Cast syndrome: the superior mesenteric artery syndrome

Cast syndrome, clinically known as superior mesenteric artery syndrome (SMAS), is gastric dilatation with partial or complete obstruction of the duodenum. Although rare, it is most frequently seen in orthopaedic patients who have had spinal surgery or who are in hip spica or body casts. Obstruction occurs when there is compression of the duodenum between the superior mesenteric artery anteriorly and the aorta and spinal column posteriorly. Obstruction can occur within days of surgery or casting or may not develop for several weeks. Treatment for SMAS varies from conservative nonoperative to operative procedures. Complications can be severe if symptoms are not quickly recognized and treatment instituted in a timely manner.     

The "nutcracker syndrome" of the renal vein (superior mesenteric artery syndrome) as the cause of gastrointestinal complaints

HISTORY AND CLINICAL FINDINGS: Since the age of 19 a now 22-year-old man had complained of intermittent abdominal pain, irregular stools and paroxysmal tachycardia. The only preceding illness had been a single episode of iron-deficiency anemia. A laparoscopy, done 8 months after the onset of symptoms, had revealed an inflamed Meckel's diverticulum which was surgically removed. After transient improvement the symptoms recurred 5 months postoperatively. On admission to clarify the cause of the symptoms he had discrete abdominal pain on pressure, but physical examination was otherwise unremarkable. INVESTIGATIONS: Routine biochemical tests and endoscopy were normal. Abdominal computed tomography was suspicious of severe narrowing of the left renal artery by a crossing superior mesenteric artery. As a result the left testicular vein and the peripelvic venous network were markedly dilated by retrograde congestion, strongly suggesting the "nutcracker syndrome" of obstruction of the left renal vein. This diagnosis was confirmed by selective renal phlebography and pressure measurement. TREATMENT AND COURSE: The vascular anomaly was corrected surgically by reimplanting the left renal vein into the inferior vena cava 3-4 cm further caudally. The patients has been completely symptom-free since then. CONCLUSIONS: The nutcracker-syndrome is a rare cause of hematuria. The coexistence of this anomaly with gastrointestinal symptoms has not been previously described, but it is likely that congestion of the splanchnic veins by obstruction of the left renal vein was at least partly responsible for them, in view of the postoperative relief.     

Two-step portal bypass to reconstruct an invaded superior mesenteric vein in pancreatic cancer

Advanced cancer of the pancreatic head, especially in its caudal portion, has a limited surgical resectability due to its frequent invasion to the superior mesenteric vein (SMV). A patient with advanced carcinoma of the pancreatic head with vascular invasion to the major bifurcation of the SMV, underwent a pancreatico-duodenectomy under a two-step passive bypass of the portal flow. The marginal colic veins were dilated and formed a long collateral route to the inferior mesenteric vein and the splenic vein due to stenosis of the SMV. The venous flow in this vein was then easily interrupted with the surgical manipulation of the transverse colon. The first passive bypass was thus inserted into the accessory right colic vein to preserve the venous return from both the small intestine and the colon, and also to enable surgical dissection of the invaded SMV itself. After a thorough dissection of the invaded SMV, a second bypass was inserted into the main trunk of the SMV through the dissected vascular stump. Subsequently the passive bypass was maintained until the portal reconstruction with an interposition of the left common iliac vein could be performed. The patient recovered well from the surgery without any complications throughout the postoperative course. In summary, the two-step portal bypass describes, is thus considered a stable and safe procedure for the reconstruction of the superior mesenteric vein, during pancreatoduodenectomy for advanced carcinoma of the pancreatic head.     

Preservation of the superior hemorrhoidal artery in resection of the colon and rectum

As an alternative to anterior resection of the rectum requiring ligature of the inferior mesenteric artery at its origin, it is proposed to carry out this procedure preserving the inferior mesenteric artery and freeing it as far as the origin of the superior hemorrhoidal artery and its division into rectal branches to improve the blood supply to the rectal stump. The results of this new procedure were compared with those of anterior resection. Post-operatively, the blood supply of the rectum was studied by means of angiography. The results of 84 anterior resections for neoplastic disease of the colon were studied. In 56 patients, the inferior mesenteric artery was preserved and in 28 the inferior mesenteric artery was ligated. Postoperative complications due to leakage of the colorectal anastomosis rarely occurred in the first group and were frequent in the latter. In patients in whom the inferior mesenteric artery was preserved, arteriograms showed that vascularization of the preserved rectal stump is supplied essentially by the branches of the superior hemorrhoidal artery.     

