Superior Mesenteric Arteriogram Research Articles

正中弓状靱帯症候群に起因する膵十二指腸動脈瘤破裂を来した5例の臨床的検討(Ruptured aneurysm of the pancreaticoduodenal artery caused by median arcuate ligament syndrome: five case reports)

要旨正中弓状靱帯症候群（median arcuate ligament syndrome: MALS）に起因する膵十二指腸動脈瘤破裂には経カテーテル的動脈塞栓術（transcatheter arterial embolization: TAE）による止血が第一選択とする報告が近年散見される。一方で，TAE後の臨床経過に関する報告は少ない。今回，5例のMALSに起因する膵十二指腸動脈瘤破裂症例を経験し，TAE後の臨床経過を後方視的に検討したので報告する。5例の年齢中央値は58歳（49–78歳），男性4例で，全例でTAEによる止血が行われた。4例は単発症例で1例では多発性に動脈瘤を認めた。TAE後に再出血が生じたのは2例あり，いずれもTAE後約1週間以内に新たな部位に動脈瘤が出現した。追跡期間の中央値は26か月（7～92か月）であるが，正中弓状靱帯切離術を施行された1例を含め，急性期以降は，全例無症状で経過している。MALSに起因する膵十二指腸動脈瘤破裂に対しTAEによる止血を施行した場合は，約1週間以内の早期に新たな動脈瘤形成の危険がある。またその時期を過ぎれば，MALSへの直達手術の有無に関わらず再発や新規の動脈瘤出現の可能性は低く，消化管虚血の症状がなければ保存的に観察できる可能性があると思われた。

Retroportal arterial aneurysmの破裂による血腫形成にて門脈圧排を生じた1例(A case of portal blood failure caused by rupture of retroportal arterial aneurysm)

