[Replantation of IMA and accessory right RA during infrarenal AAA repair and a current view on indications for IMA replanting]

INTRODUCTION

Replanting the inferior mesentery artery during infrarenal aortic aneurysm repair is a measure which might prevent development of colon ischemia under certain circumstances. These circumstances and patients who would benefit from this procedure are not well defined.

CASE REPORT

64-year old man underwent an elective operation on infrarenal AAA at our institution in December 2009. From preoperative CT angiography we knew about the accessory right renal artery branching directly from AAA and bilateral occlusion of hypogastric arteries. We performed open resection of AAA with implantation of a bifurcated graft. Proximal anastomosis was situated below renal arteries, distal anastomoses were bilaterally constructed on external illiac arteries. The accessory right renal artery was anastomosed into the right limb of the graft and IMA was replanted into the body of the graft. Postoperative recovery of the patient was uneventful. His follow-ups 3 and 6 months after the operation have been showing good clinical state of the patient, absence of abdominal complaints and normal levels of urea and creatinine. CT angiography which was performed 3 months after the operation discovered an occlusion of the reimplanted IMA, but patent replanted accessory right renal artery.

DISCUSSION

Assessment of collateral circulation of large intestine during infrarenal AAA repair is influenced by many preoperative and intraoperative factors. Most surgeons judge the adequacy of the collateral circulation by IMA backbleeding combined with inspection of sigmoid colon after restoring aortic flow. There have been numerous attempts to replace this subjective approach with more objective methods like intraoperative colon mucosal saturation measurement, laser Doppler flowmetry, IMA stump pressures, photophletyzmographic technique. Even though these methods describe conditions when a collateral circulation of rectosigmoid is inadequate after IMA ligature, they are unable to fully eliminate the occurrence of colon ischemia because of its multifactorial nature. Solving the problem of collateral circulation of the large intestine represents only a part of the obstacle presented by colon ischemia after infrarenal AAA repair.

CONCLUSION

IMA replantation during infrarenal AAA repair does not fully prevent an occurance of colon ischemia. On the other side, this moneuver does not increase perioperative morbidity, nor prolongs an operation significantly. Our policy is to replant IMA whenever we thing the circulation of large intestine is under threat or in borderline situations.

[Role of different ligation of the inferior mesenteric artery in sigmoid colon or rectal cancer surgery: a meta-analysis]

OBJECTIVE

To evaluate the effect of different ligation of the inferior mesenteric artery in sigmoid colon or rectal cancer surgery on 5-year overall survival rate and operative mortality.

METHODS

The results of several literatures from different countries on high or low ligation of the inferior mesenteric artery and prognosis were analyzed using meta-analysis.

RESULTS

Seven studies were included. The 5-year overall survival rate was compared between low and high ligation. The odd ratio (OR) for 5-year survival was 0.87 (95% CI=0.76-0.98, P=0.02), and the OR for perioperative mortality was 1.28 (95% CI=0.94-1.75, P=0.19).

CONCLUSIONS

High ligation of the inferior mesenteric artery may improve 5-year overall survival rate. Perioperative mortality may not be influenced by the level of ligation.

Mesenteric revascularisation in a young patient with antiphospholipid syndrome and fibromuscular dysplasia: report of a case and review of the literature

Fibromuscular dysplasia or fibromuscular hyperplasia is a rare non-atherosclerotic and non-inflammatory vascular disease that primarily involves medium-size and small arteries, most commonly the renal and carotid arteries, and less frequently the vertebral, iliac, subclavian or visceral arteries (mesenteric, hepatic, splenic). Antiphospholipid syndrome is one of the most commonly acquired hypercoagulable states, defined by the association of laboratory evidence of anti-phospholipid antibodies with arterial or venous thrombosis or recurrent pregnancy losses. The presence of these antibodies is associated with an increased risk of thromboembolic phenomena, including peripheral thrombophlebitis, pulmonary thromboembolism, stroke, retinal artery occlusion, myocardial infarction, placental thrombosis and Budd-Chiari syndrome. In this report we discuss the uncommon case of a young male patient with both antiphospholipid syndrome and fibromuscular dysplasia that came to our attention for pulmonary embolism and "angina abdominis" due to occlusion of three mesenteric vessels. The possible relationship between antiphospholipid syndrome and fibromuscular dysplasia encountered in our patient still remains unclear. We treated the patient as if he had the two different diseases. After partial failure of endovascular surgery, the patient underwent surgery with reimplantation of three visceral arteries to the aorta. Subsequently he was treated with stent placement after development of a re-stenosis of one of the three reimplanted visceral arteries. The patient was treated conservatively for antiphospholipid syndrome with anticoagulant oral therapy for life.

