Superior Mesenteric Artery Injury Research Articles

Division of the right posterior attachments of the head of the pancreas with a linear stapler during pancreaticoduodenectomy: vascular and oncological considerations based on an anatomical cadaver-based study

Section of the right posterior attachment (RPA) of the pancreatic head from the adventicia of the superior mesenteric artery (SMA) is the last step of pancreaticoduodenectomy. This procedure might be technically demanding, time consuming and potentially dangerous. A method using a stapler has been proposed to simplify this step of the pancreaticoduodenectomy. To evaluate the potential consequences of RPA section using this new method, we used an experimental model of pancreaticoduodenectomy in 20 cadavers. After RPA stapling, the residual areolar tissue located between the staple line and SMA was removed (by sub adventicial dissection) and weighed. This allowed an evaluation of: (1) the theoretical risk of SMA injury and (2) the potential carcinological consequences of using stapling division, in comparison with the lymphadenectomy obtained with the conventional sub-adventicial dissection. A right hepatic artery was accidentaly injured in 10% of cases because of the lack of arterial dissection and arterial anatomy recognition. Forty-three percent of the RPA containing nerves and lymphatics remains in place. Using the stapling technique for RPA division theoretically increases the risk of micro or macroscopically positive margin after surgical resection. The result of this human cadaver-based dissection suggests that the use of the mechanical stapling device for final division of the RPA might increase the risk of SMA injury. The risk of vascular injury has been reported in surgical literature and is confirmed by this study. Such results (10% of accidentaly injury) may not be representative in leaving human patients, thanks to the use of a detectable palpable pulse of the SMA. The latter is important in avoiding vascular injury during RPA division. This study also shows that this new technique may increase the risk of incomplete tumor resection.

Temporary intravascular shunts as a damage control adjunct to maintain intestine perfusion after superior mesenteric artery injury in a swine model

Temporary intravascular shunts as a damage control adjunct to maintain intestine perfusion after superior mesenteric artery injury in a swine model

Establishment of an acute superior mesenteric artery injury model for damage control surgery

Establishment of an acute superior mesenteric artery injury model for damage control surgery

Establishment of an Acute Superior Mesenteric Artery Injury Model for Damage Control Surgery

Managements of superior mesenteric artery (SMA) injuries are difficult and often result in a disappointing outcome. Damage control surgery (DCS) has been approved to be an effective and reliable strategy for severe trauma victims. We aimed to build up a severe trauma-shock-hypothermia model of SMA injuries for DCS study and determine the optimal time to institute DCS. Pigs were anesthetized and instrumented with arterial and a thermodilution cardiac output catheter. SMA flow was interrupted while animals were hemorrhaged to 45% estimated blood volume. Pigs were maintained shock and intestine ischemia for three durations: intestine ischemia for 30 min (I-30; n = 6), 60 min (I-60; n = 6), and 90 min (I-90; n = 6). Cold lactated Ringer's (10 mL/kg) was infused to induce hypothermia. SMA was then declamped and kept in reperfusion for 6 h. Hemodynamic data and serum samples were collected during shock and resuscitation. Distal ileum was collected at the end of ischemia and reperfusion. All animals presented with disastrous conditions at the end of ischemia: low temperature, severe acidosis, decreased blood pressure, depressed cardiac output, and oxygen delivery. I-90 animals suffered the lowest temperature, the most severe acidosis, lowest blood pressure, and depressed cardiac output and oxygen delivery. Coagulopathy developed in I-90, whereas normal prothrombin time and thrombin time were detected in I-30 and I-60. Aspartate aminotransferase, lactate dehydrogenase, creatine kinase, and alkaline phosphatase were equally within groups (P > 0.05). All (6/6) of I-30, 83.3% (5/6) of I-60, and 16.7% (1/6) of I-90 pigs survived (P < 0.01). Base excess in I-90 was much lower than that in I-30 and I-60 animals. We first built up an acute SMA injury animal model for DCS investigations and determined that the optimal institution time of DCS was before 60 min after SMA injury in the trauma-shock-hypothermia swine model.

