Mesenteric Artery Research Articles

Anatomical variants of the jejunal veins and their technical implications in pancreaticoduodenectomy: a systematic review and meta-analysis.

One of the most common causes of bleeding during pancreaticoduodenectomy (PD) is dissection of the pancreatic head from the superior mesenteric vein (SMV) and superior mesenteric artery (SMA). Knowledge of the anatomical variants of the veins draining the proximal jejunum may allow a better control of bleeding during detachment of the uncinate process and pancreatic head from the mesenteric pedicle and division of the mesopancreas. The aim of this systematic review and meta-analysis is to evaluate the anatomical variations of the first jejunal vein (FJV) and jejunal trunk (FJT). Fourteen studies (1,888 patients) were included. We performed a systematic review of the available Literature according to the PRISMA guidelines. The analysis has shown that the posterior course of the FJT and FJV represents the most frequent topographical location (PPE 79.6%) with the anterior jejunal trunk (JT) having a lower rate (PPE 20.4%). Few articles reported the variations with separate trunks for the first and second jejunal vein. A thorough preoperative radiological assessment of the anatomical variation of FJT and FJV may confer some advantage to establish the best therapeutic strategy and the best surgical approach in case of pancreatic head carcinoma, as it can allow a better estimate of the extent of the neoplasm and improve the accuracy of surgical dissection with potential for reduced bleeding.

SURGICAL TREATMENT OF RECTAL CANCER WITH PRESERVATION OF THE LEFT COLIC ARTERY AND ICG NAVIGATION

Goal. To analyze the peculiarities of surgical diagnosis of lymphogenic metastasis in patients with colorectal cancer. Generalization of data from Ukrainian and foreign literature, results of randomized studies and meta-analyses. The study is based on the results of observation of 88 patients with colorectal cancer (CRC) of the prospective study group. To analyze the features of surgical diagnostics of lymphogenic metastasis in patients with colorectal cancer. Materials and methods. The results of surgical treatment of 88 patients with rectal cancer were analyzed and systematized. These patients underwent examination and treatment in 2023-2024 at the "Prykarpattian Clinical Oncology Center of the Ivano-Frankivsk Regional Council." The study included patients with stage II-III colorectal cancer (T2-3N0-2M0) without complicated courses. All patients received treatment based on NCCN recommendations. Surgical treatment was performed in standard volume with the removal of all regional lymph node groups and preservation of the left colic artery using real-time lymph node mapping with indocyanine green. All patients were divided into two study groups: Group I included 45 patients who underwent anterior or low anterior resection of the rectum with preservation of the left colic artery. This group was subdivided into two subgroups: Ia – 13 patients who underwent intraoperative indocyanine green injection for real-time lymph node visualization. Ib – 32 patients who did not receive this drug but underwent the same volume of surgery. Group II consisted of 43 patients who underwent anterior or low anterior resection of the rectum with high ligation of the inferior mesenteric artery. This group served as the control group. Results. The main mechanisms of lymphogenic metastasis in colorectal cancer patients in Ivano-Frankivsk were characterized. Literature data on the features of surgical diagnostics of colorectal cancer metastasis were summarized. A review of literature shows the social significance of these studies, as this pathology often leads to patient disability, requiring surgical interventions and further palliative treatment due to the widespread metastasis associated with this disease. The priority task for researchers remains the search for the most effective treatment methods for this pathology, based on randomized studies of colorectal cancer treatment and international protocols. According to the literature, surgical treatment of colorectal cancer remains insufficiently effective at the current stage of oncology. Modern methods offer low 5-year survival rates, emphasizing the need to study factors for individualized treatment. The overall 5-year survival rate for colorectal cancer patients from 2018-2022 was (45.8±2.3)%. The effectiveness of using real-time ICG navigation for lymph node mapping and preservation of the left colic artery in stage II-III (T2-4N1-2M0) rectal cancer patients has been proven. This technique allows for optimal lymphadenectomy, reducing the frequency of surgical complications by 14.7% (p<0.05). Conclusion. Ensuring radical resection of rectal cancer while maximizing blood supply preservation to the anastomosis is the main goal of colorectal surgeons. Over the past two decades, surgical techniques have significantly improved due to advancements in surgical equipment. It is anticipated that surgical technologies will further evolve towards enhancement and individualization in the future. Our procedure serves as an example of modern and personalized rectal cancer surgery.

Endovascular Treatment of Complex Aorto-Iliac Atherosclerotic Occlusive Disease With Chimney Covered Endovascular Reconstruction of Aortic Bifurcation.