[Laparoscopic anterior resection of rectal carcinoma with preservation of the left colonic artery]

OBJECTIVE

To evaluate the feasibility and efficacy of laparoscopic anterior resection of rectal carcinoma with preservation of the left colonic artery.

METHODS

From February 2006 to February 2009, 52 patients with rectal carcinoma formerly scheduled for Dixon operation (clinical stage I and II) received laparoscopic Dixon surgery. The inferior mesenteric artery, left colonic artery, sigmoid artery or superior rectal artery, and lymph nodes were dissected through the vasa vasorum approach. The left colonic artery was retained by transecting the inferior mesenteric artery inferior to the left colonic artery. The operative time, intraoperative hemorrhage volume, intraoperative complications, anastomotic tension, number and histopathological features of the dissected lymph nodes surrounding the inferior mesenteric artery, and the rates of local recurrence, lymph node metastasis and anastomotic leakage were analyzed.

RESULTS

The operation was successfully completed in all the 52 cases. The operative time ranged from 115 to 320 min with a mean of 150 min. The mean intraoperative hemorrhage was 25 ml (range 15-75 ml). None of the patients had perforation of the rectum, injuries to blood vessel, ureter or adjacent organs, or anastomotic tension. The number of dissected lymph nodes surrounding the inferior mesenteric artery ranged from 4 to 8, with a mean of 6.2. The dissected lymph nodes in the base of the inferior mesenteric artery showed no cancer cell metastasis, while 4 patients had cancer cell metastasis in the lymph nodes surrounding superior rectal artery. None of patients had anastomotic leakage. Local recurrence was found in only 1 case at 7 months after the operation.

CONCLUSION

Laparoscopic anterior resection of the rectal carcinoma with preservation of the left colonic artery can be completed in patients with rectal carcinoma planning to receive Dixon operation (clinical stage I or II). This surgical approach preserves more supplying vessels and prevents anastomotic leakage without increasing the anastomotic tension or affecting lymph node dissection surrounding the inferior mesenteric artery.

[Lymphadenectomy adjacent to inferior mesenteric artery root during radical operation and prognosis in rectal cancer]

OBJECTIVE

To investigate the effect of lymphadenectomy adjacent to inferior mesenteric artery root on the prognosis of rectal cancer.

METHODS

Clinicopathological data of 260 cases with rectal cancer undergone radical operation were analyzed retrospectively. The patients were divided into two groups. Group D(2): the lymph nodes adjacent to mesenteric artery root were not excised (n=188). Group D(3): the lymph nodes adjacent to mesenteric artery root were excised (n=72). Prognosis of two groups was compared during the follow-up period.

RESULTS

In group D(2), the 1-, 3-, 5-year total survival rates (TS) were 97.3%, 87.2% and 77.1%, and tumor-free survival rates (TFS) were 93.1%, 83.0% and 76.8% respectively. In group D(3 ), the 1-, 3-, 5-year total survival rates (TS) were 94.4%, 79.2% and 73.6%, and tumor-free survival rates (TFS) were 86.1%, 76.4% and 71.0% respectively. The differences of TS and TFS between two groups were not significant according to Kaplan-Meier analysis (P>0.05). Multivariate analysis revealed that the excision of lymph nodes adjacent to mesenteric artery root was not statistically correlated with the recurrence, metastasis and survival time after radical operation of rectal cancer.

CONCLUSION

Excision of lymph nodes adjacent to inferior mesenteric artery root has no significant impact on prognosis and it is unnecessary in the radical operation of rectal cancer.

