Superior Mesenteric Vessels Research Articles

Complete mesocolic excision for right colon cancer

Total mesorectal excision (TME) improves local recurrence rates and so it is accepted as the gold standard surgical method for locally advanced rectal cancer surgery. Based on these experiences, the concept of embryonic plane dissection was translated to surgery of colon cancer as complete mesocolic excision (CME) and central vascular ligation (CVL). CME aims to remove the specimen with an intact peritoneal tissue in according to embryonic planes and to ligate the vessels as close as possible to their separation point from the superior mesenteric vessels. With CME technique, more lymph nodes are harvested and better quality specimen is obtained. This procedure is feasible in both open and minimal invasive surgery, however, technical difficulties should not be overlooked. It is very important to learn correctly the anatomy and the embryology of right colon for successful resection. Many studies on this issue have significant limitations, being generally retrospective and non-homogeneous. There is no consensus on the routine implementation of CME due to the lack of prospective randomized controlled trials.

The effect of vascular anatomy and gender on bowel function after right colectomy with extended D3-mesenterectomy

Background: Extended D3-mesenterectomy for right-sided colon cancer, removes all tissue around the superior mesenteric vessels beneath pancreas leading to transection of superior mesenteric plexus. In a previous study, the denervation was associated with 0.48 more stools/day. The study aims are to examine how presence of arterial branches proximal to the dissection area, gender and prolonged observation time after surgery affect bowel function following denervation. Methods: The study compares bowel function and Quality of Life in two groups undergoing right colectomy with extended D3-mesenterectomy and traditional D2-mesenterectomy. For further comparison, the denervated group was divided into groups with and without arterial branches arising proximal to the denervation. Instruments used were Gastrointestinal Quality of Life Index (0–144; 144= best) (GIQLI), Diarrhea Assessment Scale (0–12; 0= best) (DAS) and 3 additional questions (Ability to postpone defecation, night defecation, degree of distress). A second interview with prolonged observation time was performed for patients with abnormal bowel habits, defined as a) having 4 or more stools/day or b) being much or very much bothered. Results: Eighty-three D3-patients and 61 D2-patients, comparable for age and sex with shorter follow-up in the D3-group. In the D3-group 67 patients (80.7%) had one or more arteries proximal to the denervation. Sixteen patients (19.3%) had no proximal arteries. Regression analysis (correcting for confounding factors) revealed 0.30 (P=0.012) lower consistency score (increased consistency) and 0.27 (P=0.096) fewer stools/day in the D2- than the D3-group. DAS subscores, DAS, GIQLI and GIQLI-subscales revealed no differences between the groups. Within the D3-group, the estimated differences between patients with and without proximal arteries (adjusted for age, gender and time between surgery and interview) were significant for DAS and subscores; DAS: −1.526 (P=0.012), stool frequency: −0.653 (P=0.007), stool consistency: −0.432 (P=0.054), stool urgency: −0.595 (0.009). Negative scores represent lower (better) scores in the group with proximal arteries. GIQLI scores and subscales showed no difference. When genders were compared separately, the T-test revealed significantly lower (better) DAS and subscores for D2-females than D3-females, a difference not found in the male group. When controlled for observation time and age (regression) the difference disappears. A second interview with prolonged observation time (1. interview: 15.1 months, 2. interview: 56.4 months) for patients with abnormal bowel function reveals reduced (better) Extended DAS score (DAS + additional questions) in 8 of the 10 patients interviewed. 7 had no longer abnormal bowel function. Conclusions: D3-patients without arteries proximal to the nerve transection have significantly higher (worse) DAS-scores and subscores. The allover difference between the D2 and the D3 patients is small and only significant for consistency. Normalizing of the bowel function takes longer than assumed and continues for months and even years. Women are less able to compensate for the altered bowel habits during normalization.