Treatment of atherosclerotic occlusive disease of the infrarenal aorta poses several challenges. Traditionally, open surgery has been the preferred method of treatment in standard risk patients, although, it is burdened by high morbidity and mortality. There are many classifications to establish the patient risk for surgery. Among the most common is the American College of Cardiology (ACC)/American Heart Association (AHA) classification. ACC/AHA high-risk patients benefit from the increase in endovascular technology and skills. The treatment modality of atherosclerotic aortic disease has shifted towards a minimally invasive approach, including kissing stents, covered endovascular reconstruction of the aortic bifurcation (CERAB) and, aorto-uniiliac stent grafts. When there is an involvement of vital branches such as the inferior mesenteric (with concomitant occluded superior mesenteric artery) or the renal arteries, Chimney- CERAB technique has been successfully utilized to overcome this challenge. We present three patients with aortoiliac occlusive disease (AIOD) successfully treated with the chimney- CERAB technique to preserve a large inferior mesenteric artery in the setting of occlusion/near occlusion of the other mesenteric vessels.

Superior cervical ganglionectomy attenuates vascular remodeling in spontaneously hypertensive rats.

Sympathetic hyperactivity contributes to the pathogenesis of hypertension. However, it is unclear whether the excessive sympathetic activity is an independent and crucial factor for vascular remodeling in hypertension. This study focused on the effect of local sympathetic denervation with superior cervical ganglionectomy (SCGx) on vascular remodeling. Surgical bilateral SCGx was performed in 9-week-old male Wistar-Kyoto rats (WKY) and spontaneously hypertensive rats (SHR). Control rats received sham-operation without SCGx. All measurements were made 4 weeks after the surgery. The effectiveness of SCGx was confirmed by the eye features of Horner syndrome, greatly reduced tyrosine hydroxylase (TH) contents in the superior cervical ganglion (SCG)-innervated arteries in the head. Although SCGx had no significant effects on blood pressure and heart rate in WKY and SHR, it attenuated vascular remodeling of facial artery and superficial temporal artery in SHR, two representative SCG-innervated extracranial arteries, without significant effects on non-SCG-innervated thoracic aorta and mesenteric artery. SCGx-treated SHR had more auricular blood flow and retina microvasculature than sham-operated SHR. However, SCGx had only a mild effect in attenuating the vascular remodeling of basilar artery and middle cerebral artery, two representative SCG-innervated intracranial arteries, in SHR. SCGx-treated SHR exhibited upregulation of α-smooth muscle actin, downregulation of proliferating cell nuclear antigen, and attenuation of oxidative stress and inflammation in facial artery and superficial temporal artery. Sympathetic denervation by SCGx in SHR attenuated local vascular remodeling, suggesting that sympathetic overactivity is a crucial pathogenic factor of vascular remodeling in SHR.

Extrarenal Visceral Arteries Injuries during Left Radical Nephrectomy: A 50-Year Continuing Problem

Due to their proximity to the left renal hilum, injuries to the superior mesenteric artery and celiac trunk are still reported during left radical nephrectomy, whether performed via open, laparoscopic, or robotic methods. The aim of this 50-year narrative review is to emphasize the anatomical and pathophysiological bases, risk factors, and strategies for the prevention, diagnosis, and treatment of such injuries.

Evaluation of vascular invasion in pancreatic head tumors and its impact on radical surgical treatment

