The clinical spectrum of penetrating injury to the superior mesenteric arterial circulation

Management of a traumatic superior mesenteric artery injury using superselective angioembolization

We report the successful use of angioembolization to treat mesenteric bleeding in a patient who sustained blunt abdominal trauma. Angiography revealed extravasation from a distal branch of the right colic or ileocolic artery. Interventional radiology superselectively embolized a distal arterial branch supplying the ileum. Total hospital stay was 4 days. Laparotomy is the standard treatment for active mesenteric bleeding. This case highlights the usefulness of superselective embolization to mitigate the need for surgical intervention in a patient with active mesenteric bleeding. Treatment outcomes depend on close clinical monitoring for intestinal ischemia and patient counselling on the potential for surgical intervention.

Extrarenal Visceral Arteries Injuries during Left Radical Nephrectomy: A 50-Year Continuing Problem

Due to their proximity to the left renal hilum, injuries to the superior mesenteric artery and celiac trunk are still reported during left radical nephrectomy, whether performed via open, laparoscopic, or robotic methods. The aim of this 50-year narrative review is to emphasize the anatomical and pathophysiological bases, risk factors, and strategies for the prevention, diagnosis, and treatment of such injuries.

Superior Mesenteric Artery Injury during Robotic Radical Nephrectomy: Scenarios and Management Strategies

Injury to the superior mesenteric artery (SMA) is a rare, underreported, and potentially devastating complication. This study aims to propose a systematic workup to describe how to prevent and manage SMA injury in a standardized stepwise manner. Three different instances of intraoperative injury to the SMA are described in an accompanying video. All three occurred when the SMA was misidentified as the left renal artery during left robotic radical nephrectomy. In the first case, the SMA was mistakenly identified as the renal artery, but after further dissection, the real renal artery was identified and SMA injury was prevented. In the second case, the SMA was clipped and the real left renal artery was subsequently identified, requiring clip removal. In the third case, the SMA was clipped and completely transected, requiring prompt repair by vascular surgery with a successful outcome. This study aims to propose a systematic workup to describe how to prevent and manage SMA injury in a standardized stepwise manner. The proper anatomic recognition of the SMA may prevent its injury. Intraoperative SMA injury should be promptly identified and repaired to avoid its devastating consequences.

Superior Mesenteric Artery Injury During Robot-assisted Laparoscopic Nephrectomy: A Robotic Nightmare

Major vascular injuries during robotic renal surgery are rare, but the close proximity of the superior mesenteric artery (SMA) to the left renal artery means that it is liable to iatrogenic injury with potentially catastrophic implications. In this review, we present a case of accidental SMA ligation during a robot-assisted laparoscopic nephrectomy for a 12-cm upper pole renal mass. Prompt recognition and early vascular surgical assistance with conversion to open surgery allowed a primary vascular anastomosis to be made. A computed tomography angiogram at 6 wk was normal. On review of the imaging, the left renal artery take-off was higher than the SMA, which represents an anatomical variant and may have contributed to the injury. The risk of accidental SMA ligation is highest in left-sided tumours and in larger medial tumours that lead to significant distortion of the anatomy. The anatomy of the renal artery can also vary greatly. Surgeons must be knowledgeable of common variations and meticulously review preoperative imaging for the number and course of renal vessels as well as the location of the SMA. In cases of significant bleeding, rapid conversion to open surgery and urgent vascular consultation are critical.

Patient summary

In this article, we describe an accidental injury to a major blood vessel (the superior mesenteric artery) during a left robotic radical nephrectomy (kidney removal) for a tumour. We discuss the anatomical relationships of the blood vessels of the small bowel and kidneys, and how to anticipate, recognise, and manage such accidental injuries.

H12-(ADP)-liposomes for hemorrhagic shock in thrombocytopenia: Mesenteric artery injury model in rabbits

BACKGROUND

Damage control resuscitation improves patient outcomes after severe hemorrhage and coagulopathy. However, effective hemostasis methods for these critical situations are lacking.

OBJECTIVE

We evaluated the hemostatic efficacy of fibrinogen γ-chain (HHLGGAKQAGDV, H12)-coated, adenosine-diphosphate (ADP)-encapsulated liposomes (H12-[ADP]-liposomes) in thrombocytopenic rabbits with hemorrhagic shock.

METHODS

Acute thrombocytopenia (80%) was induced in rabbits that also received mesenteric vessel injury, leading to hemorrhagic shock. Five minutes after injury, subjects received intravenous bolus injection with H12-(ADP)-liposomes (20 mg/kg), followed by isovolemic transfusion with stored red blood cells (RBCs)/platelet poor plasma (PPP) (RBC:PPP = 1:1 [vol/vol]), or lactated Ringer solution every 5 min to compensate blood loss. One group received H12-(phosphate buffered saline [PBS]) liposomes followed by RBC/PPP. Additional groups were received isovolemic transfusion with RBC/platelet rich plasma (PRP) (RBC:PRP = 1:1 [vol/vol]), RBC/PPP, PPP alone, or lactated Ringer solution.