Intestinal Thromboangiitis Obliterans (Buerger’s Disease): a Case Report

Buerger’s disease is an unknown etiology, inflammatory vaso-occlusive, and non-arteriosclerotic vascular disease. It affects medium- or small-sized arteries and veins; uncommonly it involves in vesical vessels. A 43-year-old man, previously diagnosed with Buerger’s disease for 25 years, presented with acute abdomen. Urgent laparotomy was done, and a perforated jejunal ulcer and peritonitis were detected. The patient had to undergo recurrent laparotomy for mesenteric ischemia. A case of intestinal manifestation of the disease with superior mesenteric vessels occlusion represents unexpected manifestation of the disease. Early diagnosis is the key for true clinical management and good willing prognosis.

Gastrointestinal motility should be emphasized after laparotomy treatment for complete small intestinal volvulus in older adults

Rationale:Complete small intestinal volvulus is a rare entity in adults, unlike partial intestinal volvulus. Although prompt surgical intervention is the mainstay of treatment, attention should also be paid to recovery of intestinal function postoperatively. Ignoring this issue during the postoperative recovery process can have serious consequences. We report the case of an 82-year-old woman with complete small intestinal volvulus at the root of the superior mesenteric vessel.Patients concerns:The patient was admitted for acute onset (22 hours) of abdominal pain and distention. Nausea and vomiting also developed during this period.Diagnoses:Abdominal physical examination was suspicious for peritoneal irritation. Computed tomography scan showed anticlockwise swirl of the mesenteric vessels at the lower margin of the pancreas with distension of the entire small intestine. A complete small intestinal volvulus was diagnosed.Interventions:Laparotomy and detorsion of the volvulus were performed after early diagnosis.Outcomes:The patient developed intestinal wall edema because of ischemic–reperfusion damage. She exhibited severe abdominal distention and absent intestinal motility. Two days later, she went into septic shock; she died 19 days after surgical intervention.Lessons:Because complete small intestinal volvulus involves the entire intestine, ischemic–reperfusion intestinal damage after detorsion may be severe and can predict prognosis.

HugeNon-Organ Retroperitoneal Tumor inCombination with aCystoma of Uterine Appendages

The article describes the experience of successful diagnostics and treatment of giant non-organ extraperitoneal tumor combined with a cystoma of uterine appendages.Patient P., 43 years old, was hospitalized in the oncology department, diagnosed with “Abdominal tumor, right ovary?” The state was satisfactory, after palpation of the abdomen, a lumpy formation of a densely elastic consistency, from the womb to the epigastric region, was found. An ultrasound revealed a homogeneous tumor formation 30×28 cm from the border of the uterus to the liver. When performing median laparotomy, a dumbbell-shaped tumor (36×26×20 cm) was found in the retroperitoneal space with involvement of the mesentery of the small intestine, lower horizontal portion of the duodenum, mesentery of the transverse colon, superior mesenteric vessels, aorta and jejunum. In the right appendages, a cystoma 12–15 cm in diameter was found, with inversion and necrosis. Adnexectomy was performed. An express lymph node biopsy revealed cells suspicious for malignancy. The tumor was mobilized and removed as a single unit with retroperitoneal tissue, lymph nodes in combination with resection of 70 cm of the jejunum and fenestrated resection of the duodenum. The resulting gut defect 9×7 cm was sutured with a precision single-row suture. Inter-intestinal anastomosis “endto-end” was formed. Nasointestinal intubation was performed. The abdominal cavity was sutured, and two tubular drainages were installed. The postoperative period was uneventful. The histological conclusion: fibrous histiocytoma of the mesentery of the intestine with malignancy in the center of the node, in the ovary – total hemorrhagic infiltration of all layers, edema. The tumor conference consultation was recommended. After 1.5 years, the patient was admitted with the same clinical picture. During laparotomy, a tumor recurrence was discovered, the nodes of which were located in the retroperitoneal space, in the abdominal cavity with invasion to organs and large vessels. The case was recognized as inoperable, the laparotomic wound was closed completely. Sixteen days after surgery the patient was discharged.

