Variant origins of the middle colic artery from the coeliac trunk and its branches

The middle colic artery usually arises from the superior mesenteric artery, but in rare cases it may arise from the coeliac trunk or its branches. The aim of this study was to investigate variant origins of the middle colic artery on computed tomography and anatomical dissection. Variant middle colic arteries were identified on computed tomography as part of an ongoing study investigating anatomical variations of vessels of the upper abdomen. Three-dimensional reconstructions were made to demonstrate the variant findings. Cadaveric dissections were performed as part of a routine dissection course. We report five cases of rare variant origins of the middle colic artery arising from the coeliac axis. Among these sites of origin were the coeliac trunk, the gastrosplenic trunk, the splenic artery, and the common hepatic artery. Four cases were identified on multi-detector computed tomography and one in a cadaver. In all cases, the vessels passed posterior to the body of the pancreas before entering the transverse mesocolon. Knowledge of middle colic artery variations is important to prevent inadvertent injury in digestive surgery, especially in the hepatopancreatic area. Variant origins of the middle colic artery are rare, and their knowledge is crucial to prevent unnecessary iatrogenic injury during abdominal surgery.

Duodenal ulcer bleeding from a branch of the middle colic artery: A case report

RATIONALE

Duodenal ulcer bleeding is a potentially life-threatening condition commonly caused by the erosion of the duodenal arteries.

PATIENT CONCERNS

A 55-year-old male was referred to our hospital with abdominal pain for the past 3 days. Contrast-enhanced computed tomography of the abdomen revealed wall thickening in the descending part of the duodenum and a cystic lesion (27 × 19 mm) contiguous with the duodenum, with an accumulation of fluid. An esophagogastroduodenoscopy showed the significantly stenotic duodenum, which prevented passage of the endoscope and evaluation of the main lesion. Based on these findings, duodenal ulcer perforation and concomitant abscess formation were suspected. Two days after admission, he had massive hematochezia with bloody drainage from the nasogastric tube.

DIAGNOSES

Emergency angiography revealed duodenal ulcer bleeding from the gastroduodenal artery and the branch artery of the inferior pancreaticoduodenal artery and middle colic artery (MCA).

INTERVENTIONS

The patient was treated with transcatheter arterial embolization (TAE) of the gastroduodenal artery, the branch vessel of the inferior pancreaticoduodenal artery, and the main trunk of the MCA.

OUTCOMES

Hemostasis was achieved with TAE. The patient recovered uneventfully and undergone a gastro-jejunal bypass surgery for the duodenal stenosis 2 weeks after TAE. He was discharged without any abnormal complaints on postoperative day 12.

LESSONS

We have experienced a rare case of duodenal ulcer bleeding from a branch of the MCA. In patients with refractory upper gastrointestinal bleeding, careful evaluation of bleeding sites is recommended considering unexpected culprit vessels.

Evaluation of Multiple Embolic Agents for Embolization of the Superior Rectal Artery in an Animal Model

OBJECTIVE

To prospectively compare the safety of transcatheter embolization of superior rectal arteries in healthy pigs with multiple agents such as coils, spheres and liquids.

MATERIALS AND METHODS

Nine adult domestic pigs (three males, mean weight: 60 kg [50-70]) were randomly assigned to the embolization group: copolymer of ethylene vinyl alcohol (EVOH)-Onyx® (group 1, n = 3), microspheres 500 µ (group 2, n = 3), 2-mm micro-coils (group 3, n = 3). After a selective angiogram has been acquired, the embolic agent was infused at the distal part of rectal arteries. An angio-CT was performed before and after each embolization. After one week, angiography was repeated prior to euthanasia. At necropsy, the anorectal juncture was removed for histopathologic examination.

RESULTS

At necropsy, 100% of animals embolized with Onyx developed a significant necrosis zone of the distal part of the rectum. Histological examination revealed a mural infarction. For the micro-coil and microsphere groups, gross examination of the intestines did not reveal any evidence of ischaemia. The coils were found in the distal arterial vasculature of the meso-rectum, allowing a downstream revascularization by collaterals. The microspheres and onyx in the rectal wall, more distally.

CONCLUSION

Microspheres appear to induce fewer histologic complications than the liquid embolic agent and provide a more distal occlusion than micro-coils. These results suggest that, for superior rectal artery embolization, a super-selective embolization using spheres in human clinical conditions should be more effective and as safe as coil embolization. EVOH might be an unsafe embolization agent for haemorrhoids.

Preservation of the superior rectal artery in laparoscopic colectomy for slow transit constipation: Is it really associated with better outcomes?

Few patients with slow-transit constipation refractory to conservative treatment can benefit with a subtotal colectomy with ileorectal anastomosis with the preservation of the superior rectal artery. In this letter to the editor some important issues were discussed. First, the study did not include a comparison group. Second, they did not present the functional results in the short or long term related to the bowel function of these patients after surgery. Finally, the authors showed that this surgical procedure was safe, and no cases of leakage were found.

Superior Rectal Artery Embolization for Symptomatic Grades 2 and 3 Hemorrhoidal Disease: 6-Month Follow-up among 43 Patients

PURPOSE

To assess the technical and clinical success rates of superior rectal artery embolization in the treatment of symptomatic Grades 2 and 3 hemorrhoidal disease.

MATERIALS AND METHODS

Since March 2019, 43 patients (24 men and 19 women; mean age, 52 years [18-77 years]) with symptomatic hemorrhoidal disease have been treated and completed the 6-month follow-up with anamnestic questionnaire and disease scores, including French bleeding, Goligher prolapse, visual analog scale for pain, and quality of life. Clinical success was assessed at 7 days, 1 month, and 6 months of follow-up by updating the clinical scores. Statistical analysis was performed using SPSS 25.0.

RESULTS

In all, 25 patients had Grade 2 prolapse and 18 patients had Grade 3 prolapse, with 96% and 77%, respectively, having bleeding as a symptom. All patients were discharged within 24 hours. The reduction in the French bleeding score (global and single entity) in Grade 3 prolapse was statistically significant (P = .001). Improvement in the quality of life was significant in both groups (P < .05). No serious complications were registered.

CONCLUSIONS

Hemorrhoidal embolization was a safe and effective technique in the treatment of symptomatic hemorrhoidal disease with minimal hospitalization, pain, and disruption of daily activities. It can be offered to patients unwilling to undergo a surgical procedure but can also be indicated in the emergency setting for patients on anticoagulant therapy or those unfit for surgery.

Preservation of superior rectal artery in laparoscopically assisted subtotal colectomy with ileorectal anastomosis for slow transit constipation

BACKGROUND

Slow transit constipation (STC) has traditionally been considered as a functional disorder. However, evidence is accumulating that suggests that most of the motility alterations in STC might be of a neuropathic etiology. If the patient does not meet the diagnosis of pelvic outlet obstruction and poorly response to conservative treatment, surgical intervention with subtotal colectomy may be effective. The most unwanted complication of the procedure is anastomotic leakage, however, preservation of the superior rectal artery (SRA) may reduce its incidence.

AIM

To evaluate the preservation of the SRA in laparoscopically assisted subtotal colectomy with ileorectal anastomosis in STC patients.