RESULTS

Treatment with H12-(ADP)-liposomes followed by RBC/PPP transfusion and RBC/PRP transfusion effectively stopped bleeding in all thrombocytopenic rabbits. In contrast, three of 10 rabbits treated with RBC/PPP failed hemostasis, and no rabbits receiving lactated Ringer solution stopped bleeding or survived. Twenty-four hours after hemorrhage, 80% of rabbits receiving H12-(ADP)-liposome followed by RBC/PPP transfusion survived and 70% of rabbits receiving RBC/PRP transfusion also survived, although RBC/PPP-transfused rabbits showed 40% survival. Rabbits receiving H12-(ADP)-liposomes followed by lactated Ringer solution showed a transient hemostatic potential but failed to survive. H12-(PBS)-liposomes showed no beneficial effect on hemostasis. Neither the PPP group nor the lactated Ringer group survived.

CONCLUSION

H12-(ADP)-liposome treatment followed by RBC/PPP may be effective in lethal hemorrhage after mesenteric vessel injury in coagulopathic rabbits.

Superior Mesenteric Artery and Vein Injuries: Operative Strategies and Outcomes

Traumatic injuries to the mesenteric vessels are rare and often lethal. Visceral vessels, such as the superior mesenteric artery (SMA) and vein (SMV), supply blood to the small and large bowel by a rich system of collaterals. Because fewer than 100 such injuries have been described in the literature, they pose challenges in both diagnosis and management and can unfortunately result in high mortality rates. Prompt diagnosis, surgical intervention, and resuscitation can lead to improved outcomes. Here, we review the literature surrounding traumatic injuries of the SMA/SMV and discuss management strategies.

Superior Mesenteric Artery Injury during Radical Nephrectomy in an Infant: Delayed Diagnosis and Successful Management

Superior mesenteric artery (SMA) injury during a left radical nephrectomy is an uncommon complication in children with a potentially devastating outcome. Successful management depends on early diagnosis and re-establishing SMA perfusion. We report the successful management of an iatrogenic SMA injury during radical nephrectomy in a 10-month-old boy with left upper polar Wilms' tumor.

Cross-Sectional Imaging Evaluation of Vascular Lesions in the Gastrointestinal Tract and Mesentery

Gastrointestinal (GI) tract and mesenteric vascular lesions can have various clinical presentations, of which GI bleeding is the most common. This collection of pathology is highly variable in etiology ranging from occlusive disease to vascular malformations to trauma to neoplasms which makes for a challenging workup and diagnosis. The advent of multiple imaging modalities and endoscopic techniques makes the diagnosis of these lesions more achievable, and familiarity with their various imaging findings can have a significant impact on patient management. In this article, we review the gamut of GI tract and mesenteric vascular lesions and their associated imaging findings.

Mesenteric Vascular Injury in Trauma: An NTDB Study

BACKGROUND

Although abdominal trauma remains a major cause of morbidity and mortality, there has not been a large-scale multicenter study regarding outcomes in patients who incur mesenteric vascular injuries. The goal of this retrospective analysis was to investigate the factors associated with outcomes in patients with trauma diagnosed with mesenteric vascular injuries.

METHODS

A retrospective database analysis was performed on patients who sustained a mesenteric vascular injury (MVI, ICD-9 902.20-902.29) identified by the 2012 National Trauma Data Bank. Data were analyzed to identify differences in hospital length of stay, emergency room (ER) and final hospital disposition, and mortality based on patient age, gender, race, Injury Severity Score (ISS), and injury type (blunt or penetrating).

RESULTS

Of the 1,133 total patients included, blunt trauma accounted for 740 (65%) of the injuries, whereas penetrating trauma accounted for 364 of the injuries (32%). Patients with penetrating injuries were 1.43 times more likely to die from their injuries than those suffering from blunt trauma (95% CI 1.04-1.98, P < 0.05). Patients with a higher ISS (>16) were 5.39 times more likely to die from their injuries than those with a lower ISS (95% CI 1.89-15.4, P = 0.002); if ISS was >25, the patient was 15.1 times more likely to die (95% CI 5.5-41.7, P < 0.001). Men were more likely to suffer from penetrating injuries than women (37% vs. 13%, P < 0.001), and African Americans were nearly 4 times more likely to present with penetrating injuries (69% vs 17%, P < 0.001). Age was also associated with mortality as patients >65 years and between 21 and 44 years were more likely to die from their injuries than patients in other age categories. Of the 740 patients with blunt MVIs, 326 (44%) were taken directly from the ER to the operating room (OR) and 306 (41%) to the intensive care unit (ICU), whereas with penetrating MVIs, 311 (85%) were taken to the OR from the emergency department and 18 (5%) to the intensive care unit. Of the 740 blunt MVIs, 115 died (16%), compared with 76 (21%) of the penetrating MVIs (P < 0.001). Injuries to the hepatic and superior mesenteric arteries were associated with higher mortality, with OR 2.03 and 3.03, respectively (P < 0.001).

CONCLUSIONS

The presence of mesenteric arterial injury warrants rapid identification and management as these injuries are associated with significant morbidity and mortality, with penetrating mechanism, injury to large mesenteric vessels, and increased ISS associated with increased mortality.