Bowel Motility After Injury to the Superior Mesenteric Plexus During D3 Extended Mesenterectomy

BackgroundImprovement of lymphadenectomy in right colectomy requires removal of all tissue surrounding the superior mesenteric vessels beneath the pancreatic notch. Short- and long-term bowel motility disorders after D3 extended mesenterectomy with consecutive superior mesenteric plexus transection are studied. MethodsPatients without pre-existing motility disorders undergoing D3 extended mesenterectomy were examined 3 times using the wireless motility capsule: before, at 3 wk, and 6 mo after surgery. Segmental transit times and contractility were analyzed using mixed effect modeling. Correlation between contractility and transit time was assessed by the Pearson correlation coefficient. ResultsFifteen patients (4 men), with median age 62 y, were included. Mean values for the three consecutive examinations are as follows. Gastric transit time increased from 237 to 402 and 403 min, respectively. Small bowel transit time decreased from 246 to 158 (P < 0.01) and 199 (P = 0.03) min, respectively. Colonic transit time decreased from 1742 to 1450 and 1110 (P = 0.02) min, respectively. Gastric contractions per minute (CPM) varied from 1.73 to 1.05 (P = 0.01) and 2.47 (P < 0.01), respectively. Small bowel CPM decreased from 3.43 to 2.68 and 3.34, respectively. Colonic CPM ranged from 1.59 to 1.45 and 1.91 (P = 0.08), respectively. Correlation between small bowel (SB) transit time and CPM was −0.45 (P = 0.09) preoperatively, and −0.03 (P = 0.91) 6 mo postoperatively. ConclusionsExtrinsic SB denervation leads to significantly accelerated SB transit, reduced contractility, and disturbed correlation between transit time and contractility early after denervation. Both number of contractions and transit time in the denervated SB show a clear tendency toward normalization at 6 mo.

Fully Robotic Resection of a Splenic Flexure Tumor with Intracorporeal Anastomosis.

Surgical resection of splenic flexure tumors (SFTs) is challenging because of the proximity of the spleen, stomach, and pancreas and the dual blood supply from the superior and inferior mesenteric vessels.1,2 A minimally invasive approach to SFT resection offers the advantage of avoiding a large inc

Mapping of the superior mesenteric vessels for artery first pancreatoduodencectomy in patients with high visceral fat

Mapping of the superior mesenteric vessels for artery first pancreatoduodencectomy in patients with high visceral fat

Mapping of the superior mesenteric vessels for artery first pancreatoduodencectomy in patients with high visceral fat

Mapping of the superior mesenteric vessels for artery first pancreatoduodencectomy in patients with high visceral fat

Endoscopic Ultrasound Isolates Type B Aortic Dissection

An aortic dissection (AD) occurs when the inner layer of the aorta tears. ADs have a predilection toward men and those aged 60 to 70 [1]. Type A aortic dissections are more dangerous due to the tear situated in the ascending aorta whereas Type B is more rare with the tear limited to the descending aorta. Symptoms of aortic dissections such as chest pain are similar to other cardiovascular conditions, making aortic dissection detection tricky [1,2]. We report a 74 year old female with constant chest pain radiating from the right breast to the right upper quadrant after eating Chinese food for dinner. The pain was accompanied with non-radiating back pain and nausea. Physical examination was significant for a tender mass palpated in the right upper and lower quadrants. Right upper quadrant ultrasound showed choledocholithiasis with common bile duct dilation at 1.1cm, unchanged from 1 year prior, and sludge in the gallbladder but no cholecystitis. Her vitals were stable with mild hypertension (149/67 mmHg). Endoscopic ultrasound examination showed a gallbladder filled with stones and sludge as well as a thickened wall consistent with possible cholecystitis. Mild intrahepatic biliary dilation was present. The celiac axis, superior mesenteric vessels, splenic vessels and portal vein were normal. Type B Dissection of the thoracic aorta and aortic arch was identified in the endoscopic ultrasound. Traditionally, CTs with contrast dye, echocardiograms and MRIs are commonly used to diagnose AD [1]. Meanwhile, endoscopic ultrasound (EUS) provides clear images to facilitate the diagnosis of gastrointestinal conditions. Our case highlights that EUS can also be used to examine cardiovascular disorders. EUS offers complete visualization of the aortic valve, the mitral valve, ascending and descending aorta, pericardium, left atrial appendage, and interatrial septum [3]. The proximity of the aorta to the esophagus allows for a very detailed view of the aorta [2,3]. It is essential that every complete endoscopic ultrasound exam include an evaluation of the thoracic organs in order to capture critical incidental findings that would be otherwise missed.2139_A Figure 1. Type B aortic dissection as seen on endoscopic ultrasound.2139_B Figure 2. Type B aortic dissection as seen on endoscopic ultrasound.