Isolated injury of the superior mesenteric artery caused by a lap belt in a child

Isolated vascular injuries are rare in cases of blunt abdominal trauma, and superior mesenteric artery injury is extremely rare but potentially lethal. The incidence of this kind of life-threatening injury has increased in recent years. The diagnosis of these isolated injuries is difficult, and its delay is associated with a higher morbidity and mortality. The authors report on the case of a child with an isolated injury of the superior mesenteric artery caused by a lap belt, during a motor-vehicle crash which was successfully managed. Correct use of all types of restraints is to be recommended. The diagnosis of this rare intraabdominal vascular injury is possible especially when the major signs are evident, but an awareness of this rare possibility is essential for the outcome.

Repair of superior mesenteric artery ligation during left nephrectomy with a native renal vein patch

Injury to the superior mesenteric artery (SMA) during nephrectomy is a rare but potentially catastrophic complication. SMA injury during nephrectomy most commonly occurs with large tumors or bulky lymphadenopathy, with inadvertent injury or mistaken ligation of the SMA instead of the renal artery. Failure to recognize and repair an SMA injury results in ischemic bowel and death for most patients. We report a case of SMA ligation during left nephrectomy for xanthogranulomatous pyelonephritis, review the intraoperative evaluation of suspected SMA injury, and describe our vascular repair using a vein patch from the native left renal vein.

Role of nitric oxide and peroxynitrite anion in lung injury induced by intestinal ischemia-reperfusion in rats.

To evaluate effects of nitric oxide (NO) and peroxynitrite anion (ONOO(-)) on lung injury following intestinal ischemia-reperfusion (IR) in rats. A rat model of intestinal ischemia was made by clamping superior mesenteric artery and lung injury was resulted from reperfusion. The animals were randomly divided into 3 groups: sham operation (Sham), 2 h ischemia followed by 2 h reperfusion (IR) and IR pretreated with aminoguanidine (AG) - an inhibitor of inducible NO synthase (iNOS) 15 minutes before reperfusion (IR+AG). The lung malondialdehyde (MDA) and nitrate/nitrite (NO(2)(-)/NO(3)(-)) contents and morphological changes were examined. Western blot was used to detect the iNOS protein expression. Immunohistochemical staining was used to determine the change of nitrotyrosine (NT)- a specific "footprint" of ONOO(-). The morphology revealed evidence for lung edema, hemorrhage and polymorphonuclear sequestration after intestinal IR. Compared with sham group, lung contents of MDA and NO(2)(-)/NO(3)(-) in IR group were significantly increased (12.00+/-2.18 vs 23.44+/-1.25 and 76.39+/-6.08 vs 140.40+/-4.34, P<0.01) and the positive signals of iNOS and NT were also increased in the lung. Compared with IR group, the contents of MDA and NO(2)(-)/NO(3)(-) in IR+AG group were significantly decreased (23.44+/-1.25 vs 14.66+/-1.66 and 140.40+/-4.34 vs 80.00+/-8.56, P<0.01) and NT staining was also decreased. Intestinal IR increases NO and ONOO(-) production in the lung, which may be involved in intestinal IR-mediated lung injury.

Multiinstitutional Experience with The Management of Superior Mesenteric Artery Injuries

Multiinstitutional Experience with The Management of Superior Mesenteric Artery Injuries

Multiinstitutional experience with the management of superior mesenteric artery injuries.