A Novel Approach for Repairing Superior Mesenteric Artery Injury During Left Nephrectomy-6-year Follow-up

OBJECTIVE

To describe a novel approach for reconstructing the superior mesenteric artery (SMA) during left nephrectomy and review the literature.

MATERIALS AND METHODS

The patient was a 57-year-old man with left back pain from an unknown cause for more than 3 hours. A computed tomography scan showed a 12- × 15-cm firm mass and a subcapsular hematoma in the left kidney. It was considered to be bleeding and rupture of the solid renal mass, and because of persistent pain and no documented distant metastatic disease, a transperitoneal laparoscopic nephrectomy was elected, but the procedure was converted to open surgery for SMA injury. We reconstructed the SMA with end-to-end anastomosis between the SMA and the left renal artery stump.

RESULTS

At the 6-year follow-up, the patient had no intestine-related sequelae.

CONCLUSION

Our novel approach of an end-to-end anastomosis between the SMA and the left renal artery stump is an option for SMA injury, especially when orthotopic anastomosis or repair of the SMA is not indicated.

A Short Series of Laparoscopic Mesenteric Bypasses for Chronic Mesenteric Ischemia

Background

Laparoscopic aortomesenteric bypass may be performed to treat the chronic mesenteric ischemia patients who are not suitable for endovascular treatment. This study presents an initial experience with a limited series of laparoscopic mesenteric artery revascularization for the treatment of mesenteric ischemia.

Methods

Chronic mesenteric ischemia (CMI) patients with previous unsuccessful endovascular treatment or with arterial occlusion and extensive calcification precluding safe endovascular treatment were offered laparoscopic mesenteric revascularization. From October 2015 until November 2018, nine patients with CMI underwent laparoscopic revascularization. In addition to demographic data and perioperative results of the treatment, graft patency was assessed with Duplex ultrasound at 1, 3, 6 and 12 months, and annually thereafter. A descriptive analysis of the data was performed.

Results

All bypasses were constructed with an 8 mm ring enforced expanded polytetrafluoroethylene graft in a retrograde fashion (from infrarenal aorta or iliac artery) to either superior mesenteric artery or splenic artery (2 cases). Median operation time was 356 mins (range 247–492 mins). Five patients had a history of unsuccessful endovascular treatment. Laparoscopic technical success was 78%, and the primary open conversion rate was 22%. All laparoscopic revascularization procedures remained patent after discharge during a median follow-up time of 26 months (range 18–49 months). The primary graft patency at 30 days was 78%. Primary assisted, and secondary graft patency was 78% and 100%, respectively. Median weight gain was 2 kg (range 2–18 kg), and all patients achieved relief from postprandial pain and nausea. No mortality was observed during the follow-up period.

Conclusion

Laparoscopic aortomesenteric revascularization procedures for chronic mesenteric ischemia are feasible but require careful patient selection. These procedures should only be performed at referral centers by vascular surgeons with prior experience in laparoscopic vascular surgery.

Incidence, morbidity, and mortality of traumatic superior mesenteric artery injuries compared to other visceral arteries

Objectives

Celiac artery, superior mesenteric artery, and inferior mesenteric artery injuries are often grouped together as major visceral artery injuries with an incidence of <1%. The mortality rates range from 38–75% for celiac artery injuries and 25–68% for superior mesenteric artery injuries. No large series have investigated the mortality rate of inferior mesenteric artery injuries. We hypothesize that from all the major visceral artery injuries, superior mesenteric artery injury leads to the highest risk of mortality in adult trauma patients.

Methods

The Trauma Quality Improvement Program (2010–2016) was queried for patients with injury to the celiac artery, superior mesenteric artery, or inferior mesenteric artery. A multivariable logistic regression model was used for analysis. Separate subset analyses using blunt trauma patients and penetrating trauma patients were performed.

Results

From 1,403,466 patients, 1730 had single visceral artery injuries with 699 (40.4%) involving the celiac artery, 889 (51.4%) involving the superior mesenteric artery, and 142 (8.2%) involving the inferior mesenteric artery. The majority of patients were male (79.2%) with a median age of 39 years old, and median injury severity score of 22. Compared to celiac artery and inferior mesenteric artery injuries, superior mesenteric artery injuries had a higher rate of severe (grade >3) abbreviated injury scale for the abdomen (57.5% vs. 42.5%, p < 0.001). The overall mortality for patients with a single visceral artery injury was 20%. Patients with superior mesenteric artery injury had higher mortality compared to those with celiac artery and inferior mesenteric artery injuries (23.7% vs. 16.3%, p < 0.001). After controlling for covariates, traumatic superior mesenteric artery injury increased risk of mortality (OR = 1.72, CI = 1.24–2.37, p < 0.01) in adult trauma patients, while celiac artery ( p = 0.59) and inferior mesenteric artery ( p = 0.31) injury did not. After stratifying by mechanism, superior mesenteric artery injury increased risk of mortality (OR = 3.65, CI = 2.01–6.45, p < 0.001) in adult trauma patients with penetrating mechanism of injury but not in those with blunt force mechanism (OR = 1.22, CI = 0.81–1.85, p = 0.34).

