts for less than 5% of gastrointestinal (GI) bleeds, in non-IBD patients, with an even smaller portion originating from the jejunum [1]. Locating SB bleeds poses great challenges, frequently resulting in delay in diagnosis. Although SB arteriovenous malformations (AVMs) are most common, other rare etiologies such as infectious enteritis should be considered. CASE DESCRIPTION/METHODS: A 62 year old male was diagnosed with T-cell lymphoma with EBV positivity and placed on high-dose steroids for one month. Staging CT chest, abdomen, and pelvis incidentally revealed intraperitoneal free air with concerns for a gastric wall neoplasm. EGD revealed a 4cm, deep, non-bleeding, non-perforated ulcer in the gastric body (Image 1). Two weeks after, he had painless melanotic stools, requiring multiple transfusions. Emergent arteriography of the celiac and mesenteric arteries did not identify a source of bleeding. Repeat CT imaging was negative for worsening free air. His course continued to worsen, requiring high-dose vasopressors and continued transfusions. Emergent EGD and colonoscopy were performed. EGD revealed a known, non-bleeding gastric ulcer. Colonoscopy showed bright red blood to the cecum with scattered, non-bleeding, ischemic-appearing ulcers (Image 2). Repeat celiac angiogram was performed two more times, eventually revealing active bleeding from small jejunal artery branches which were embolized. Due to concern for ongoing bleeding, surgical resection of the distal jejunum and proximal ileum was performed. Gross pathology demonstrated extensive ulcerations, with biopsies negative for malignancy (Image 3). Serum testing for Cytomegalovirus (CMV) was positive for strongly elevated quantitative levels and the patient was started on Valganciclovir. DISCUSSION: Delays in diagnosing SB bleeds are not uncommon and can frequently be fatal. Our case presents a complex diagnostic scenario where bleeding was presumed to be from the known gastric lesion, but complicated by inability to perform EGD safely with pneumoperitoneum. Ultimately, the patient’s immunocompromised state and steroids predisposed him to opportunistic infections such as CMV, resulting in bleeding ulcers in the jejunum and ileum. Upon literature review, CMV enteritis is exceedingly rare and accounts for under 5% of all CMV infections in the GI tract [2]. Though rare, CMV enteritis has been reported to cause massive hemorrhage requiring emergent surgery and is often associated with high mortality.Figure 1.: 4cm non-bleeding ulcer in the gastric body seen on the initial EGD.Figure 2.: Scattered ischemic-appearing colonic ulcers.Figure 3.: Gross specimen of resected and ulcerated jejunum.

46 ESOPHAGECTOMY FOR ESOPHAGEAL CANCER TO THE PATIENT ACCOMPANIED WITH PROTEIN C DEFICIENCY

Abstract Protein C deficiency is a rare genetic disease that predisposes to thrombotic disease, which is characterized by tendency to form thrombus due to hypercoagulation. The incidence of protein C deficiency with clinical symptoms has been reported to be estimated at 1 in 20,000. Only a few cases of surgery for gastrointestinal cancer with protein C deficiency have been reported, however, there have been no reports regarding the perioperative management in detail for those patients. Methods We present. We assess perioperative management for the case of esophagectomy for an esophageal cancer accompanied with protein C deficiency. Results A 63-year-old male with protein C deficiency underwent thoracoscopic esophagectomy and digestive reconstruction using gastric tube for thoracic esophageal cancer whose clinical stage was T1bN0M0. On postoperative day 3, his gastric tube was removed due to gastric tube necrosis. Digestive reconstruction using free jejunal graft has been attempted after 140 days from first surgery, however, thrombus formation in the jejunal artery and vein caused the reconstruction to failure. Ten days after this surgery, digestive reconstruction using colon was performed with anticoagulation control by administrating intraoperative heparin. The patient went fine without thrombus formation afterward. Conclusion During digestive reconstruction in patients with conditions predisposing to thrombus formation as typified by protein C deficiency, the perioperative management should be done with careful attention to prevent thrombus formation. In particular, because there is likely to develop necrosis of reconstructed organ due to thrombus formation, the appropriate anticoagulation control such as intraoperative heparin administration is recommended in patients with protein C deficiency.

The technique of fourth jejunal artery-based jejunal conduit for oesophagojejunostomy after thoracolaparoscopic oesophagogastrectomy for locally advanced Siewert type II tumour.

Background:Locally advanced long Siewert type II tumor requires total gastrectomy and D2 lymphadenectomy with distal esophagectomy and mediastinal lymphadenectomy for curative resection. In this scenario, a laparoscopic transhiatal approach is not feasible, and the conventional left thoracoabdominal approach is associated with increased morbidity.Aims and Objectives:To describe a novel technique of fourth jejunal artery based jejunal conduit for thoracoscopic esophagojejunostomy after laparoscopic esophagogastrectomy.Materials and Methods:The laparoscopic total gastrectomy with distal esophagectomy specimen is extracted through the periumbilical incision. A pedicled jejunal conduit based on the fourth jejunal artery is prepared, and the jejunal conduit is placed in the mediastinum under laparoscopic guidance. Using the thoracoscopic approach in a prone position, additional esophageal clearance and subcarinal lymphadenectomy are performed. Handsewn end to side esophagojejunostomy is performed at the level of the carina.Results:Three patients with long Siewert type II underwent this procedure after neoadjuvant chemotherapy. None of the patients had conduit related complications. All three patients had abdominal lymph node involvement and two patients had mediastinal lymph node involvement.Conclusion:Pedicled jejunal conduit based on the fourth jejunal artery is safe for intrathoracic anastomosis after minimally invasive esophagogastrectomy for locally advanced Siewert type II tumor.