Effects of high and low ligation on survival in patients operated for colorectal cancer

In spite of numerous studies on the subject, it is still unclear whether or not high ligation of the inferior mesenteric artery (at about 1 cm from its origin) improves the 5-year survival rate in patients operated on for colorectal cancer in comparison to low ligation (ligation below the origin of the left colic artery). From February 2000 to November 2001 40 patients with cancer of the colic segment between the descending sigmoid junction and the low rectum underwent surgical colorectal resection and low ligation of the inferior mesenteric artery. At the end of 5 years of observation we report a survival rate of 70% which is not very far from the value reported in the literature. In our study, the incidence of lymph-node metastases, inexistent in patients with T1 grading increases with the increase in the TNM T grading but does not depend on the location of the cancer. In our patients age below 65 years was a negative prognostic indicator because colorectal tumours in patients of that age are associated with a higher incidence of lymph-node metastases. On the basis of the data we obtained, it is also evident that the 5-year survival rate decreases in proportion to the increase in the distance of the lymph-node metastases from the mesenteric margin of the colon. In conclusion, in the treatment of cancers located between the descending sigmoid junction and the low rectum, we prefer to execute a low ligation of the inferior mesenteric artery because it exposes the patient to a lower risk of intra- and postoperative complications and also because several authors have demonstrated that high ligation with removal of lymph nodes at the origin of the artery for colorectal cancer does not improve the 5-year survival rate.

Level of arterial ligation in rectal cancer surgery: low tie preferred over high tie. A review

Consensus does not exist on the level of arterial ligation in rectal cancer surgery. From oncologic considerations, many surgeons apply high tie arterial ligation (level of inferior mesenteric artery). Other strategies include ligation at the level of the superior rectal artery, just caudally to the origin of the left colic artery (low tie), and ligation at a level without any intraoperative definition of the inferior mesenteric or superior rectal arteries. Publications concerning the level of ligation in rectal cancer surgery were systematically reviewed. Twenty-three articles that evaluated oncologic outcome (n = 14), anastomotic circulation (n = 5), autonomous innervation (n = 5), and tension on the anastomosis/anastomotic leakage (n = 2) matched our selection criteria and were systematically reviewed. There is insufficient evidence to support high tie as the technique of choice. Furthermore, high tie has been proven to decrease perfusion and innervation of the proximal limb. It is concluded that neither the high tie strategy nor the low tie strategy is evidence based and that low tie is anatomically less invasive with respect to circulation and autonomous innervation of the proximal limb of anastomosis. As a consequence, in rectal cancer surgery low tie should be the preferred method.

Influence of prophylactic apical node dissection of the inferior mesenteric artery on prognosis of colorectal cancer

BACKGROUND/AIMS

Middle ligation (ML) of the inferior mesenteric artery (IMA) maintains adequate blood supply to an anastomosis and has no risk of autonomic nerve injury. If apical node dissection of the IMA improves the prognosis, ML and prophylactic dissection of the apical node without division of the IMA above the colic artery may also result in an additional prognostic improvement in patients with sigmoid colon or rectal cancer.

METHODOLOGY

Four hundred and one patients with either Dukes' B or Dukes' C colorectal cancer were clinicopathologically examined. In order to evaluate the influence of the prophylactic dissection of the apical node on the prognosis, the two groups of ML with and without apical node dissection were compared.

RESULTS

The 5-year survival rates in the groups of ML and ML with apical node dissection were 90% and 91%, respectively, in 218 Dukes' B patients. The 5-year survival rates in the groups of ML and ML with apical node dissection were 73% and 71%, respectively, in 183 Dukes' C patients. There were no significant differences between the two groups in both Dukes' B and Dukes' C patients.

CONCLUSIONS

When ML is adopted for patients with sigmoid colon or rectal cancer, additional dissection of the apical node is not needed.

Percutaneous protective coil occlusion of the proximal inferior mesenteric artery before N-butyl cyanoacrylate embolization of type II endoleaks after endovascular repair of abdominal aortic aneurysms

Bowel ischemia can complicate treatment of type II endoleak with liquid or semiliquid agents such as n-butyl cyanoacrylate (NBCA) if nontarget embolization of the inferior mesenteric artery (IMA) occurs. The current report describes four cases of type II endoleak in which the IMA was the main outflow vessel and was prophylactically occluded with embolization coils before NBCA injection into the endoleak nidus. The purpose was to prevent unintentional embolization of the NBCA into IMA branches. If feasible, protective IMA coil occlusion should be considered in type II endoleaks with IMA outflow in cases of NBCA embolization.