Conclusions

Compared to injuries of the celiac artery and inferior mesenteric artery, traumatic superior mesenteric artery injury is associated with a higher mortality. Moreover, while superior mesenteric artery injury does not act as an independent risk factor for mortality in adult patients with blunt force trauma, it nearly quadruples the risk of mortality in adult trauma patients with penetrating mechanism of injury. Future prospective research is needed to confirm these findings and evaluate factors to improve survival following major visceral artery injury.

Visceral artery aneurysms: review on indications and current treatment strategies

Visceral arterial aneurysms and pseudoaneurysms are rare entities. Despite infrequent, these lesions are clinically important and potentially lethal, since 22% present as clinical emergencies and 8.5% result in death. As such, early detection and treatment is essential. Through this work, we aim to address both visceral arterial aneurysms and pseudoaneurysms, with particular focus on their epidemiology, etiology and risk factors, as well as report current diagnostic workups and treatment strategies. A full literature review was performed through a comprehensive electronic search of PubMed databases, including articles published until the end of November 2018 and using the following keywords: "visceral aneurysm," "pseudoaneurysm" and "endovascular treatment." From this research, 2043 articles had their abstract assessed, 359 were read integrally, 213 were excluded for not being directly related to the subject and 146 were included, according to the authors preference and scientific relevance in this work's context. Visceral arterial aneurysms and pseudoaneurysms have fairly similar clinical presentations and diagnostic workups. Differences reside mainly in their etiology and indications for treatment, since immediate treatment is recommended for pseudoaneurysms regardless of their size, while true aneurysms have specific treatment cutoffs. Despite a significant improvement on current diagnostic and treatment strategies, these lesions are still frequently diagnosed only upon rupture, with significant mortality rates. Endovascular strategies represent the first line of treatment on the majority of cases, although open surgery continues to play a role in specific conditions. Visceral arterial aneurysms and pseudoaneurysms are rare but potentially fatal and, as such, proper diagnosis and treatment is of capital importance. Due to its minimally invasive nature, endovascular therapies currently represent the standard of care in the majority of situations, although there are still solid indications for open surgery. Technique selection should be performed according to the clinical scenario and baseline anatomy.

Splenomesenteric bypass as revascularisation technique after iatrogenic injury of the superior mesenteric artery during radical nephrectomy: A case report

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Iatrogenic injury of the superior mesenteric artery is rare.

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This injury imparts a high risk of mortality due to visceral ischemia and death.

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An anastomosis to the splenic artery may be an easier solution than an aorto-mesenteric bypass.

Introduction

Iatrogenic vascular injuries during radical nephrectomy are rarely reported. In the case of an injury of the superior mesenteric artery, the consequences for the patient are potentially catastrophic. It occurs more frequently in patients with large renal tumors, due to the presence of bulky perihilar adenopathies, or in cases of pyelonephritis. In most cases, the inadvertent injury of the artery occurs due to the difficulty in distinguishing it from the left renal artery.

Case

69-year-old male, with a malignant neoplasm of the left kidney with the involvement of the tail of the pancreas, tumor thrombus in the left renal vein and multiple left para-aortic adenopathies, whose histological examination revealed to be a renal sarcomatoid carcinoma pT4N1M0G3. A radical nephrectomy was performed with caudal splenopancreatectomy and left paraaortic lymphadenectomy, with an iatrogenic injury of the superior mesenteric artery at its origin. A terminoterminal anastomosis was performed from the proximal stump of the splenic artery. The postoperative period went uneventfully. Control imaging in the follow-up showed permeability of the celiac trunk and the superior mesenteric artery.

Conclusions

Intra-operative superior mesenteric artery injury should be promptly identified and repaired to prevent gut ischemia and all its dire consequences. There are different repair options, and the technique should be chosen according to the degree of injury. The splenomesenteric bypass has numerous advantages.

Successful conservative treatment of acute traumatic occlusions of the celiac artery and superior mesenteric artery: A case report emphasizing the importance of the visceral collateral circulations

RATIONALE

Blunt injury of major visceral arteries such as celiac artery (CA) and superior mesenteric artery (SMA) are very rare but fatal, therefore, these injuries are challenging to trauma surgeons. The patient with occlusion of CA or SMA is theoretically viable by visceral collateral circulation. However, there are very rare cases in clinics. To date, there have been few reports of both CA and SMA occlusions after blunt trauma. Herein we describe our successful conservative treatment of patients with both CA and SMA occlusions.

PATIENT CONCERNS

Fifteen-year-old girl suffering from schizophrenia was transferred to our hospital after a fall from 3-floor-height with a purpose of suicide.

DIAGNOSES

An abdominal computed tomography (CT) scan with contrast enhancement showed proximal CA and proximal SMA occlusions with surrounding retroperitoneal hematoma, however, distal parts of occlusion were supplied by the collateral vessels (enlarged marginal artery of left colon from inferior mesenteric artery and pancreaticoduodenal arcade).