Superior mesenteric artery (SMA) injuries are rare and often lethal injuries incurring very high morbidity and mortality. The purposes of this study are to review a multiinstitutional experience with these injuries; to analyze Fullen's classification based on anatomic zone and ischemia grade for its predictive value; to correlate the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury with mortality; and to identify independent risk factors predictive of mortality, describing current trends for the management of this injury in America. We performed a retrospective multiinstitutional study of patients sustaining SMA injuries involving 34 trauma centers in the US over 10 years. Outcomes variables, both continuous and dichotomous, were analyzed initially with univariate methods. For the subsequent multivariate analysis, stepwise logistic regression was used to identify a set of risk factors significantly associated with mortality. There were 250 patients enrolled, with a mean Revised Trauma Score (RTS) of 6.44 and a mean Injury Severity Score (ISS) of 25. Surgical management consisted of ligation in 175 of 244 patients (72%), primary [corrected] repair in 53 of 244 patients (22%), autogenous grafts were used in 10 of 244 (4%), and prosthetic grafts of PTFE in 6 of 244 patients (2%). Overall mortality was 97 of 250 patients (39%). Mortality versus Fullen's zones: zone I, 39 of 51 (76.5%); zone II, 15 of 34 (44.1%); zone III, 11 of 40 (27.5%); and zone IV, 25 of 108 (23.1%). Mortality versus Fullen's ischemia grade: grade 1, 22 of 34 (64.7%). Mortality versus AAST-OIS for abdominal vascular injury: grade I, 9 of 55 (16.4%); grade II, 13 of 51 (25.5%); grade III, 8 of 20 (40%); grade IV, 37 of 69 (53.6%); and grade V, 17 of 19 (89.5%). Logistic regression analysis identified as independent risk factors for mortality the following: transfusion of greater than 10 units of packed RBCs, intraoperative acidosis, dysrhythmias, injury to Fullen's zone I or II, and multisystem organ failure. SMA injuries are highly lethal. Fullen's anatomic zones, ischemia grade, and AAST-OIS abdominal vascular injuries correlate well with mortality. Injuries to Fullen's zones I and II, Fullen's maximal ischemia grade, and AAST-OIS injury grades IV and V, high-intraoperative transfusion requirements, and presence of acidosis and disrhythmias are significant predictors of mortality. All of these predictive factors for mortality must be taken into account in the surgical management of these injuries.

Traumatic injury to the superior mesenteric artery

Background: Superior mesenteric artery (SMA) injuries are rare and devastating injuries incurring very high mortality rates. It is the purpose of this study to review our experience with these injuries, to analyze Fullen’s classification based on anatomical zone and injury grade for its predictive value, and to correlate the American Association for the Surgery of Trauma–Organ Injury Scale (AAST-OIS) for abdominal vascular injury with mortality. Methods: Retrospective study was made over a 65-month period of all patients sustaining SMA injuries in an urban level I trauma center. Results: Thirty-five patients, mean age 31, had a mean Revised Trauma Score of 5.86 and a mean Injurity Severity Score of 23. Mechanisms of injury were penetrating 27 (77%) and blunt 8 (23%). Mean admission systolic blood pressure was 85 mm Hg. Mean estimated blood loss was 8,500 mL and mean total fluid replacement 17,000 mL. Operating room findings were retroperitoneal hematoma in 34 (97%) and “black bowel” in 2 (6%). Number of associated injuries was nonvascular, mean 4.2, and vascular, mean 1.5. Surgical management consisted of ligation in 18 (51%), primary repair in 14 (40%), and interposition graft in 2 (6%). Overall mortality was 19 of 35 (54%). Mortality versus Fullen’s zones was zone I, 100%, zone II, 43%, and zones III and IV, 25%. Mortality versus Fullen’s ischemia grade was grade 1, 89%, grade 2, 58%, grade 3, 100%, and grade 4, 19%. Mortality versus AAST-OIS: was grade I, 0%, grade II, 20%, grade III, 0%, grade IV, 59%, and grade V, 88%. Conclusions: SMA injuries are highly lethal. Most deaths are due to exsanguination. A higher number of associated vascular injuries increases mortality. “Black bowel” is an uncommon finding. Both Fullen’s anatomical zones and the AAST-OIS for abdominal vascular injuries correlate with mortality. Fullen’s ischemia grade does not.