Lymph node metastases in splenic flexure colon cancer: Is subtotal colectomy warranted?

Tumors of the splenic flexure (TSF) can be associated with metastatic lymph nodes (LN) along the left colic pedicle, but also along the superior mesenteric vessels. We aimed to detail the anatomical distribution of metastatic LNs in patients undergoing elective subtotal colectomy for TSF. Between 2000 and 2016, 65 patients were included. At pathological analysis, LNs were classified into two groups: locoregional LN (along the left colic artery) and distant LN (along the middle colic, right colic, and ileocolic arteries). The median number of LNs examined was 20. Eighteen patients (27%) were pN+. Among them, six (33% of pN+ patients and 9% of the series) had at least one positive distant LN. All these patients had a positive distant LN along the right colic artery. These patients had a significantly advanced stage and more positive LNs than the others (stage III-IV: 100% vs 22%, P = 0.0009 and 6 [3-15] vs 0 [0-15], P < 0.0001, respectively). The presence of synchronous metastases was predictor of metastatic distant LNs (P = 0.042). Elective subtotal colectomy for TSF allows to discover distant positive LNs in nearly 10% of patients. For those having TSF and synchronous metastatic disease enable to resection, subtotal colectomy should be recommended.

Neonatologist performed point-of-care bowel ultrasound: Is the time right?

This review acquaints neonatal clinicians using point-of-care ultrasound with a range of pathological bowel ultrasound findings, with the aim to promote utility of this skill as a diagnostic assessment tool in diseased neonatal intestinal states. A range of normal and pathological bowel ultrasound findings are illustrated with case examples from our neonatal intensive care unit. The technical challenges of lack of familiarity with sonographic appearance of bowel (healthy and diseased), occurrence of gas artefacts and requirements of high-resolution linear transducer probes are described to allow the development of skills amongst neonatologists trained in point-of-care ultrasound. Plain abdominal radiography continues to remain the standard investigation to differentiate benign bowel states such as continuous positive airway pressure (CPAP) belly syndrome in preterm infants from life-threatening pathological intestinal states such as necrotising enterocolitis. Although plain radiography is the gold standard modality in the evaluation of neonatal diseased bowel states, real-time point-of-care bowel ultrasound performed in conjunction can provide valuable information on bowel peristalsis, bowel wall thickness and bowel vascularity. Abnormal configuration of superior mesenteric vessels on colour Doppler can alert the clinician to the diagnosis of neonatal intestinal malrotation-a time critical emergency. Further research is needed to explore true-negative and true-positive predictive values of bowel ultrasound. However, with expansion of knowledge, appropriate training of techniques, neonatologists will be able to enhance their diagnostic acumen by performing point-of-care bowel ultrasound in conjunction with plain radiography in the evaluation of broad array of neonatal intestinal states.

Improved superior mesenteric artery exposure and reduced blood loss risk using temporary mesocaval shunt for locally advanced pancreatic cancer