INTERVENTIONS

She was treated by only supportive care without anticoagulant due to retroperitoneal hematoma.

OUTCOMES

The patient was discharged 25 days after admission without complications.

LESSONS

We think that our patient could survive because her vascular status was healthy and collateral circulations were plenty according to the young age. We believe that this case can provide a basis for ligation in these forbidding and handless major visceral arterial injuries such as CA or SMA.

Contemporary Strategies in the Management of Civilian Abdominal Vascular Trauma

The evaluation and management of patients with abdominal vascular trauma or injury requires immediate and effective decision-making in these unfavorable circumstances. The majority of these patients arrive at trauma centers in profound shock, secondary to massive blood loss, which is often unrelenting. Moreover, ischemia, compartment syndrome, thrombosis, and embolization may also be life threatening and require immediate intervention. To minimize the risk of these potentially lethal complications, early understanding of the disease process and emergent therapeutic intervention are necessary. In the literature, the management of acute traumatic vascular injuries is restricted to traditional open surgical techniques. However, in penetrating injuries surgeons often face a potentially contaminated field, which renders the placement of prosthetic grafts inappropriate. Currently, however, there are sparse data on the management of vascular trauma with endovascular techniques. The role of endovascular technique in penetrating abdominal vascular trauma, which is almost always associated with severe active bleeding, is limited. It is worth mentioning that hybrid operating rooms with angiographic radiology capabilities offer more opportunities for the management of this kind of injuries by either temporary control of the devastating bleeding using endovascular balloon tamponade or with embolization and stenting. On the other hand, blunt abdominal injuries are less dangerous and they could be treated at most times by endovascular means. Since surgeons continue to encounter abdominal vascular trauma, open and endovascular techniques will evolve constantly giving us encouraging messages for the near future.

Abdominal vascular trauma

Abdominal vascular trauma, primarily due to penetrating mechanisms, is uncommon. However, when it does occur, it can be quite lethal, with mortality ranging from 20% to 60%. Increased early mortality has been associated with shock, acidosis, hypothermia, coagulopathy, free intraperitoneal bleeding and advanced American Association for the Surgery of Trauma Organ Injury Scale grade. These patients often arrive at medical centers in extremis and require rapid surgical control of bleeding and aggressive resuscitation including massive transfusion protocols. The most important factor in survival is surgical control of hemorrhage and restoration of appropriate perfusion to the abdominal contents and lower extremities. These surgical approaches and the techniques of definitive vascular repair can be quite challenging, particularly to the inexperienced surgeon. This review hopes to describe the most common abdominal vascular injuries, their presentation, outcomes, and surgical techniques to control and repair such injuries.

Historical and current trends in colon trauma

The authors discuss the evolution of the evaluation and management of colonic trauma, as well as the debate regarding primary repair versus fecal diversion. Their evidence-based review covers diagnosis, management, surgical approaches, and perioperative care of patients with colon-related trauma. The management of traumatic colon injuries has evolved significantly over the past 50 years; here the authors describe a practical approach to the treatment and management of traumatic injuries to the colon based on the most current research. However, management of traumatic colon injuries remains a challenge and continues to be associated with significant morbidity. Familiarity with the different methods to the approach and management of colonic injuries will allow surgeons to minimize unnecessary complications and mortality.

A proposed new system of coding and injury classification for arteries in the trunk and extremities

STUDY DESIGN

Retrospective review of arterial injury with prospective intra-observer and inter-observer analyses.

AIM

To introduce a new classification system for arterial injuries in the extremities and trunk.

METHODS

Retrospective review of all patients with arterial injuries treated at a level I trauma centre during a 3.5-year period. Major arteries were located and coded, and the arteries' lesion was categorised in reference to the alphanumeric format of the AO fracture coding system and injury classification. Each major artery was coded in a numeric format and further divided into three segments: proximal, middle and distal. The severity of artery injury was classified into different types and subtypes in an alphanumeric format. Inter-observer and intra-observer reliabilities were tested.

RESULTS

Systemic arteries were coded and arterial injuries were classified in the alphanumeric notation. The intra- and inter-observers' reliabilities were found to be acceptable in the application of the new system.

CONCLUSION

The preliminary data demonstrate that the new coding and injury classification system for arteries in the trunk and extremities are reliable and efficient for data storage and retrieval, and provide a favourable environment for discussion among different physicians or centres.

Temporary intravascular shunting improves survival in a hypothermic traumatic shock swine model with superior mesenteric artery injuries

BACKGROUND

Repairs of superior mesenteric artery (SMA) injuries are difficult and often result in high mortality. Our group has employed temporary intravascular shunts (TIVS) as a damage control procedure in a SMA transection model and hypothesized that TIVS would improve survival when compared with primary vascular anastomosis in the setting of a damage control surgery.

