Initial transcatheter thrombolysis for acute superior mesenteric venous thrombosis

AIM: To determine the optimal initial treatment modality for acute superior mesenteric vein thrombosis (ASMVT) in patients with circumscribed peritonitis.

Nomogram for predicting transmural bowel infarction in patients with acute superior mesenteric venous thrombosis

BACKGROUND The prognosis of acute mesenteric ischemia(AMI)caused by superior mesenteric venous thrombosis(SMVT)remains undetermined and early detection of transmural bowel infarction(TBI)is crucial.The predisposition to develop TBI is of clinical concern,which can lead to fatal sepsis with hemodynamic instability and multi-organ failure.Early resection of necrotic bowel could improve the prognosis of AMI,however,accurate prediction of TBI remains a challenge for clinicians.When determining the eligibility for explorative laparotomy,the underlying risk factors for bowel infarction should be fully evaluated.AIM To develop and externally validate a nomogram for prediction of TBI in patients with acute SMVT.METHODS Consecutive data from 207 acute SMVT patients at the Wuhan Tongji Hospital and 89 patients at the Guangzhou Nanfang Hospital between July 2005 and December 2018 were included in this study.They were grouped as training and external validation cohort.The 207 cases(training cohort)from Tongji Hospital were divided into TBI and reversible intestinal ischemia groups based on the final therapeutic outcomes.Univariate and multivariate logistic regression analyses were conducted to identify independent risk factors for TBI using the training data,and a nomogram was subsequently developed.The performance of the nomogram was evaluated with respect to discrimination,calibration,and clinical usefulness in the training and external validation cohort.RESULTS Univariate and multivariate logistic regression analyses identified the following independent prognostic factors associated with TBI in the training cohort:The decreased bowel wall enhancement(OR=6.37,P<0.001),rebound tenderness(OR=7.14,P<0.001),serum lactate levels>2 mmol/L(OR=3.14,P=0.009)and previous history of deep venous thrombosis(OR=6.37,P<0.001).Incorporating these four factors,the nomogram achieved good calibration in the training set[area under the receiver operator characteristic curve(AUC)0.860;95%CI:0.771-0.925]and the external validation set(AUC 0.851;95%CI:0.796-0.897).The positive and negative predictive values(95%CIs)of the nomogram were calculated,resulting in positive predictive values of 54.55%(40.07%-68.29%)and 53.85%(43.66%-63.72%)and negative predictive values of 93.33%(82.14%-97.71%)and 92.24%(85.91%-95.86%)for the training and validation cohorts,respectively.Based on the nomogram,patients who had a Nomo-score of more than 90 were considered to have high risk for TBI.Decision curve analysis indicated that the nomogram was clinically useful.CONCLUSION The nomogram achieved an optimal prediction of TBI in patients with AMI.Using the model,the risk for an individual patient inclined to TBI can be assessed,thus providing a rational therapeutic choice.

Superior mesenteric venous thrombosis: Endovascular management and outcomes

BACKGROUND Superior mesenteric venous thrombosis(SMVT)is a rare but fatal condition that is typically treated initially with anticoagulation therapy,and if this fails,with endovascular interventions.However,due to its rarity,there are not many studies that have explored the effectiveness of anticoagulation and endovascular therapies in treating SMVT.AIM To evaluate patients diagnosed with SMVT who received endovascular therapy in addition to anticoagulation and report technical and clinical outcomes.METHODS A retrospective analysis of the patients who underwent endovascular treatment for SMVT at Mayo Clinic from 2000-2019 was performed.Technical success was defined as angiographic improvement in SMV flow after intervention.Primary patency was defined as the interval from reestablishing mesenteric venous flow until the first repeat thrombotic event or need for additional intervention.Secondary patency was defined as successful restoration of flow after repeat intervention until rethrombosis or last follow-up.The adverse events were reported through Clavien-Dindo classification.RESULTS Twenty-four patients were included for analysis.The median age at intervention was 60 years(35-74 years)and 16(67%)were men.Nineteen patients presented with acute thrombosis(79.2%)and 5 with chronic thrombosis with acute manifestations(20.8%).The most commonly used endovascular modalities were thrombectomy in 12 patients(50.0%)and catheter-directed thrombolysis in 10 patients(41.7%).Technical success was achieved in 18 patients(75%).The 14-d and 30-d primary patency rates were 88.9%and 83.3%,respectively.Adverse events were reported in two patients(8.3%),one marked as grade IIIB,and 1 death marked as grade V.Five-year overall survival rate was 82%(58%-100%).CONCLUSION Endovascular intervention with anticoagulation appears to be effective for managing SMVT.This treatment combination may be considered as first-line therapy for SMVT management in select patients.

Significance of pathological positive superior mesenteric/portal venous invasion in pancreatic cancer

BACKGROUND： Pancreaticoduodenectomy with superior mesenteric/portal venous resection for pancreatic ductal ad- enocarcinoma （PDAC） is frequently performed with no added morbidity or mortality in case of tumor abutment to the superior mesenteric or portal vein so as to obtain a margin negative resection. True histopathological portal vein invasion is found only in a small subset of such patients. The aim of this review aimed to discuss the significance of histopathological venous invasion in PDAC.DATA SOURCES： For this review available data was searched from PubMed and analyzed. No randomized trials have been published on this topic. RESULTS： Existing data on prognostic factors in histopathological venous invasion by PDAC are limited and recent studies indicate worse survival in this subgroup of patients. In addition, venous invasion in PDAC has been associated with large tumors, involved lymph nodes, perineural invasion and R1 resection. The survival of patients with portal venous re- section but without histologic venous invasion is reportedly better than those with histopathological venous invasion; though conflicting studies do exist on the subject. Some studies also relate the depth of venous invasion to prognosis after surgical resection of PDAC. CONCLUSIONS： Frank/＇histopathological＇ invasion of superior mesenteric/portal venous and R1 resection indicate a very poor survival. Such patients may be given the opportunity of benefit of neoadjuvant treatment.

A rare cause of gastro-intestinal hemorrhage in a patient with a Roux-en-Y gastric bypass

This case illustrates a rare cause of gastro-intestinal bleeding following bariatric surgery.Though it is essential to rule out common causes of variceal formation accompanied by intermittent,profuse bleeding,there should be a high degree of suspicion of this rare etiology in patients who have previously undergone alteration of their anatomy,especially Roux-en-Y gastric bypass(RYGB).The case emphasizes the need for a multidisciplinary medical-surgical team in evaluating and treating patients who present with complex intra-abdominal pathology.