症例は49歳，男性。15年前に胆石症に対して腹腔鏡下胆嚢摘出術を受けた既往がある。心窩部痛を主訴に前医を受診した。造影computed tomography（CT）にて門脈血栓症の疑いがあり，当院へ転院搬送となった。生化学検査で著明な肝酵素の上昇を認めた。再度造影CTを施行すると，正中弓状靭帯症候群（median arcuate ligament syndrome: MALS）による腹腔動脈起始部狭窄を来しており，加えて上腸間膜動脈からの側副血行路が発達していた。さらに肝十二指腸間膜と後腹膜に一部extravasationを伴った血腫と肝側の門脈血流不全を認めた。血管造影検査では，上腸間膜動脈（superior mesenteric artery: SMA）からの分枝が肝十二指腸間膜内で動脈瘤を形成して，肝門部で右肝動脈に流入していた。血管分布の解剖学的な観点からretroportal arterial aneurysmの破裂と診断した。lipiodolで希釈したhistoacrylを用いて動脈塞栓術を施行した。術後の経過は良好で，第12病日に退院となった。MALSに伴った腹部内臓動脈瘤に関して，retroportal arterial aneurysmの破裂の報告はなく，若干の文献的考察を踏まえて報告する。 The patient was a 49–year–old male who underwent laparoscopic cholecystectomy for cholelithiasis 15 years earlier. He presented with sudden epigastric pain at the emergency room of another hospital. Portal vein thrombosis was suspected on computed tomography and he was then referred to our hospital. Laboratory examination showed marked hepatic dysfunction. CT revealed median arcuate ligament syndrome, an aneurysm in the hepatoduodenal ligament, portal venous insufficiency, and retroperitoneal hematoma with extravasation. We performed emergency interventional radiology. Angiography showed that collateral circulation from the superior mesenteric artery had developed from stenosis of the origin of the celiac artery, with a retroportal arterial aneurysm. We diagnosed rupture of the retroportal arterial aneurysm and performed arterial embolization. The postoperative course was uneventful and the patient was discharged on the 12th postoperative day. To our knowledge, there are no previous reports of retroportal arterial aneurysms, although there are reports of ruptured abdominal visceral aneurysms with median arcuate ligament syndrome. 正中弓状靭帯症候群（median arcuate ligament syndrome: MALS）は外因性圧迫による腹腔動脈（celiac artery: CA）起始部の慢性狭窄によって，食後上腹部痛や嘔気・嘔吐，腹部膨満など消化器症状を呈する病態である。MALSに伴う腹部内臓動脈瘤の好発部位は膵十二指腸動脈が大半であり，稀に中結腸動脈や背側膵動脈での瘤形成の報告も散見される 1, 2, 3が，retoroportal arteryでの報告はない。一般に内臓動脈瘤が破裂すると，腹腔内出血，後腹膜出血や消化管出血などを来し，死亡率は約20%である 4。我々は，MALSによりretroportal arteryに形成された動脈瘤が破裂したことにより，肝十二指腸間膜内に血腫を形成し，二次的に門脈血流不全を来した1例を経験したので若干の文献的考察を加えて報告する。 患 者：49歳，男性 主 訴：心窩部痛 既往歴：15年前に胆石症に対して腹腔鏡下胆嚢摘出術を受けた。 内服薬：なし 現病歴：突然の心窩部痛が出現し，症状が改善しないために前医へ救急搬送された。造影CT検査にて門脈血栓症を疑われ，同日当院へ転院搬送となった。 来院時現症：体温35.9度，血圧166/89mmHg，脈拍69/分，SpO2 99%（room air），呼吸数18/分でやや血圧上昇を認めた。腹部はやや膨隆し，心窩部を最強点として圧痛を認めたが筋性防御は認めなかった。 血液・生化学検査：AST 580IU/L, ALT 472IU/L, ALP 356IU/L, LDH 562IU/L, T–Bil 3.8mg/dL, WBC 15,000/ µLと肝胆道系酵素と炎症所見の上昇を認めた。Hb 16.4g/dL, Hct 45.6%で貧血を認めなかった（Table 1）。 造影CT：MALSでCAが狭窄しており，上腸間膜動脈（superior mesenteric artery: SMA）からの側副血行路が発達し，肝十二指腸間膜内に動脈瘤を疑わせる造影剤の貯留を認めた。平衡相では，上腸間膜静脈（superior mesenteric vein: SMV）周囲の腸間膜に血腫が形成され，extravasationを認めたが出血点ははっきりしなかった。さらにSMVから門脈本幹への血流不全を認めた（Fig. 1）。 Abdominal computed tomography. a: A retroportal arterial aneurysm is seen in the hepatoduodenal ligament (arrow). b: A hematoma is seen in the mesentery (arrow). c: The portal vein is obstructed by a hematoma in the hepatoduodenal ligament (arrow). d: Stenosis of the origin of the celiac artery is seen and caused by median arcuate ligament syndrome (arrow). 来院後経過①：造影CTの結果を踏まえて，診断かつ治療目的に緊急血管内治療（interventional radiology: IVR）を施行した。 IVR所見：右大腿動脈アプローチで5Fロングシース（メディキット）を挿入し，シェファードフック型の5F造影用カテーテル（テルモ―クリニカルサプライ）でSMAと腹腔動脈にアクセスした。SMA造影で膵十二指腸動脈を含めて求肝性に側副血行路の著明な発達を認めた。とくにSMA分枝から右肝動脈に流入する非常に発達した側副血行路であるretroportal arteryを認めた。同部位に動脈瘤が形成されており，その周囲にextravasationを認めたため，動脈瘤破裂と診断した。腹腔動脈造影にてCA起始部の狭窄を認めた。狭窄部を越えて総肝動脈から造影すると左右肝動脈まで偏位なく造影された。ラジフォーカスガイドワイヤー（0.035インチ，先端アングルタイプ，テルモ）を固有肝動脈まで進めた。コブラ型カテーテル5Fr（テルモ―クリニカルサプライ）をさらに右肝動脈まで進め，coaxial techniqueでProgreat Σ（130cm，先端形状アングル，テルモ）を右肝動脈から分岐するretroportal arteryへ選択的にカテーテルを挿入した。