Preliminary application of 3D-printed coplanar template for iodine-125 seed implantation therapy in patients with advanced pancreatic cancer

AIM

To evaluate a 3D-printed coplanar template for iodine-125 seed implantation therapy in patients with pancreatic cancer.

METHODS

A retrospective analysis of our database was performed, and a total of 25 patients with pancreatic cancer who underwent iodine-125 seed implantation between January 2014 and November 2017 were analyzed. Of these, 12 implantations were assisted by a 3D-printed coplanar template (group A), and 13 implantations performed freehand were selected as a control group (group B). A 3D coplanar template was designed and printed according to a preoperative CT scan and treatment planning system. The iodine-125 seeds were then implanted using the template as a guide. Dosimetric verification was performed after implantation. Pre- and postoperative D90, V100, and V150 were calculated. The success rate of iodine-125 seed implantation, dosimetric parameters, and complications were analyzed and compared between the two groups.

RESULTS

Iodine-125 seed implantation was successfully performed in both groups. In group A, the median pre- and postoperative D90 values were 155.32 ± 8.05 Gy and 154.82 ± 16.43 Gy, respectively; the difference between these values was minimal and not statistically significant (P > 0.05). Postoperative V100 and V150 were 91.05% ± 4.06% and 64.54% ± 13.40%, respectively, which met the treatment requirement. A better dosimetric parameter was observed in group A than in group B, and the difference was statistically significant (V100: 91.05% ± 4.06% vs 72.91% ± 13.78%, P < 0.05). No major procedure-related complications were observed in either group. For group A, mild hemorrhage was observed in 1 patient with a peritoneal local hematoma due to mesenteric vein damage from the iodine-125 seed implantation needle. The hematoma resolved spontaneously without treatment. Postoperative blood amylase levels remained within the normal range for all patients.

CONCLUSION

A 3D-printed coplanar template appears to be a safe and effective iodine-125 seed implantation guidance tool to improve implantation accuracy and optimize dosimetric distribution.

D3 Extended Mesenterectomy in Right Colectomy for Cancer: A Cadaver Simulation Model

BACKGROUND

D3 extended mesenterectomy (D3EM) for right colon cancer has received increased attention owing to suggested improvement of oncological outcomes. The aim of this study was to evaluate the proficiency-based progression of content-valid metrics in a cadaveric model for right colectomy with D3EM.

MATERIALS AND METHODS

Three expert surgeons were enrolled. Surgeon one performed the procedure robotically and surgeons two and three performed open D3EM. Proficiency-based progression was recorded for eight content-valid outcomes. The superior mesenteric vein (SMV) and artery were cannulated by independent observers to evaluate vascular tears. The specimens were analyzed for lymph node harvest by a pathologist blinded to surgical access and to the surgeon.

RESULTS

Operating times did not differ among surgeons (50.2, 32.4 and 43.7 min). SMV tears occurred in procedures A and B only. There was no significant progression in lymph node harvest for D2 (p=0.913) and D3EM (p=0.264).

CONCLUSIONS

Cadaveric training in D3EM was associated with progression in avoidance of vascular tears with no significant changes in operating time and lymph node harvest.

Outcome from Traumatic Injury of the Portal and Superior Mesenteric Veins

Traumatic injuries to the portal vein (PV) and superior mesenteric vein (SMV) are rare and carry a high mortality rate, and the best approach and method of repair is still subject to debate. The objective of the present study was to analyze risk factors for mortality in portal and superior mesenteric venous injuries. A retrospective analysis of 18 patients during a 5-year period was performed. Mechanism of injury, shock upon admission, Revised Trauma Score (RTS), Injury Severity Score (ISS), intraoperative fluid requirements, classification of venous injury severity, and associated injuries were analyzed as potential predictors of outcome. All patients were male, 9 were victims of gunshot wounds, and 11 were in shock at the time of admission. Eight patients sustained PV, and 12 sustained SMV injuries. The great majority of patients had more than 1 associated injury and 61% had an associated vascular injury. Mortality rate correlated with injury severity. Overall mortality rate was 72%. Nonsurvivors had higher ISS than survivors (24 ±0.4 and 20 ±1.7, respectively; p= 0.006). Uncontrollable intraoperative hemorrhage was the cause of death in 5 of 13 patients (38.4%). Six patients died during the postoperative period from complications of prolonged shock and multiple organ failure, and 2 died of sepsis. The physiologic status upon admission, the number of associated injuries, and the severity of the vascular injury are the most important factors related to mortality in PV and SMV injuries.

