BackgroundPostpancreatectomy hemorrhage (PPH) is a severe complication in pancreatic surgery. This study focused on early PPH (E-PPH), aiming to identify its characteristics, evaluate the existing grading criteria by the International Study Group of Pancreatic Surgery (ISGPS), and explore effective treatment strategies.MethodsPatients undergoing pancreatic surgery between March 2020 and January 2024 in two institutions were screened from prospectively maintained databases. Patients with E-PPH were divided into intervention group and the conservative group. The sites of hemorrhage were determined and categorized. Clinical presentation and outcomes were compared among different grades and interventions.ResultsAmong 4062 patients who underwent pancreatic surgery, 113 cases of E-PPH were identified, with an incidence of 2.8%. E-PPH was more concentrated within 24 h (76.2%) and occurred more extraluminally (78.2%). The intervention group had a higher proportion of hemodynamic instability (40.9%) and ICU stays (54.5%). E-PPH in the mesenteric region was more common in pancreaticoduodenectomy (81.9%) and open surgery (90.9%). Branches of the common hepatic artery and superior mesenteric vessel were the majority responsible vessels. Appropriate E-PPH treatment was effective, with successful hemostasis in all intervention cases. The occurrence of ICU admission, the length of ICU and postoperative hospital stay and 90-day mortality were not significantly different between different grades with intervention.ConclusionAppropriate therapy for E-PPH could lead to a favorable prognosis. The current definitions and grades for PPH are inadequate and require further modification.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00423-025-03896-1.

Appropriate extent of lymph node dissection in patients with muscle-invasive gallbladder cancer.

Right hemicolectomy with Complete Mesocolic Excision (CME) and Central Vascular Ligation (CVL) is a complex surgical procedure, partly due to the significant anatomical variability of the superior mesenteric vessels. Three-dimensional (3D) vascular reconstruction, through segmentation-a process that groups pixels with similar characteristics into segments-is a technique that enables the three-dimensional visualization of blood vessels from medical images, usually obtained through CT or magnetic resonance imaging. 3D vascular reconstruction of the superior mesenteric vessels obtained from preoperative images of surgical patients enhances preoperative anatomical understanding, making surgery safer, especially for young surgeons approaching this technique. The primary outcome of this study was to obtain an objective score reflecting surgical residents' understanding of the patient's vascular anatomy from 3D reconstructions of CT images. The secondary outcome was the subjective feedback from senior colorectal surgeons regarding pre-operative use of 3D vascular reconstructions. A total of 20 patients who underwent right hemicolectomy from 01/10/2023 to 30/09/2024 were included in the study. For each patient, 3D vascular reconstruction was obtained from preoperative CT images. Four surgical residents and two experienced colorectal surgeons were recruited. The residents' understanding of each patient's vascular anatomy was assessed after they looked at the standard pre-operative CT images first and then at their 3D reconstructions respectively. Moreover, the senior colorectal surgeons' opinion on the use of pre-operative 3D vascular reconstruction was assessed. Overall, 3D reconstructions significantly improved residents' anatomical understanding compared to baseline testing (6.71 ± 2.27 vs. 5.26 ± 1.97; p < 0.0001). For three out of four residents examined, 3D vascular reconstruction was statistically superior to standard CT. Colorectal surgeons also gave positive feedback to the use of pre-operative 3D reconstruction. Three-dimensional vascular reconstruction models may help improve surgical trainees' anatomical understanding of mesenteric vascular anatomy compared to conventional CT image interpretation. 3D models may be a useful adjunct to 2D imaging for residents' training and pre-operative planning of CME surgery. More studies are needed to further evaluate the impact of using pre-operative 3D vascular reconstruction.