Introduction: Patients with locally advanced pancreatic cancer (LAPC) represent a challenging group to resect given their putative unreconstructible nature of vascular encasement. In selected patients with anatomy beyond “borderline,” temporary mesocaval shunt can facilitate the pancreatectomy by enhancing exposure to the superior mesenteric vessels. Methods: This is a video of a pancreaticoduodenectomy (PD) with temporary mesocaval shunt with left internal jugular (LIJ) vein conduit. Results: A 65 year-old woman presented with LAPC originating in the uncinate causing complete occlusion of the superior mesenteric vein (SMV) and encasement of the first jejunal artery. After neoadjuvant therapy, decision was made to perform a PD with temporary mesocaval shunt to divert SMV flow, reduce blood loss and prevent bowel ischemia during the anticipated longer time needed for the retroperitoneal-superior mesenteric artery (SMA) portion of the PD. During the procedure, the main mesenteric collateral (lieocolic vein) was divided flush to use as landing zone to sew the shunt to the inferior vena cava with the LIJ interposition. The remaining SMV tributaries encased by the tumor were divided. The uncinate dissection was performed with an SMA-first approach with the SMV divided and out of the way. Once the resection was completed, the shunt was stapled from the IVC graft and transposed to the upper SMV for final reconstruction. Standard reconstructions were performed. Estimated blood loss was 250cc. No perioperative complications occurred. Conclusion: In LAPC, PD with temporary mesocaval shunt can facilitate margin-negative resection and transfusion-free venous reconstruction in patients with otherwise unreconstructible complete PV/SMV occlusion.

Radical pancreatectomy with superior mesenteric vein resection and reconstruction in patients with tumor located in uncinate process invading mesenteric root

Pancreatic neoplasm may be deemed locally unresectable because they appear to encase the superior mesenteric vessels. A radical pancreatectomy with venous resection and reconstruction offer an important benefit in selected patients. At present, superior mesenteric vein /portal vein resection is performed in up to 25% of patients in our center. A variety of venous reconstruction have been described: Longitudinal or transverse venorrhaphy with a small ellipse vein excised or Segmental vein resection with or without splenic vein preservation. A primary end to end suture or interposition graft conduit (internal yugular vein or renal vein graft) can be performed to re-establish the venous continuity. For short segment resection (< 3 cm), primary end to end reconstruction and transverse venorrhaphies provide superior outcome to the other alternatives. For longer segmental resections, interposition grafting with an aprópiate size match achieve a greater long-term patency. The more important surgical challenge is always in tumors located in uncinate process with mesenteric root invasión. In these cases, after pancreatic and vascular resection, a patch venoplasty with 2, 3 or 4 native veins can be performed with or without interposition grafts. We discuss the different surgical steps used to restore vein continuity in patients with this complex tumor location.

Optimizing the laparoscopic steps in right colectomy with complete mesocolic excision to reduce the intraoperative vascular injuries

Laparoscopic right colectomy by the rule of complete mesocolic excision is becoming a standard operation for right colon cancer. Intraoperative iatrogenic vascular injuries are rare but disastrous complications. In addition to the dissection along the embryonic plane, reducing iatrogenic bleeding is of crucial importance to safeguard the surgical procedure. Keeping the operative field clear by gentle suction to have a good exposure is essential to identify the origin of bleeding, and then to make decision how to control the bleeding by bipolar coagulation, clipping and transection, suturing or conversion to open surgery. For small bleeding, the grasping forceps with bipolar coagulation or clipping would usually be effective. When there is laceration locating on the stem of superior mesenteric vein or Henle trunk, suturing with 4-0 or 5-0 prolene monofilament is suggested. Self-saphenous graft or bridge is advised for stem stricture after suturing. The ileocolic vessels are most anatomically constant, but with a different relationship between the artery and the vein. The tributaries to form the Henle trunk vary quite often, and they usually have close relation to the middle colic vein. Right colic artery rarely arises from the superior mesenteric artery, and the right colic vein seldom drains into the superior mesenteric vein. Anatomical variations are commonly observed in the pancreaticoduodenal area, where bleeding happens frequently. Selecting an optimal laparoscopic approach and dissecting order, awareness of vascular variation, and understanding the anatomical configuration of superior mesenteric vessels and their tributaries are important to minimize the intraoperative iatrogenic injuries during the meticulous dissections.

