Multidetector computer tomography and magnetic resonance imaging of double superior mesenteric veins:A case report

BACKGROUND This study aimed to describe the findings of double superior mesenteric veins(SMVs),a rare anatomical variation,on multidetector computer tomography(MDCT)and magnetic resonance imaging(MRI)images.CASE SUMMARY We describe the case of a 34-year-old male,who underwent both MDC and MRI examinations of the upper abdomen because of liver cirrhosis.MDCT and MRI angiography images of the upper abdomen revealed an anatomic variation of the superior mesenteric vein(SMV),the double SMVs.CONCLUSION The double SMVs are a congenital abnormality without potential clinical manifestation.Physicians need to be aware of this anatomical variation during abdominal surgery to avoid iatrogenic injury.

Laparoscopic pancreaticoduodenectomy with portal or superior mesenteric vein resection and reconstruction for pancreatic cancer:A single-center experience

Background: Open pancreaticoduodenectomy(OPD) with portal or superior mesenteric vein resection and reconstruction has been applied in pancreatic cancer patients with tumor infiltration or adherence. However, it is controversial whether laparoscopic pancreaticoduodenectomy(LPD) with major vascular resection and reconstruction is feasible. This study aimed to evaluate the safety and feasibility of LPD with major vascular resection compared with OPD with major vascular resection. Methods: We reviewed data for all pancreatic cancer patients undergoing LPD or OPD with vascular resection at Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, between February 2018 and May 2022. We compared the preoperative, intraoperative, and postoperative clinicopathological data of the two groups to conduct a comprehensive evaluation of LPD with major vascular resection. Results: A total of 63 patients underwent pancreaticoduodenectomy(PD) with portal or superior mesenteric vein resection and reconstruction, including 25 LPDs and 38 OPDs. The LPD group had less intraoperative blood loss(200 vs. 400 m L, P < 0.001), lower proportion of intraoperative blood transfusion(16.0% vs. 39.5%, P = 0.047), longer operation time(390 vs. 334 min, P = 0.004) and shorter postoperative hospital stay(11 vs. 14 days, P = 0.005). There was no perioperative death in all patients. There was no significant difference in the incidence of total postoperative complications, grade B/C postoperative pancreatic fistula, delayed gastric emptying and abdominal infection between the two groups. No postpancreatectomy hemorrhage nor bile leakage occurred during perioperative period. There was no significant difference in R0 resection rate and number of lymph nodes harvested between the two groups. Patency of reconstructed vessels in the two groups were 96.0% and 92.1%, respectively( P = 0.927). Conclusions: LPD with portal or superior mesenteric vein resection and reconstruction was safe, feasible and oncologically acceptable for selected patients with pancreatic cancer, and it can achieve similar or even better perioperative results compared to open approach.

Ligamentum teres hepatis as a graft for portal and/or superior mesenteric vein reconstruction:From bench to bedside

