Branch Of Superior Mesenteric Vein Research Articles

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

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

Anatomical change of SMV branches after the Cattell Braasch maneuver facilitates safe resection around the uncinated process in pancreatoduodenectomy

BackgroundThe aims of the present study were to demonstrate the anatomical change of superior mesenteric vein (SMV) branches and to show how the Cattell Braasch maneuver facilitates a safer ligation of these venous branches during a pancreatoduodenectomy (PD).MethodsBetween January 2010 and December 2019, 97 patients with peripancreatic tumors underwent pancreatectomy. We retrospectively reviewed preoperative triple-phase enhanced computed tomography (CT) images and analyzed variations in SMV branches. Anatomical changes in SMV branches after the Cattell Braasch technique were observed using our operation video and illustrations.ResultsThe first jejunal vein (J1v) in 75% of patients ran posterior to the superior mesenteric artery (SMA), while the remainder (25%) ran anterior to it. The inferior pancreatoduodenal vein (IPDV) was preoperatively detected in 91% of patients. The IPDV drained into the J1v in 74% of patients and into the SMV in 37%. After the Cattell Braasch maneuver, the J1v which ran posterior to the SMA now was found to lie to the right anterolateral side the SMA and the visualization of both the J1v and the IPDV were much more clearly visualized.ConclusionsThe most frequent venous variation was the IPDV draining into the J1v posterior to the SMA. After the Cattell Braasch maneuver, the IPDV was now located to the right anterolateral anterior aspect of the SMA which facilitates its visualization and should allow a safer ligation.

Successful hybrid surgery for ileal conduit stomal varices following oxaliplatin-based chemotherapy in a patient with advanced colorectal cancer

BackgroundEctopic variceal bleeding is a rare but life-threatening complication of portal hypertension (PH). Oxaliplatin-based chemotherapy for colorectal cancer (CRC) is associated with sinusoidal obstruction syndrome of the liver, which can lead to PH.Case presentationHere, we report a successful hybrid surgery that included intraoperative obliteration of ileal conduit stomal varices (ICSVs) for a 66-year-old woman with CRC and liver metastasis that had been treated multimodally during the previous 4 years, including 17 courses of oxaliplatin-based chemotherapy. She was admitted to our hospital for massive hemorrhage from an ileal conduct stoma. Image findings showed ICSVs as a part of portosystemic shunt, which were afferently supplied from the superior mesenteric vein (SMV) and drained by the numerous cutaneous veins connected to the left femoral vein. Obliteration of the stomal varices by interventional radiologic techniques alone was inappropriate because of difficulties of cannulating the efferent cutaneous veins. We, therefore, performed hybrid surgery for the ICSV, which included cannulation into the SMV branch and antegrade obliteration of the varices with a 5% solution of ethanolamine oleate with iopamidol under blocking the SMV flow, using a vascular clip and ligation. Hemorrhage in her ileal conduit stoma disappeared completely.ConclusionCustomized treatment of ectopic varices should be based on their precise vascular anatomy; hybrid surgery with intraoperative angiography is an alternative treatment for ectopic varices such as ICSV.

Spontaneously resolving duodenal obstruction after balloon-occluded retrograde transvenous obliteration–assisted endoscopic Histoacryl injection in duodenal varices

A 46-year-old woman with cirrhosis presented with recurrent upper GI bleeding. EGD revealed small esophageal varices and large ectopic varices in the second part of the duodenum without any active bleeding (A). CT portovenogram revealed a branch of superior mesenteric vein as afferent and right gonadal vein as efferent for the varices (B). Balloon-occluded retrograde transvenous obliteration (BRTO) was done with the balloon inflated in the right gonadal vein. Because superselective cannulation of the ectopic varices could not be achieved, BRTO-assisted endoscopic injection of 12 mL N-butyl-2-cyanoacrylate (Histoacryl) and lipoidal (1:2 ratio) was done into the varices to minimize systemic embolization. Two weeks after discharge, the patient presented with repeated vomiting. EGD revealed partial occlusion of the duodenal lumen by the Histoacryl cast (C). Her symptoms resolved on conservative management (nothing by mouth, nasogastric drainage, and intravenous fluids). She continued to experience intermittent vomiting for the next 2 months. Because spontaneous expulsion of Histoacryl casts after variable intervals is known and each episode of duodenal obstruction subsided with conservative management, we did not plan any surgery. After about 2 months, she became asymptomatic. EGD after 2 months showed no residual Histoacryl cast (D).