The D3 lymphadenectomy with extended mesenteric/mesocolic excision is becoming a standard in the surgery of small and large bowel carcinoma. The aim of this study is to present the feasibility of macro- and microdissection of the mesenteric lymphatics in the root of the mesentery with accompanying morphometry of the lymphatic clearances. The study was carried out on three embalmed cadavers from the body donor program. After the removal of the anterolateral abdominal wall, the greater omentum was retracted cranially, giving access to the mesentery, right, and transverse mesocolon. After marking the pertinent landmarks (ileocolic fold, middle colic fold, duodenojejunal angle), the visceral peritoneum was carefully incised along the approximate larger perimeter of the D3 volume and removed. The subperitoneal fatty and connective tissue was removed by gentle centrifugal scraping, revealing the underlying deep lymphatic and blood vessel network. We used narrow spatulas, micro-dissection scissors, small tweezers, curved forceps, and 5x magnifying lens with a fluorescent ring. The centrally positioned superior mesenteric vessels were pivotal in identifying their branches, affluents, and the accompanying lymphatic network. The lymph vessels were identified by continuity with the collector vessels and their link to the lymph nodes. Finally, the lymphatic clearances, i.e., distances between the mentioned arteries and their neighboring vessels, were measured by a digital caliper. In conclusion, the dissection of the mesenteric lymphatics gives a synoptic view of the lymph vessels network and provides valuable information for D3 surgery of small and large bowel tumors.

Retroperitoneal sarcomas (RPS) comprise a heterogenous group of rare mesenchymal tumours. A complete macroscopic en bloc resection of the tumour with involved adjacent structures is the only curative treatment modality. There remain no consensus criteria regarding the definition of a resectable versus unresectable RPS. This study examined the rate, rationale and outcomes for resectable and unresectable RPS from a single large tertiary referral centre. All patients with primary non-metastatic RPS referred between January 2017 and March 2023 were identified. Patient and tumour details as well as survival analyses were compared between resectable and unresectable cohorts, and factors for unresectability were analysed. A total of 104 patients were considered for the analysis, of which 91 (87.5%) were resectable and 13 (12.5%) unresectable. Gender, age, tumour size and side were similar in both cohorts. Unresectability was determined on pre-operative imaging in seven patients (53.8%) and intra-operatively in six (46.2%) patients. The most common technical cause for unresectability was the involvement of superior mesenteric vessels (38.5%). At a median follow-up of 18 months, 84.6% of the unresectable cohort and 8.8% of the resectable cohort had died. Approximately 12% of patients with primary RPS were unresectable at presentation, and in most cases, unresectability can be determined pre-operatively. Defining resectable and unresectable disease may improve the prognostication and management for patients with primary RPS.

Sclerosing mesenteritis is a rare and often misdiagnosed inflammatory condition of the mesenteric fat with nonspecific symptoms. We report the case of a 41-year-old woman admitted for profuse rectal bleeding, an exceptional resentation of this disease. Endoscopic findings were inconclusive, while CT angiography revealed a retractile, hypodense mass at the mesenteric root encasing the superior mesenteric vessels, with associated varices, mesenteric fat infiltration, and bowel wall thickening. These features were highly suggestive of advanced sclerosing mesenteritis. Surgical exploration confirmed the diagnosis, and a right hemicolectomy was performed with good clinical evolution. Rectal bleeding was attributed to venous compression and collateral mesenteric varices. This case highlights the crucial role of CT in diagnosing sclerosing mesenteritis and guiding treatment, especially in atypical presentations that may mimic malignancy.

Abstract Background Colorectal cancer (CRC) affects 4.5% of the general population, with 15% involving the right colon. Surgery, when feasible, varies from conventional right colectomy to Complete Mesocolic Excision (CME). Although better oncological outcomes were reported in the literature after CME, there is an acknowledged higher risk of operative vascular lesions. Various approaches have been proposed to facilitate CME, such as the “open book” model and 3D modelling of the mesenteric vessels, however CME remains technically challenging. Aims Our study aims to analyze whether preoperative CT imaging with vascular mapping (PVM) of the superior mesenteric vessels could offer guidance on the vascular anatomy during CME. Methods This prospective, monocentric study aims to include 30 patients undergoing CME for right CRC. Preoperatively, a biphasic CT scan with 3-D vascular reconstruction of the superior mesenteric vessels is performed. Vascular distances are calculated based on CT, then compared to intraoperative documentation of the mesenteric vessels. Primary outcomes are the surgeons’ evaluation of the benefit of vascular mapping and the statistical correlation of the vascular distances between CT guidance and operative finding. Results To this day, 22 patients have been included. Surgeons found the preoperative vascular mapping very useful (3.58/5 on a Likert scale). Mean operation time was 263 minutes, with a mean of 36 lymph nodes harvested and no vascular lesions. Postoperative ileus occurred in 27% (6/22), Clavien-Dindo complications III-V in 13,6% (3/22) with one anastomotic leak (4,5%) and one death after discharge at home of unknown cause. Statistical analysis of the vascular distances will be performed upon completion of the study. Conclusion Our preliminary data suggest that PVM may be a valuable tool for reducing the risks associated with CME and aiding vascular ligation in this complex surgical technique. Further studies are required to asses PVM utility in CME and confirm these outcomes.