Giant cell tumour of the retropharynx

INTRODUCTION: Few pancreatic carcinomas (5-22%) are resectable at the time of diagnosis because this lesion is seldom diagnosed in an early stage. Unresectability is mainly due to the presence of metastases to the liver, peritoneum and lymph nodes and to tumor spread especially to the portal mesenteric trunk where it can invade, compress, reduce, or occlude the vessels. We investigated the diagnostic yield of multiplanar and 3D spiral CT in the assessment of pancreatic carcinoma resectability. MATERIAL AND METHODS: Twenty-seven patients with histologically confirmed pancreatic head cancer were submitted to spiral CT and color Doppler US in the Surgical Clinic I of the Bologna University. The examination results were correlated with the intraoperative findings of careful inspection and palpation and of US studies of the pancreatic mass and adjacent structures. The tumors were classified in relation to some CT parameters: tumor size (T), infiltration of the stomach (S) and/or duodenum, lymph nodes (N) or distant (M) metastases, involvement of vascular structures (V), particularly of portal or superior mesenteric vein, or superior mesenteric artery. Five grades of vascular involvement were considered. The results of these techniques were correlated with intraoperative findings from careful inspection and palpation and with US studies of the pancreatic mass and adjacent structures. RESULTS: Spiral CT revealed vascular involvement in 19 of 27 cases (70.4%): involvement of portal and superior mesenteric vein was found in 14 (73.6%), superior mesenteric vein was involved in 2 (10.6%), the portal vein in one (2%) and, finally the portal, superior mesenteric vein and superior mesenteric artery in 2 cases (10.6%). The spiral CT results were confirmed intraoperatively in 26 of 27 cases (96.3%); spiral CT did not reveal hepatic metastasis only in one case. Spiral CT with multiplanar reconstructions had very high specificity and sensitivity (100%) in the assessment of vascular involvement, while color Doppler US had the same specificity but lower sensitivity (84.2%). Spiral CT was less sensitive (80%) in the detection of liver metastases. CONCLUSIONS: We believe that spiral CT is currently the best technique for pancreatic carcinoma staging, providing useful information for correct surgical planning.     

Internal mammary artery and vein supercharge in TRAM flap breast reconstruction

To improve the blood supply of the pedicled flap we have performed an additional microvascular augmentation to this type of breast reconstruction procedure since 1991. The ipsilateral deep inferior epigastric pedicle is anastomosed to the internal mammary artery and vein (IMAV supercharge). In 19 of 20 patients this technique proved to be feasible. For the venous anastomoses the 3M microvascular anastomosis system facilitated the procedure. In one patient the venous anastomosis failed due to the small calibre of two internal mammary veins. In a majority of the cases rapid improvement of flap perfusion could be observed as the direct result of the supercharging. The IMAV supercharged flap is quite comparable with the free flap as regards to the operative procedure. Disadvantages are a slightly more extensive dissection and less freedom in positioning the flap due to the presence of the superior muscular pedicle. The main advantage is that the supercharge procedure minimises the risk of total flap loss. Further technical improvement may be obtained by the use of a contralateral vascular pedicle dissected with muscle-sparing techniques.     

Venous dissection injuries during laparoscopic urological surgery

PURPOSE: The incidence of major venous dissection injuries during laparoscopic procedures is assessed and recommendations are made for management. MATERIALS AND METHODS: We evaluated our experience with all major intra-abdominal injuries occurring during 274 consecutive laparoscopic procedures performed within a 4-year period. Five patients (1.7%) had a total of 6 major vascular injuries, including gonadal vein avulsion in 1 case, lumbar vein avulsion in 1 and a tear in the inferior vena cava in 4. Two patients sustained inferior vena caval injuries during nephrectomy because of adhesions from previous surgery and 1 of them had 2 venacavotomies. RESULTS: All vascular injuries were venous and 5 of the 6 major vessel injuries were treated successfully endoscopically via intracorporeal suturing techniques. The injury requiring open repair was a gonadal vessel avulsion that occurred during retroperitoneal lymph node dissection early in our laparoscopic experience. Major vessel injuries were more likely to occur during complex laparoscopic procedures in patients who had undergone previous ipsilateral retroperitoneal surgery. CONCLUSIONS: In select situations new techniques can allow for safe endoscopic control and repair of venous injuries during laparoscopic surgery.     