METHODS

This was a single-center retrospective observational study. STC was diagnosed after a series of examinations which included a colonic transit test, anal manometry, a balloon expulsion test, and a barium enema. Eligible patients underwent laparoscopically assisted total colectomy with ileorectal anastomosis and were examined between January 2016 and January 2018. The operation time, blood loss, time to first flatus, length of hospital days, and incidence of minor or major complications were recorded.

RESULTS

A total of 32 patients (mean age, 42.6 years) who had received laparoscopic assisted subtotal colectomy with ileorectal artery anastomosis and preservation of the SRA. All patients were diagnosed with STC after a series of examinations. The mean operative time was 151 min and the mean blood loss was 119 mL. The mean day of first time to flatus was 3.0 d, and the mean hospital stay was 10.6 d. There were no any patients conversions to laparotomy. Post-operative minor complications including 1 wound infection and 1 case of ileus. There was no surgical mortality. No anastomosis leakage was noted in any of the patients.

CONCLUSION

Laparoscopically assisted subtotal colectomy with ileorectal anastomosis and preservation of the SRA can significantly improve bowel function with careful patient selection. Sparing the SRA may protect against anastomosis leakage.

Do We Have Another Option to Treat Bleeding Hemorrhoids? The Emborrhoid Technique: Experience in 16 Patients

BACKGROUND

Hemorrhoidal disease is very common in western countries and rectal bleeding is the main symptom complained by patients. Nowadays the ultimate goal of treatment is to block the bleeding with minimally-invasive techniques to minimize post-procedural pain.

OBJECTIVE

The aim of this study is to assess the preliminary results of the emborrhoid technique (embolization of the superior rectal arteries branches) as a new tool for the proctologist to treat severe bleeding hemorrhoids causing anemia. Many categories of patients might benefit from this treatment, such as patients not eligible for conventional surgery, patients not responding to conventional treatment and fit patients with severe bleeding who refused endorectal surgical therapy.

METHODS

From May 2017 to November 2018 a total of 16 patients with chronic rectal bleeding due to hemorrhoids underwent super-selective embolization of the superior rectal arteries at the department of General Surgery in La Spezia, S. Andrea Hospital, Italy. Median age was 59 years. 14 patients were males (87.5%).

RESULTS

No post-procedural and short-term complications were observed at maximum follow up (12 months). The reduction of rectal bleeding with improvement of the quality of life was obtained in 14 patients (87.5%).

CONCLUSION

Our study, although small in number, demonstrates that embolization of superior rectal arteries with coils to treat severe bleeding due to hemorrhoids is safe and effective and does not lead to immediate complications.

Should Surgeons Evaluate the Anatomy of Drummond Marginal Artery and Riolan's Arch Preoperatively?

INTRODUCTION

The Drummond marginal artery and the Riolan's arch are important links between the superior mesenteric artery (SMA) and inferior mesenteric artery (IMA), which provide collateral flow in case of arterial occlusion or significant stenosis. The Riolan's arch is important in colorectal surgery since it allows for vascularization of the descending colon by the SMA after ligation of the IMA at its origin, especially in cancer patients. In this study, we aimed to evaluate the presence of the Drummond marginal artery and the Riolan's arch. In addition, we assessed anatomic variants of the middle colic artery (MCA) and classified the anatomic relationships between SMA and SMV.

MATERIALS AND METHODS

Following screening, 115 abdominal CT scans were included in the study. For all cases, the presence of the Drummond marginal artery and the Riolan's arch, the first diameter of these arterial structures at their origins, the first emerging diameter and anatomic variants of the MCA, and the anatomic relationships between SMA and SMV were evaluated.

RESULTS

Drummond marginal artery was present in all participants (100%). The Riolan's arch was observed in 27.8% of all cases and was higher than in other studies. This can be related to the focus of this arch. In addition, we did not find any similar study in the literature that evaluated MCA origin types, SMA-SMV variants with the presence of the Drummond artery and the Riolan's arch, and the first emerging diameters of vascular structures, such as the Drummond marginal artery, the Riolan's arch, and MCA.

CONCLUSION

Evaluating and stating whether the Drummond marginal artery and the Riolan's arch are seen in thin section abdominal computed tomography (CT) and CT angiographies preoperatively may help in planning appropriate resections and can reduce unwanted postoperative morbidity.

Retained Products of Conception Fed by the Inferior Mesenteric Artery: A Case Report

Retained products of conception (RPOC) refer to the persistence of placental or fetal tissue in the uterus following delivery or miscarriage. RPOC may cause massive postpartum or post-abortion hemorrhage. Arterial embolization (AE) is an effective choice of management for postpartum hemorrhage including RPOC. We report a case of hemorrhagic RPOC, in which uterine artery embolization with transcervical resection did not achieve hemostasis, and laparotomy with uterine compression sutures was subsequently required. The RPOC was apparently fed by an aberrant branch derived from the inferior mesenteric artery (IMA). AE of IMA was not performed because of possible necrosis of the descending colon and rectum. A physician should be aware that AE is not an all-encompassing hemostatic technique for postpartum bleeding, such as with RPOC, and should keep alternatives in mind.

[A swollen leg because of an aortocaval fistula]

Aortocaval fistulas are a rare and potentially life-threatening complication of aortic aneurysms. They pose a significant diagnostic challenge due to their aspecific presentation. We describe two cases of patients who were admitted to the emergency room with an unusual presentation. The first patient was a 69-year-old male, with a history of hypertension and hyperlipidemia, who was admitted to our hospital with a painful and swollen left leg. The second patient was a 75-year-old male with a history of coronary artery bypass graft and cholecystectomy who was admitted due to a swollen left leg and dyspnea. We also give a review of the literature regarding the clinical presentation, diagnosis and management of aortocaval fistulas.

[Meta-analysis for high-risk factor of anastomotic leakage after anal-preserving surgery for rectal cancer]

OBJECTIVE

To systematically evaluate the effect of defunctioning stoma, preoperative radiotherapy, and level of inferior mesenteric artery (IMA) ligation on the postoperative anastomotic leakage in rectal cancer by meta-analysis.

METHODS

Randomized controlled trials (RCT) published before December 2017 regarding the effects of defunctioning stoma, preoperative radiotherapy, and level of inferior mesenteric artery ligation on the postoperative anastomotic leakage in rectal cancer were searched from PubMed, Embase, Scopus, Cochrane Library, CNKI, Wanfang database, meanwhile open data in unpublished trials from clinicaltrials.gov were retrieved. Associated data were screened according to standard and their quality was evaluated strictly. Review manager 5.3 software was used to perform meta-analysis with data. Random effect model based on DerSimonian and Laird method was applied. Heterogenicity among trials was estimated with Chi-square test.

RESULTS

Twenty articles were included in the meta-analysis. The overall incidence of anastomotic leakage was 7.0%(488/7004). The incidence of anastomotic leakage in the defunctioning stoma group and non-defunctioning stoma group was 5.2%(24/459) and 17.3%(77/445) respectively. The incidence of anastomotic leakage in the radiotherapy group and non-radiotherapy group was 6.5%(188/2900) and 6.1%(179/2946) respectively. The incidences of anastomotic leakage in the low and high IMA ligation groups was 4.7%(6/129) and 11.2%(14/125) respectively. Meta-analysis showed that the incidence in defunctioning stoma group was significantly lower than that in non-defunctioning stoma group (RR:0.33, 95%CI:0.21-0.50, P<0.00001); the incidences between radiotherapy group and non-radiotherapy (RR:1.05, 95%CI: 0.80-1.38, P=0.72), and between low IMA ligation group and high IMA ligation group (RR:0.50, 95%CI:0.20-1.23, P=0.13) were not significantly different. Funnel figure drawn with RCTs about defunctioning stoma and preoperative radiotherapy revealed no significant publication bias existed within included studies.