Objective. To evaluate the informativeness and sensitivity of radiological criteria for vascular invasion in pancreatic head tumors in comparison with intraoperative data and results of routine pathological examination. Materials and methods. The study included 98 patients with ductal adenocarcinoma of the pancreatic head with suspected venous invasion and spread of tumor growth along the vessels of the portomesenteric axis, who were operated on at the Department of Pancreatic and Bile Duct Surgery of the National Research Center of Surgery and Transplantation named after O. A. Shalimov in the period from 2019 to 2023. Group 1 included 51 (52.0%) patients who underwent radical surgery with resection of the superior mesenteric/hepatic portal vein and extended lymph and neurodissection, and group 2 included 47 (48.0%) patients who had positive vascular margins of pancreatic resection according to routine pathological examination. Diagnostic criteria for vascular alterations were developed. A comparative analysis of the informativeness of the developed criteria and the results of a routine pathological examination was performed. The edges of the pancreatic resection were evaluated, including the neck of the gland, common bile duct, duodenum/gastric duct, and the bed of the superior mesenteric/hepatic portal vein and superior mesenteric artery separately. R1 status was defined as the presence of tumor cells at a distance of less than 1 mm to the resection margin. Results. According to the criteria of the National Comprehensive Cancer Network (NCCN) 2023.2, 61 (62.2%) patients had a marginally resectable stage of ductal adenocarcinoma of the pancreatic head and tumor contact with the superior mesenteric/hepatic veins according to multislice computed tomography of the abdominal cavity. In group 1, there were 36 (70.6%) such patients, in group 2 – 25 (53.2%). According to the proposed radiologic criteria for vascular invasion, tumor contact with the superior mesenteric/hepatic portal veins was suspected in 76 (77.6%) patients, which is higher than in the standard approach. Determination of vascular alterations according to the results of our study is a more reliable method for diagnosing invasion of the superior mesenteric/hepatic portal vein (χ2 = 5.46, p = 0.019) and predicting the performance of radical surgery, including vascular resection. Conclusions. The proposed criteria for the radiological diagnosis of vascular invasion at the preoperative stage increased the sensitivity of this method from 62.2 to 77.6%. The most frequent radiological signs of vascular alteration are vascular wall irregularity (47.7%) and parapancreatic tissue density (62.5%). In the presence of any of the radiological signs of vascular alteration, resection of the affected area of the superior mesenteric/hepatic portal vein with extended lymph and neurodissection is indicated, which allows a statistically significant increase in the number of R0 resections.

A New Bailout Maneuver to Manage Type IIIa Endoleak Due to Displaced Renal Bridging Stent Graft in Narrow Aorta.

To present endovascular management of an intraoperative type IIIc endoleak (EL) in a patient with migration of the right renal artery (RRA) bridging stent graft (BSG) during branched aortic aneurysm repair. The technique is demonstrated in an 80-year-old woman who underwent branched endograft repair of a symptomatic 6-cm type II TAAA. The t-Branch thoracoabdominal stent graft was positioned without difficulty. A "partial graft deployment" was performed, with the distal portion of the device remaining inside the delivery system and the right renal and superior mesenteric arteries were stented. When the constraining wires were removed, the RRA BSG migration from the branch was displayed, due to endograft twisting resulting in a horizontal rotation of the t-Branch. The RRA BSG remained oriented upward with the proximal edge positioned above the distal edge of the directional branch, making cannulation very difficult. This bailout technique uses a balloon placed at the level of the RRA BSG through the celiac artery (CA) directional branch; keeping the balloon inflated and in thrust, the edge of the BSG has moved downward making it possible to engage it and relining through the RRA directional branch. This paper describes an endovascular bailout technique for relining a displaced bridging stent graft, oriented upwards with the proximal edge positioned above the distal edge of the directional branch. This sophisticated technique adds to the spectrum of bailout techniques that can be applied in cases of type IIIa EL with migration and complete separation of BSG.

Efficacy of lymph node dissection around the inferior mesenteric artery with preservation of the left colic artery for rectal cancer

AbstractObjectiveWe investigated how Japanese D3 dissection with left colic artery (LCA) preservation affects anastomotic leakage after anterior resection with anastomosis for rectal cancer, based on the leak rate. The correlation between LCA preservation, survival, and cancer recurrence after resection was also analyzed.Summary and Background DataIt remains unclear how LCA preservation affects the anastomotic leak rate and oncological outcomes after resection remains unclear. Some reports suggested that anastomotic leakage increases local recurrence and decreases cancer‐specific survival.MethodsIn this study, we enrolled and analyzed 457 patients who underwent radical resection of rectal cancer in the period October 2011 through December 2016. The attending surgeon decided preoperatively and registered whether to preserve the LCA. This trial was registered under the UMIN‐CTR Identifier UMIN000006160.ResultsD3 with LCA preservation was successfully completed in 218 (89.3%) of the 244 patients registered in this group, whereas D3 without LCA preservation was successfully completed in all 213 patients registered in this group. After propensity score matching, the anastomotic leakage rate was 7.86% (11/140) after D3 with LCA preservation and 7.14% (10/140) after D3 without LCA preservation. The overall survival rates were 90.1% and 89.3%, and the recurrence‐free survival rates were 77.6% and 77.3%, respectively.ConclusionsOur findings suggest that LCA preservation has no effect on the incidence of anastomotic leakage after rectal resection with anastomosis using DST and that oncological outcomes may not be affected.

Protective Effects of Trimetazidine and Dexmedetomidine on Liver Injury in a Mesenteric Artery Ischemia-Reperfusion Rat Model via Endoplasmic Reticulum Stress.