METHODS

The SMA was clamped and completely transected while pigs were hemorrhaged to a mean arterial pressure of 40 mmHg and maintained in shock for 30 minutes. Cold lactated Ringer's solution was gradually infused while the abdomen was open to induce hypothermia. Animals were randomized to control (no resuscitation), primary anastomosis (PA), or temporary shunting (TS) of the SMA. Animals were resuscitated for 6 hours with the shed blood and lactated Ringer's solution. Delayed anastomosis was performed in TS animals after resuscitation. Surviving animals were humanely killed 2 days after operation. Systemic hemodynamic parameters were recorded hourly. The ileum was harvested at the end of resuscitation and experiment for pathologic evaluation.

RESULTS

All animals suffered extreme physiologic conditions: hypothermia, severe acidosis, hypotension, and depressed cardiac output and oxygen delivery. Control animals suffered 100% mortality. Compared with the PA group, TS animals required less resuscitation fluid, retained higher SMA flow rates, normalized lactate levels faster, suffered less severe intestine histopathology, and had greater early survival.

CONCLUSION

Damage control surgery in the setting of SMA transection seems better managed with TS than with PA. Further validation of this model is required before generalization to human applications.

Anatomical basis for Wilms tumor surgery

Wilms tumor surgery requires meticulous planning and sophisticated surgical technique. Detailed anatomical knowledge can facilitate the uneventful performance of tumor nephrectomy and cannot be replaced by advanced and sophisticated imaging techniques. We can define two main goals for surgery: (1) exact staging as well as (2) safe and complete resection of tumor without spillage. This review aims to review the anatomical basis for Wilms tumor surgery. It focuses on the surgical anatomy of retroperitoneal space, aorta, vena cava and their large branches with lymphatics. Types and management of vascular injuries are discussed.

Superior mesenteric venous injuries: to ligate or to repair remains the question

BACKGROUND

Superior mesenteric vein injuries are rare and incur high mortality. Given their low incidence, little data exist delineating indications for when to institute primary repair versus ligation. The purposes of this study are to review our institutional experience, to determine the additive effect on mortality of associated vascular injuries, to correlate mortality with the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury and to examine and define the indications and outcomes for primary repair versus ligation.

MATERIAL

Retrospective 156 months study (January 1992 through December 2004) in a large Level I urban trauma center of all patients admitted with superior mesenteric vein injuries. Patients were stratified, according to surgical technique employed to deal with their injuries, into those undergoing primary repair versus ligation to determine outcomes and define the surgical indications of these methods. The main outcome measure was overall survival. Cases of survival were stratified according to surgical method: primary repair versus ligation.

RESULTS

There were 51 patients with a mean Injury Severity Score of 25 +/- 12. Mechanism of injury was penetrating for 38 (76%), blunt for 13 (24%), and patients undergoing emergency department thoracotomy for 4 (8%). Surgical management was ligation for 30 (59%), primary repair for 16 (31%), and 5 (10%) patients were exsanguinated before repair. The overall survival rate was 24/50 (47%). The survival rate excluding patients undergoing emergency department thoracotomy was 51%. The survival rate excluding patients that sustained greater than 3 to 4 associated vessels injured was 65%. The survival rates of patients with superior mesenteric vein and superior mesenteric artery was 55% and superior mesenteric vein and portal vein (PV) was 40%. The survival rate of patients with isolated superior mesenteric vein injuries was 55%. Mortality stratified to AAST-OIS grade III, 44%; grade IV, 42%; and grade V, 42%. Survival rates stratified to method of management consisted of primary repair (60%) versus ligation (40%).

CONCLUSIONS

SMV injuries are highly lethal. Multiple associated vessel injuries increase mortality. Mortality correlates well with the American Association for the Surgery of Trauma-Organ Injury Scale for abdominal vascular injuries. Patients undergoing primary repair have higher survival rates (63%) and lesser numbers of associated vascular and nonvascular injuries; whereas those undergoing ligation have a smaller survival rate (40%) and higher number of associated vascular and nonvascular injuries. Ligation appears to be safe and should be selected for hemodynamically unstable patients with a large number of associated injuries.

Repair of superior mesenteric artery ligation during left nephrectomy with a native renal vein patch

Injury to the superior mesenteric artery (SMA) during nephrectomy is a rare but potentially catastrophic complication. SMA injury during nephrectomy most commonly occurs with large tumors or bulky lymphadenopathy, with inadvertent injury or mistaken ligation of the SMA instead of the renal artery. Failure to recognize and repair an SMA injury results in ischemic bowel and death for most patients. We report a case of SMA ligation during left nephrectomy for xanthogranulomatous pyelonephritis, review the intraoperative evaluation of suspected SMA injury, and describe our vascular repair using a vein patch from the native left renal vein.