Successful partial pancreatotomy as a salvage procedure for massive intraoperative bleeding during head coring for chronic pancreatitis. Report of a case

CONTEXT

Chronic pancreatitis is a continuous inflammatory disease of the pancreas resulting in scarring and fibrosis with consequent decline in exocrine and endocrine function. The inflammatory process leads to the development of a head mass, and strictures and stones in the pancreatic duct which present as pain, or loco regional complications such as duodenal obstruction and biliary obstruction. The gold standard for the treatment of pain and loco regional complications remains surgery, which is usually a combination of drainage and partial resection (coring). This can be hazardous due to adhesions, inflammation or portal hypertension.

CASE REPORT

We report a case in which severe bleeding from the pancreatic duct was encountered during a Frey procedure. It was from the superior mesenteric vein/splenic vein confluence and would have warranted a Whipple procedure.

CONCLUSION

We describe a pancreatotomy for exposure and control of the bleeding, with re-suturing of the cut pancreas and completion of the pancreaticojejunostomy.

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.

[Abdominal bleeding due to spontaneous mesenteric vein rupture]

Hepatic cirrhosis is the leading cause of portal hypertension and is usually associated with the development ofsplacnic varices. Variceal intraabdominal rupture is a rare cause of hemoperitoneum. A case of spontaneous mesenteric vein rupture is reported.

CLINICAL CASE

43-year-old man with hepatic cirrhosis (Child-Pugh C stage) and previous bleeding of esophageal varices, admitted to hospital because of orthostatic hypotension episodes (positive tilt test) and abdominal distention. Laboratory: anemia, low platelet count and abnormal coagulation tests. CT scan showed abdominal fluid. Exploratory laparotomy was performed and 3 liters of blood were found into the abdominal cavity. The mesenteric vein had a ruptured variceal dilatation with intermitent jet bleeding. No organ abnormalities were found. Repair of the dilated vein was performed. The patient evolved well and was dismissed from hospital ten days after admittance.

OBJECTIVE

To present a case in which a rare cause of intraabdominal bleeding, usually associated with high mortality rate, is follawed by a good clinical evolution.

Poly-ADP-ribose polymerase inhibition reduces mesenteric injury after cardiopulmonary bypass

BACKGROUND

We investigated the effects of PARS inhibition on intestinal injury in a canine model of cardiopulmonary bypass (CPB).

METHODS

Twelve dogs underwent 90 minutes of hypothermic CPB. 6 dogs received 5 mg/kg PJ34, a selective PARP inhibitor during CPB, 6 vehicle-treated animals served as controls. Mesenteric blood flow (MBF) and mesenteric vascular resistance (MVR) were measured before and 60 minutes after weaning from CPB. Endothelium-dependent vasorelaxation to acetylcholine (ACH) and endothelium-independent vasorelaxation to sodium-nitroprusside (SNP) were expressed as percent change of MVR. In addition, mesenteric creatine kinase (CK) and lactate release were determined.

RESULTS

Baseline hemodynamics, MBF, response to ACH (- 41 +/- 3 vs. - 55 +/- 6 %) and SNP (- 60 +/- 2 vs. - 56 +/- 4 %) did not differ significantly between the groups. The response to ACH decreased significantly in the control group while it remained unchanged in the PJ34 group (- 29 +/- 5 vs. - 46 +/- 9 %, p < 0.05). The response to SNP did not change. Mesenteric CK release (325 +/- 99 vs. 16 +/- 10 U/l, p < 0.05) and lactate production (0.96 +/- 0.17 vs. 0.4 +/- 0.2 mmol/l, p < 0.05) were significantly lower in the PJ34 group.