Acute mesenteric ischemia can lead to severe liver damage due to ischemia-reperfusion (I/R) injury. This study investigated the protective effects of trimetazidine (TMZ) and dexmedetomidine (DEX) against liver damage induced by mesenteric artery I/R via endoplasmic reticulum stress (ERS) mechanisms. Twenty-four rats were divided into four groups: control, I/R, I/R+TMZ, and I/R+DEX. TMZ (20 mg/kg) was administered orally for seven days, and DEX (100 µg/kg) was given intraper-itoneally 30 min before I/R induction. Liver tissues were analyzed for creatinine, alanine ami-notransferase (ALT), aspartate aminotransferase (AST), thiobarbituric acid reactive substances (TBARS), and total thiol (TT) levels. Compared with the control group, the I/R group presented significantly increased AST, ALT, TBARS, and TT levels. TMZ notably reduced creatinine levels. I/R caused significant liver necrosis, inflammation, and congestion. TMZ and DEX treatments reduced this histopathological damage, with DEX resulting in a more significant reduction in infiltrative areas and vascular congestion. The increase in the expression of caspase-3, Bax, 8-OHdG, C/EBP homologous protein (CHOP), and glucose-regulated protein 78 (GRP78) decreased with the TMZ and DEX treatments. In addition, Bcl-2 positivity decreased both in the TMZ and DEX treatments. Both TMZ and DEX have protective effects against liver damage. These effects are likely mediated through the reduction in ERS and apoptosis, with DEX showing slightly superior protective effects compared with TMZ.

Resistance artery vasodilator pathways involved in the antihypertensive effects of cocoa shell extract in rats exposed to fetal undernutrition.

Fetal undernutrition establishes the foundations for hypertension development, with oxidative stress being a key hallmark. A growing interest in nutraceuticals for treating hypertension and environmental waste concerns prompted the present study aiming to evaluate whether supplementation with a polyphenol enriched extract from cocoa shell (CSE), a by-product from the chocolate industry with antioxidant properties, reduces hypertension of developmental origin, thus improving mesenteric resistance artery (MRA) vasodilatation. Adult male and female offspring from rats exposed to 50% food restriction from mid-gestation (maternal undernutrition, MUN) and controls were used. Supplementation was given through a gelatine (vehicle, VEH) or containing CSE (250mgkg-1day-1) 5daysweek-1 for 3weeks. Systolic blood pressure (SBP) was assessed by tail-cuff plethysmography. MRA function was studied by wire myography, and superoxide anion and nitric oxide were investigated by fluorescent indicators and confocal microscopy. Compared to control-VEH, MUN-VEH males showed significantly higher SBP, reduced MRA as well as relaxation to ACh, sodium nitroprusside and the AMPK agonist 5-aminoimidazole-4-carboxamide riboside, but not to isoproterenol. In MUN males, endothelial endothelium-derived hyperpolarizing factor and nitric oxide were unaltered, but MRA released a vasoconstrictor prostanoid and produced higher levels of superoxide anion. CSE normalized blood pressure and improved all above-mentioned MRA alterations in MUN males without an effect on control counterparts, except the reduction of superoxide anion. MUN-VEH females were normotensive and only showed a tendency towards larger superoxide anion production, which was abolished by CSE. CSE supplementation reduces SBP improving endothelium-dependent and independent MRA vasodilatation, related to local superoxide anion reduction, being a potential nutraceutical ingredient to counteract hypertension, in addition to contributing to the circular economy. KEY POINTS: Fetal undernutrition induces hypertension in males associated with deficient resistance artery vasodilatation, being normalized by cocoa shell extract (CSE). Release of a cyclooxygenase-derived contractile factor is the main endothelial alteration, which is abolished by CSE. AMPK and soluble guanylyl cyclase-mediated relaxation are also reduced in smooth muscle cells from maternal undernutrition resistance arteries, being improved by CSE. Vascular oxidative damage caused by excess superoxide anion generation can account for impaired vasodilatation, which is improved by CSE. The capacity of CSE to improve relaxation is probably related to its antioxidant bioactive factors, and thus cocoa shell is a potential food by-product to treat hypertension.