Laparoscopic Repair of a Type II Endoleak

A 72-year-old male underwent an uncomplicated endovascular repair of a 6.1-cm infrarenal abdominal aortic aneurysm. Routine follow-up at 18 months postoperatively revealed the presence of a type II endoleak, and that the aneurysm had increased in size. The endoleak was repaired by laparoscopic ligation of the inferior mesenteric artery. A postoperative computerized tomography scan revealed cessation of flow through the inferior mesenteric artery. The patient tolerated the procedure well and was discharged home on the same day.

Survival benefit of high ligation of the inferior mesenteric artery in sigmoid colon or rectal cancer surgery

BACKGROUND

The aim of this study was to assess the impact of inferior mesenteric artery (IMA) root nodal dissection before high ligation of the artery on survival in patients with sigmoid colon or rectal cancer.

METHODS

Data on 1188 consecutive patients who underwent resection for sigmoid colon or rectal cancer, with high ligation of the IMA, were identified from a prospective database (April 1965 to December 1999). Survival of patients with involvement of nodes along the IMA proximal to the origin of the left colic artery (root nodes, station 253) through the bifurcation of the superior rectal artery (trunk nodes, station 252) was determined.

RESULTS

Twenty patients (1.7 per cent) had metastatic involvement of station 253 lymph nodes and 99 (8.3 per cent) had metastases to station 252. The 5- and 10-year survival rates of patients with metastases to station 253 were 40 and 21 per cent, and those for patients with metastases to station 252 were 50 and 35 per cent, respectively.

CONCLUSION

High ligation of the IMA allows curative resection and long-term survival in patients with cancer of the sigmoid colon or rectum and nodal metastases at the origin of the IMA.

Replanting the inferior mesentery artery during infrarenal aortic aneurysm repair: influence on postoperative colon ischemia

BACKGROUND

Replanting the inferior mesentery artery (IMA) to prevent ischemic colitis (IC) has been discussed for many years; yet, to our knowledge, no prospective studies have been conducted to compare the incidence of histologically proven IC in patients with and without IMA revascularization. The aim of this prospective study, with histologic evaluation of the sigmoid colon mucosa, was to assess the influence of replanting the IMA on IC and mortality.

METHODS

From January 1999 to December 2003, 160 consecutive patients who were operated on for a symptomatic (n = 21) or asymptomatic (n = 139) infrarenal aortic aneurysm were prospectively assessed and randomly assigned either to replanting or ligating the IMA. Sigmoidoscopy with biopsy was performed on day 4 or 5 after surgery; an autopsy was performed on patients not surviving to day 5 after surgery. All patients gave written informed consent.

RESULTS

Of the 160 randomized patients, 128 had a confirmed patent IMA and formed the basis of this study. Their age was 70 +/- 8 years (men, 70 +/- 8 years; women, 73 +/- 7 years). The IMA was replanted in 67 patients (52%) and ligated in 61 (48%) intraoperatively. IC developed in six patients with a replanted IMA and in 10 with a ligated IMA (relative risk [RR], 0.55; 95% confidence interval [CI], 0.21 to 1.41; chi2 = 1.62; P = .203). Blood loss in the two cohorts did not differ significantly (P = .788); however, patients with IC had a significantly higher blood loss compared with the cohort without IC (P = .012) and were older (P = .017). Age, sex distribution, clamping time, the use of tube or bifurcated grafts, and intraoperative hypotension did not differ between patients with ligated or replanted IMA.

CONCLUSION

Although replanting the IMA did not confer a statistically significant reduction of perioperative morbidity or mortality in this study, it appears that older patients and patients with increased intraoperative blood loss might benefit from IMA replantation, because this maneuver does not increase perioperative morbidity or substantially increase operation time.

[Preservation of the autonomic nerve in rectal cancer surgery: anatomical factors in ligation of the inferior mesenteric artery]

OBJECTIVE

To evaluate the regional anatomy between the abdominal autonomic nerves including the abdominal aortic plexus (AAP) and the inferior mesenteric artery (IMA), and explore the safe ligation point on the IMA and the optimal dissection method to avoid autonomic nerve injuries.