CONCLUSION

PARP inhibition prevents CPB-induced mesenteric endothelial dysfunction and tissue damage.

Isolated Superior Mesenteric Vein Injury from Blunt Abdominal Trauma: Report of a Case

Solitary injury of the superior mesenteric vein (SMV) after blunt abdominal trauma is a rare but frequently fatal injury. A 63-year-old man was admitted to our hospital after falling on his right side from a height of 5 m. Computed tomography (CT) showed blood in the peritoneal cavity, but no liver or spleen injury. Emergency laparotomy revealed complete disruption of the SMV across the site of confluence with the splenic vein. We performed primary reconstruction by connecting both ends of the vein as an end-to-end anastomosis. Following restoration of gastrointestinal passage the patient was discharged in good health. At his 6-month follow-up, angio-CT showed an unobstructed SMV and portal vein. There was slight stenosis at the site of the suture and no sign of development of collateral venous circulation into the liver. This case report shows that primary repair of an SMV injury can be done in a stable patient without concomitant life-threatening injuries once proximal and distal control of bleeding has been achieved. Ligation should be reserved for patients with multiple injuries and an unstable condition.

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.

Superior mesenteric vein tear with total hip arthroplasty

Total hip arthroplasty imparts significant physical forces on the patient at the time of surgery. We report a case of an injury to the superior mesenteric vein that is thought to have occurred at the time of impaction of the acetabular component of a total hip arthroplasty. This complication has been reported previously only from high-energy nonpenetrating trauma, such as motor vehicle accidents.

Control of major hemorrhage from the spleno-mesenteric vein junction during pancreaticoduodenectomy: successful use of an occlusion balloon catheter

BACKGROUND/AIMS

Vascular disruption is sometimes associated with intractable hemorrhage due to either vessel fragility or increased blood flow rates in patients with chronic pancreatitis during surgical operation. This paper describes the successful use of an occlusion catheter for repairing a major laceration at the spleno-mesenteric vein junction.

METHODS

A 14-Fr Fogarty occlusion balloon catheter was directly inserted into the splenic vein through the site of venous laceration and inflated to stop blood flow from the splenic vein.

RESULTS

This procedure perfectly controlled massive hemorrhage from the spleno-mesenteric vein junction. The injured site was repaired with a continuous suture in 5 min.

CONCLUSION

The direct insertion of a balloon catheter to the injured site is simple and expeditious to control major hemorrhage from the spleno-mesenteric vein junction when the situation is otherwise unmanageable.

Fatal retroperitoneal haemorrhage: an unusual complication of percutaneous endoscopic gastrostomy

A 93-year-old lady with dementia, neurological dysphagia and aspiration pneumonia, died from massive retroperitoneal haemorrhage which developed as a rare and, it is believed, hitherto unreported, complication of percutaneous endoscopic gastrostomy (PEG), which was performed for feeding purposes. It is postulated that the initial, unsuccessful attempt at needle puncture of the stomach, under endoscopic guidance, had resulted in iatrogenic perforation and laceration of the splenic and superior mesenteric veins close to their confluence with the portal vein. It would also appear that dense fibrous adhesions between the pyloro-antral region of the stomach and the posterior hepatic surface had altered the immediate anatomical relations of the stomach in such a manner as to have predisposed to these events.

Operative management and outcome of 302 abdominal vascular injuries

BACKGROUND

Abdominal vascular injuries incur high mortality rates. The purposes of this study are (1) review institutional experience, (2) determine additive effect on mortality of multiple vessel injuries, (3) determine mortality of combined arterial and venous injuries, and (4) correlate mortality with American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury.

METHODS

A retrospective 6-year study was made at an urban level I trauma center of patients with abdominal vascular injuries. Main outcome measure was survival.