Hybrid Stent Graft Technique in Bridging Hostile Renal Arteries in Thoracoabdominal Branched Endografting

Patency of target arteries is crucial for fenestrated and branched endovascular aortic repair (F/B-EVAR) in thoracoabdominal aortic aneurysms (TAAAs). Occlusions more frequently occur in renal arteries (RAs) than in coeliac and superior mesenteric arteries, especially in patients with hostile anatomy treated by BEVAR. This study aimed to report RA outcomes using a hybrid bridging stent graft technique with distal self expandable (SE) combined with proximal balloon expandable (BE) stent graft during BEVAR with hostile RA anatomies. Clinical data from consecutive patients treated for TAAA by F/B-EVAR in three aortic centres (two in the USA, one in Europe) from 2016 to 2022 were prospectively collected. Renal artery orientation was defined as hostile in case of upward (type B) or downward + upward (type D) orientation. Hostile RAs accommodated by BEVAR and combination of SE + BE stent grafts were retrospectively evaluated. Intra-operative RA related complications, technical success, and branch occlusions were assessed as early outcomes. Primary and secondary RA patency, freedom from RA related re-interventions, and freedom from RA instability were assessed during follow up. Of 584 TAAAs managed by F/B-EVAR, 83 patients (14.2%) had 125 hostile RAs (type B, 45.6%; type D, 54.4%) managed by BEVAR with hybrid SE + BE stent grafts. Intra-operative complications occurred in three RAs (2.4%), including two dissections and one disconnection, all successfully managed with additional stent. Technical success was achieved in all cases, with no RA occlusions at 30 days. The median follow up was 21 (interquartile range 4, 38) months. Estimated three year RA primary patency was 97 ± 2%. Re-interventions were performed in five RAs (4.0%), including two RA branch embolisations for bleeding, two catheter thrombectomies with stent relining (bilateral occlusion in one patient), and one revision of type Ic endoleak. Freedom from RA related re-interventions and RA instability was 95 ± 2% and 91 ± 3% at three years, respectively. Renal artery secondary patency was 99 ± 1% at three years. In hostile RA anatomies, a combination of distal SE and proximal BE stent grafts as bridging stenting in BEVAR is safe and effective, with low rates of occlusion, re-interventions, and branch instability at midterm follow up.

Association of Superior Mesenteric Artery Syndrome and Lumbar Scoliosis

Association of Superior Mesenteric Artery Syndrome and Lumbar Scoliosis

Acute mesenteric ischemia secondary to complete AV block and acute systolic heart failure: a case report

BackgroundAcute mesenteric ischemia (AMI) usually presents with abrupt and severe abdominal pain associated with nausea and vomiting. This case is notable due to the occurrence of AMI secondary to acute systolic heart failure caused by new onset complete heart block.Case PresentationA 65-year-old male presented with sudden onset epigastric pain. ECG showed complete AV block and acute ischemia, and a subsequent CTA revealed complete occlusion of the mid superior mesenteric artery. His emergent left heart catheterization showed non-occlusive coronary artery disease. The patient underwent emergent laparotomy and SMA thrombectomy. Postoperative complications included worsening congestive heart failure and persistent bradycardia, requiring a permanent pacemaker. The patient was discharged to a skilled nursing facility in stable condition.ConclusionsThis case highlights the diagnostic challenges of AMI in the setting of acute heart failure and new onset AV block mimicking acute cardiac events and emphasizes the importance of a multidisciplinary approach in managing such complex cases.

α1C S1928 Phosphorylation of CaV1.2 Channel Controls Vascular Reactivity and Blood Pressure.

Increased vascular CaV1.2 channel function causes enhanced arterial tone during hypertension. This is mediated by elevations in angiotensin II/protein kinase C signaling. Yet, the mechanisms underlying these changes are unclear. We hypothesize that α1C phosphorylation at serine 1928 (S1928) is a key event mediating increased CaV1.2 channel function and vascular reactivity during angiotensin II signaling and hypertension. The hypothesis was examined in freshly isolated mesenteric arteries and arterial myocytes from control and angiotensin II-infused mice. Specific techniques include superresolution imaging, proximity ligation assay, patch-clamp electrophysiology, Ca2+ imaging, pressure myography, laser speckle imaging, and blood pressure telemetry. Hierarchical "nested" and appropriate parametric or nonparametric t test and ANOVAs were used to assess statistical differences. We found that angiotensin II redistributed the CaV1.2 pore-forming α1C subunit into larger clusters. This was correlated with elevated CaV1.2 channel activity and cooperativity, global intracellular Ca2+ and contraction of arterial myocytes, enhanced myogenic tone, and altered blood flow in wild-type mice. These angiotensin II-induced changes were prevented/ameliorated in cells/arteries from S1928 mutated to alanine knockin mice, which contain a negative modulation of the α1C S1928 phosphorylation site. In angiotensin II-induced hypertension, increased α1C clustering, CaV1.2 activity and cooperativity, myogenic tone, and blood pressure in wild-type cells/tissue/mice were averted/reduced in S1928 mutated to alanine samples. Results suggest an essential role for α1C S1928 phosphorylation in regulating channel distribution, activity and gating modality, and vascular function during angiotensin II signaling and hypertension. Phosphorylation of this single vascular α1C amino acid could be a risk factor for hypertension that may be targeted for therapeutic intervention.