Successful Living-Donor Liver Transplantation With Intraoperative Endovascular Recanalization via Transsplenic Access in a Recipient With Grade III Portal Vein Thrombosis: A Case Report

Extensive portosplenomesenteric thrombosis is regarded as a relative contraindication to liver transplantation because of the complexity of the surgical procedure. This report describes a case of living-donor liver transplantation (LDLT) for a patient with extensive portosplenomesenteric thrombosis, in whom portal flow was successfully restored by intraoperative transplenic portal vein and superior mesenteric vein stenting after surgical thrombectomy. The patient’s liver function remained normal with a patent portal vein stent 6 months after LDLT, and Doppler ultrasonography demonstrated a normal wave form for portal flow. To the best of our knowledge, this is the world’s first case of endovascular management of the portal vein via percutaneous transsplenic access during LDLT, demonstrating that transsplenic access can be an alternative approach without liver graft injury when the superior mesenteric vein branch and inferior mesenteric vein cannot be used as access routes.

Relative factors of transmural intestinal necrosis in acute superior mesenteric vein thrombosis

Objective: To examine the relative factors of transmural intestinal necrosis (TIN) during multidisciplinary stepwise management facilitating the decision making in patients with acute superior mesenteric vein thrombosis (ASMVT). Methods: Clinical data of patients with ASMVT admitted to Department of General Surgery, Jinling Hospital from January 2009 to June 2017 were reviewed retrospectively. There were 52 males and 37 females, aging (45.9 ± 12.6) years (range: 20 to 69 years). According to the postoperative pathological results and follow-up, the patients were divided into TIN group (n=31) and non-TIN group (n=58, including 18 cases of intestinal stricture). The related factors were compared between ASMVT patients with TIN and patients without TIN by univariate analysis using t test, U test and χ(2) test accordingly, and factors with statistically significance were subsequently submitted to binary Logistic regression analysis. The predictive value and cut-off point of factors were evaluated by receiver operator characteristic (ROC) curve and area under the curve. Results: In univariate analysis, smoking, hypertension, peritonitis, white blood cell count,haemoglobin, international normalized ratio, blood albumin, thrombosis of superior mesenteric branches vein, free intraperitoneal fluid, decrease of bowel wall enhancement and pneumatosis intestinalis were TIN risk factors (all P<0.05). According to the binary Logistic regression analysis, white blood cell count (OR=1.093, 95%CI: 1.010 to 1.182, P=0.027), thrombosis of the superior mesenteric branches vein (OR=11.519, 95%CI: 1.906 to 69.615, P=0.008), pneumatosis intestinalis (OR=11.140, 95%CI: 2.360 to 52.585, P=0.002) were independent relative factors of TIN in patients with AMI, and the area under the ROC curve of the above factors and predictive model was 0.759 (95%CI: 0.647 to 0.871), 0.745 (95%CI: 0.641 to 0.848), 0.737 (95%CI: 0.621 to 0.854), 0.909 (95%CI: 0.847 to 0.971), respectively. The cutoff value of white blood cell count was 18.1 × 10(9)/L. Conclusion: White blood cell levels, superior mesenteric vein branch thrombosis and pneumatosis intestinalis are independent predictors of TIN in ASMVT.

An atypical mesenteric-saphenous collateral portosystemic pathway in a cirrhotic patient.

We defined an atypical portosystemic collateral pathway in a 63-year-old patient with cirrhosis who underwent a prior surgery for rectal carcinoma and had a right-sided stoma on the anterior abdominal wall from a prior colostomy. Abdominal Multi-Detector Computed Tomography (MDCT) images revealed a cirrhotic liver with a contour abnormality and shrinkage at the medial portion of the left lobe and right lobe anterior segments, as well as heterogeneous internal architecture seen on Figure 1. The presence of splenomegaly, enlarged splenic and portal veins and paraesophageal, splenorenal, spleno-retroperitoneal and paraumblical collateral veins were also striking (Figure 1). In contrast with the classic portosystemic collateral pathways, the patient had another collateral flow between the superior mesenteric and greater saphenous veins. A branch of the superior mesenteric vein was coursing through the right anterior abdominal wall musculature and extending to the right greater saphenous vein in the subcutaneous fat tissue (Figure 2, ​,3).3). The superior mesenteric vein branch used the right-sided prior colostomy site to complete the portosystemic pathway. The right-sided inferior epigastric vein seemed normal in caliber and course. Figure 1. A thick section MIP image shows the collateral vein passing through the anterior abdominal musculature to the subcutaneous fat tissue (arrow). Figure 2. An axial image at the portal venosus phase shows the esophageal (short arrow) and paraesophageal varices (arrow). A cirrhotic liver with surface nodularity is also shown. Figure 3. A multiplanar reformatted image of the collateral vein between the superior mesenteric vein branch and greater saphenous vein coursing through the subcutaneous fat tissue of the anterior abdominal wall (arrows). In portal hypertension, some blood in the portal venous system may reverse direction and pass through the portosystemic anastomoses into the systemic venous system. As a result, a variety of major hepatofugal collateral pathways can develop in patients with portal hypertension. The portosystemic collateral vessels are the esophageal, paraesophageal, splenic, splenorenal, mesenteric, short gastric, retroperitoneal and paraumbilical veins as well as the mesenteric- saphenous collateral (1).