METHODS AND RESULTS

Dissections and observation were carried out on 16 fixed male cadavers. The AAP located in the thin fascia layer covering the surface of the aorta and its branches. No autonomic nerves were found in the area around the root of the IMA, and the point where the IMA and the left trunk of the AAP intersected was highly variable. The left trunk of the AAP adhered more closely to the IMA than to the aorta.

CONCLUSIONS

In view of autonomic nerve preservation, the only safe site for ligation of the IMA is at its origin, and no other such sites are available along the IMA trunk and its branches. The IMA and the posterior fascia layer containing the autonomic nerves constitute the optimal surgical plane for IMA ligation, which should be performed following skeletonization of the IMA with careful preservation of the integrity of the posterior fascia layer.

Combined Laparoscopic and Percutaneous Treatment of a Type II Endoleak Following Endovascular Abdominal Aortic Aneurysm Repair

We describe a novel approach in treating a persistent type II endoleak related to the inferior mesenteric artery (IMA) and the lower lumbar arteries. The endoleak failed to thrombose following percutaneous IMA coil embolization. We proceeded to one-stage laparoscopic IMA division and intra-sac thrombin injection under direct laparoscopic vision and fluroscopy. A CT scan at 1 and 7 months post-intervention showed no evidence of endoleak and the growth of the aneurysm was arrested. This combined laparoscopic and percutaneous approach may be a useful treatment option in the management of persistent complex type II endoleak. Its durability, however has yet to be defined.

Distribution of lymph node metastasis in T1 sigmoid colon carcinoma: should we ligate the inferior mesenteric artery?

OBJECTIVE

In standard oncological sigmoid colectomy, the inferior mesenteric artery is ligated either at its origin or at the level of the left colic artery. However, in patients with early-stage carcinoma, the distribution of metastatic nodes may be limited. The aim of this study was to clarify the prevalence and distribution of lymph node metastasis in T1 sigmoid colon carcinoma and to determine the adequate range of lymph node dissection.

MATERIALS AND METHODS

The study included 121 consecutive patients treated for T1 sigmoid colon carcinoma. Clinicopathologic factors associated with nodal metastasis and the distribution of metastatic nodes were analyzed.

RESULTS

Of 121 patients, 12 (10%) had nodal involvement. The depth of invasion and the presence of lymphatic and vascular invasion were significantly associated with nodal metastasis. Of these 12 patients, 11 (92%) had lymph node metastasis confined to pericolic nodes. Nodes along the sigmoidal artery were involved in one patient. There was no involved node along the superior rectal artery or at the root of the inferior mesenteric artery.

CONCLUSIONS

Lymph node dissection for T1 sigmoid colon carcinoma should be limited to the root of the sigmoidal artery, and the inferior mesenteric artery should be preserved.

Experimental Percutaneous Extrahepatic Portacaval Shunt Creation by Transjugular Approach in Swine

The purpose of the study was to evaluate the feasibility of the creation of a percutaneous extrahepatic portacaval shunt (PEPS) in swine by a transjugular approach and to find a suitable stent-graft to use in PEPS. In 12 swine, the extrahepatic portal vein (PV) was entered from the inferior vena cava (IVC) by a needle system introduced from the transjugular approach. A catheter introduced through the transhepatic approach served as a target. Five types of stent-graft consisting of homemade Z stents and a polytetrafluoethylene cover were explored for PEPS creation. Eight animals had follow-up venograms up to 6 weeks or until the shunt became severely stenotic. Gross and histologic examinations were performed after the final follow-up venography. The PV punctures and stent-graft placement were difficult, but the PEPS was established in all animals. In four animals, the stent-graft failed to adequately cover the tract, causing severe hemorrhage. Only two shunts remained patent up to 6 weeks. The other shunts exhibited severe stenosis or occlusion. At gross examination, all shunts traversed the liver parenchyma of the caudate lobe surrounding the IVC. The extravascular PEPS portion was 4 mm to 2 cm long. All shunts entered the PV close to the splenomesenteric junction and exhibited neointimal formation. Shunt stenoses were caused by neointimal hyperplasia and occlusions by a superimposed thrombus. PEPS can be created by the transjugular approach in swine, but only the PV shunt entrance is extrahepatic. None of the tested rigid stent-grafts were suitable for PEPS creation. A short flexible stent-graft with flanged ends is suggested for further exploration.