retroportal arteryの造影ではCT所見と同様にextravasationを認めた。そこで，責任血管の出血点を前後に挟む形で，lipiodol（テルモ）で33%の濃度に希釈したhistoacryl（ゲルベ・ジャパン）溶液0.5mLにより塞栓した。良好な血流遮断を確認して治療を終了した（Fig. 2）。 Superior mesenteric arteriogram. a, b: A retroportal arterial aneurysm (arrow) is seen arising from the superior mesenteric artery. c, d: Transcatheter arterial embolization was successful and leakage from the arterial aneurysm resolved (arrow). 来院後経過②：第2病日の造影CTにてextravasationは消失しており，門脈血流の改善を認めた。腸間膜内血腫は残存していたが，治療前と比して血腫拡大は認めなかった。門脈血流不全は動脈瘤破裂により形成された血腫が肝十二指腸間膜で門脈を圧排していたことが原因と判断した。血液・生化学データにて肝胆道系酵素は改善し，貧血の進行も認めなかった（Table 2）。高ビリルビン血症のみ遷延していたが，術後経過とともに消退した。その後，病状が再燃することなく経過し，第12病日に軽快退院となった。MALSに関しては，保存的な経過観察の方針とし，定期的な画像検査にて，動脈瘤をフォローアップすることとした。現在2か月経過しているが再発を認めていない（Fig. 3）。 Follow–up abdominal computed tomography. a: On the day of admission, portal venous flow was obstructed by a hematoma from a ruptured aneurysm. b: Two months post–procedure, portal flow was restored by resolution of the hematoma (arrow). 正中弓状靭帯（median arcuate ligament: MAL）は第12胸椎―第1腰椎の高さで大動脈の前方で横隔膜脚を橋渡しするように位置しており，呼吸変動や姿勢によってCAを圧排することがある。MALSは1963年にHarjola 5が最初に報告した病態で，慢性的にCAを圧迫することで盗血現象が生じ，消化器症状が出現するといわれている。主に30～50歳台の痩せ型女性に多く，それが進行すると，側副血行路であるSMAや膵十二指腸動脈アーケードなどの血流が逆行性に増大し，動脈の血行学的ストレスが加わって動脈瘤が形成されると報告 6されている。なかでも，好発部位は膵十二指腸動脈アーケードである 1。retoroportal arteryは総胆管を栄養する血管の一部で，上十二指腸部の総胆管に分布する 7。本来は，血管造影でも同定できないほどの微細な血管である 2。このような微細血管が発達する原因としては，血管奇形，血管周囲の器質化病変や血栓による血流障害や悪性腫瘍による新生血管の造成などが挙げられる。同血管以外にも，総胆管や肝管を栄養する血管として胆管周囲血管叢（epicholedochal plexus）が分布している 8。しかし，過去に胆管周囲血管叢がSMAから流入しているという報告はなく，今回の責任血管ではないと考えられた。そのため，本症例では，MALSが原因でretroportal arteryに動脈瘤が発生したと推察される。 医原性動脈瘤は破裂頻度が高く，大出血を来し，致死率も高いとされており，その原因として，術中に損傷を受けた動脈壁に感染や炎症が加わり動脈瘤が形成されると推測されている 9。一般的に，手術に伴う動脈瘤の発生部位としては，膵頭十二指腸切除後には総肝動脈に多く，胆嚢摘出術や胆管空腸吻合術後には右肝動脈に多いと塩田ら 10は報告している。本症例においても，胆嚢管周囲の組織剥離操作時にretroportal arteryを損傷したことで動脈瘤形成に至った可能性は否定できない。 医学中央雑誌で「正中弓状靭帯」「腹腔動脈起始部狭窄（MALSについて記載された症例のみ）」「動脈瘤」を検索したところ，論文報告は24症例で，うち破裂例は14例であった（Table 3）。平均年齢は55歳，男女比は17：7，膵十二指腸動脈瘤が19例と最多であった（重複例を含む）。しかし，retroportal arterial aneurysmの報告例はなかった。藤沢ら 11は膵十二指腸動脈瘤破裂71例を検討して，一般に消化管出血を呈すると出血性ショックを来すことが多いが，後腹膜出血ではタンポナーデ効果により，ショック状態になることが少なく，全身状態が比較的安定していることが多いと報告している。本症例は，動脈瘤破裂が後腹膜や腸間膜内にとどまっていたため出血性ショックを呈さなかったものの，肝十二指腸間膜内を走行している門脈を血腫が圧排し，門脈血流障害を呈していた。造影CTのみでは診断に苦慮し，緊急血管造影検査が非常に有用であった。 Miyayama (2015) Hiramatsu (2015) Kumazu (2015) Kamata (2015) Iwai (2014) bloating nausea/emesis Nakano (2014) Takase (2014) abdominal pain nausea/emesis abdominal pain nausea/emesis Nagao (2014) Uga (2014) EA PDA Sato (2013) abdominal pain hematemesis Kajioka (2013) Maeda (2013) Yoshida (2012) Sato (2012) Yamaguchi (2010) abdominal pain bloating Kimura (2009) Yoshida (2009) Saito (2009) bloating nausea/emesis Oishi (2008) Tsunashima (2008) Fukuda (2003) abdominal pain back pain Suzuki (1998) 腹部内臓動脈瘤の治療は，診断と治療が同時に可能で，低侵襲であるIVRが第一選択である 1。但し，再出血，塞栓部の再開通や臓器虚血の可能性もあり，全身状態と動脈瘤の部位に応じて治療方針を慎重に選択する必要がある。近年では，IVRによる動脈塞栓術と塞栓による側副血行路の血流不全が生じるリスクも考慮して動脈バイパス術を施行するハイブリッド治療も報告 12されている。外科的治療の場合はdisorientationによる副損傷や膵炎の合併，動脈瘤破裂によるショックバイタルなどの要因でIVRに比して成績が悪い 13。MALSによる動脈瘤の治療としてIVRのみでは，血流不均衡は改善されず動脈瘤再発の可能性が残される。開腹手術による血行再建術やMAL切離術を施行し，血流改善を考慮すべきである。海外では，CAのバルーン拡張やステント留置などIVRでの狭窄解除を行った報告 14も散見される。ただし，海外においてもIVR後に動脈瘤が再発したという報告はなかった。 本症例では，動脈瘤が門脈に近接しており，術後の癒着や多量の血腫による解剖学的偏位がみられ，開腹手術にて出血部位の同定は困難と判断し，IVRの選択は妥当であったと考える。また，CAのステント留置はCA根部での屈曲が強く困難であった。今後は，外来で厳重にフォローアップし，動脈瘤の再発時には破裂のリスクも考慮して瘤の処置のみでなく，MALSに対する治療も検討する必要があると思われる。 MALSと胆摘後の複合的な要因でSMAの分枝であるretroportal arteryに生じた動脈瘤の1例を経験した。本症例では，出血部位が肝十二指腸間膜というごく限られたスペースのため門脈が血腫で圧排されるという非常に珍しい病態を呈していた。本症例のように，全身状態が安定しており，出血部位が不明の後腹膜出血に対しては診断と治療を兼ねた血管造影検査を第一選択することで，早期診断と低侵襲のIVRを行うことができた。 利益相反はない。