Extent of lymph node dissection in patients with gallbladder cancer

Definitions of regional lymph nodes for gallbladder cancer differ according to staging system. Hence, the appropriate extent of lymph node dissection has not yet been standardized. Pathological stages and disease-specific survival (DSS) of patients who had undergone surgical resection of gallbladder cancer between 1990 and 2016 were reviewed. Patients with nodal metastases limited to the hepatoduodenal ligament or common hepatic artery, extending to the posterosuperior pancreatic head lymph nodes (PSPLNs), or in nodes along the coeliac axis or superior mesenteric vessels were grouped as having Na, Nb and Nc disease respectively. Metastases beyond these regions were defined as distant metastases (M1). Absence of distant metastasis was expressed as M0. A total of 259 patients were evaluated. There were 74, 31 and nine patients respectively in the Na, Nb and Nc groups. Twenty-five, nine and four patients in the respective groups had M1 disease (P = 0·682). The 5-year DSS rate was comparable between patients with Na M0 and those with Nb M0 disease (36 versus 34 per cent respectively; P = 0·950), whereas the rate in patients with Nc M0 status (0 per cent) was worse than that of patients with Nb M0 (P = 0·017) and comparable to that of patients with M1 disease (14 per cent; P = 0·590). Among 22 patients with Nb M0 disease, the 5-year DSS rate did not differ between those who had undergone pancreatoduodenectomy and those who had had dissection of PSPLNs without pancreatoduodenectomy (50 versus 30 per cent respectively; P = 0·499). PSPLNs and nodes along the hepatoduodenal ligament and hepatic artery should be considered regional nodes for gallbladder cancer, and should be resected.

Introducing Anatomically Correct CT-Guided Laparoscopic Right Colectomy with D3 Anterior Posterior Extended Mesenterectomy: Initial Experience and Technical Pitfalls.

Laparoscopic D3 anterior posterior extended mesenterectomy (D3APEM) in right colectomy has received increased attention. The aim of this study is to prove feasibility, systemize technical accomplishment, and provide short-term outcomes data. From July 2013 to February 2017, 18 patients with adenocarcinoma in the right colon underwent right colectomy with laparoscopic D3APEM, including lymph nodes anterior and posterior to the superior mesenteric vessels. A reconstructed three-dimensional anatomy map derived from the staging computed tomography was used as a road map at surgery. The procedure was systematized into seven operative steps: Step 1, trocar placement and inspection; Step 2, release of the transverse colon; Step 3, identification of the terminal mesenteric vessels; Step 4, release of the anterior flap; Step 5, division of the transverse mesocolon; Step 6, release of the posterior flap; and Step 7, anastomosis and specimen removal. Patient disposition and variations regarding vascular anatomy and ability to expose consequentially may necessitate a variation in the sequence of the steps. A total of 7 (39%) cases were converted, 3 due to bleeding and 4 due to challenging dissection. Median operative time and blood loss were 276 minutes (168-439 minutes) and 200 mL (< 50-1300 mL), respectively. Postoperative complications occurred in 6 (33%), including 2 (11%) major complication requiring reoperation. Median hospital stay was 5 days (3-13 days). R0 resection was achieved in all cases. Median number of the lymph nodes harvested was 40 (25-86), including 11.5 (4-35) in the D3 volume. Six patients (33%) had positive nodes, 3 of them affecting the D3 zone, including 1 case of a skip metastasis. There was no mortality, and at present all the patients are alive. One patient developed distant lymph node metastases. Laparoscopic right colectomy with D3APEM is feasible, associated with acceptable morbidity and fast recovery; now in readiness for introduction in specialized colorectal institutions.

Surgical Anatomy of the Superior Mesenteric Vessels Related to Colon and Pancreatic Surgery: A Systematic Review and Meta-Analysis

The surgeon dissecting the base of the mesenterium, around the superior mesenteric vein (SMV) and artery, is facing a complex tridimensional vascular anatomy and should be aware of the anatomical variants in this area. The aim of this systematic review is to propose a standardized terminology of the superior mesenteric vessels, with impact in colon and pancreatic resections. We conducted a systematic search in PubMed/MEDLINE and Google Scholar databases up to March 2017. Forty-five studies, involving a total of 6090 specimens were included in the present meta-analysis. The pooled prevalence of the ileocolic, right colic and middle colic arteries was 99.8%, 60.1%, and 94.6%, respectively. The superior right colic vein and Henle trunk were present in 73.9%, and 89.7% of specimens, respectively. In conclusion, the infra-pancreatic anatomy of the superior mesenteric vessels is widely variable. We propose the term Henle trunk to be used for any venous confluence between gastric, pancreatic and colic veins, which drains between the inferior border of the pancreas and up to 20 mm downward on the right-anterior aspect of the SMV. The term gastrocolic trunk should not be synonymous, but a subgroup of the Henle trunk, together with to gastropancreatocolic, gastropancreatic, or colopancreatic trunk.