BACKGROUND Pancreaticoduodenectomy combined with portal vein(PV)and/or superior mesenteric vein(SMV)resection in patients with pancreaticobiliary malignancy has become a common surgical procedure.There are various grafts currently used for PV and/or SMV reconstruction,but each of these grafts have certain limitations.Therefore,it is necessary to explore novel grafts that have an extensive resource pool,are low cost with good clinical application,and are without immune response rejection or additional damage to patients.AIM To observe the anatomical and histological characteristics of the ligamentum teres hepatis(LTH)and evaluate PV/SMV reconstruction using an autologous LTH graft in pancreaticobiliary malignancy patients.METHODS In 107 patients,the post-dilated length and diameter in resected LTH specimens were measured.The general structure of the LTH specimens was observed by hematoxylin and eosin(HE)staining.Collagen fibers(CFs),elastic fibers(EFs),and smooth muscle(SM)were visualized by Verhoeff-Van Gieson staining,and the expression of CD34,factor VIII-related antigen(FVIIIAg),endothelial nitric oxide synthase(eNOS),and tissue type plasminogen activator(t-PA)were detected using immunohistochemistry in LTH and PV(control)endothelial cells.PV and/or SMV reconstruction using the autologous LTH was conducted in 26 patients with pancreaticobiliary malignancies,and the outcomes were retrospectively analyzed.RESULTS The post-dilated length of LTH was 9.67±1.43 cm,and the diameter at a pressure of 30 cm H2O was 12.82±1.32 mm at the cranial end and 7.06±1.88 mm at the caudal end.Residual cavities with smooth tunica intima covered by endothelial cells were found in HE-stained LTH specimens.The relative amounts of EFs,CFs and SM in the LTH were similar to those in the PV[EF(%):11.23±3.40 vs 11.57±2.80,P=0.62;CF(%):33.51±7.71 vs 32.11±4.82,P=0.33;SM(%):15.61±5.26 vs 16.74±4.83,P=0.32].CD34,FVIIIAg,eNOS,and t-PA were expressed in both LTH and PV endothelial cells.The PV and/or SMV reconstructions were successfully completed in all patients.The overall morbidity and mortality rates were 38.46%and 7.69%,respectively.There were no graft-related complications.The postoperative vein stenosis rates at 2 wk,1 mo,3 mo and 1 year were 7.69%,11.54%,15.38%and 19.23%,respectively.In all 5 patients affected,the degree of vascular stenosis was less than half of the reconstructed vein lumen diameter(mild stenosis),and the vessels remained patent.CONCLUSION The anatomical and histological characteristics of LTH were similar to the PV and SMV.As such,the LTH can be used as an autologous graft for PV and/or SMV reconstruction in pancreaticobiliary malignancy patients who require PV and/or SMV resection.

Mesenterico-portal vein invasion should be an important factor in TNM staging for pancreatic ductal adenocarcinoma: Proposed modification of the 8th edition of the American Joint Committee on Cancer staging system

BACKGROUND The 8^th edition of the American Joint Committee on Cancer(AJCC)staging system for pancreatic ductal adenocarcinoma(PDAC)excludes extrapancreatic extension from the assessment of T stage and restages tumors with mesenterico-portal vein(MPV)invasion into T1-3 diseases according to tumor size.However,MPV invasion is believed to be correlated with a poor prognosis.AIM To analyze whether the inclusion of MPV invasion can further improve the 8th edition of the AJCC staging system for PDAC.METHODS This study retrospectively included 8th edition AJCC T1-3N0-2M0 patients undergoing pancreaticoduodenectomy/total pancreatectomy from two cohorts and analyzed survival outcomes.In the first cohort,a total of 7539 patients in the surveillance,epidemiology,and end results database was included,and in the second cohort,689 patients from the West China Hospital database were enrolled.RESULTS Cox regression analysis showed that MPV invasion is an independent prognostic factor in both databases.In the MPV-group,all pairwise comparisons between the survival functions of patients with different stages were significant except for the comparison between patients with stage IIA and those with stage IIB.However,in the MPV+group,pairwise comparisons between the survival functions of patients with stage IA,stage IB,stage IIA,stage IIB,and stage III were not significant.T1-3N0 patients in the MPV+group were compared with the T1N0,T2N0,and T3N0 subgroups of the MPV-group;only the survival of MPV-T3N0 and MPV+T1-3N0 patients had no significant difference.Further comparisons of patients with stage IIA and subgroups of stage IIB showed(1)no significant difference between the survival of T2N1 and T3N0 patients;(2)a longer survival of T1N1 patients that was shorter than the survival of T2N0 patients;and(3)and a shorter survival of T3N1 patients that was similar to that of T1-3N2 patients.CONCLUSION The modified 8th edition of the AJCC staging system for PDAC proposed in this study,which includes the factor of MPV invasion,provides improvements in predicting prognosis,especially in MPV+patients.

Pancreaticoduodenectomy with portal vein/superior mesenteric vein resection for patients with pancreatic cancer with venous invasion