CONCLUSION

Defunctioning stoma can effectively prevent the occurrence of postoperative anastomotic leakage, whereas the preoperative radiotherapy and high IMA ligation may not increase the risk of anastomotic leakage.

[Prevention of anastomotic leakage after robotic surgery for rectal cancer]

With popularity of robotic surgery system, robotic rectal cancer surgery is increasing. Precautionary measures of different perioperative periods should be taken to reduce the risk for anastomotic leakage. First, the general condition of patients should be acquainted and improved, and the risk for anastomotic leakage should be evaluated preoperatively. Preoperative neoadjuvant chemoradiotherapy may not increase the risk for anastomotic leakage after rectal surgery. The impact of routine bowel preparation to prevent anastomotic leakage needs to be verified further. Second, surgical techniques are crucial to prevent anastomotic leakage. Surgical procedures and resected intestines should be carefully selected. Careful surgery, adequate mobilization of the proximal colon, anastomosis with direct view will be required. Tension-free anastomosis and sufficient blood supply are necessary. We selected low ligation of the inferior mesenteric artery and preservation of the left colic artery in our routine practice to guarantee sufficient blood supply of the anastomosis site. Using the robotic Da Vinci system, indocyanine green(ICG) florescence can identify the collateral vessels in the inferior mesenteric artery zone. For patients with high risk for anastomotic leakage, pelvic drains, defunctioning stoma, and rectal tube may be useful to prevent anastomotic leakage. Early diagnosis and treatment are crucial for patients with anastomotic leakage.

[Associated vessel heteromorphosis in laparoscopic complete mesocolic excision and solutions to intraoperative hemorrhage]

Vessel identification and dissection are the key processes of laparoscopic complete mesocolic excision (CME). Vascular injury will lead to complications such as prolonged operative time, intraoperative hemorrhage and ischemia of anastomotic stoma. Superior mesenteric artery (SMA), superior mesenteric vein(SMV), gastrointestinal trunk, left colic artery(LCA), sigmoid artery and marginal vessels in the mesentery have been found with possibility of heteromorphosis, which requires better operative techniques. Surgeons should recognize those vessel heteromorphosis carefully during operations and adjust strategies to avoid intraoperative hemorrhage. Preoperative abdominal computed tomography angiography(CTA) with three-dimensional reconstruction can find vessel heteromorphosis within surgical area before operation. Adequate dissection of veins instead of violent separation will decrease intraoperative bleeding and be helpful for dealing with the potential hemorrhage. When intraoperative hemorrhage occurs, surgeons need to control the bleeding by simple compression or vascular clips depending on the different situations. When the bleeding can not be stopped by laparoscopic operation, surgeons should turn to open surgery without hesitation.

Inferior mesenteric arteriovenous fistula with nonpulsatile abdominal mass: A case report and a mini-review

RATIONALE

Inferior mesenteric arteriovenous fistula (IMAVF) is a rare condition principally characterized by portal hypertension and ischemic bowel disease. Up to now, only 30 cases have been reported. Presented here is an IMAVF patient with nonpulsatile abdominal mass as the main manifestation.

PATIENT CONCERNS

A 62-year-old Chinese male who complained of abdominal discomfort for a month was admitted to our hospital. Physical examination revealed a hard and hardly mobile mass.

DIAGNOSES

Space-occupying lesions were first suspected but endoscopy did not reveal any masses. The computed tomography angiography exhibited no definite boundary between the inferior mesenteric artery and vein. The patient was diagnosed with IMAVF.

INTERVENTIONS

The treatment of IMAVF mainly includes intra-arterial embolization and surgery. In our case, fistulas were complex and the patient had symptoms of colon ischemia, so we suggested a surgical resection instead of embolization. And the postoperative biopsy also confirmed the diagnosis.

OUTCOMES

After surgery, gastrointestinal symptoms disappeared and the patient began to gain weight gradually. During the follow-up, colonoscopy showed that the anastomotic astium and colonic mucosa were normal.

LESSONS

Analysis of the case showed that computed tomography angiography is an important auxiliary examination for establishing the diagnosis of IMAVF and surgery is an effective treatment.

[Preservation of left colic artery in laparoscopic radical operation for rectal cancer]

OBJECTIVE

To evaluate the clinical significance of low ligation of inferior mesenteric artery (IMA) and preservation of left colic artery in laparoscopic radical operation for rectal cancer.

METHODS

Clinical data of 103 rectal cancer patients undergoing laparoscopic radical operation in Ruijin Hospital from May 2015 to January 2016 were retrospectively analyzed, including 61 cases with preservation of left colic artery (low ligation group, LL group) and 42 cases without preservation of left colic artery (high ligation group, HL group). Clinical conditions during operation and after operation were compared between the two groups.

RESULTS

All the patients underwent operation successfully without transferring to laparotomy, intra-operative or post-operative death, and severe intra-operative or anesthetic complications. Age, gender, BMI, ASA score, tumor size and tumor location were not significantly different between the two groups. Four cases(9.5%) in HL group presented ischemic changes in colonic stump during operation, receiving additional colonic resection and no such ischemic changes were found in LL group (P=0.025). The number of harvested lymph node was 16.1±6.8 in HL group and 15.5±7.2 in LL group, number of harvest lymph node in the root of IMA was 4.2±1.7 in HL group with positive rate of 9.5%(4/42) and 4.3±1.7 in LL group with positive rate of 4.9%(3/61), both were not significantly different between the two groups. Lower margin was (2.2±1.4) cm in LL group and (2.8±1.7) cm in HL group, and difference was not significant as well(all P>0.05). There were no significant differences in terms of operation time, blood loss, post-operative complication, recovery of bowel movement and hospital stay. Median follow-up time was 4.5 months(2 to 10 months) and no long-term complications and local recurrence were found.

CONCLUSION

Low ligation of IMA with preservation of left colic artery in laparoscopic radical operation for rectal cancer can provide better blood supply for proximal colon and anastomosis, and can achieve same radical clearance of lymph nodes as high ligation without prolonged operation time, which is worth clinical promotion.