The clinical significance of the lymph node ratio as a recurrence indicator in ampullary cancer after curative pancreaticoduodenectomy.

The clinical significance of the lymph node ratio (LNR), the number of metastatic lymph nodes per dissected lymph node, has not been sufficiently clarified in ampullary cancer. Among patients diagnosed histopathologically with ampullary cancer between 1980 and 2018, the study included 106 who underwent pathological radical resection by pancreaticoduodenectomy. The relationships between the LNR and metastatic lymph node sites and prognosis were examined. Multivariate analysis revealed that sex and lymph node metastasis were independent prognostic factors. In the 46 patients (43%) with metastatic lymph nodes, the LNR in the recurrence group was significantly higher than that in the non-recurrence group (0.15 ± 0.11 vs. 0.089 ± 0.071, p = 0.025). The receiver operating characteristic curve demonstrated that the LNR cut-off value, 0.07 (area under the curve = 0.70, sensitivity 81%, specificity 56%), was a significant indicator for recurrence (22% vs. 61%, p = 0.016) and prognosis (5-year survival: 48% vs. 83%, p = 0.028). Among the metastatic lymph node sites in the 46 positive cases, lymph node metastases developed from the peripancreatic head region (80%, 37/46) to the superior mesenteric artery (33%, 15/46) and para-aortic (11%, 5/46) regions. Lymph node metastasis is an independent prognostic factor, and the LNR is a significant indicator for recurrence and prognosis in patients with ampullary cancer.

The value evaluation of Nomogram prediction model based on CTA imaging features for selecting treatment methods for isolated superior mesenteric artery dissection

ObjectiveTo evaluate value of Nomogram prediction model based on CTA imaging features for selecting treatment methods for isolated superior mesenteric artery dissection (ISMAD).MethodsSymptomatic ISMAD patients were randomly divided into a training set and a validation set in a 7:3 ratio. In the training set, relevant risk factors for conservative treatment failure in ISMAD patients were analyzed, and a Nomogram prediction model for treatment outcome of ISMAD was constructed with risk factors. The predictive value of the model was evaluated.ResultsLow true lumen residual ratio (TLRR), long dissection length, and large arterial angle (superior mesenteric artery [SMA]/abdominal aorta [AA]) were identified as independent high-risk factors for conservative treatment failure (P < 0.05). The receiver operating characteristic curve (ROC) results showed that the area under curve (AUC) of Nomogram prediction model was 0.826 (95% CI: 0.740–0.912), indicating good discrimination. The Hosmer-Lemeshow goodness-of-fit test showed good consistency between the predicted curve and the ideal curve of the Nomogram prediction model. The decision curve analysis (DCA) analysis results showed that when probability threshold for the occurrence of conservative treatment failure predicted was 0.05–0.98, patients could obtain more net benefits. Similar results were obtained for the predictive value in the validation set.ConclusionLow TLRR, long dissection length, and large arterial angle (SMA/AA) are independent high-risk factors for conservative treatment failure in ISMAD. The Nomogram model constructed with independent high-risk factors has good clinical effectiveness in predicting the failure.

Assessing anatomical variations of the superior mesenteric artery via three-dimensional CT angiography and laparoscopic right hemicolectomy: a retrospective observational study.