Mast cell inhibition by ketotifen reduces splanchnic inflammatory response in a portal hypertension model in rats

Experimental early prehepatic portal hypertension induces an inflammatory exudative response, including an increased infiltration of the intestinal mucosa and the mesenteric lymph nodes by mast cells and a dilation and tortuosity of the branches of the superior mesenteric vein. The aim of this study is to verify that the prophylactic administration of Ketotifen, a stabilizing drug for mast cells, reduces the consequence of splanchnic inflammatory response in prehepatic portal hypertension. Male Wistar rats were used: Sham-operated and with Triple Partial Portal Vein Ligation, which were subcutaneously administered poly(lactide -co-glycolide) acid microspheres with vehicle 24 h before the intervention and SO and rats with Triple Partial Portal Vein Ligation, which were administered Ketotifen-loaded microspheres. Around 48 h after surgery, the portal pressure was measured; the levels of chymase (Rat Mast Cell Protease-II) were assayed in the superior mesenteric lymph complex and granulated and degranulated mast cells in the ileum and cecum were quantified. Prophylactic administration of Ketotifen reduced portal pressure, the incidence of dilation and tortuosity of the superior mesenteric vein branches, the amount of Rat Mast Cell Protease-II in the superior mesenteric lymph complex and the number of activated mast cells in the cecum of rats with portal hypertension. In summary, the administration of Ketotifen reduces early splanchnic inflammatory reaction in the rat with prehepatic portal hypertension.

Protective effect of curcumin against liver warm ischemia/reperfusion injury in rat model is associated with regulation of heat shock protein and antioxidant enzymes

To investigate the hypothesis that the protective effects of curcumin in hepatic warm ischemia/reperfusion (I/R) injury are associated with increasing heat shock protein 70 (Hsp70) expression and antioxidant enzyme activity. Sixty Sprague-Dawley male rats were randomly divided into sham, I/R, C + I/R groups. The model of reduced-size liver warm ischemia and reperfusion was used. Curcumin (50 mg/kg) was administered by injection through a branch of superior mesenteric vein at 30 min before ischemia in C + I/R group. Five rats were used to investigate the survival during 1 wk after operation in each group. Blood samples and liver tissues were obtained in the remaining animals after 3, 12, and 24 h of reperfusion to assess serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), liver tissue NO(2)(-) + NO(3)(-), malondialdehyde (MDA) content, superoxide dismutase (SOD), catalase (CAT), nitricoxide synthase (NOS) and myeloperoxidase (MPO) activity, Hsp70 expression and apoptosis ratio. Compared with I/R group, curcumin pretreatment group showed less ischemia/reperfusion-induced injury. CAT and SOD activity and Hsp70 expression increased significantly. A higher rate of apoptosis was observed in I/R group than in C + I/R group, and a significant increase of MDA, NO(2)(-) + NO(3)(-) and MPO level in liver tissues and serum transaminase concentration was also observed in I/R group compared to C + I/R group. Curcumin also decreased the activity of inducible NO synthase (iNOS) in liver after reperfusion, but had no effect on the level of endothelial NO synthase (eNOS) after reperfusion in liver. The 7 d survival rate was significantly higher in C + I/R group than in I/R group. Curcumin has protective effects against hepatic I/R injury. Its mechanism might be related to the overexpression of Hsp70 and antioxidant enzymes.

Collateral pathways of the left gastric vein in portal hypertension.

Since June 1974, 347 percutaneous transhepatic portal venographic studies were performed on 246 patients with portal hypertension who had had bleeding gastroesophageal varices. Of 234 patients in whom left gastric veins (LGV) (coronary) were demonstrated, 177 (75.6%) had a single LGV and 57 (24.4%) had multiple left gastric veins (21.8% had two LGVs, 2.1% had three LGVs, and 0.5% had five LGVs). Of 193 patients undergoing selective left gastric venography, spontaneous portosystemic communications to the left renal vein were found in 55, to the inferior vena cava in two, to the inferior pulmonary veins in five, to the pericardiophrenic vein in eight, to the right inferior phrenic vein in three, and to the left intercostal veins in one. Interportal communications with the left gastric vein and varices occurred from the left portal vein in 13, from the gastroepiploic vein in one, and from a superior mesenteric vein branch in one. The predominant drainage of esophageal varices was to the azygos vein in 78 of 155 patients, to the hemiazygos vein in 13, and to multiple small unnamed veins in the mediastinum in 57. Opacified varices did not extend above the level of the azygos vein arch in 71 of 130 patients; however, 59 continued cephalad to the azygos arch and drained through more superior veins of the thorax. Knowledge of the anatomy and incidence of each of these portosystemic or interportal venous communications is important to properly treat bleeding esophageal varices by surgery or angiographic embolization.