RESULTS

(1) There was a total of 302 patients, mean age 28, mean Injury Severity Score (ISS) 25 (range 4 to 75). Mechanism of injury was penetrating in 266 (88%), blunt in 36 (12%). Emergency Department thoracotomy was done in 43 of 302 (14%), 504 vessels were injured: arteries 238(47%), veins 266(53%). Surgical management was ligation 245, primary repair 141, prosthetic interposition grafts 24, autogenous 2. Overall mortality was 162 of 302 (54%). (2) Mortality multiple vessels injured: 1 vessel 160 (45%), 2 vessels 102 (60%), 3 vessels 33 (73%), >4 vessels 5 (100%). Mortality arterial injuries: aorta isolated (I) 78% versus combined with other arterial injuries (C) 82.4%, superior mesenteric artery (SMA) I 47.6% versus C 71.4%, iliac I 53% versus C 72.7%, renal I 37.5% versus C 66.7%. Venous injuries: inferior vena cava (IVC) isolated (I) 70% versus combined with other venous injuries (C) 77.7%, superior mesenteric vein (SMV) I 52.7% versus C 65%, IMV I 16% versus C 50%. (3) Specific mortality combined arterial and venous injuries: aorta plus IVC 93%, SMA plus SMV 43%, iliac artery plus vein 45.5%. (4) Mortality versus AAST-OIS: grade II 25%, grade III 32%, grade IV 65%, grade V 88%.

CONCLUSION

Abdominal vascular injuries are highly lethal. Multiple arterial and venous injuries increase mortality. Mortality correlates with AAST-OIS for abdominal vascular injury.

Two-stage trauma pancreaticoduodenectomy: delay facilitates anastomotic reconstruction

A case of a gunshot wound to the head of the pancreas and superior mesenteric vein requiring pancreaticoduodenectomy is discussed. Managing such an injury is challenging, first because of the ongoing hemorrhage and second because of the technical difficulty in working with a normal pancreas and bile duct. In the case presented herein, enteric reconstruction was performed 72 hours after the initial surgery. A delay in reconstruction resulted in tissue changes that facilitated enteric reconstruction A two-stage pancreaticoduodenectomy may be considered if the surgeon is faced with an unstable patient.

Computed tomography (CT) findings of gastric rupture after blunt trauma

A 49-year-old carpenter was hit by timber around his upper abdomen 1 hour after breakfast. Immediate computed tomography was taken, followed by emergency laparotomy showing gastric rupture accompanied with hemorrhage from the superior mesenteric vein. Hemostasis and distal partial gastrectomy followed by Billroth-I anastomosis reconstruction was performed. Here, we report the abdominal computed tomography findings from a patient with gastric rupture after blunt trauma. The present case, which is only the second such case reported in English literature, suggested that computed tomography is useful for assessing associated injuries in gastric rupture patients, for detecting intraperitoneal free air which can be missed by X-rays, and for locating the laceration of the rupture.

Mechanisms of parenchymal cell death in-vivo after microvascular hemorrhage

OBJECTIVE

In vitro studies suggest that microhemorrhages with escape of red cells into the tissue may be cytotoxic to parenchymal cells due to oxygen free radical formation. We examined in the rat mesentery the impact of microhemorrhages on parenchymal cell death, as detected by propidium iodide staining, using an intravital approach.

METHODS AND RESULTS

Postcapillary venules were punctured with a closed-end micropipette, permitting escape of blood cells and plasma into the mesentery interstitium. Over a period of 2 h, no significant increase in parenchymal cell death was encountered in tissues with hemorrhagic sites compared with nonhemorrhagic control sites. Interstitial microinjections of plasma derived from whole blood incubated for several hours with and without a combination of sodium azide (2 mM) and hydrogen peroxide (1 mM) led to significantly increased levels of cell death compared to control experiments. Interventions against the hydroxyl radical with dimethylthiourea (DMTU, 2 mM) or 2,2'-dipyridyl (DPD, 2 mM), a lipid soluble iron chelator, provided no protective effect against the parenchymal cell death. DMTU slightly delayed tile cytotoxic reaction.