Chronic Visceral Ischemia: Symptom-Free Survival After Open Surgical Repair

A retrospective review of patients treated with a history of chronic visceral ischemia (CVI) was made to determine primary patency of open surgical repair and estimated symptom-free survival. Patients with CVI between 1990 and 2003 were reviewed. Included were those with chronic symptoms alone (C-CVI) and acute-on-chronic symptoms (A-CVI). Data were obtained from a vascular database. Symptom-free survival and graft patency were estimated by using product limit estimates. Fifty-eight patients (13 men, 45 women; mean age: 63 years) were treated surgically for C-CVI (34 patients) and A-CVI (24 patients). All patients had postprandial abdominal pain and weight loss (mean: 17 kg). One fourth reported food fear. Preoperative imaging demonstrated disease of the superior mesenteric artery (SMA) (100%; 64% occluded), celiac axis (89%; 37% occluded), and inferior mesenteric artery (IMA) (54%; 60% occluded). Multiple vessels were involved in 95% of patients (mean: 2.3 vessels/patient). Operative management included antegrade revascularization of 80 vessels. Combined aortic and/or renal procedures were performed in 7 patients. Patient demographics and visceral disease did not differ for C-CVI and A-CVI; however, perioperative mortality differed significantly (10% for C-CVI vs 54% for A-CVI [p<0.001]). Intestinal gangrene at presentation was associated with perioperative (hazard ratio [HR]: 7.6; 95% CI: 2.7–21.6; p=0.0002) and follow-up death (HR: 7.8; CI 2.8–21.9; p< 0.0001). Follow-up (mean: 34 months) was complete for 54/68 vessels (79%). Estimated primary and primary assisted patency at 5 years were 81% and 89% respectively. Estimated symptom-free survival for hospital survivors was 57% at 70 months. Open antegrade methods of visceral artery repair for CVI were durable and associated with 57% symptom-free survival at 70 months. Patient demographics and distribution of visceral artery anatomy were similar; however, perioperative mortality for C-CVI and A-CVI differed dramatically. Improved outcomes for A-CVI require recognition and treatment of CVI before onset of intestinal gangrene.

Embolization of Inferior Mesenteric Artery for Intractable Intrapelvic and Vaginal Bleeding After Hysterectomy

Branches of the internal iliac artery or ovarian artery are the typical sources of pelvic hemorrhage. The inferior mesenteric artery has been rarely reported as the origin of pelvic bleeding. We present 2 cases of intractable intrapelvic and vaginal bleeding after hysterectomy. One patient underwent a hysterectomy because of uncontrolled postpartum hemorrhage and another underwent a vaginal hysterectomy to treat vaginal prolapse. Both patients were subjected to angiography to control continuous vaginal bleeding after hysterectomy. The angiography revealed that the bleeding originated from the inferior mesenteric artery. Selective embolization of the inferior mesenteric artery successfully controlled the intractable intrapelvic and vaginal bleeding without complications. The inferior mesenteric artery is a potential source of intractable intrapelvic and vaginal bleeding for patients with a lower genital tract injury.

[Clinical analysis on lymph node metastasis pattern in left-sided colon cancers]

OBJECTIVE

To investigate the pattern of lymph node metastasis in patients with left-sided colon cancer in order to provide evidences for the choice of operation mode and the range of lymph node clearance.

METHODS

Clinical data of 556 cases with left-sided colon carcinoma undergoing surgical treatment in Department of Colorectal Surgery, Fujian Medical University Union Hospital from January 2000 to October 2014 were retrospectively analyzed. Among these patients, cancer of splenic flexure and transverse colon close to splenic flexure (splenic flexure group) was found in 41 cases, descending colon cancer in 73 cases(descending colon goup) and sigmoid colon cancer in 442 cases (sigmoid colon group), respectively; T1 was found in 29 cases, T2 in 63 cases, T3 in 273 cases, T4 in 191 cases. All the patients underwent D3 radical operation or complete mesocolic excision(CME). Para-bowel lymph node was defined as the first station, mesenteric lymph node as the second station, and lymph node in root of mesentery and around upper and inferior mesenteric arteries as the third station. Metastasis was compared among these 3 stations with regard to different sites and tumor invasions.

RESULTS

The total lymph node metastasis rate was 49.6%(276/556). The lymph node metastasis rates of splenic flexure, descending colon and sigmoid colon groups were 53.7%(22/41), 52.1%(38/73) and 48.9%(216/442) respectively without significant difference (P>0.05). The lymph node metastasis rates of the first, second, and third stations were 47.3%(263/556), 16.9%(94/556) and 5.8%(32/556) respectively with significant difference (χ(2)=287.54, P=0.000). In the first, second and third station, the lymph node metastasis rate was 13.8%(4/29), 0 and 0 in T1; 25.4%(16/63), 4.8%(3/63) and 3.2%(2/63) in T2; 45.8%(125/273), 14.7%(40/273) and 4.8%(13/273) in T3; 61.8%(118/191), 26.7%(25/191) and 8.9%(17/191) in T4 respectively. In splenic flexure group, metastasis rates were similar between No.222 and No.232[14.6%(61/41) vs. 12.2%(5/41), χ(2)=0.11, P=1.000] and between No.223 and No.253 [7.3% (3/41) vs. 2.4% (1/41), χ(2)=1.05, P=0.616]. In descending colon group, metastasis rate of No.232 was higher as compared to No.222[15.1%(11/73) vs. 2.7% (2/73), χ(2)=6.84, P=0.017]; metastasis rate of No.253 was slightly higher as compared to No.223 without significant difference [4.1%(3/73) vs. 0, χ(2)=3.06, P=0.245]. Metastasis rates of No.222 and No.223 in splenic flexure group were significantly higher than those in descending colon and sigmoid colon groups (χ(2)=5.69, P=0.025; Fisher exact test, P=0.044); While such rates of No.232(No.242 for sigmoid colon group) and No.253 were not significantly different among 3 groups respectively (χ(2)=0.90, P=0.660; χ(2)=1.14, P=0.611).

CONCLUSIONS

Left-sided colon cancers in T1 should undergo D2 radical operation, while cancers in T2 to T4 should undergo D3 radical operation. The D3 radical operation for splenic flexure cancers and cancers of transverse colon close to splenic flexure should clear No.223 and No.253. The D3 radical operation for descending colon cancer should clear No.222 and No.253. The D3 radical operation for sigmoid colon should clear No.253.

[Effect of preserving left colic artery during radical operation of rectal cancer on anastomotic leakage and operation time]

Surgical treatment for rectal cancer has changed radically in recent years since the introduction of the principle of total mesorectal excision (TME) and technique of laparoscopic approach. The emphasis of management for vessels in laparoscopic TME surgery for rectal cancer is mainly focused on the inferior mesenteric artery (IMA) and its branches. Two alternatives of the level to execute the IMA are high ligation(without preservation of left colic artery, LCA) and low ligation (with preservation of LCA). In this article, we review the latest literature from China and foreign countries concerning this issue, and combine with our own experience to investigate the effect of LCA preserving on anastomotic leakage and operation time, which may provide a reference for proper choice of the management of IMA in rectal cancer surgery.

Robotic Low Ligation of the Inferior Mesenteric Artery for Rectal Cancer Using the Firefly Technique

PURPOSE

By integrating intraoperative near infrared fluorescence imaging into a robotic system, surgeons can identify the vascular anatomy in real-time with the technical advantages of robotics that is useful for meticulous lymphovascular dissection. Herein, we report our initial experience of robotic low ligation of the inferior mesenteric artery (IMA) with real-time identification of the vascular system for rectal cancer using the Firefly technique.

MATERIALS AND METHODS

The study group included 11 patients who underwent a robotic total mesorectal excision with preservation of the left colic artery for rectal cancer using the Firefly technique between July 2013 and December 2013.

RESULTS

The procedures included five low anterior resections and six ultra-low anterior resections with loop ileostomy. The median total operation time was 327 min (226-490). The low ligation time was 10 min (6-20), and the time interval between indocyanine green injection and division of the sigmoid artery was 5 min (2-8). The estimated blood loss was 200 mL (100-500). The median time to soft diet was 4 days (4-5), and the median length of stay was 7 days (5-9). Three patients developed postoperative complications; one patients developed anal stricture, one developed ileus, and one developed non-complicated intraabdominal fluid collection. The median total number of lymph nodes harvested was 17 (9-29).