Mesentaric Vasculitis as a Cause for Colonic Ulceration in a Patient with Sytemic Lupus Erythematosus (SLE)

Purpose: A 49 year old female with a new diagnosis of systemic lupus erythematosus (SLE) made in May 2011, presented to the ED one month later in June 2011 with severe “doubling over” abdominal pain with radiation to the back. She had two days of “loose non-bloody stools. Her dose of oral prednisone was recently reduced from 60 mg to 30 mg because of subjective improvement of her pulmonary status. CT of the abdomen upon admission was consistent with diffuse ischemic small bowel and colonic injury. Colonoscopy to the splenic flexure and transverse colon revealed deep ulceration of the colonic wall. A selective superior mesenteric arteriogram demonstrated narrowing of the small mesenteric arterial branches supplying the left colon with small microaneurysms. Large and medium sized vessels of the SMA were of normal caliber. Colonic biopsies were confirmatory for ischemic changes. Documentation of small vessel disease by these imaging studies of the colon impacted clinical management by increasing the steroid dosage and adding an immunosuppressant (azathioprine) agent. The patient responded well to these pharmacologic changes and her symptoms resolved. This case demonstrates vasculitis of the small mesenteric vessels causing colonic ischemic damage. Vascular injury should be in the endoscopist's differential diagnosis for observed colonic ulcerations in this subset of patients with autoimmune disease.

A dialysis patient with hyperammonaemia: inferior mesenteric-caval shunt as a cause of portal-systemic encephalopathy.

Sir, We report here a rare case of portal-systemic encephalopathy with occasional loss of consciousness caused by an inferior mesenteric-caval shunt via the internal iliac vein in a peritoneal dialysis (PD) patient who was switched to haemodialysis (HD). A 71-year-old man with end-stage renal disease, who had undergone PD and was shifted to HD, was admitted to our hospital for occasional loss of consciousness. Physical examination showed dysarthria, asterixis and ataxic gait without clinical signs of portal hypertension and liver cirrhosis. Laboratory studies revealed normal liver function (albumin 2.3 g/dL, total bilirubin 0.62 mg/dL, lactate dehydrogenase 174 IU/L, aspartate aminotransferase 12 IU/L, alanine transferase 8 IU/L, and gamma-glutamyl transpeptidase 8 IU/L) and increased ammonia concentration in peripheral blood (151.5 μmol/L, normal range: 17.7–47.0). Neither hepatitis B surface antigen nor antibodies to hepatitis C were detected. Results from the brain computed tomography (CT) scan and magnetic resonance imaging were normal. An electroencephalogram showed an increase in delta waves. An endoscopy did not find esophageal varices or haemorrhoids. An enhanced abdominal pelvic cavity CT scan detected the presence of the inferior mesenteric vein (IMV)–internal iliac vein shunt. The inferior vena cava (IVC) was enhanced through the shunt in an early phase of enhanced CT. The venous phase of both the superior and inferior mesenteric arteriogram revealed a large shunt between the IMV and left internal iliac vein, with blood flowing from the portal vein to the IVC (Figure 1). Selective venous sampling for blood ammonia levels showed a higher value of 180.3 μmol/L in the shunt vessel in contrast with 132.1 μmol/L in the IVC and 94.5 μmol/L in the left external iliac vein. Portal vein pressure was normal, 10–16 mmHg. A transcatheter coil embolization of the shunt vessel was performed. The high preoperative serum ammonia concentration decreased to the normal range postoperatively. Two years after the embolization, a follow-up enhanced CT scan showed a narrowing of the shunt. The patient has suffered no further episodes (such as occasional loss of consciousness or an increase in blood ammonia levels) after the embolization. Fig. 1. The venous phase of superior mesenteric arteriography shows a large shunt between the inferior mesenteric vein and left internal iliac vein. Portal-systemic encephalopathy without portal hypertension by an IMV–internal iliac vein shunt in a patient undergoing HD following unsuccessful PD is a very rare [1–3]. Our case may have a congenital portal-systemic venous shunt, since the shunt vessel was single and he did not have liver dysfunction and/or portal hypertension [4]. The placement of peritoneal catheter for a long period also might cause peritoneal fibrosis and sclerosis although this patient did not have any findings of peritoneal damages during surgery for catheter extraction. Haemodynamic changes during both HD and PD may also increase the flow of ammonia-rich portal venous blood into the systemic circulation through the shunt vessel [1]. Portal-systemic encephalopathy should be recognized as one of the neuropsychiatric disorders and be considered in the diagnosis of a hyperammonaemia-induced conscious disturbance in the dialysis population without liver dysfunction.