BACKGROUND： With the development of new surgical tech- niques, pancreaticoduodenectomy （PD） with portal vein or superior mesenteric vein （PV/SMV） resection has been used in the treatment of patients with borderline resectable pan- creatic cancer. However, opinions of surgeons differ in the effectiveness of this surgical technique. This study aimed to investigate the effectiveness of this approach in patients with pancreatic cancer. METHODS： Follow-up visits and retrospective analysis were carried out of 208 patients with pancreatic cancer who had undergone PD （PD group） and PD combined with PV/SMV resection and reconstruction （PDVR group） from June 2009 to May 2013 at our center. Statistical analysis was performed to compare the clinical features, the difference of survival time and risk factors of venous invasion in pancreatic cancer. Factors relating to postoperative survival time of pancreatic cancer were also investigated. RESULTS： In the PDVR group, which consisted of 42 cases, the 1-, 2- and 3-year survival rates were 70%, 41% and 16%, respective- ly and the median survival time was 20.0 months. Among the 166 patients in the PD group, the 1-, 2- and 3-year survival rates were 80%, 52%, and 12%, respectively with the median survival time of 26.0 months. No significant difference in survival time and R0 resection ratio was found between the two groups. Lum- bodorsal pain, tumor with pancreatic capsular invasion and bile duct infiltration were found to be independent risk factors for PV invasion in pancreatic cancer. In addition, non R0 resection,large tumor size （〉2 cm） and poorly differentiated tumor were independent risk factors for survival time in post-PD. CONCLUSIONS： The tumor has a higher chance of venous invasion if preoperative imagings indicate that it juxtaposes with the vessel. Lumbodorsal pain is the chief complaint. Pa- tients with pancreatic cancer associated with PV involvement should receive PDVR for R0 resection when preoperational assessment shows the chance for eradication.

Small Bowel Stricture Complicating Superior Mesenteric Vein Thrombosis

Superior mesenteric vein (SMV) thrombosis is a relatively rare disease.Most patients may be successfully treated with anti-coagulation alone.However,bowel stricture may develop due to intes-tinal ischemia which may require surgical treatment.This report describes a rare case of small bowel stricture occurring one month after successful treatment of SMV thrombosis.After segmental resection of strictured bowel,the patient’s post-operative course was uneventful.

Acute appendicitis complicated by mesenteric vein thrombosis: A case report

BACKGROUND Acute appendicitis with mesenteric vein thrombosis(MVT)is an uncommon condition and usually lacks specific clinical manifestations,which leads to a high rate of misdiagnosis or delayed diagnosis,especially when it is accompanied by other abdominal diseases.Prompt and accurate recognition is vital for treatment and prognosis.CASE SUMMARY A 37-year-old woman had a history of acute metastatic right lower abdominal pain,nausea,and fever.A contrast-enhanced computed tomography(CT)scan showed a filling defect in the mesenteric vessels.The patient was diagnosed with acute appendicitis complicated by MVT and was treated with anticoagulation and intravenous antibiotics.The follow-up CT scan showed full resolution of the thrombosis and inflammation.CONCLUSION Clinical awareness is essential for recognizing MVT,especially when it is accompanied by other common acute abdominal diseases,such as acute appendicitis.Contrast-enhanced CT is helpful for the diagnosis of MVT and is recommended for patients with acute abdominal diseases.

Idiopathic acute superior mesenteric venous thrombosis after renal transplantation: A case report

BACKGROUND Acute superior mesenteric venous thrombosis(MVT)is a rare condition associated with a high mortality rate.The treatment strategy for MVT is clinically challenging due to its insidious onset and rapid development,especially when accompanied by kidney transplantation.CASE SUMMARY Here we present a rare case of acute MVT developed 3 years after renal transplantation.A 49-year-old patient was admitted with acute abdominal pain and diagnosed as MVT with intestinal necrosis.An emergency exploratory laparotomy was performed to remove the infarcted segment of the bowel.Immediate systemic anticoagulation was also initiated.During the treatment,the patient experienced bleeding,anastomotic leakage,and sepsis.However,after aggressive treatment was administered,all thrombi were completely resolved,and the patient recovered with his renal graft function unimpaired.CONCLUSION The present case suggests that accurate diagnosis and timely surgical treatment are important to improve the survival rate of MVT patients.Bleeding with anastomotic fistula needs to be treated with caution because of grafts.Also,previously published cases of mesenteric thrombosis after renal transplantation were reviewed.