CONCLUSION

Robotic low ligation of the IMA with real-time identification of the vascular system for rectal cancer using the Firefly technique is safe and feasible. This technique can allow for precise lymph node dissection along the IMA and facilitate the identification of the left colic branch of the IMA.

[Injection of methylene blue into inferior mesenteric artery improves lymph node harvest in rectal cancer after neoadjuvant chemotherapy]

OBJECTIVE

To confirm the feasibility of improving lymph node harvest by injecting methylene blue into inferior mesenteric artery in rectal cancer after neoadjuvant therapy.

METHODS

Forty two ex vivo specimens were collected from rectal cancer patients with neoadjuvant therapy and radical operation at our hospital. Traditional method with palpation and injection of methylene blue into inferior mesenteric artery were employed. The data of lymph node harvest were analyzed by paired t and chi-square tests.

RESULTS

The average number of detected lymph node in traditional method and methylene blue groups were 6.1 ± 4.3 and 15.2 ± 6.4 respectively (P<0.001). The proportions of lymph nodes <5 mm were 14.1% and 46.7% in traditional method and methylene blue groups respectively (P<0.001). And the injection of methylene blue added 13 extra metastatic lymph nodes and caused a shift to node-positive stage (P=0.89).

CONCLUSION

Neoadjuvant therapy decrease lymph node retrieval in rectal cancer. Injecting methylene blue into inferior mesenteric artery improves lymph node harvest especially for small nodes and helps to acquire more metastatic nodes for accurate pathological staging.

[Techniques of autonomic nerve preservation in laparoscopic radical resection for rectal cancer]

Pelvic autonomic nerve is a three-dimensional structure surrounding the rectum. There are several key points related to nerve injury during laparoscopic radical resection for rectal cancer. Hypogastric nerve has close relation with the upper and middle part of the rectum. Combined with S2-S4 pelvic splanchnic nerve, hypogastric nerve forms pelvic plexus. Incorrect operation in pelvic parietal peritoneum during dissection of upper rectum will lead to nerve injury. When performing dissection of inferior mesenteric artery, bilateral nerve tracts should be pushed to posterior abdominal wall and anterior fascia of the abdominal aorta should be well protected to avoid nerve injury. Pelvic plexus fibers located lateral to the rectum of pelvic floor, as well as neurovascular bundle closed to Denonvillier's fascia, also have close relations with nerve injury. Dissection of either lateral or anterior wall of rectum should be performed behind the Denonvillier's fascia and in front of the proper fascia of rectum. Sharp dissection should be performed closed to the mesorectum to protect branches of pelvic plexus.

[Measures to anatomic variations of the colonic vessels in laparoscopic operations]

In laparoscopic colorectal resection, the poor blood supply of the anastomosis after tumor excision is difficult to be determined during the operations sometimes. The change in blood supply of the bowel is mainly due to the mesenteric anatomy and the operative techniques. The direct blood supply of colon is the marginal vessels in the mesentery. The integrity and patency of the marginal vessels determine the vitality of the bowel. However, the marginal vessels are different in diameter, pulsation or even discontinue in various areas, affecting the excision of the colon and following anastomosis. The most common three dangerous areas to anastomosis include:(1)area between ileocolic artery and right colonic artery; (2)area between middle colonic artery and left colonic artery-the Griffiths point. (3)area between the terminal branch of sigmoid colonic artery and superior rectal artery-Sudeck dangerous area. In laparoscopic colorectal resection, one should pay attention to protect the blood supply of the bowel and the marginal blood vessels, and be vigilant to the three vascular variations above mentioned. The vessels should be ligated accurately to ensure sufficient blood supply to the anastomosis and consequent normal healing of the rectal and colonic anastomosis. More attention should be paid to the elderly, morbid, and diabetic patients. If the safety of the anastomosis is unsure, prophylactic ileostomy should be performed.

[Intrathrombus embolization of giant mesenteric inferior artery to prevent type II endoleak]

INTRODUCTION

One of the most common complications of endovascular repair of abdominal aortic aneurysm is type II endoleak - retrograde branch flow.

CASE REPORT

A 76-year-old man with abdominal aortic aneurysm, 7.1 cm in diameter and aneurysm of the right common iliac artery, 3.2 cm in diameter was admitted to our Department with abdominal pain. The patient had no chance of having open repair of abdominal aortic aneurysm because of high perioperative risk (cardiac ejection fraction of 23%, chronic pulmonary obstructive disease). Multislice computed angiography also revealed a large inferior mesenteric artery, 6mm in diameter with the origin in thrombus of aneurysm. We decided to repair abdominal aortic aneurysm with GORE EXCLUDER stent-graft with crossed right hypogastric, but first we decided to embolize the inferior mesenteric artery. Angiography was performed through the right femoral approach and the good Riolan arcade was found. After that the inferior mesenteric artery was embolized with two coils, 5 mm in diameter, at the origin of artery in aneurysm thrombus. At the end of procedure, abdominal aortic aneurysm was repaired with GORE stent-graft, and the control angiography was performed. There was no endoleak, and the Riolan arcade was very good. The patient was discharged after 5 days. There were no signs of ischemia of the left colon, and peristaltic was excellent. Control multislice computed angiography was done after 1 and 3 months. There were no signs of endoleak. On the control colonoscopy there were no signs of ischemia of the colon.

CONCLUSION

Endovascular repair of symptomatic abdominal aortic aneurysm in high risk patients with preoperative embolization of large branch is the best choice to prevent rupture of abdominal aortic aneurysm and to prevent type II endoleak.

Injection of methylene blue solution into the inferior mesenteric artery of resected rectal specimens for rectal cancer as a method for increasing the lymph node harvest

BACKGROUND

The aim of the present study was to determine whether the injection of methylene blue solution into the inferior mesenteric artery could improve the lymph node harvest in rectal specimens of rectal cancer patients treated with rectal resection with total mesorectal excision.

METHODS

The study group consisted of 20 randomly selected fresh rectal specimens from patients with stages I-III rectal cancer treated at the Surgery Clinic at the Institute of Oncology of Vilnius University during the period from February 2008 to December 2010, and 20 specimens were selected under the same conditions to serve as the control group. The patients underwent conventional rectal resection with total mesorectal excision and coloanal anastomosis for low rectal cancer performed by the same surgeon, did not receive preoperative radiotherapy and had no distant metastases. After the removal of the specimen, 30 ml of 0.5% methylene blue solution was injected into the inferior mesenteric artery of the specimens in the study group (methylene blue group). The specimens from both the methylene blue and control groups were examined using the standards established by the Lithuanian National Centre of Pathology. The pathologist was not required to make any special macroscopic preparations. A retrospective analysis of clinical and histopathological records was performed.

RESULTS

Comparison of the mean lymph node harvest showed a significant difference between methylene blue and control groups with average lymph node numbers per specimen of 18 ± 5 and 14 ± 6, respectively (p = 0.025). The specimens from 12 of the 20 patients in the methylene blue group and the specimens from 7 of the 20 patients from the control group had positive nodes.

CONCLUSIONS

Injecting methylene blue solution into the inferior mesenteric artery is an efficient and simple method for improving the lymph node harvest in the histopathological examination of rectal specimens of rectal cancer patients treated with rectal resection with total mesorectal excision.