Hepatic encephalopathy after liver transplantation in a patient with a normally functioning graft: Treatment with embolization of portosystemic collaterals

Received April 5, 2008; accepted May 11, 2008.Portosystemic encephalopathy is one of the most im-portant complications of liver cirrhosis. The restorationof normal hepatic function and the reduction of porto-systemic shunts by means of a liver graft are followedby the resolution of hepatic encephalopathy. We reportthe case of a patient with a normal functioning graftthat developed recurrent encephalopathy after trans-plantation. The patient was successfully treated by em-bolization of a large portosystemic shunt between thesuperior mesenteric vein and both gonadal veins, thiscausing an inversion of the superior mesenteric veinflow.

Left Colic Artery Pseudoaneurysm from Pancreatitis Presenting as Upper Gastrointestinal Hemorrhage

Visceral pseudoaneurysms resulting from pancreatitis occur in approximately 10% of cases. The present report describes a left colic artery pseudoaneurysm from pancreatitis presenting with active duodenal bleeding. Based on the clinical and endoscopic demonstration of duodenal bleeding, celiac and superior mesenteric arteriograms were initially obtained, and their findings were negative. Repeat arteriography, including an inferior mesenteric artery injection, demonstrated a left colic pseudoaneurysm with rupture into the pancreatic duct and retrograde flow into the duodenum. Because of inconsistent diagnostic yields for arteriography performed for pancreatitis-related bleeding, the authors recommend disciplined interrogation of all three major mesenteric vessels, unbiased by initial endoscopic findings, to reduce false-negative examination results and empiric embolization.

Successful Management of Duodenal Varices by Balloon-occluded Retrograde Transvenous Obliteration

We describe a case of duodenal varices successfully treated with balloon-occluded retrograde transvenous obliteration (BRTO) alone. A 63-year-old man presented with tarry stools. Computed tomography demonstrated dilated varices around the duodenum. Emergency endoscopic examination revealed varices of the second portion of the duodenum without active bleeding. There was no evidence of bleeding in the esophagus or stomach. Colonoscopy revealed no bleeding sites in the colon. On the day after admission, a superior mesenteric arteriogram obtained in the venous phase demonstrated a collateral vein from the inferior pancreaticoduodenal vein to the inferior vena cava. Retrograde venography performed via the right femoral vein confirmed that the right inferior adrenal vein was the draining vein and that the collateral vein was occluded. There were no tarry stools after BRTO. The patient was discharged 7 days after BRTO. Two months after discharge, computed tomography showed no dilated varices around the duodenum. Three months after discharge, endoscopy confirmed the absence of varices. No bleeding has been detected as of 10 months after discharge. We conclude that BRTO is an effective treatment for duodenal varices.

Massive Hemoperitoneum Caused by Rupture of an Aneurysm of the Marginal Artery of Drummond

Aneurysms of visceral arteries are uncommon and their rupture is rare. We report a case of an aneurysm of the marginal artery of Drummond, which was complicated by rupture leading to massive hemoperitoneum. A selective superior mesenteric arteriogram suggested the possibility of segmental arterial mediolysis (SAM) as a possible etiology and this was confirmed by histological examination. This is the first report of symptomatic SAM of the marginal artery of Drummond to date. This case demonstrates that the marginal artery of Drummond should be considered during the angiographic explorations for the source of hemoperitoneum. Management options are discussed.