BackgroundThe prolonged ductal patency in preterm newborns despite being associated with short- and long-term morbidities has failed to show significant improvement in the long-term outcome with routine ductal treatment. Echocardiography has been shown to have a predictive and diagnostic role in identifying the significant patent ductus arteriosus (PDA) before its clinical detection and providing selective treatment for PDA to avoid unnecessary therapy or delay of necessary therapy. Several echocardiographic ductal markers have been evaluated for their predictive utility with a wide range of sensitivity (26%-100%) and specificity (6%-100%). Ductal diameter, left pulmonary artery (LPA) velocity, and left atrial to aortic width (La/Ao) ratio are the common markers being used routinely for PDA. This research was planned to assess the predictive utility of additional ductal echocardiographic markers in preterm newborns.MethodsIt was a prospective observational cohort study conducted in the tertiary care neonatal intensive care unit (NICU) at Lady Hardinge Medical College, Delhi. 50 very low birth weight newborns underwent four sequential Echo scans within the first 72hrs; the first within 12hours, and the next three scans at completed 24hrs, 48hrs, and 72hrs of age. These newborns were then monitored for clinical signs of PDA up to 2weeks of life.ResultsThe left atrial volume index (LAVI), left ventricle to aortic width (Lv/Ao ratio), left ventricular output/superior vena cava (LVO/SVC) flow ratio with different cut-off values at different hours of life, shunt pattern and altered blood flow in the anterior cerebral, and superior mesenteric vessels predicted persistence of ductus arteriosus.ConclusionThis study provides insights into the predictive utility of additional ductal echo markers apart from the routinely measured ones.

Aim: to develop and describe the technique of primary retroperitoneal approach to the superior mesenteric vessels for D3 lymph node dissection in minimally invasive surgical treatment of the right colon cancer; to evaluate the shortterm results of the first series of patients operated by this technique.Materials and methods. Patients with adenocarcinoma of the right colon were included in the study. The technique of primary retroperitoneal approach consisted in mobilization of the right mesocolon along the posterior surface in the direction of the superior mesenteric vessels, D3 lymph node dissection with crossing of the feeding vessels from the retroperitoneal side using a single-port access system and consisted of five consecutive steps. At the last step of the procedure the peritoneum and the remaining part of the mesentery were crossed laparoscopically to the intended borders of the colon resection. The specimen was extracted through the incision for the single port, followed by the formation of an anastomosis extracorporeally. The endpoints of the study were the short-term results of surgical treatment.Results. The study presents data of the first 5 patients with adenocarcinoma of the right colon who underwent surgical treatment with D3 lymph node dissection using primary retroperitoneal approach to the superior mesenteric vessels. The duration of the retroperitoneal step averaged 110 (90–140) min. The average blood loss was 62 (10–100) mL. The first two patients underwent a three-stage retroperitoneal portion of the surgery. The other three patients were successfully operated by primary retroperitoneal approach with performing of all five steps of the operation. The number of removed regional lymph nodes was on average 36 (18–57), apical lymph nodes — 6 (4–5), metastatic regional lymph nodes — 3 (2–4). One patient developed a Class 1 Clavien — Dindo complication, which did not require a change in treatment tactics. The average postoperative hospital stay was 8 (5–12) days.Conclusion. The technique of primary retroperitoneal approach to the superior mesenteric vessels to perform D3 lymph node dissection was described for the first time. The obtained results demonstrated the possibility of using this method for minimally invasive radical treatment of right colon cancer.