Spontaneous isolated inferior mesenteric artery dissection

This report presents a case of a spontaneous isolated inferior mesenteric artery (IMA) dissection. To the best of our knowledge, it is the first report in the literature. A fifty-eight-year-old female who suffered from acute left lower abdominal pain was admitted. CT scan and digital subtraction angiography indicated dilation in the proximal part of the IMA and occlusion in its distal part. Signs of peri-artery exudation also seen in the CT scan. Laparotomy confirmed the diagnosis of IMA dissection and secondary thrombosis in its branches. After thrombectomy and intimal flap resection, the artery was successfully reconstructed with an autogenous vein patch. Isolated IMA dissection should be considered as one of the differentiation for patients with acute abdomen. Dilation, occlusion of the artery, and signs of peri-artery edema were important clues to suspect the IMA dissection. High resolution spiral CT, which may sometimes reveal the signs such as double lumen and intimal flap, helped to establish the diagnosis of such lesion.

[Integrity evaluation of resected mesentery specimen after total mesorectal excision by methylene blue perfusion via superior rectal artery]

OBJECTIVE

To evaluate the integrity of the resected mesentery specimen after total mesorectal excision (TME) for low rectal cancer using methylene blue perfusion via the superior rectal artery.

METHODS

Twenty patients with low rectal cancer were randomly divided into the methylene blue group (n=10) and the control group (n=10). All the patients received TME and macroscopic examination of the mesorectal surface was performed to evaluate the quality of the surgical specimen. The methylene blue was injected into the specimen postoperatively via superior rectal artery.

RESULTS

The mesorectal surface of all the specimens was intact on macroscopic examination. However, after methylene blue perfusion, 2 specimens were found to be incomplete. The number of lymph nodes in the methylene blue group were significantly larger (17.3+/-2.4 vs 12.4+/-5.4, P=0.016).

CONCLUSIONS

Integrity evaluation of TME specimen is necessary. Methylene blue perfusion is a convenient and effective method to identify subtle incompleteness of specimen and can improve the detection of lymph node.

Massive hemoperitoneum caused by rupture of an aneurysm of the marginal artery of Drummond

Aneurysms of visceral arteries are uncommon and their rupture is rare. We report a case of an aneurysm of the marginal artery of Drummond, which was complicated by rupture leading to massive hemoperitoneum. A selective superior mesenteric arteriogram suggested the possibility of segmental arterial mediolysis (SAM) as a possible etiology and this was confirmed by histological examination. This is the first report of symptomatic SAM of the marginal artery of Drummond to date. This case demonstrates that the marginal artery of Drummond should be considered during the angiographic explorations for the source of hemoperitoneum. Management options are discussed.

A Rare Case of Thromboembolism in a 21-year Old Female with Elevated Factor VIII

In this article we present the history of a previously healthy female adolescent, who was seen at our hospital with abdominal pain. This was the result of a large floating thrombus in the aorta. Widespread embolism occurred, which lead to the loss of a limb and a left hemicolectomy. Although our patient is a smoker, used oral contraceptives and was found to have a heterozygote mutation at the factor V Leiden gene, the most important factor contributing to her thrombophilia is thought to be her significantly elevated factor VIII. We stress an aggressive diagnostic and therapeutic approach in young patients with unknown embolism in order to avoid the grave consequences of delay.

Reteplase provocative visceral arteriography

GOALS

To present the results of a new protocol for provocative visceral arteriography.

BACKGROUND

Acute lower gastrointestinal hemorrhage (LGIB) usually stops spontaneously. In the absence of an identifiable source, if bleeding is recurrent, provocative visceral arteriography has been advocated for diagnosis. Prior studies using Streptokinase, Urokinase, or tissue plasminogen activator have reported a 33% to 37.5% rate of identifying the site of hemorrhage.

STUDY

We report a retrospective analysis of 9 patients in whom provocative visceral arteriography was performed using a new protocol with Reteplase as the fibrinolytic agent. All patients had recurrent, massive LGIB without definable source. Initial arteriography did not elicit a site of bleeding. Five units of Reteplase were administered over 1 minute into the inferior mesenteric artery, the superior mesenteric artery or both vessels sequentially. Arteriography was repeated after 5 to 10 minutes.

RESULTS

Colonic hemorrhage was induced in 89% of patients. There were no procedure-related complications.

CONCLUSIONS

Reteplase may prove safe and effective as a provocative agent, stimulating bleeding to allow localization, in patients with occult, recurrent, massive LGIB.

Inferior mesenteric artery aneurysm combined with renal artery stenosis in a patient with neurofibromatosis

A case is reported of an inferior mesenteric artery aneurysm that starts approximately 1 cm from its origin and ends at the proximal portion of the bifurcation of the sigmoidal and left colic arteries accompanied with complete absence of the celiac axis and superior mesenteric arteries. Additionally, left renal artery stenosis existed. The diagnosis was made by digital subtraction arteriography and confirmed by magnetic resonance arteriogram. Disease involving the inferior mesenteric artery is extremely uncommon. This may be the first reported case of neurofibromatosis in combination with renal artery stenosis and inferior mesenteric artery aneurysm associated with celiac and superior mesenteric artery occlusion and treated surgically.

Visceral Artery Aneurysms

OBJECTIVE

Visceral artery aneurysms are rare vascular malformations and the literature lacks satisfactory general information about the pathology. The aim of this study was to review our experiences in the diagnosis and treatment of visceral artery aneurysms.

MATERIALS AND METHODS

We retrospectively reviewed data on 10 patients who were diagnosed with visceral artery aneurysms at our institution between June 2002 and September 2005. All available clinical, pathologic, and postoperative data were reviewed and analyzed for postoperative outcome.

RESULTS

Four splenic artery aneurysms, 2 hepatic artery aneurysms, 5 renal artery aneurysms, 1 superior mesenteric artery aneurysm, and 1 inferior mesenteric artery aneurysm (13 total visceral artery aneurysms) were diagnosed in 10 patients. All the patients were treated except 1 patient with bilateral renal artery aneurysms. One patient required emergent surgical treatment due to splenic artery aneurysm rupture. Only 1 patient underwent endovascular treatment (ie, coil embolization for a superior mesenteric artery aneurysm); otherwise all the patients were treated surgically on an elective basis. Surgical treatment modalities included ligation with exclusion in 4 patients (2 splenic artery aneurysms, 1 renal artery aneurysm, 1 hepatic artery aneurysm) and resection with revascularization in 4 patients (1 splenic artery aneurysm, 2 renal artery aneurysms, 1 hepatic artery aneurysm, 1 inferior mesenteric artery aneurysm). Histopathologic examination of the vascular materials revealed major atherosclerotic changes except one that showed inflammatory vasculitic changes. One patient required bleeding revision, and mortality did not occur in any of the patients.

CONCLUSIONS

Visceral artery aneurysms are rare and potentially life-threatening vascular disorders. The number of cases diagnosed every year increases because of advanced radiologic diagnostic methods and screening programs. Careful consideration and early management of these malformations can be life saving.