大量下血によるショックで発症した小腸クローン病の1例

We report small intestinal Crohn's disease presenting with acute major rectal bleeding as the first symptom of the disease. A 16-year-old boy was admitted with a history of bloody stools followed by a syncopal episode. After admission, esophagogastroscopy and sigmoidoscopy were conducted with normal results. Superior mesenteric arteriogram revealed the extravasation of dye into the lumen of bowel from ileal branches. After 10 units of blood were transfused, he was taken to surgery on the fourth hospital day. Changes characteristic of Crohn's disease about 80 cm 40 cm proximal to the ileocecal valve were found and removel. Pathologic examination showed a 65-cm serial longitudinal ulceration and 2 small ulcers in the ileum. Microscopic sections showed transmural inflamation and multinucleated giant cells without central caseous necrosis. It is not generally appreciated that life-threatening hemorrhage may complicate Crohn's disease. The boy remained well for 6 years and 7 months without recurrent bleeding or other complications.

Spiral-shaped iatrogenic arterial dissection during superior mesenteric arteriography: a latent risk of diagnostic angiography using the power injector

We report a rare case of iatrogenic arterial dissection of the superior mesenteric artery (SMA) during diagnostic angiography. A conventional superior mesenteric arteriogram obtained using an automated power injector revealed an arterial dissection 2 s after the initiation of contrast-medium injection. This case indicates that although careful catheter manipulations during angiography are essential, certain unavoidable complications may occur.

A CASE OF BENIGN NON-PARASITIC SOLITARY HEPATIC CYST WITH OBSTRUCTIVE JAUNDICE

A 70-year-old man was referred to the hospital because of an upper abdominal pain, fever and jaundice. Laboratory data showed mild jaundice (T-Bil 4.0mg/dl, D-Bil 3.1mg/dl) and high levels of bile duct enzymes, CRP and CA19-9 (340U/ml). CT revealed a cyst, 9×8cm in size, in the segment 4 of the liver, atrophy of the lateral segment and dilatation of the left intrahepatic bile duct. MRCP revealed the compression of the left hepatic duct by the cyst and a dilatation of the bile duct in the lateral segment. ERCP revealed no communication between the bile duct and cyst, and the left hepatic duct retracted downwards and obstructed by compression of the cyst. Portography via superior mesenteric arteriogram did not demonstrated the left portal branch. After improvement of jaundice and inflammation, a left hepatic lobectomy including the left caudate lobe was performed. The cyst was filled with 500cc of serous fluid, and its wall was smooth. The bile duct in the lateral segment was filled with biliary sludge. Histological examination showed that the cyst wall had single layer of cuboidal epithelium without any malignancy.

Solitary ileocolic arteriovenous malformation: spongostan and silk therapeutic embolisation.

A debilitated patient with liver cirrhosis and poor haemostasis had a severe lower gastrointestinal haemorrhage. A superior mesenteric arteriogram revealed an early persistent and promiment draining vein in the ileocolic...

CARCINOID TUMOR OF THE TERMINAL ILEUM DETECTED BY NODAL METASTASIS-REPORT OF A CASE-

A 66-year-old man was admitted to the hospil because of abdominal pain which was not relieved by medical treatment. Abdominal CT scan, magnetic resonance imaging and selective superior mesenteric arteriogram showed a 3.0×3.0cm mesenteric tumor. An operation was performed with a suspicion of mesenteric tumor. A 1.3×1.3cm ileal tumor existed 40cm apart from the ileocecal valve, and a 3.0×3.0cm mesenteric tumor was seen close to the ileal tumor, which retracted its mesenterium. Pathologically the ileal tumor was diagnosed as carcinoid tumor with the invasion depth of se, and the mesenteric tumor was its metastatic lymph node, with strongly positive reactions in Grimelius and chromogranin stains. Mesenteric fibrosis was seen near the metastatic mesenteric Iymph node. Carcinoid tumors of the terminal ileum are quite rare in Japan. In this case the metastatic lesion which was far larger than the primary lesion presented an opportunity for detecting the primary carcinoid tumor of the terminal ileum. The metastatic lesion also had the retracted mesenterium which is characteristic of metastatic mesenteric lymph node.