Clinical usefulness of saphenous vein graft in major arterial reconstruction during extended pancreatectomy.

Extended pancreatectomy for locally advanced pancreatobiliary malignancy often involves combined major arterial resection (AR) and reconstruction (ARc). By limiting candidate inflow for ARc after combined resection of the celiac arterial system over a long distance, we evaluated whether great saphenous vein graft (GSVG) is an alternative conduit for obtaining non-anatomical arterial inflow. ARc with GSVG conduit was undertaken prior to resection. GSVG was harvested and anastomosed end-to-side with the reconstructing artery and then mostly passed via the retroperitoneal para-inferior vena cava route. Side-to-end anastomosis of GSVG inflow was established with the right common iliac artery or abdominal aorta. Among 468 consecutive pancreatobiliary surgeries, ARc with GSVG was undertaken in seven cases. Primary cancers were in the pancreas in six patients and distal bile duct in one. Radical surgery was performed with pancreaticoduodenectomy in six patients and total pancreatectomy in one. Hepatic artery (HA) was concomitantly resected and reconstructed by GSVG in six patients or by the jejunal artery in one patient. Median operative time and intraoperative blood loss were 763min and 350ml, respectively. Serum level of AST, ALT, and LDH in patients with HA reconstruction by GSVG peaked by the second postoperative day and promptly normalized. Postoperative morbidity (CD ≥ III) was encountered in one patient. No surgical mortality was observed. Postoperative serum liver enzymes promptly decreased in ARc patients with GSVG to HA. Arterial reconstruction with GSVG prior to resection was performed securely and might help to reduce postoperative liver dysfunction.

Vascular Anatomy of Mesopancreas in Pancreatoduodenectomy Using an Intestinal Derotation Procedure.

Mesopancreas excision in pancreatoduodenectomy is technically complicated because of the anatomical complexity of the mesopancreas with the inferior peripancreatic blood vessels which is caused by intestinal rotation in fetal life. We have developed a novel artery-first approach (the intestinal derotation procedure) for facilitating mesopancreas excision. The aim of this study was to clarify the vascular anatomy of the mesopancreas after derotation. The right-sided colon and small intestine are mobilized from the retroperitoneum, and the intestinal loop is then derotated. In 136 cases of pancreatoduodenectomy employing the derotation procedure, we analyzed the vascular anatomy of the mesopancreas. After derotation, the anatomy was simplified. The mesopancreas extended from the right aspect of the superior mesenteric artery (SMA), forming a horizontal plane. The first jejunal trunk (FJT) was situated in parallel with the second jejunal artery and was anterior (91%) or posterior (9%) to the SMA. The inferior pancreaticoduodenal vein (IPDV) entered the right side of the FJT (83%) or the superior mesenteric vein (17%). Besides the IPDV, 1-4 tributaries entered the right wall of the FJT, in 89% of cases. The inferior pancreaticoduodenal artery was observed to originate from the right wall of the SMA, sharing a common stem with the first jejunal artery (70%) or branching directly from the SMA (29%). Intestinal derotation simplifies the mesopancreas anatomy and reveals the anatomical details of the inferior peripancreatic blood vessels in pancreatoduodenectomy.

Optimal Lymphadenectomy of the Mesopancreas Based on Fluorescence Imaging During Pancreaticoduodenectomy

BackgroundExcision of the mesopancreas with lymphadenectomy is an important component of pancreatoduodenectomy. However, the optimal extent of lymphadenectomy remains unclear. Furthermore, accurate description of the mesopancreatic lymphatic pathways is difficult, probably because of the complex anatomy. Intestinal derotation simplifies the anatomy and facilitates both examination of lymphatic flow and the surgical procedure. The aim of this study was to evaluate lymphatic flow in the mesopancreas using indocyanine green fluorescence imaging with an intestinal derotation technique, and to clarify the optimal extent of mesopancreas excision and lymphadenectomy in pancreatoduodenectomy. MethodsIndocyanine green solution (2.5 × 10−3 mg) was injected into the pancreatic head parenchyma. After intestinal derotation, the spread of indocyanine green was observed using near-infrared imaging. ResultsParticipants comprised 10 patients who underwent pancreatoduodenectomy for periampullary neoplasms. With indocyanine green fluorescence imaging, 9 of the 10 patients showed lymphatic flow from the pancreatic head to the superior mesenteric artery via the inferior pancreaticoduodenal artery and first jejunal artery (but not via the second and more distant arteries), with eventual drainage into the paraaortic region. ConclusionsLymphatic pathways from the pancreatic head were connected to the superior mesenteric artery via the inferior pancreaticoduodenal artery and first jejunal artery. Excision of the mesopancreas with the inferior pancreaticoduodenal artery and first jejunal artery while preserving the second or more distant arteries appears optimal in pancreatoduodenectomy for periampullary malignancies.