Inferolateral retraction reduces the risk of thermal injury to biliary structures

A liver transplant technique is described in a patient with a thrombosed portal vein and a functioning surgically created renal-lieno shunt. Permanent portal inflow to the graft was provided by division of the left renal vein (LRV) at its junction with the inferior vena cava and anastomosis of the LRV end-to-end with the donor portal vein. Although this results in splanchnic blood traversing a 360 degree roundabout from the superior mesenteric vein via the splenic and disconnected left renal veins to the donor portal vein, the anastomosis lay well and the procedure was successful.     

Unexpected opportunities: incidental findings detected during impairment evaluations for coal workers'' pneumoconiosis

We describe a case of intestinal angina caused by spontaneous dissection of the celiac artery and thrombosis of the superior mesenteric artery. Spontaneous dissection of a visceral artery is an uncommon occurrence that is usually diagnosed after fatal hemorrhage or ischemia. The underlying mechanism is unclear but the frequent association with multiple arterial lesions suggests general arterial disease. In symptomatic forms, surgical reconstruction is mandatory, to treat the lesion and allow definitive histological diagnosis.     

Angiokeratoma circumscriptum]

A case of superior mesenteric artery branch aneurysm is described. A 43-year-old female patient was hospitalized after the incidental discovery of a low echogenic mass next to the superior mesenteric artery trunk. A selective superior mesenteric arteriography confirmed aneurysms of the inferior pancreaticoduodenal artery and an aortogram demonstrated occlusion of the celiac trunk. Bypass between the abdominal aorta and the common hepatic artery and resection of aneurysms were performed. The possible etiology and operative procedure are discussed.     

Left-sided laparoscopic para-aortic lymphadenectomy: anatomy of the ventral tributaries of the infrarenal vena cava

OBJECTIVE: We evaluated the anatomy of the infrarenal portion of the human inferior vena cava and their ventral tributaries by video laparoscopy. STUDY DESIGN: A total of 112 patients underwent laparoscopic para-aortic lymphadenectomy for gynecologic malignancies. All procedures were videotaped. The number and anatomic distribution of the infrarenal tributaries of the anterior part of the inferior vena cava was evaluated retrospectively from videotapes. The inferior vena cava was divided into 3 levels: the area of the bifurcation of the vena cava (level 1), the area between the bifurcation and the inferior mesenteric artery (level 2), and the area between the inferior mesenteric artery and the right ovarian vein (level 3). RESULTS: Tributaries were found in level 1 in 65 (58%) patients, in level 2 in 22 (19.6%) patients, and in level 3 in 1 (0.9%) patient; in 24 (21.5%) patients no tributaries were found. A total of 237 tributaries was counted: 82.3% (195 of 237) were located at level 1, 17.3% (41 of 237) at level 2, and 0.4% (1 of 237) at level 3. Patients with tributaries had a mean of 3 tributaries in level 1, a mean of 1.7 tributaries in level 2, and 1 patient had 1 tributary in level 3. CONCLUSIONS: The ventral tributaries of the inferior vena cava show a specific distribution pattern. The knowledge of these anatomic landmarks can be important for laparoscopic surgeons to avoid accidental injury.     