Advances in Diagnostics and Successful Repair of Proximal Posttraumatic Superior Mesenteric Arteriovenous Fistula

Posttraumatic arteriovenous fistulas affecting the superior mesenteric artery and vein are extremely rare. Twenty-four cases of posttraumatic superior mesenteric arteriovenous fistulas (SMAVFs) have been reported. We presented two cases of SMAVFs occurring in a young woman and man secondary to a gunshot and a grenade shrapnel wound in the epigastrium, respectively. Nausea, heartburn, emesis, and cramping abdominal pain were the clinical signs of SMAVF. Abdominal pains, particularly after meals, tense and meteoristic abdomen, frequent liquid bowel movements, oliguria, subfebrility, abdominal thrill, and bruit were also present. Abdominal duplex ultrasonic scanning and computed tomograms with a contrast agent were especially useful screening tools. As our results demonstrated, those methods were not only suitable for clinical use, but were also as good as arteriography in defining both the exact location and the extent of the mesenteric vessel involvement. However, the superior mesenteric arteriogram remains mandatory for complete preoperative evaluation. Arteriovenous fistulas were successfully treated by suturing the arterial and venous sides of the fistula in one case, and resectioning the fistula and end-to-end anastomosis in the other case.

Misperfusion of the liver during hepatic artery infusion chemotherapy: value of preoperative angiography and postoperative pump scintigraphy.

One purpose of this study was to determine if patients who have anatomic variations in their hepatic arteries are at increased risk for complications associated with the use of intrahepatic arterial infusion pumps. We also tried to determine the value of perfusion studies obtained with 99mTc-microspheres or 99mTc-macroaggregated albumin in detecting postoperative hepatic or visceral misperfusion and in predicting complications in patients with anatomic variants despite pre- or intraoperative attempts to correct the arterial abnormality. We prospectively compared findings on scintigrams obtained after delivering the radionuclide through intrahepatic arterial infusion pumps with anatomic variations in hepatic arteries seen on celiac and superior mesenteric hepatic arteriograms obtained before placement of the pump in 49 consecutive patients with colon carcinoma metastatic to the liver. Despite pre- or intraoperative attempts to correct arterial abnormalities to ensure optimal perfusion of the liver in 24 patients with hepatic arterial anomalies seen on preoperative arteriograms, only two patients had normal findings on postoperative perfusion studies performed with 99mTc-microspheres and/or 99mTc-macroaggregated albumin. Abnormalities included perfusion of extrahepatic organs, including the spleen in 12 patients, stomach in seven, bowel in four, and pancreas in three. Eight patients had no perfusion of the left lobe of the liver, and three had no perfusion of the right lobe. Two patients had minimal or no perfusion of both lobes. In 23 of 25 patients with no demonstrable variations in vascular anatomy on preoperative celiac and superior mesenteric arteriograms, findings on hepatic pump scintigrams were normal. Of the 24 patients with abnormal scintigraphic findings, 20 had subsequent clinical complications. However, only two of the 25 patients with normal scintigraphic findings had clinical complications. Our results indicate that patients with anatomic variations in the hepatic arterial system are at high risk for misperfusion during chemotherapy despite pre- or intraoperative efforts to alter the perfusion for chemotherapeutic agents delivered by intrahepatic arterial infusion pumps. Misperfusion can be detected by using pump scintigraphy, and therefore patients should be closely monitored with 99mTc-macroaggregated albumin perfusion studies to ensure successful delivery of the chemotherapeutic agents and to avoid serious clinical complications caused by inadvertent perfusion of other organs.

Polysplenia with pulmonary arteriovenous malformations

A patient with polysplenia syndrome, dextrocardia, left atrial isomerism, normal great vessel relationships, and no intracardiac shunts developed progressive cyanosis and clubbing. Pulmonary arteriovenous malformations (PAVMs) were diagnosed by angiography and confirmed by lung biopsy. Superior mesenteric arteriogram revealed hypoplasia of the intrahepatic portal vein branches and a portosystemic shunt. The possible etiologies of PAVMs are discussed.

Early hemodynamic changes following selective distal splenorenal shunt for portal hypertension: Comparison of surgical techniques