Intestinal and multivisceral transplantation after abdominal trauma

SUMMARY

BACKGROUND Some trauma victims who survive acute illness develop lingering, debilitating syndromes that are incompatible with any semblance of normalcy. Intestinal failure, in particular, exacts a high price in terms of quality of life. Total parenteral nutrition (TPN) has served these patients well, but complications limit its long-term therapeutic effect. Consequently, transplantation is emerging as a life-saving therapy for some patients with the short gut syndrome. METHODS We reviewed eight adult and two pediatric recipients of intestinal and multivisceral transplants after severe abdominal trauma. Background demographics, type of abdominal trauma, transplant procedure, postoperative complications, and survival rates were appraised. This group was also compared with 47 nontrauma recipients of intestinal transplants performed during the same period. RESULTS Four patients (40%) died postoperatively (postoperative days 7, 53, 87, and 91) as a result of multiple organ failure after graft pancreatitis (n = 1), viral encephalitis (n = 1), and sepsis after severe rejection (n = 2). Six patients (60%) are alive (postoperative days 52-1,783). All are off TPN. The 4-year patient survival was 58%, with no significant difference between trauma and nontrauma patients.CONCLUSION Intestinal and multivisceral transplantation are viable options for the treatment of irreversible intestinal failure associated with severe trauma. Surviving patients are TPN independent and have a satisfactory quality of life.

Visceral vascular injuries

This article deals with injuries to the celiac trunk, superior and inferior mesenteric arterial injuires. Surgical approaches and physiological implications of interruption of the mesenteric arterial circulation are addressed in detail. Surgical techniques for the management of these injuries and the need for second look operations are also examined.

Traumatic injury to the superior mesenteric artery

BACKGROUND

Superior mesenteric artery (SMA) injuries are rare and devastating injuries incurring very high mortality rates. It is the purpose of this study to review our experience with these injuries, to analyze Fullen's classification based on anatomical zone and injury grade for its predictive value, and to correlate the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury with mortality.

METHODS

Retrospective study was made over a 65-month period of all patients sustaining SMA injuries in an urban level I trauma center.

RESULTS

Thirty-five patients, mean age 31, had a mean Revised Trauma Score of 5.86 and a mean Injurity Severity Score of 23. Mechanisms of injury were penetrating 27 (77%) and blunt 8 (23%). Mean admission systolic blood pressure was 85 mm Hg. Mean estimated blood loss was 8,500 mL and mean total fluid replacement 17,000 mL. Operating room findings were retroperitoneal hematoma in 34 (97%) and "black bowel" in 2 (6%). Number of associated injuries was nonvascular, mean 4.2, and vascular, mean 1.5. Surgical management consisted of ligation in 18 (51%), primary repair in 14 (40%), and interposition graft in 2 (6%). Overall mortality was 19 of 35 (54%). Mortality versus Fullen's zones was zone I, 100%, zone II, 43%, and zones III and IV, 25%. Mortality versus Fullen's ischemia grade was grade 1, 89%, grade 2, 58%, grade 3, 100%, and grade 4, 19%. Mortality versus AAST-OIS: was grade 1, 0%, grade II, 20%, grade III, 0%, grade IV, 59%, and grade V, 88%.

CONCLUSIONS

SMA injuries are highly lethal. Most deaths are due to exsanguination. A higher number of associated vascular injuries increases mortality. "Black bowel" is an uncommon finding. Both Fullen's anatomical zones and the AAST-OIS for abdominal vascular injuries correlate with mortality. Fullen's ischemia grade does not.

Temporary vascular continuity during damage control: intraluminal shunting for proximal superior mesenteric artery injury

"Damage control" is an accepted technique for the treatment of the patient with exsanguinating injuries to the abdomen and intraoperative coagulopathy. We describe the use of an intraluminal shunt to maintain temporary vascular continuity of the superior mesenteric artery during rewarming and correction of coagulopathy in the intensive care unit following a gun shot wound to the abdomen. Successful complex reconstruction was achieved at definitive laparotomy using an autogenous vein interposition graft.

Advances in diagnostics and successful repair of proximal posttraumatic superior mesenteric arteriovenous fistula

Posttraumatic arteriovenous fistulas affecting the superior mesenteric artery and vein are extremely rare. Twenty-four cases of posttraumatic superior mesenteric arteriovenous fistulas (SMAVFs) have been reported. We presented two cases of SMAVFs occurring in a young woman and man secondary to a gunshot and a grenade shrapnel wound in the epigastrium, respectively. Nausea, heartburn, emesis, and cramping abdominal pain were the clinical signs of SMAVF. Abdominal pains, particularly after meals, tense and meteoristic abdomen, frequent liquid bowel movements, oliguria, subfebrility, abdominal thrill, and bruit were also present. Abdominal duplex ultrasonic scanning and computed tomograms with a contrast agent were especially useful screening tools. As our results demonstrated, those methods were not only suitable for clinical use, but were also as good as arteriography in defining both the exact location and the extent of the mesenteric vessel involvement. However, the superior mesenteric arteriogram remains mandatory for complete preoperative evaluation. Arteriovenous fistulas were successfully treated by suturing the arterial and venous sides of the fistula in one case, and resectioning the fistula and end-to-end anastomosis in the other case.