CONCLUSIONS

These observations suggest that a newly formed microhemorrhage is not necessarily cytotoxic to parenchymal tissue cells. Interstitial microinjections of plasma, derived from whole blood after prolonged exposure to oxygen free radicals or just aging under in vitro conditions, may be cytotoxic to mesenteric parenchymal cells without effective blockade by interventions against the hydroxyl radical.

Gastrocolic vein. Definition and report of two cases of avulsion

The gastrocolic v. or Henle's gastrocolic trunk was described in 1868 [9]. We suggest defining this vein as the confluence of the right gastroepiploic and right upper colic vv. We report two original cases of avulsion of the gastrocolic v. occurring during a blunt abdominal trauma. The aim of this paper is a description, based on the literature, of the anatomy of the gastrocolic v. in order to precise the lesional mechanism. The gastrocolic v. is present in 70% of individuals. It is short (less than 25 mm) but of major calibre (3 to 10 mm). The gastrocolic v. is situated close beneath the root of the transverse mesocolon, and travels along the anterior surface of the head of the pancreas. Anatomic variations are detailed and a meta-analysis of interpretable studies was made. Both the supra- and infra-mesocolic surgical approaches are described. The radiologic and surgical importance of the gastrocolic v. is discussed. The lesional mechanism in both our cases of injury of the gastrocolic v. is explained.

Abdominal vascular injuries

Injuries to major abdominal arteries and veins frequently are associated with exsanguinating hemorrhage and visceral ischemia. Expeditious management is the key to survival and good outcome. Knowledge of anatomic relationships between viscera and vessels forms the basis for directed dissection, optimal exposure, and lasting repair of vessels. Although penetrating mechanism of injury remains the most common cause of these injuries, trauma surgeons must be familiar with patterns of blunt trauma-mediated injury to avoid the devastating consequences of delayed management.

Gastrointestinal perforation or vascular injury? A diagnostic dilemma for computed tomography in blunt abdominal trauma

The authors describe an unconscious 20-year-old woman with Crohn's disease who was examined after a motor vehicle accident. During dynamic computed tomography after intravenous and oral administration of contrast material, contrast agent was observed in the peritoneal cavity. The source of the free contrast material was active bleeding, but it was initially mistaken for extravasation from the bowel. Exploratory laparotomy revealed transection of the superior mesenteric vein.

Successful management of traumatic mesenteric arteriovenous fistula after failure of steel coil embolization: case report

Arteriovenous fistulas affecting the mesenteric circulation are rare. To our knowledge, this is the first case report in which a large fistula was initially treated by steel coil embolization and, after failure of this procedure, subsequently surgically corrected. A case is reported and the literature reviewed.

Vascular injuries during pancreatobiliary surgery

Fourteen cases of vascular injury during pancreatobiliary surgery have been treated at our institution. The patients' mean age was 49 years, and nine were males. Six operations were performed for chronic pancreatitis, six for cancer, and two for an inflammatory process. Operations included 11 pancreatic resections and one laparoscopic cholecystectomy, one sphincteroplasty, and one pseudocyst drainage. Vessels injured included the portal vein (7), superior mesenteric vein (6), superior mesenteric artery (3), hepatic arteries (4), splenic vein (3). Six patients experienced more than one vascular injury. In all but one case, the injury was recognized and repaired during the initial operation. Primary repair was possible in seven cases. Six cases utilized autogenous tissue for repair. The one unrecognized injury was a right hepatic artery ligation, and a delayed repair was not possible. Follow-up demonstrated two occlusions, one following a portal vein repair without clinical sequela and a superior mesenteric artery repair which resulted in a small bowel stricture. The one unrecognized hepatic artery injury resulted in necrosis of the proximal common hepatic duct. Vascular injury following pancreatobiliary injury tends to occur in the presence of pancreatitis or cancer with its associated dense adhesions and inflammatory process. The variable anatomy of this area contributes to vascular injuries. Immediate recognition of the injury and repair appears to yield excellent results.