Celiomesenteric trunk compression and absence of collateral vessels in the large intestine--a case report

The authors report the case of a rare mesenteric anomaly in a 71-year-old man who presented with a preexisting abdominal aortic aneurysm (AAA) and a progressive history of postprandial abdominal pain and 10-lb weight loss. Aortography revealed a common celiomesenteric trunk, an absent middle colic artery, and a stenotic inferior mesenteric artery. At operation, neural fibers compressing the common celiomesenteric trunk were lysed, the AAA was repaired, and the inferior mesenteric artery was subjected to endarterectomy and then reimplanted. The patient remains well and free of symptoms 1 year after operation. This rare case demonstrates the many different causes of intestinal angina and its surgical relief.

Irreversible lower limb ischaemia following ligation of the inferior mesenteric artery in the surgical treatment of rectal cancer

Rectal cancer and cardiovascular disease are both commoner in the elderly and may coexist. In some severe arteriopaths the blood supply to the lower limbs may be a collateral circulation from the inferior mesenteric artery. Patients with aorto-iliac occlusion or severe stenosis may have collaterals from the inferior mesenteric artery to the lower limb blood vessels. Ligation of the inferior mesenteric artery in treating rectal cancer can result in irreversible ischaemia as outlined in this report. Routine palpation of the femoral pulses and awareness of collateral circulation may avoid the disastrous consequences seen in the two cases described.

[Prevention of intestinal ischemia after abdominal aortic reconstructive surgery]

The aim of this study was to estimate rate of intestinal ischemic complications after abdominal aortic reconstructive surgery, to evaluate risk factors and to provide means of prevention of complication.

MATERIAL AND METHODS

Study group consisted of 172 patients who underwent aortic reconstruction in 2000-2003 in the Department of Vascular Surgery of Kaunas University of Medicine Hospital. Six patients underwent intestinal ischemia in the postoperative period, i. e. 3.5%; four of them died. This indicated that 13% of patients died after abdominal aortic surgery. Ninety-four patients underwent operation for aortoiliac occlusive disease, colon ischemia occurred in 1 case (1.1%). Seventy-eight patients underwent abdominal aortic aneurysm; 33 patients -- ruptured aneurysm, and 45 -- aneurysm without rupture. In ruptured abdominal aortic aneurysm group with III degree colon ischemia there were 3 cases (9.1%); 2 of them died, which formed 11% of all deaths in this group. In the group of non-ruptured abdominal aortic aneurysm with III degree colon ischemia there were 2 cases (4.4%). Both patients died, which formed 50% of all deaths in this group. For all patients operated for abdominal aortic aneurysm, a. mesenterica inferior stump pressure was evaluated. In case of stump pressure 50 mmHg and more a. mesenterica inferior was ligated. If pressure was lower than 50 mmHg a. mesenterica inferior was reimplanted into vascular graft. Forty-nine reconstructions of a. mesenterica inferior were made in abdominal aortic aneurysm group: 25 in ruptured cases, and 24 in non-ruptured cases. Despite the fact that a. mesenterica inferior was reconstructed, 2 patients had colon ischemia after this reconstruction in the group of ruptured aneurysm. In the group of non-ruptured aneurysm, colon ischemia developed only after ligation of a. mesenterica inferior. We conclude that a. mesenterica inferior is very important for normal circulation of left colon. Correct evaluation of preoperative aortography, correct operative strategy, and reimplanted a. mesenterica inferior if it is necessary -- are the main means of colon ischemia prevention after abdominal aortic surgery.

Total laparoscopic abdominal aortic aneurysm repair with reimplantation of the inferior mesenteric artery

We performed a total laparoscopic reimplantation of the inferior mesenteric artery (IMA) during laparoscopic infrarenal aortic aneurysm repair. The postoperative course was uneventful, and angiograms showed a patent IMA after reimplantation. To our knowledge, total laparoscopic reimplantation of the IMA in human beings has not previously been described.