Levels of cefmenoxime in sera and peritoneal tissues of patients undergoing gastrointestinal surgery

It is not known whether a prophylactic antibiotic administered prior to surgery reaches adequate levels in the peritoneum, where peritonitis may take place. This study determined levels of cefmenoxime in sera and peritoneal tissues of patients undergoing gastrointestinal surgery. Fifteen patients who underwent elective gastrointestinal surgery received an intravenous drip infusion of cefmenoxime (2 g) over 1 h prior to surgery. In patients who underwent gastrectomy, the level of cefmenoxime in serum was 130.8 +/- 6.9 micrograms/ml at laparatomy and decreased to 5.0 +/- 0.7 micrograms/ml at 4 h. Levels in parietal peritoneal and omental tissues at laparotomy were 35.3 +/- 5.2 and 19.2 +/- 3.5 micrograms, respectively, and decreased time dependently. In patients who underwent cholecystectomy, the level of cefmenoxime in serum was 137.9 +/- 7.3 micrograms/ml at laparotomy and decreased to 5.0 +/- 1.2 micrograms/ml at 4 h. Levels in parietal peritoneal and omental tissues were 31.0 +/- 8.4 and 13.7 +/- 3.3 micrograms/g, respectively, and decreased time dependently. The level of cefmenoxime in serum correlated with the levels of cefmenoxime in parietal peritoneum (r = 0.64, P less than 0.01) and in omentum (r = 0.47, P less than 0.02). In patients with appendicitis who received a bolus injection of 2 g of cefmenoxime, the level of drug in inflammatory omental tissue correlated with the level in serum. The levels in peritoneal tissue during surgery lasting up to 2 h were significantly greater than in MIC of cefmenoxime against almost all bacteria reported. A preoperative single dose of 2 g of cefmenoxime probably is effective as a prophylactic for intraoperative contamination.

Superior mesenteric artery injury during nephrectomy for Wilms' tumor

Iatrogenic injury to the aorta or its major branches during nephrectomy for Wilms' tumor in children is rarely reported but may be more common than is currently acknowledged. We identified four patients with ligation of the superior mesenteric artery (SMA) that occurred during nephrectomy for nephroblastoma and another child in whom SMA thrombosis developed postoperatively. All of the tumors were on the left side. Interruption of the SMA was recognized intraoperatively in all four children, and primary repair was done. In three patients, appearance of the bowel remained normal before repair of the injury. Three of the arteries were repaired by primary reanastomosis, and one was joined with an interpositioned hypogastric artery graft. None of these patients had gastrointestinal complications postoperatively. In the fifth patient, SMA thrombosis developed after repair of an aortic tear during nephrectomy. This patient required subsequent small bowel resection for bowel infarction and died in the perioperative period. Every surgeon treating children with Wilms' tumor should be aware of the possibly distorted vascular anatomy and take precautions to avoid such a significant injury. Attempts at early ligation of the vessels may not be justified until the renal vasculature is clearly identified.

Traumatic superior mesenteric artery--portal vein fistula

An interesting and rare case of traumatic superior mesenteric artery-to-portal vein arteriovenous fistula is presented. Initial operative control of the bleeding superior mesenteric artery injury required ligation of the superior mesenteric artery at its origin to prevent exsanguination in an extremely unstable patient with multiple injuries. Early postoperative visceral arteriography documented ligation of the superior mesenteric artery with a proximal superior mesenteric artery-to-portal vein arteriovenous fistula. Percutaneous catheter embolization of the arteriovenous fistula was undertaken successfully at this time. Superior mesenteric artery ligation was surprisingly well tolerated. Major arterioportal fistulas require treatment to prevent long-term complications of intestinal ischemia, portal hypertension, and cirrhosis. Although traditional treatment involves ligation of the arteriovenous fistula and arterial bypass, percutaneous embolization is becoming a viable alternative. Arteriography remains the cornerstone of diagnosis and treatment planning.

Traumatic injury of the proximal superior mesenteric artery

Injuries of the proximal superior mesenteric artery (SMA) are relatively uncommon, but extremely perplexing lesions. Fifteen consecutive patients with this injury, 13 injuries from gunshot wounds and two injuries from blunt trauma, have been treated. Associated lesions and massive blood loss were common, averaging 3.6 injuries and 4800 ml per patient, respectively. Methods of SMA repair include lateral arteriorrhaphy (11 patients), primary reanastomosis (3 patients), and saphenous vein grafts (1 patient). Two of three patients whose injuries included segmental loss of the SMA that required a primary end-to-end anastomosis suffered subsequent thrombosis. Second-look operations were performed in five patients with two of these requiring a further reconstructive procedure. The only late death occurred in a patient with a severe head injury and a failure of his SMA repair, which potentially could have been prevented by a second-look procedure. There were five deaths (33%), with four occurring from acute hemorrhages and one late death occurring following intestinal necrosis and sepsis. Malabsorption or other late intestinal complications did not occur. Our experience 1) supports the concept that proximal SMA lesions must be repaired, 2) suggests that primary anastomosis to repair arterial defects is associated with a high failure rate, and 3) demonstrates that the second-look operation is a useful adjunct in improving survival in these patients.

Superior mesenteric artery injury: a case report

A case of blunt trauma to the upper abdomen with multiple organ injury is described. The lesion involveing the superior mesenteric artery was undiagnosed at operation. The subsequent diagnosis and handling of the case is described with a review of the literature on blunt injury to this vessel.