Effects of different hirudins and combinations of low doses of hirudin, heparin and acetylsalicylic acid in a rat microcirculatory thrombosis model

Two recombinant hirudins (r-hirudin), natural hirudin and hirudin in combination with heparin or acetylsalicylic acid (ASA) have been studied in a thrombosis model in which rat mesenteric venules of a diameter of 20-30 microns were injured by well-defined argon laser lesions. In the animal model all hirudins showed significant and dose-dependent antithrombotic effects in doses between 0.05 and 0.1 mg/kg after single intravenous and subcutaneous injections. The antithrombotic effect of single (0.2 mg/kg i.v. or 0.1 mg/kg s.c.) injections lasted longer than 4 h (i.v.) or 6 h (s.c.). Hirudin at a dose of 0.1 mg/kg and heparin at doses of 0.05 mg/kg showed a significant antithrombotic effect 2 h after subcutaneous injection. When heparin and hirudin were injected together at this dosage, the effect of the combination was in the same range as that of unfractionated heparin or hirudin alone. An additive antithrombotic effect was observed if a low dose of r-hirudin (0.1 mg/kg) was combined with a moderate dose of ASA (10 mg/kg).

Endothelin-1 and U46619 potentiate selectively the venous responses to nerve stimulation within the perfused superior mesenteric vascular bed of the rat

The effects were examined of endothelin-1 and U46619 on the responses to perivascular nerve stimulation of the simultaneously perfused arterial and venous vessels of the superior mesenteric arterial bed of the rat. Stimulation of the nerves at 4-16 Hz for 30 s caused frequency dependent constrictions of both the arterial and venous vessels similar to those produced by bolus doses of exogenous noradrenaline (0.1-10 nmol). Infusion of either endothelin-1 (0.1 nM) or U46619 (1-3 nM) caused small (less than or equal to 5 mmHg) increases in arterial and venous perfusion pressures and selectively potentiated the venous, but not arterial, responses to nerve stimulation. Conversely, endothelin-1 and U46619 potentiated the responses of both the arterial and venous vessels to exogenous noradrenaline. Thus, as reported previously for the arterial vessels of the rat mesentery, the isolated venous vessels constrict to perivascular nerve stimulation in a frequency dependent manner. In addition, endothelin-1 and U46619 potentiate selectively the effects of nerve stimulation on the veins.

Intraoperative assessment of blood flow and tissue viability in small-bowel ischemia by laser Doppler flowmetry

Laser Doppler flowmetry (LDF) was used for intraoperative assessment of blood flow and tissue viability in 23 patients with small-bowel ischemia, and the signal levels in ischemic bowel were compared with previously obtained reference values from normal ileum and jejunum. The average LD signal was 6.8 +/- 2.9 V in nonischemic bowel, 0.3 +/- 0.2 V in segments with macroscopically irreversible ischaemia and 2.1 +/- 1.2 V in segments with clinically uncertain viability. In 12 cases with strangulated bowel it was possible, following LDF, to avoid resecting nine of ten bowel segments with clinically uncertain viability. In four of the six patients with mesenteric vascular occlusion, LDF indicated that clinical judgement had underestimated the extent of severe ischemia. Among the five cases of iatrogenic ischemia there was one failure, with postoperative irreversible ischemia and anastomotic leakage. LDF is concluded to be a useful method for intraoperative assessment of intestinal blood flow in patients with small-bowel ischemia and it provides substantial information on tissue viability affecting surgical strategy.