This study aimed to analyse the anatomical relationships and differences between the superior mesenteric vessels and their branches by reviewing a laparoscopic right hemicolectomy surgery video and comparing it with preoperative three-dimensional computed tomography (3D-CT) angiography and to verify the accuracy of 3D-CT vascular reconstruction techniques. Surgical videos and preoperative imaging data of 52 patients undergoing laparoscopic right hemicolectomy were analysed to observe and summarize the probability of occurrence and adjacency of superior mesenteric vascular branches, and the lengths of specific sites of their branches were measured using the above two methods. Preoperative CT images and surgical video showed that the ileocolic artery (ICA) was present in 98.1% (51/52) and the ileocolic vein (ICV) was present in 100% (52/52), and ICA was present in 13.7% (7/51) of the ICV directly anteriorly, 13.7% (7/51) anteriorly superiorly, 3.9% (2/51) anteriorly inferiorly, 11.8% (6/51) directly posteriorly, 37.2% (19/51) post superiorly, and 19.7% (10/51) posteriorly inferiorly. In the surgical video, the probability of presence of the right colic artery (RCA) was 21.2% (11/52). On CT images, the RCA was present in 10 patients. The length of the origin of the middle colic artery (MCA) from its bifurcations was 2.33 ± 0.87 cm measured intraoperatively using a sterile isometric filament, and the length measured using 3D-CT vascular reconstruction was 2.36 ± 0.91 cm; the difference was not statistically significant (P = 0.348). The length of the MCA and ICA initiation points was 3.22 ± 0.75 cm measured intraoperatively using sterile isometric filaments and 3.36 ± 0.72 cm measured using 3D-CT vascular reconstruction, which was a statistically significant difference (P < 0.001). 3D-CT vascular reconstruction can accurately predict the vessels related to right hemicolectomy in most cases. It is an important method for preoperative prediction of superior mesenteric vessels, which can guide surgeons in the intraoperative vessel identification.

Perivascular Adipose Tissue Becomes Pro-Contractile and Remodels in an IL10-/- Colitis Model of Inflammatory Bowel Disease.

Inflammatory Bowel Diseases (IBDs) are associated with aberrant immune function, widespread inflammation, and altered intestinal blood flow. Perivascular adipose tissue (PVAT) surrounding the mesenteric vasculature can modulate vascular function and control the local immune cell population, but its structure and function have never been investigated in IBD. We used an IL10-/- mouse model of colitis that shares features with human IBD to test the hypothesis that IBD is associated with (1) impaired ability of PVAT to dilate mesenteric arteries and (2) changes in PVAT resident adipocyte and immune cell populations. Pressure myography and electrical field stimulation of isolated mesenteric arteries show that PVAT not only loses its anti-contractile effect but becomes pro-contractile in IBD. Quantitative immunohistochemistry and confocal imaging studies found significant adipocyte hyperplasia and increased PVAT leukocytes, particularly macrophages, in IBD. PCR arrays suggest that these changes occur alongside the altered cytokine and chemokine gene expression associated with altered NF-κB signaling. Collectively, these results show that the accumulation of macrophages in PVAT during IBD pathogenesis may lead to local inflammation, which ultimately contributes to increased arterial constriction and decreased intestinal blood flow with IBD.

12459 Exceptional Response To A Single Dose Of Pembrolizumab As Salvage Therapy In A Patient With Metastatic Adrenocortical Carcinoma (ACC)

Abstract Disclosure: L. Branchaud-Croisetière: None. J. Castilloux: None. E. Turcotte: None. A. Bégin: None. M. St-Jean: Advisory Board Member; Self; GlaxoSmithKline, HRA Pharmaceuticals. Research Investigator; Self; AstraZeneca, Novo Nordisk, Spruce Biosciences. Speaker; Self; GlaxoSmithKline, Recordati Rare Diseases. In advanced ACC, limited effective treatment options are available beyond mitotane and cytotoxic chemotherapy. PD-L1 blockade has shown promising results in small numbers of advanced ACC. In ACC, the reported partial response rate to pembrolizumab is around 25%.[1] Only one case of a significant partial response to a single dose of Pembrolizumab as salvage therapy for metastatic ACC was previously published.[1] In April 2023, a 19-year-old woman presented with severe hypertension, hypokalemia and clinical signs of Cushing syndrome (CS). Thoraco-abdominal scan revealed a left-sided cluster of confluent adrenal masses (7.3 x 14.4 x 11.4 cm), a left cortical renal lesion (2.8x2x2.1cm), a right ovarian teratoma (7.9 x 7.8x7.9 cm) and at least 25 pulmonary micronodules. FDG-PET SCAN revealed a significant hypermetabolism of the left adrenal lesions (SUV 18.6), ovarian teratoma (SUV 5.5) and pulmonary micronodules (SUV 1.1-2). Cortisol and androgens secretion was confirmed biochemically. Initially, she was not candidate for a debulking surgery because the tumor was surrounding the aorta, and mesenteric arteries. Hypertension and hypokalemia were treated with spironolactone, amlodipine, amiloride and irbesartan. Cushing syndrome was treated with metyrapone. In April 2023, Etoposide-Doxorubicine-Cisplatin (EDP) was administered in combination with Mitotane (max: 8g/day). After 6 cycles of EDP-M the disease regressed slightly but was considered stable based on RECIST criteria. After 8 cycles, the follow-up imaging showed a progression of the adrenal lesion (9.2x18.2cm) but stable pulmonary micronodules. A biopsy of the adrenal lesion, for therapeutic purpose, revealed microsatellite stability (MSS). The patient refused germinal genetic testing. It was decided in multidisciplinary tumor board to try Pembrolizumab. In December 2023, she received one cycle of Pembrolizumab (140mg), but the treatment was complicated by grade 4 immune-mediated hepatitis. A few weeks following Pembrolizumab she completely normalized her blood pressure and hypokalemia despite cessation of all her anti-hypertensive drugs. Pembrolizumab and Mitotane were stopped and hepatitis completely resolved after two months of Mycophenolate Mofetil and ongoing decreasing dose of prednisone. In March 2024, CT scan showed a 60% regression of the adrenal mass (4.1 x 7.2 cm), stability of the renal lesion and ovarian teratoma and complete resolution of the pulmonary micronodules. We suspect an ongoing effect of immunotherapy and Mitotane, since Mitotane levels were still in the therapeutic range (15.1 mg/L) six weeks following cessation. Mitotane was resumed in March 2024. The patient will potentially have a resection of the left adrenal lesion in the next month. This is second published case of a significant response to Pembrolizumab as second-line therapy for advanced ACC. [1] Raj Net al. J Clin Oncol. 2020 Presentation: 6/1/2024