Surgical standards in primary colon cancer

The surgical standards in the treatment of primary cancer of the colon include the radical resection of the tumor-bearing colon with truncal ligation of its vessels. Eradication of the tumor with complete dissection of the lymphatic drainage area increases the chance for cure (R0). The lymphatic dissection determines the extent of colonic resection: right hemicolectomy (ileo-transversostomy) with truncal ligation of the iliocolic and right colonic arteries for carcinomas of the cecum and ascending colon; transverse colectomy (ascendo-descendostomy) with ligation of the middle colic artery for carcinomas in the middle of the transverse colon; left hemicolectomy (transverso-rectostomy) with ligation of the inferior mesenteric artery at the aorta for cancer of the descending and sigmoid colon; extended sigmoid resection (descendo-rectostomy) with central lymphadenectomy and ligation of the inferior mesenteric artery distal to the left colic artery for cancer of the distal sigmoid colon. Carcinomas located in between two drainage areas (lateral transverse colon, hepatic or splenic flexure) are treated by extended hemicolectomies or subtotal colectomies with dissection of two lymphatic drainage areas. The monobloc no-touch isolation technique requires the ligation of vessels prior to the mobilisation of the colon. Exceptions from these standard operations (limited resections) are necessary for metastatic disease or in the acute emergency situation of perforation or obstruction. Application of these surgical principles will ensure the best possible treatment results in primary colonic cancer.     

Left colon gangrene after acute inferior mesenteric artery occlusion

We report here an experience with five patients, aged 58 to 70, suffering gangrene of the left colon after spontaneous inferior mesenteric artery occlusion. All cases were the result of arteriosclerosis; in two, small aortic aneurysms were present and might have been responsible for emboli to the inferior mesenteric artery. The dead bowel was resected in all patients; three patients survived. No primary anastomoses were done and they are not recommended. Because ligation of the patent inferior mesenteric artery has been done so often without ill effects during aortic surgery, the collateral circulation to the left colon can be considered excellent. Gangrene is therefore rare and requires major interference with collateral circulation by emboli or arteriosclerotic occlusion. The clinical symptoms and signs may be confusing.     

Virion incorporation of human immunodeficiency virus type-1 Vif is determined by intracellular expression level and may not be necessary for function

OBJECTIVE: To define the role of laparoscopic ultrasound (LUS) in the staging of pancreatic tumors. SUMMARY BACKGROUND DATA: Laparoscopy has recently been established as a valuable tool in the staging of pancreatic cancer. It has been suggested that the addition of LUS to standard laparoscopy could improve the accuracy of this procedure. METHODS: A prospective evaluation of 90 patients with pancreatic tumors undergoing laparoscopy and LUS was performed over a 27-month period. LUS equipped with an articulated curved and linear array transducer (6 to 10 MHz) was used. All patients underwent rigorous laparoscopic examination. Clinical, surgical, and pathologic data were collected. RESULTS: The median age was 65 years (range 43 to 85 years). Sixty-four patients had tumors in the head, 19 in the body, and 3 in the tail of the pancreas. Four patients had ampullary tumors. LUS was able to image the primary tumor (98%), portal vein (97%), superior mesenteric vein (94%), hepatic artery (93%), and superior mesenteric artery (93%) in these patients. LUS was particularly helpful in determining venous involvement (42%) and arterial involvement (38%) by the tumor. This resulted in a change in surgical treatment for 13 (14%) of the 90 patients in whom standard laparoscopic examination was equivocal. CONCLUSIONS: LUS is useful in evaluating the primary tumor and peripancreatic vascular anatomy. When standard laparoscopic findings are equivocal, LUS allowed accurate determination of resectability. Supplementing laparoscopy with LUS offers improved assessment and preoperative staging of pancreatic cancer.     

Portal decompression using the inferior mesenteric vein

We report five patients with variceal hemorrhage, in three cases secondary to diffuse thrombosis of the portal, superior mesenteric and splenic veins. Mesenteric angiography demonstrated patency of the inferior mesenteric vein (IMV) in each, and successful portal decompression by anastomosis of the IMV to the left renal vein (n = 4) or the inferior vena cava (n = 1) was accomplished. Bleeding was permanently controlled: four patients have survived from one to eight years post-operatively. Because shunt procedures utilizing the IMV are technically straightforward, subtotally decompress the portal system and avoid the right upper quadrant, they may be advantageous in certain clinical settings.     