[Transcatheter embolization of an inferior mesenteric arteriovenous fistula with frequent mucous diarrhea]

We report a case of inferior mesenteric arteriovenous fistula without portal hypertension or mesenteric ischemia. A 64-year-old man had developed frequent mucous diarrhea during the previous month. Colonoscopy showed highly edematous mucosa of the rectum. Barium enema demonstrated localized stricture of the same part but no evidence of malignancy. Finally we established a diagnosis by 3D-CT and selective abdominal angiography. Transcatheter arterial embolization was successfully performed. After that, his symptoms gradually improved as all abnormal findings on colonoscopy, barium enema and abdominal CT disappeared.

IMA Clipping for a Type II Endoleak

We describe herein a combined laparoscopic and endovascular approach to treat a type II endoleak due to retrograde flow in the patent inferior mesenteric artery (IMA). A 61-year-old gentleman presented with enlarging aneurysm sac confirmed on computed tomography scan evaluation after elective endovascular repair of an infrarenal abdominal aortic aneurysm. A combined laparoscopic and endovascular approach was used. After distal IMA was identified and marked with a clip laparoscopically, on-table angiography showed a proximal left colic branch and persistent flow in the IMA. Therefore, further laparoscopic exploration was performed by dissection along the distal branch. The origin of IMA was then located and subsequently sealed with 2 surgical clips. The completion angiography confirmed the proper position of the surgical clips and absence of endoleak. Our case demonstrated useful role of endovascular techniques in identifying the origin of IMA during laparoscopic approach for treating type II endoleak.

Type 2 Endoleaks after Abdominal Aortic Aneurysm Stent Grafting with Systematic Mesenteric and Lumbar Coil Embolization

We evaluated the results of our policy of systematic coil embolization of the inferior mesenteric artery (IMA) and/or lumbar arteries (LAs) prior to endovascular abdominal aortic aneurysm (AAA) repair (EVAR). We retrospectively reviewed all patients undergoing EVAR over a 4-year period at one hospital. Results were analyzed using uni- and multivariate analyses. Fifty-five male patients with an average age of 71 years were evaluated. Follow-up averaged 15 +/- 13 months. The IMA was either coiled or occluded in 30 cases. One or more LAs were coiled in 29 patients. An average of 1.3 LAs per patients were coiled (range 0-6). There were no immediate or late complications from coiling. At last follow-up, 14 AAAs showed no change in diameter, one increased by 2 mm, and the remainder (n = 40) decreased by 7.5 +/- 6 mm in maximal diameter. Only five (9%) type 2 endoleaks were detected during follow-up. Three were associated with AAA size increase. Four of the five were treated with additional coiling, with good results. By logistic regression, neither endoleak occurrence nor AAA shrinkage correlated with LA or IMA coiling. However, by multivariate analysis, completeness of lumbar coiling correlated negatively with aneurysm shrinkage (p = 0.04) and IMA coiling correlated positively with aneurysm shrinkage (p = 0.04). Coil embolization of the IMA and/or LAs prior to EVAR can be safely accomplished in a large number of cases and is associated with a low incidence of type 2 endoleaks. We cannot at present demonstrate a benefit to LA embolization in terms of endoleak prevention or AAA shrinkage. However, IMA embolization may be of benefit in terms of AAA shrinkage.

[Thoracoabdominal aortic aneurysm combined with inferior mesenteric artery aneurysm and occlusion of celiac and superior mesenteric arteries]

A 56-year-old man with thoracoabdominal aortic aneurysm combined with inferior mesenteric artery aneurysm and occlusion of celiac and superior mesenteric arteries is presented. Contrast-enhanced computed tomography (CT) and aortography revealed thoracoabdominal aortic aneurysm of 6 cm in diameter, accompanied by inferior mesenteric aneurysm of 3 cm in diameter. Severe calcification of the abdominal aorta and occlusion of the celiac and the superior mesenteric arteries were also noted, whose territories were perfused by collateral circulation of the inferior mesenteric artery. At the operation, orifice of the left renal artery was stenosed by severe calcification, which was resected. Because of severe adhesion around the origins of celiac and superior mesenteric arteries, they were left unrevascularized. The thoracoabdominal aortic aneurysm was replaced with an Dacron tube graft, whose side branch was anastomosed to the inferior mesenteric artery after resection of its aneurysm. The postoperative course was uneventful, and no symptoms of intestinal ischemia were noted. As blood supply to the abdominal viscera mostly depends on the inferior mesenteric artery, careful follow-up is necessary.

Laparoscopic lymph node dissection around the inferior mesenteric artery for cancer in the lower sigmoid colon and rectum: is D3 lymph node dissection with preservation of the left colic artery feasible?

BACKGROUND

When we perform laparoscopic lymph node dissection around the inferior mesenteric artery (IMA), we preserve the left colic artery (LCA) to maintain the blood supply to the proximal sigmoid colon. In this study, we present our laparoscopic D2 and D3 lymph node (LN) dissection technique and evaluate its applicability and safety.

METHODS

We performed LN dissection on 23 rectal and lower sigmoid colon cancer cases from April 2002 to December 2004. For D3 LN dissection, the incision to the mesosigmoid extends to just before the root of the IMA, which is exposed with an ultrasonic cutting and coagulating surgical device to avoid bleeding. Then, the arterial wall is exposed with a dissecting electrocautery spatula down to the LCA, at least 2 cm of which is exposed. Adipose tissue surrounding the IMA and inferior mesenteric vein is dissected. For D2 LN dissection, we partially expose the IMA to confirm the location of the LCA.

RESULTS

The mean times taken for D2 and D3 LN dissections were 36.2 and 68.2 min, respectively. Both procedures took longer in male patients. There was a trend for the procedure overall to take less time in female patients. However, D2 dissection took significantly longer in male than female patients (p < 0.05). In women, D3 dissection took significantly longer than D2 (p < 0.05), but this trend was not seen in men. Increased experience among surgeons with this procedure was associated with significantly faster LN dissections in men (p < 0.05), but not in women (p = 0.493). Pearson product moment analysis identified a relationship between body mass index (BMI) and the time taken for D2 LN dissection (r = 0.765), but not D3 LN dissection (r = 0.158). There was no treatment-related morbidity with this technique.

CONCLUSIONS

This method was safe and feasible for all patients in this series, but takes longer to perform in male patients.

Mesenteric stenting for chronic mesenteric ischemia

BACKGROUND

Mesenteric stenting has not been widely adopted for the treatment of chronic mesenteric ischemia (CMI). The recent availability of embolic protection and low-profile devices with the theoretical ability to decrease perioperative bowel necrosis, led us to begin using mesenteric stenting for patients with CMI. We review our initial experience to examine short-term outcomes.

METHODS

We performed a retrospective analysis of all patients who were treated by vascular surgeons with mesenteric stenting for CMI. Patients with acute mesenteric ischemia were excluded. We evaluated perioperative morbidity and mortality, restenosis, recurrent symptoms, and reintervention. Kaplan-Meier methods were used to assess events during follow-up. We also compared these outcomes with a historical control group of patients treated with open surgical revascularization.