Superior mesenteric vein severance from blunt abdominal trauma: report of a case

Injury of the superior mesenteric vein from blunt abdominal trauma is an uncommon but frequently fatal injury. A 63-year-old man was injured in a motorcycle accident. He was admitted to our hospital in profound shock. Immediate celiotomy revealed superior mesenteric vein injury which was repaired by end-to-end anastomosis. Rapid fluid resuscitation and expeditious exploration are the key in saving patients with this condition. Indications for exploration of retroperitoneal hematomas, techniques of exposure, modes of reconstruction of the injured vein and the importance of a second-look operation are discussed.

Abdominal vascular injuries

Abdominal vascular injuries remain rare in centers that primarily treat victims of blunt trauma, but when penetrating wounds of the abdomen are commonly treated, the incidence of abdominal vascular injuries is surprisingly high. With suitable management, many of these patients survive.

Ligation as definitive management of injury to the superior mesenteric vein

Ligation of the injured superior mesenteric vein in patients with multisystem trauma has been regarded as a hazardous procedure with a narrow spectrum of indications. We present three patients who underwent ligation of their superior mesenteric veins. A collective review of 33 superior mesenteric vein ligations and 75 superior mesenteric venorrhaphies indicated that ligation of this vein is indeed a valid option when a simple repair cannot easily be performed.

Traumatic injury to the proximal superior mesenteric vessels

Twenty-one patients were treated for 25 injuries to the proximal superior mesenteric vessels (eight, superior mesenteric artery; nine, superior mesenteric vein; four, superior mesenteric artery plus superior mesenteric vein). Mechanisms of injury were stab wounds (11 cases), motor vehicle accidents (9 cases), and iatrogenic (one case). Ten patients (48%) arrived at the emergency room in shock (two with no obtainable case blood pressure). Superior mesenteric artery repair was performed by lateral suture (seven cases), end-to-end anastomosis (three cases), autogenous vein graft (one case), and no repair (one case). All 13 venous injuries were repaired by lateral suture. Four patients (19%) died in the operating room secondary to acute blood loss and irreversible shock. There were no late deaths and no second-look operations. Further improvement in survival depends on rapid transportation from injury site to operating room.

[Iatrogenic celiac-mesenteric arteriovenous fistulae; with reference to a new case of postgastrectomy arteriovenous fistula]

The authors report a rare case of iatrogenous arteriovenous fistula between left gastric artery and vein, arising after gastric resection. The observation caused a reviewing of the literature (19 cases published, of which only one between left gastric artery and vein) and some remarks about the physiopathology, pathological anatomy, clinics and treatment of such rare diseases. The authors, in their conclusions, emphasize that such arteriovenous fistulas can remain asymptomatic for a long time; they, moreover, with evident effects on the liver physiology, can progressively cause a serious state of portal hypertension, in the genesis of which the time-factor plays a primary role.

Homicidal blunt abdominal trauma with isolated laceration of the small bowel mesentery

Nonpenetrating abdominal trauma rarely causes isolated mesenteric lacerations with fatal hemorrhages. When this does happen, it is often the result of compression by a lap seal belt or a steering wheel, only extremely rarely is it the result of a homicidal act. In the present paper, two homicide victims with resulting mesenteric tears and fatal bleeding due to sagittal compression are described. A high blood alcohol concentration may in both cases have contributed to the fatal outcome. The cases support the assumption that direct rather than indirect trauma causes this kind of lesion.

Superior mesenteric artery and vein injuries from blunt abdominal trauma

During an 8-year period, from 1974 to 1982, 13 patients were treated for superior mesenteric vascular injury secondary to blunt abdominal trauma. Ten male and three female patients ranged in age from 18 to 68 years (average age, 42.7 years). Six patients presented in profound shock, two presented in cardiopulmonary arrest, and five presented with mild shock. The 13 patients had an average of 3.2 associated intra-abdominal injuries. Six patients had devitalized bowel as a direct consequence of injury to the superior mesenteric vessels. One patient developed intestinal necrosis postoperatively from thrombosis of the superior mesenteric vein which led to extensive small bowel resection. The blood replacement ranged from 2 to 30 units, averaging 11.7 units per patient. Operative procedures included lateral arteriorrhaphy (five patients) and venorrhaphy (11 patients). Four patients required combined vessel repair and one patient required ligation of both vessels and bowel resection. The mortality rate of 57% was primarily due to massive acute hemorrhage, which was larger than could be accounted for by the associated intraabdominal injuries. Free intraperitoneal hemorrhage from the valveless portal system, which can carry up to 60% of cardiac output, causes massive bleeding until abdominal tamponade supervenes.