Pancreaticoduodenectomy with mesocaval shunt for locally advanced pancreatic adenocarcinoma

Background: Patients with locally advanced pancreatic cancer (LAPC) represent a challenging group to treat given the involvement of major vascular structures. In selected patients with favorable biology, temporary mesocaval shunt can facilitate the resection and allow for a safer procedure with enhanced exposure to the superior mesenteric vessels. Methods: We show a video of a pancreaticoduodenectomy (PD) with temporary mesocaval shunt with left internal jugular (LIJ) vein conduit. Results: A 65 year-old woman presented with LAPC in the uncinate causing total occlusion of the superior mesenteric vein (SMV) and encasement of the first jejunal artery. After neoadjuvant therapy and evidence of disease stability, decision was made to perform a PD with temporary mesocaval shunt to divert mesenteric flow to reduce blood loss and prevent bowel ischemia. During the procedure, the main mesenteric collateral (lieocolic vein) was divided to perform the shunt to the inferior vena cava with LIJ interposition. The remaining mesenteric tributaries involved by the tumor were divided. The uncinate dissection was performed with an SMA-first approach. Once the resection was completed, the shunt was stapled from the IVC graft transposed to the upper SMV for reconstruction. Standard reconstruction was performed. Total operative time was 536 minutes. The estimated blood loss was 250cc with no transfusions. No perioperative complications occurred, and the patient was ready for discharge on post-op day 5. Conclusion: In selected patients with LAPC, PD with temporary mesocaval shunt can facilitate resection and venous reconstruction in patients with complete PV/SMV occlusion.

Defining minimal clearances for adequate lymphatic resection relevant to right colectomy for cancer: a post-mortem study.

There has been a lengthy discussion on the extent of lymphatic resection for right-sided colon cancer and the central borders of the mesentery that are not yet defined. The objectives of this study are to define minimal clearances for adequate lymphatic resection in regard to colic artery origins and the superior mesenteric artery (SMA) and vein (SMV) relevant to right colectomy. Central mesenteric lymph vessels, nodes, and blood vessels were dissected in 16 cadavers. Cranial-caudal clearances were defined as distances between an individual colic artery origin (ileocolic, right colic, and median colic artery) and the outermost lymphatic vessel within its lymphovascular bundle, cranial and caudal along the SMA. Long lymphatic vessels crossing the SMV between arterial bundles were counted and they constituted the medial clearances. An arbitrary watershed between small bowel and colonic lymph was localized. Immunohistochemistry was performed to histologically verify lymphatic vessels. Cranial-caudal clearances were ileocolic 3.6 ± 1.9 and 5.7 ± 1.9; right colic 2.8 ± 1.6 and 3.3 ± 1.0; middle colic artery bundle 6.3 ± 2.7 and 5.9 ± 2.4mm, respectively. Long lymphatic vessels crossing the SMV between arterial buntles and approaching the SMA were found in all cadavers (antero/posteriorly in 12, only anteriorly in 4), median 3.5 (1-7) long lymphatic vessels anteriorly, and 1.5 (0-5) posteriorly per cadaver. Right colonic lymphovascular bundles are volumes of mesenteric tissue that surround the superior mesenteric vessels anteriorly and posteriorly. Long lymphatic vessels traverse the superior mesenteric vein anteriorly/posteriorly approaching the superior mesenteric artery between arterial bundles and placing the medial clearance on the left side of the artery. These do not correlate to arterial crossing patterns. Cranial-caudal clearances determine the tissue to be removed superior/inferior to arterial origins together with long lymphatic vessels transversing independently between the lymphovascular bundles placing the weight of lymphatic resection on the mesenteric tissue and not on the level of vessel division (High tie).