RESULTS

Fourteen patients underwent mesenteric stenting over the past 3 years. Mean age was 73, and 64% were women. There was no perioperative or 30-day mortality or major morbidity. Early restenosis and recurrent symptoms occurred in 10% and 9% of patients at 6 months. At a mean follow-up of 13 months, 53% of patients underwent reintervention. However, 93% were symptom-free at their last follow-up. Compared with open surgery, stent patients had lower perioperative major morbidity (30% vs 0%, P < .01) and shorter hospital and intensive care unit length of stay (median 10 days vs 2 days, and 3 days vs 0 days, respectively, P < .01 for both). However, stent patients were seven times as likely to develop restenosis (P < .01), four times more likely to develop recurrent symptoms (P < .01), and 15 times more likely to undergo reintervention (P < .01). There was one death 13 months after stenting due to mesenteric infarction in a patient lost to follow-up. One patient was successfully converted to open surgery after a second restenosis. He had regained 20 pounds and was determined to be a better operative candidate than at his initial presentation. There was no perioperative or 30-day mortality or major morbidity with reintervention after mesenteric stenting.

CONCLUSION

Mesenteric stenting for CMI can be performed with low perioperative risk. However, stenting is associated with early restenosis and recurrent symptoms requiring secondary procedures. Patients with severe nutritional depletion or high surgical risk may benefit from mesenteric stenting for CMI, but close follow-up is required. Later open surgery can be performed for restenosis if nutritional status and surgical risk are improved, or repeat angioplasty and stenting can be effectively performed if operative risk remains high.

Inferior mesenteric artery aneurysm: case report and literature review

A 70 year old man presented with retrosternal and epigastric pain. He was in shock. The diagnosis on admission was acute myocardial infarction. CT scan of the abdomen showed coeliac and superior mesenteric artery (SMA) occlusion. In addition there appeared to be large collateral from the inferior mesenteric artery (IMA) with a retroperitoneal collection. He underwent emergency laparotomy and a ruptured IMA aneurysm was detected. The aneurysm was excised and the IMA was ligated. He developed progressive multi-system organ failure post operatively. We discuss the aetiology, presentation, diagnosis and treatment of IMA aneurysms.

Ischemic enterocolitis examined by colonoscopy and selective angiography

AIM: To study the value of colonoscopy and selective angiography in diagnosing ischemic enterocolitis.

METHODS: Among the 16 cases under study, 10 cases had hypertension and a history of coronary artery disease (one was hospitalized for sub-ventricular-wall infarction). The blood pressure of 10 of the 16 cases ranged from 13.9-23.8 to 13.3-14.6 kPa (170-180/100-110 mmHg). Two cases had chronic auricular fibrillation, and in four cases, a cardiogram showed left-front branch conduction block. Sixteen patients were examined by colonoscopy. Among them, 14 cases had a long course of angiocardiac disease, and were further examined by selective mesenteric inferior angiography.

RESULTS: The colonoscopy revealed local mucous hyperemia edema and blood on contact. Lesions were found in the sigmoid colon in four cases, in the descending colon in eight cases and in splenic flexure in four cases, which suggests that the lesion always appeared in the left part of colon. There were different degrees of inflammatory cell infiltration, submucous bleeding, edema, fibro-embolism and hemosiderosis by biopsy in the 16 patients whose membranes affect part of the enteral wall. Of the 14 patients examined by mesenteric inferior angiography, 3 cases showed mesenteric amphraxis inferior and formation of collateral circulation. There were different degrees of stenosis in the other 11 subjects’ mesenteric inferior cavities which grew slim and their branches were stenotic, so the radiographic image was not complete and the ends of some branches even cannot be seen.

CONCLUSION: The colonoscopy and the selective mesenteric inferior angiography are both helpful in the diagnosis of ischemic enterocolitis.

[Pelvic and para-aortic lymphatic involvement in tubal carcinoma: topography and surgical implications]

OBJECTIVE

The purpose of this study is to determine the topography of pelvic and para-aortic node involvement in Fallopian tube carcinoma (PFTC). This will help us to recommend appropriate surgical treatment options to the related patients.

PATIENTS AND METHOD

A retrospective study was performed on 19 women with PFTC who underwent a systematic bilateral pelvic and para-aortic lymphadenectomy.

RESULTS

The overall frequency of lymph node involvement was 47% (9/19). The frequency of pelvic and para-aortic metastases was 21% (4/19) and 42% (8/19) respectively. The frequency of lymph node metastases according to the stage of the disease (stage I, II and III) was : 29% (2/7), 50% (1/2) and 60% (6/10) respectively. The left para-aortic chain above the level of the inferior mesenteric artery was the site most frequently involved (75%) when para-aortic nodes were involved.

DISCUSSION AND CONCLUSIONS

In patients with primary tubal carcinoma, the left para-aortic chain above the level of the inferior mesenteric artery is the most frequently involved. A complete lymphadenectomy (including all pelvic and para-aortic chains up to the level of the left renal vein) should be performed in patients with primary tubal carcinoma, even in patients with stage I disease.

Frequency and Significance of Lumbar and Inferior Mesenteric Artery Perfusion After Endovascular Repair of Abdominal Aortic Aneurysms

PURPOSE

To evaluate the frequency and influence of perfused side branches (lumbar arteries [LA] and inferior mesenteric artery trunks) on development of type II endoleaks (EL-II) and on volume changes of abdominal aortic aneurysms (AAA) after endovascular repair.

METHODS

Of 114 patients undergoing EVR of AAA, 89 patients (83 men; mean age 72+/-7.5 years, range 51-88) with >6 months' follow-up and no type I endoleaks were retrospectively analyzed to determine any relationships between retrograde perfusion, endoleaks, and sac volume. Data were derived from computed tomographic angiographic (CTA) scans taken before and after intervention, at discharge, and at 1, 3, 6, and semi-annually thereafter in follow-up. Two groups were identified and compared based on their status at 6 months post EVR: without perfused side branches (group 1) and with perfused collaterals (group 2); group 2 was further divided according to the absence (2a) or presence (2b) of endoleak.

RESULTS

Median follow-up was 24 months (range 6-36). Based on a total of 582 CTAs analyzed, 17 (19%) patients developed type II endoleaks (EL-II) during follow-up. There was a significant difference in the number of perfused LAs prior to EVR between groups 1 (n=44) and the 45 patients with postprocedural patent collateral arteries in group 2 (p<0.05); there was no significant difference between groups 2a and 2b (p=0.88) relative to the number of pre-existing patent collaterals. The number of pLAs preoperatively and the rate of type II endoleak were significantly correlated (p<0.05). No type II endoleak was seen in patients without perfused side branches (p=0.01). No significant differences in mean volumes were found between groups 1 and 2a (no EL-II), but significant differences between groups 1 and 2b were seen in later follow-up.

CONCLUSIONS

A larger number of patent LAs before EVR was associated with a significantly higher rate of type II endoleak. Patent collateral vessels were common after aneurysm repair, but the frequency decreased during follow-up. Persistent side branch perfusion was associated with increased type II endoleak after endovascular AAA repair. Significant differences in volume changes in later follow-up were seen between patients with or without type II endoleak.

Inferior mesenteric artery aneurysm in Behçet syndrome

We present a case report of an aneurysm of the inferior mesenteric artery, associated with occlusion of the celiac, superior mesenteric, and left renal arteries and severe stenosis in the right renal artery, in a 48-year-old patient with Behçet syndrome. The meandering inferior mesenteric artery, with an aneurysm 28 mm in greatest dimension, was the blood supply source for the intraperitoneal viscera. Aneurysm resection and reimplantation of the inferior mesenteric artery, and right renal artery bypass grafting with saphenous vein was performed. To our knowledge, this is the first reported case of inferior mesenteric artery aneurysm caused by Behçet syndrome.