Trauma to major visceral veins: an underemphasized cause of accident mortality

In the period 1970-1978, a mortality rate of 44% resulted in 45 patients who suffered major intra-abdominal venous injuries. An especially grave prognosis accompanied wounds to the inferior vena cava and the hepatic and portal venous systems. Management of damage to major veins presents several difficulties. Exposure is poor; veins tear easily when clamped or sutured; exsanguination can occur as rapidly as with arterial trauma; because of low intraluminal pressure, postoperative chances of thrombosis and occlusion are high; veins (unlike arteries) have no intrinsic vasomotor capabilities to halt bleeding. Finally, the misconception persists that venous wounds are less serious than comparable arterial injuries. Simple pressure by packs or hand often controls bleeding: otherwise clamps, balloons, hemostats, or ligation can be selectively chosen. Our experience suggests that atrial-caval shunting without prior identification and control of the bleeding site is doomed to failure.

Traumatic arteriovenous fistula of the superior mesenteric vessels

A case of traumatic arteriovenous fistula of the superior mesenteric vessels is added to a collective review of 16 previous cases. Nausea, vomiting, cramping abdominal pain, diarrhea, abdominal thrill and bruit were usually present. Arteriography was diagnostic. Four patients operated upon immediately or within 11 hours after penetrating abdominal trauma had superior mesenteric arteriovenous injuries repaired; the remainder had a mesenteric vascular injury missed at initial laparotomy. The location of the fistula determined the method of repair. Spontaneous obliteration occurred in one patient. In two of the three deaths, portal hypertension was persent and a fistula was discovered at autopsy; the other occurred 3 months after massive bowel resection. Thorough exploration of hematomas and lacerations of the mesentery will minimize or eliminate subsequent formation of an arteriovenous fistula.

Lower gastrointestinal bleeding: an unusual presentation for blunt abdominal trauma

A case of mesenteric vascular injury secondary to nonpenetrating steering wheel abdominal trauma is presented. Unique to this report is the presentation of blunt abdominal trauma as acute lower gastrointestinal bleeding with demonstration of the lesion preoperatively via selective celiac and superior mesenteric arteriography.

Intramesenteric perforation of sigmoid diverticulitis with nonfatal venous intravasation

Complications from barium enema are rare (0.035 per cent). A patient with venous intravasation during barium enema complicated by pylephlebitis and portal vein obstruction is the tenth to be reported on, the fourth to survive. This accident was associated with colon disease in eight of the patients studied, five of whom had diverticular disease.

Isolated mesenteric injury due to blunt abdominal trauma

Isolated injuries of the small bowel mesentery or mesocolon with subsequent bowel infarction due to blunt abdominal trauma are rare. Two cases are described: 1 involving the mesentery to the terminal ileum and 1 involving the transverse mesocolon and middle colic artery, both with bowel infarction. The modes of clinical presentation and management of patients with injuries to the mesentery, mesocolon and mesenteric vessels following blunt trauma are described.

Trauma to the portal venous system

During a 16-year period, 47 wounds of the portal and/or superior mesenteric veins were encountered. Overall mortality was 57%. Survival was greatest in patients with injury to the superior mesenteric vein, wounds repairable by lateral phleborrhaphy, absence of associated major vascular trauma, and only transient or minimal hypovolemic shock. The majority of deaths were due to uncontrollable bleeding or sequelae of profound hemorrhagic shock. Limited follow-up of survivors has demonstrated a low patency rate at the site of venous repair, suggesting that mere ligation may be all that is necessary when lateral repair is impossible.