7958 Organ Of Zuckerkandl Paragangliomas

Abstract Disclosure: L. McVicker: None. S. Egan: None. K.C. Conlon: None. J. Gibney: None. J. Feeney: None. M. Whelan: None. A. Garrahy: None. Background: The Organ of Zuckerkandl (OoZ) was first described in 1901 by an Austrian anatomist Emile Zuckerkandl as a para-aortic paraganglia located laterally to the abdominal aorta at the level of the inferior mesenteric artery. It represents the largest accumulation of extra-adrenal chromaffin cells in mammals. Paragangliomas (PGL) of the OoZ are rare entities with prior retrospective study of 371 patients with phaeochromocytoma or sympathetic PGL revealing only 21 cases of OoZ PGLs of which 14 of which (66%) had metastases at diagnosis (1). 70% of cases are in association with SDHB or less commonly, SDHD mutations (2). Clinical Case: A 48-year-old female presented with a year long history of palpitations and headache. Plasma normetanephrine level was 6340 pmol/L (lab reference 0-1180), plasma metanephrine 412 pmol/L (lab reference 0-510) and plasma 3-methoxytyramine &amp;lt;100 pmol/L (lab reference 0-180). CT adrenals showed normal adrenal glands. A 4.5 cm x 2.1 cm hyper-vascular retroperitoneal mass was visualised. A 68Ga-DOTATOC PET/CT showed no abnormal uptake in the area of the mass. [1]23I-MIBG scan showed increased uptake within the mass compatible with a PGL of the OoZ. Following surgery, histology confirmed PGL of the OoZ and plasma metanephrines normalised following. Genetic testing for predisposing mutation was negative. A 38-year-old male presented with sweating episodes, palpitations, and hypertension. Plasma normetanephrine level was 2,230 pmol/L (lab reference 0-1180) and plasma metanephrines 223 pmol/L (lab reference 0-520). CT adrenals showed normal adrenal glands with no other abnormalities noted. [1]23I-MIBG showed increased uptake in the region of the origin of the inferior mesenteric artery from the aorta consistent with PGL of the OoZ. The patient underwent laparoscopic resection with resultant normalisation of metanephrine levels. Histology showed a 21 mm encapsulated tumour in keeping with PGL with a PASS Score of 7. As with the first case, genetic testing for predisposing mutations returned negative. Conclusion: OoZ PGLs represent rare presentations of phaeochromocytoma-paraganglioma disease. This small case series is notable as neither case was associated with a predisposing genetic mutation, which has previously been shown to be more common in OoZ PGLs. There was also no evidence of metastasis in either case which is more commonly associated with this OoZ disease. The first case is also remarkable in terms of the tumour’s imaging characteristics. Previous studies have shown greater sensitivity using 68Ga-DOTA-Somatostatin Analogue PET/CT in comparison to [1]23I-MIBG in the detection of PGLs (3). In the first case, the tumour did not show any significant avidity on 68Ga-DOTATOC PET/CT but was avid on [1]23I-MIBG. Reference: 1. Ayala-Ramirez et al. J Clin Endocrinol Metab. 2011 2. Lodish et al. Endocr Relat Cancer. 2010 3. Carrasquillo et al. J Nuclear Medicine. 2021 Presentation: 6/2/2024