Proximal superior mesenteric arterial and venous injuries

In a review of more than 1000 patients with operatively managed abdominal trauma, eight patients with injuries to the proximal parts of the superior mesenteric artery or vein were identified: three with either a superior mesenteric artery or vein injury and two with combined superior mesenteric vessel injuries. All patients were in shock on arrival, and had associated abdominal injuries. All six patients with solitary superior mesenteric artery or vein injuries underwent lateral suture repair of the injured vessel with good results. The combined injuries of both of the superior mesenteric vessels required more complex types of vascular repairs: an interposition saphenous vein graft for the arterial injury and ligation of the vein in one patient who later died of bowel necrosis, and an end-to-end arterial repair and lateral venorrhaphy in the other who had a viable bowel at a second look operation. The overall mortality rate was 13%. The various management options and guidelines for injuries to the proximal parts of the superior mesenteric vessels are discussed.

Delayed Jejunal Artery Pseudoaneurysm: An Unusual Sequela of Penetrating Abdominal Trauma

Posttraumatic pseudoaneurysm of the mesenteric vasculature is rare. The authors describe the case of a forty-seven-year-old man with a jejunal artery pseudoaneurysm eleven years after a stab wound to the abdomen. The patient underwent exploratory laparotomy and ligation of the pseudoaneurysm. Late sequelae of missed superior mesenteric artery injury include superior mesenteric arteriovenous fistula and pseudoaneurysm.

Superior mesenteric artery injury during nephrectomy for Wilms' tumor

latrogenic injury to the aorta or its major branches during nephrectomy for Wilms' tumor in children is rarely reported but may be more common than is currently acknowledged. We identified four patients with ligation of the superior mesenteric artery (SMA) that occurred during nephrectomy for nephroblastoma and another child in whom SMA thrombosis developed postoperatively. All of the tumors were on the left side. Interruption of the SMA was recognized intraoperatively in all four children, and primary repair was done. In three patients, appearance of the bowel remained normal before repair of the injury. Three of the arteries were repaired by primary reanastomosis, and one was joined with an interpositioned hypogastric artery graft. None of these patients had gastrointestinal complications postoperatively. In the fifth patient, SMA thrombosis developed after repair of an aortic tear during nephrectomy. This patient required subsequent small bowel resection for bowel infarction and died in the perioperative period. Every surgeon treating children with Wilms' tumor should be aware of the possibly distorted vascular anatomy and take precautions to avoid such a significant injury. Attempts at early ligation of the vessels may not be justified until the renal vasculature is clearly identified.

Traumatic Superior Mesenteric Artery—Portal Vein Fistula

An interesting and rare case of traumatic superior mesenteric artery-to-portal vein arteriovenous fistula is presented. Initial operative control of the bleeding superior mesenteric artery injury required ligation of the superior mesenteric artery at its origin to prevent exsanguination in an extremely unstable patient with multiple injuries. Early postoperative visceral arteriography documented ligation of the superior mesenteric artery with a proximal superior mesenteric artery-to-portal vein arteriovenous fistula. Percutaneous catheter embolization of the arteriovenous fistula was undertaken successfully at this time. Superior mesenteric artery ligation was surprisingly well tolerated. Major arterioportal fistulas require treatment to prevent long-term complications of intestinal ischemia, portal hypertension, and cirrhosis. Although traditional treatment involves ligation of the arteriovenous fistula and arterial bypass, percutaneous embolization is becoming a viable alternative. Arteriography remains the cornerstone of diagnosis and treatment planning.

Superior Mesenteric Artery Injury Following Blunt Abdominal Trauma

A case of blunt abdominal trauma causing injury to the superior mesenteric artery with successful management is presented. The role of aortography in diagnosis is discussed. The patient, with multiple chest injuries sustained in an automobile accident, has recovered following surgical repair of a laceration of the SMA, treatment for respiratory distress, and spontaneous cessation of rectal diverticular bleeding.

Superior mesenteric artery injury: a case report

A case of blunt trauma to the upper abdomen with multiple organ injury is described. The lesion involving the superior mesenteric artery was undiagnosed at operation. The subsequent diagnosis and handling of the case is described with a review of the literature on blunt injury to this vessel.

Repair of Hepatic and Superior Mesenteric Artery Injury

MAY, ALLYN G. M.D.; LIPCHIK, ELLIOTT O. M.D.; DEWEESE, JAMES A. M.D. Author Information