Ninety patients with cirrhosis undergoing elective distal splenorenal shunt (DSRS) for variceal bleeding between January, 1977 and September, 1988 comprised the study group. In 63 cases, the original technique of Warren was used and, in 15, the modified Britton procedure was employed. Twelve patients had a DSRS plus splenopancreatic disconnection. Thirty-four had alcoholic cirrhosis and 56 had nonalcoholic cirrhosis. Intraoperative portal pressure remained high after the shunt (29.4 cm H2O) even if its initial value was probably decreased by the loss of the splenic flow. Splenic pressure was reduced to 21 cm H2O. The hepatic artery diameter enlarged even after selective shunt (from 6.5 to 7.1 mm). The persistence of a high portal pressure allowed for the preservation of hepatopedal portal flow in 87% of cases. Disconnection between the high-pressure mesenteric area and the low-pressure splenic area seemed to be ideal in only 17% of cases. Fifty-five percent of cases had the early development of minimal or moderate portomesenteric gastrosplenic (PM-GS) collateral pathways. In 33%, the PM-GS collaterals were generally abundant and often allowed visualization of the splenic and caval veins during the venous phase of the superior mesenteric arteriograms. In this group, portal flow was generally highly reduced and even abolished. The incidence of portal thrombosis was 11%. Early angiographic checks after DSRS did not show a different hemodynamic behavior between alcoholics and nonalcoholics. Splenopancreatic disconnection seems to prevent the development of collaterals and the loss of portal perfusion after shunt surgery.

Jejunal leiomyoma: an endoscopic diagnosis

A 22-year-old woman first presented to Cooper Hospital on December 22, 1981, with an 8to lO-day history of lightheadedness, dizziness, weakness, and a 2-day history of melena. She had passed black stools intermittently for 5 years. She took no medication and smoked one pack of cigarettes daily. Her physical examination was normal except for a heart rate of 108 beats per minute and the presence of melenic, guaiac-positive stool on rectal examination. Her admission hemoglobin was 7.5 g/100 ml with a hematocrit of 21. Her coagulation profile, platelet count, and BUN were normal. The patient was transfused with 4 units of packed red blood cells. A workup, which included esophagogastroduodenoscopy to the descending duodenum, rigid sigmoidoscopy, double contrast barium enema, small bowel series, and Meckel's scan, was normal. The hematocrit remained stable at 31 and there was no further bleeding. She was discharged on oral iron and given instructions to return at the first sign of bleeding. She was readmitted on January 1, 1982, with melena. Physical examination was unremarkable and her hematocrit was 33. A technetium sulphur colloid gastrointestinal bleeding scan, esophagogastroduodenoscopy, and colonoscopy to the cecum were normal. A selective superior mesenteric arteriogram showed a small area of dilated vessels in the proximal jejunum without suggestion of a mass lesion or arteriovenous malformation. Selective injection into the first jejunal branch showed increased vascularity in that region in one projection, but this could not be confirmed in other views. As the patient had again stopped bleeding, she was discharged. The patient was readmitted on February 2, 1982 with guaiac-positive stools and a hematocrit of 25.5%. Since

Early postoperative angiographic control of the Warren procedure in 40 patients.

AbstractBetween December 1975 and December 1980, a total of 43 patients with portal hypertension due to intrahepatic block underwent the Warren procedure for distal splenorenal anastomosis. Forty of them were submitted to celiomesenteric arteriography between the 10th and 90th postoperative days to assess the efficacy of the procedure and to estimate its effects on the portal flow to the liver. On the late venous phase of the celiac angiogram, the patency of the shunt was demonstrated in 37 patients (92.5%), along with a consistent reduction of splenic volume; there was a clear flattening of esophageal varices at esophagoscopy. The shunt was not patent in the other 3 patients (7.5%), all of whom had anatomic venous abnormalities (diameter of the splenic vein smaller than 10 mm and/or abnormal renal vein). Two of these patients rebled soon after the operation, while the third subject underwent a prophylactic renoportal shunt.The effects of the procedure on the mesentericoportal flow were studied on the late phase of the superior mesenteric arteriogram. Venous flow to the liver was unaltered in 28 patients, substantially reduced by a latent partial portal thrombosis in 10 (25%), and totally suppressed in 2. Of these 2 complete portal thromboses, one resulted in early recurrent bleeding, while the other has remained asymptomatic. In spite of the portogastric disconnection, reverse flow in large veins from the portal vein to the cardial varices was observed in 14 patients (35%). Thus, after the Warren procedure, esophageal varices are efficiently decompressed by a patent shunt but portal flow is not always preserved.

CYSTADENOMA OF THE PANCREAS: REPORT OF A CASE DIAGNOSED BY ENDOSCOPIC RETROGRADE PANCREATOGRAPHY

The first case of a cystadenoma of the pancreas occurring in an African patient is reported. cystadenoma of the pancreas is a rare tumour. It should be suspected when a patient presents with a pancreatic cyst but without a history of pancreatitis, alcoholism or abdominal trauma. Estimation of the serum amylase level, selective coeliac and superior mesenteric arteriograms, and endoscopic retrograde pancreatography (ERP) are helpful in making the preoperative diagnosis. The ERP appearances in cystadenoma of the pancreas are described.