To provide a personalized approach to D3 lymph node dissection (LND) in right colon cancer using a proper analysis and interpretation of CT angiography of superior mesenteric vessels. An observational cross-sectional study included 34 patients who underwent surgery for right colon cancer with D3 LND along superior mesenteric artery (SMA) and vein (SMV). Characteristics of surgically relevant vascular anatomy were evaluated as 0 or 1 depending on complexity of anatomical characteristic. Patients were classified into groups of standard (0 points) and complex (1-3 points) LND according to complexity of vascular anatomy. SMA and SMV crossed each other at the level of ileocolic artery (ICA) orifice or above in 23.5% of cases (n=8). In 76.5% of cases, they passed parallel to each other (n=25). Ileocolic artery passed posteriorly to SMV in 47.1% (n=16) of cases. A closed type of SMA with a restricted access to D3 area was observed in 41.2% of cases (n=14). Duration of LND significantly differed (43.6±17.8 min in standard cases and 61.9±18.6 min in complex ones, p=0.006). Ascular anatomy can predict complexity of D3 LND in right colon cancer surgery. The complexity scale is an important tool for preoperative planning of D3 LND and identifying technical difficulties associated with vascular anatomy.

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.

Abnormal relative positioning of the superior mesenteric artery (SMA) and vein (SMV) can lead to intestinal malrotation that predisposes to midgut volvulus. The aim of this study was to assess the prenatal ultrasound ability to visualize the relative position of SMA and SMV in normal pregnancies. Prospective cohort study performed in Montpellier University Hospital Centre, including 80 fetuses during routine 3rd trimester ultrasound scan. For each fetus included, the relative position of the vessels on an axial image was defined as SMV on the right, forward, or on the left of SMA. Doppler imaging was additionally used if necessary. Data were compared to the neonatal abdominal scans performed by pediatric radiologist. The superior mesenteric vessels were identified in 79 fetuses. Prenatal findings showed a usual relative position of the vessels, that is, the vein on the right of the artery, in 96.2%. In 2 cases, the vein was strictly in front of the artery, and in 1 case, the vein was on the left side of the artery. Seventy-four neonates were examined and comparison with prenatal finding showed a perfect agreement (Kappa coefficient of 100%). An intestinal malrotation was postnatally diagnosed corresponding to the case where vein was on the left side of the artery. This study showed that the relative position of the SMA and SMV could be assessed using ultrasound prenatal examination with a perfect agreement with postnatal findings. In case of abnormal vessels positioning more examinations should be promote including prenatal MRI and postnatal conventional radiologic examinations to confirm intestinal malrotation.

The study aimed to perform a systematic review of the literature on surgical treatment for right colon cancer (RCC) with complete mesocolic excision (CME) and D2/D3 lymph node dissection (LND). Material and Methods. A literature review was performed for studies published between 2013 and 2023 by the online resources from the official Web sites of the societies/panels and PubMed database. Sources included guidelines, meta-analyses, randomized and nonrandomized clinical studies, guidelines by European Society of Medical Oncology, the Japanese Society for Cancer of the Colon and Rectum, and the National Comprehensive Cancer Network, Russian clinical guidelines. Results. CME significantly improved both immediate and long-term treatment results, which was confirmed by numerous meta-analyses. The extent of LND remains one of the most controversial issues in RCC. For many Asian surgeons, D3 LND is the standard procedure for the treatment of RCC, whereas the European approach is more conservative and apical lymph node dissection is not mandatory. There are also large differences in understanding the extent of D3 LND in RCC. Most surgeons understand this term as dissection of adipose tissue along the anterior and lateral surface of the superior mesenteric vein, however, there are authors who perform circular dissection along the superior mesenteric vessels, considering this extent of surgery to be the most radical. Conclusion. It is necessary to standardize methods and effective criteria for quality control of CME for RCC and LND. In this case, external independent assessment of the quality of surgical intervention is important. There is also currently a growing number of studies in which intraoperative fluorescence imaging makes it possible to better visualize the location of the apical lymph nodes and individualize LND.