Effect of neonatal treatment with MSG (monosodium glutamate) on thyroid of the adult male rats

Percutaneous transluminal angioplasty (PTA) has been well described in the treatment of mesenteric artery stenoses but has met with limited success in ostial lesions. The authors describe a case of a 79-year-old woman diagnosed with chronic mesenteric ischemia associated with a 22-pound weight loss and postprandial pain. The celiac axis and inferior mesenteric artery were occluded. A high-grade, calcified stenosis was present in the proximal superior mesenteric artery. This was treated with primary stent placement using a Palmaz stent deployed from an axillary approach. A brief discussion of mesenteric ischemic and visceral artery PTA is included.     

Successful revascularization of mesenteric infarction following aortography

Two cases of bowel infarction following abdominal aortography are presented. In both patients, two of the three major arteries supplying the bowel were occluded before the study. The superior mesenteric artery in one and the inferior mesenteric artery in the other were the only arteries supplying the bowel and their lumens were reduced. After the aortogram, the residual lumen clotted, leading to bowel necrosis. Survival was made possible in these two cases by revascularizing the superior mesenteric artery and resecting the necrotic bowel.     

One-stage total penile reconstruction with a free sensate osteocutaneous fibula flap

This is the first series of total penile reconstructions with the free sensate osteocutaneous fibula flap. The main advantages of this flap lie in its intrinsic rigidity, its superior donor-site location, and its long vascular pedicle. The fibula flap provides better bone volume than does the radial forearm flap, which commonly results in a floppy phallus in the absence of bone. Penile prostheses in other flaps have enjoyed limited success. Forearm donor-site complications can be avoided. The donor site in the lower extremity can be readily covered with a sock. The vascular pedicle of the fibula flap is of sufficient length to allow end-to-side anastomosis of the flap to the femoral artery. Interpositional vein grafts are unnecessary, and dissection of the inferior epigastric artery system to serve as a donor artery may be avoided. The appearance of the neophallus is excellent. We present only the first four continuous cases of the six we have performed because sufficient follow-up data are available only for these four. The advantages and disadvantages of fibula and forearm donor sites, the long-term fate of the bony component, the importance of sensation, and the vascularized urethral reconstruction are discussed. High patient satisfaction and the advantages of the technique convince us that the fibula osteocutaneous flap is superior for total penile reconstruction.     

A new porto-systemic bypass technique for hepatopancreatoduodenectomy with portal vein resection

When reconstructing the portal vein (PV) following hepatopancreatoduodenectomy (HPD) with PV resection, a new porto-systemic bypass (PSB) technique can be employed to prevent intestinal vascular congestion. The Whipple procedure is performed in a standard manner, as long a portion of the gastrocolic trunk is preserved for insertion of an antithrombogenic catheter (ATC). After harvesting the left external iliac vein and exposing the right great saphenous vein, the end of the ATC is inserted in the superior mesenteric vein via the gastrocolic trunk in the distal direction and the other end of the ATC is inserted in the greater saphenous vein. PSB is achieved as a result of the venous pressure gradient. By employing this technique, an ATC can be inserted without damaging another mesenteric venous branch and with minimal damage to the endothelium, and the small intestine is not exposed in the operative field until enteric reconstruction is started. This technique is a promising option for PSB during HPD with PV resection.     

Posterolateral approach. An alternative strategy in laparoscopic splenectomy

Laparoscopic splenectomy (LS) is effective and technically feasible for treating various hematological diseases, especially idiopathic thrombocytopenic purpura (ITP). An anterior approach to the vascular pedicle is usually described. However, in this approach to the splenic hilum, the dissection of the splenic artery is often difficult. A total of 13 patients with ITP underwent elective laparoscopic splenectomy. We utilized a laparoscopic posterolateral approach involving dissection of the suspensory ligaments at the lower pole, then dissection and division of the posterolateral attachments, followed by the dissection and ligation of all splenic branches near the splenic parenchyma. This procedure was completed in 11 of our 13 patients and converted to open surgery in the other two patients. Mean operative time was 3 h; mean postoperative stay was 3 days. No blood transfusion was required, and no complications were noted in the postoperative period. The posterolateral approach provides better visualization and control of branches of the splenic vein and artery in the splenic hilum. It also permits visualization and control of surgical hemorrhage through the operating ports.