Mesocolic hernia, a case series

By selectively perfusing the first three jejunal arteries (JA), we aim to assess the individual perfusion length of small bowel (SB) and its impact on nodal resection in stage III-up small-intestinal neuroendocrine tumors (SI-NET). Our anatomical research protocol implies a midline laparotomy and three measures of the SB length. We then perform a classical anterior approach of the superior mesenteric vessels. We carry on with the complete dissection and checking of the superior mesenteric artery (SMA) in order to identify the first three JA. Then we selectively perfuse each artery with colored latex solutions and measure the length of small bowel perfused respectively. We conducted our protocol on six cadaveric subjects. Mean(SD) SB length was 413(5.7), 535(13.2), 485(15), 353(25.1), 730(17.3) and 525(16° cm respectively from subject one to six. Most JA originated from the left side of the SMA. The first JA originated from its posterior wall in two subjects. Mean(SD) distance of origin of the first three JA was 4.6(1.3)cm, 6(1.1)cm and 7.1(0.9)cm respectively. Mean(SD) diameter of SMA was 10.8(3.3)mm. Mean diameter of the three first JA was 4(1.4)mm, 4(1.5)mm and 5(1.2)mm respectively. Mean(SD) SB length perfused by first and second JA was 224(14.9)cm, 175(8.6)cm, 238.3(7.6)cm, 84.3(5.1)cm, 233.3(5.8)cm and 218.3(10.4)cm respectively from subject one to six. We observed a trend suggesting that the first and second JA may sustain a SB length beyond the viable 1.5m limit, implying the feasibility of stage III-up SI-NET resection with just two JA.

Nodal recurrence mapping and clinical target volumes after resection of intrahepatic cholangiocarcinoma or combined hepatocellular-cholangiocarcinoma

Pre-operative diagnosis and staging of small intestine neuroendocrine tumors (SI-NETs) remain sub-optimal, with open palpation during surgery still considered the gold standard. This limits a standardized implementation of minimally invasive surgery (MIS). The aim of this single-center retrospective study was to assess a tailored diagnostic work-up to identify candidates at low risk of undetected disease who may benefit from MIS. Patients diagnosed with SI-NETs between 2013 and 2022 who underwent contrast-enhanced computed tomography enterography (CTE) and Ga68-DOTATOC-positron emission tomography-CT (68Ga DOTATATE PET/CT) preoperatively and subsequently underwent open surgical resection were included. Imaging studies were reassessed by two radiologists. Combined use of CTE and 68Ga DOTATATE PET/CT in determining primary lesion disease burden (number of lesions) and LN disease stage (distal and proximal relative to superior mesenteric vessels) was assessed, using surgical reports and pathology as gold standard. Overall, 56 patients were included. Sensitivity of CTE and 68Ga DOTATATE PET/CT for at least one primary SI-NET was 100% and 94%, respectively. In the presence of concordance between studies, combined use of CTE and 68Ga DOTATATE PET/CT for detection of single primary tumors improved specificity to 89% (n = 25/28) with a positive predictive value of 87.5% (n = 21/24). Distal LN disease was identified in 89.2% of cases (n = 33/37). The association of single lesion and distal LN disease was found pre-operatively in 32% of patients (n = 18). Combined use of CTE and 68Ga DOTATATE PET/CT enables identifying low-risk surgical candidates (single SI-NET lesions with distal LN disease).

According to Hohenberger's original description, complete mesocolic excision for colon cancer involves precise dissection of the avascular embryonic plane between the parietal retroperitoneum and visceral peritoneum of the mesocolon. This ensures mesocolic integrity, access to high ligation of the supplying vessels at their origin and an associated extended lymphadenectomy. Results from centres which have adopted this approach routinely have demonstrated that oncological outcomes can be improved by the rigorous implementation of established principles of cancer surgery. Meticulous anatomical dissection along embryonic planes is a well-established principle of precision cancer surgery used routinely by the specialist colorectal surgeon. Therefore, the real question concerns the need for true central vascular ligation and associated extended (D3) lymphadenectomy or otherwise, particularly along the superior mesenteric vessels when performing a right colectomy. Whether this approach results in improved overall or disease-free survival remains unclear and its role remains controversial particularly given the potential for significant morbidity associated with a more extensive central vascular dissection. Current literature is limited by considerable bias, as well as inconsistent and variable terminology, and the results of established randomized trials are awaited. As a result of the current state of equipoise, various national guidelines have disparate recommendations as to when complete mesocolic excision should be performed if at all. This article aims to review the rationale for and technical aspects of complete mesocolic excision, summarize available short and long term outcome data and address current controversies.

Neoadjuvant Stereotactic MR-Guided Ablative Radiation Therapy (SMART) and Surgical Outcomes in Patients with Pancreatic Cancer

Segmental Duodenal Resections: Toward Defining Indications, Complexity, and Coding