Prognosis and feasibility of en-bloc vascular resection in stage Ⅱ pancreatic adenocarcinoma

AIM:To establish the prognosis and feasibility of en-bloc vascular resection of stage pancreatic adenocarcinoma of the head and uncinate process.METHODS:We retrospectively analyzed 87 patients with stage pancreatic adenocarcinoma,who were subjected to pancreaticoduodenectomy (PD) and pylo-rus-preserving PD (PPPD) between 1996 and 2006 in Chang Gung Memorial Hospital,Taiwan. Twelve and 75 patients underwent PD/PPPD with and without resection of portal vein/superior mesenteric vein (PV/SMV),respectively.RESULTS:The overall 1-and 3-year survival rates of patients undergoing PD/PPPD with and without vas-cular resection were 50.0% and 16.7%,and 44.4% and 12.2%,respectively. Morbidity and mortality rates in the PV/SMV resection vs non-resection group were 50.0% and 0.0%,and 40.0% and 2.7%,respectively. In multivariate analysis,serum bilirubin,histological differentiation and adjuvant chemotherapy were independent prognostic factors that influenced survival.CONCLUSION:In stage adenocarcinoma of the pancreatic head and uncinate process,serum bilirubin,histological differentiation and adjuvant chemotherapy were independent prognostic factors,and en-bloc vascular resection is a feasible option in carefully selected patients.

Successful treatment of acute symptomatic extensive portal venous system thrombosis by 7-day systemic thrombolysis

Acute portal venous system thrombosis(PVST)can cause acute mesenteric ischemia and even intestinal infarction,which are potentially fatal,and requires recanalization in a timely fashion.Herein,we report a 56-year-old man with acute non-cirrhotic symptomatic extensive PVST who achieved portal vein recanalization after systemic thrombolysis combined with anticoagulation.Initially,anticoagulation with enoxaparin sodium for 4 d was ineffective,and then systemic thrombolysis for 7 d was added.After that,his abdominal pain completely disappeared,and portal vein system vessels became gradually patent.Long-term anticoagulation therapy was maintained.In conclusion,7-d systemic thrombolysis may be an effective and safe choice of treatment for acute symptomatic extensive PVST which does not respond to anticoagulation therapy.

Multidetector computed tomography three-dimensional and multiplanar reconstruction diagnosis of a rare cause of gastrointestinal bleeding: A case report

BACKGROUND Anastomosis of the testicular vein with the superior mesenteric vein rarely causes severe gastrointestinal bleeding.To date,there have been few studies describing its appearance on medical imaging.Here,we present multidetector computed tomography three-dimensional and multiplanar reconstruction(MPR)images of a typical digital subtraction angiography showing proven ectopic bleeding and provide the first review of the image performance.CASE SUMMARY A 68-year-old man who had been rushed to the hospital with a four-day history of melena and fainting underwent multiple esophagogastroduodenoscopy procedures that failed to identify the source of bleeding.We used MPR combined with three-dimensional reconstruction images,and found that the testicular vein had anastomosed with the superior mesenteric vein,and they clustered together in the jejunal vessel wall,which caused severe gastrointestinal bleeding.Digital subtraction angiography confirmed the location of bleeding.After transfusion and embolization therapy,the patient’s condition improved.CONCLUSION Computed tomography-MPR combined with three-dimensional images offers significant value in the localization and qualitative assessment of rare gastrointestinal hemorrhage.The features of multiphase spiral scanning can improve the accuracy of the diagnosis.

Current concepts in the management of non-cirrhotic non-malignant portal vein thrombosis

Non-cirrhotic non-malignant portal vein thrombosis(NCPVT)is an uncommon condition characterised by thrombosis of the portal vein,with or without extension into other mesenteric veins,in the absence of cirrhosis or intra-abdominal malignancy.Complications can include intestinal infarction,variceal bleeding and portal biliopathy.In this article,we address current concepts in the management of NCPVT including identification of risk factors,classification and treatment,and review the latest evidence on medical and interventional management options.

A systematic review of the management of acute superior mesenteric vein thrombosis in adults

Background:Acute thrombosis of the superior mesenteric vein(SMV)is a rare but potentially catastrophic condition.Clinically separate from portal venous thrombosis due to a higher proportion of associated thrombophilic disorders and intestinal infarction,SMV thrombosis warrants a distinct approach to management.The aim of this review is to report the evidence for current practice.Methods:A systematic review was carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.Four clinical trials databases and 4 trial registries were searched.This search was not limited by language or study type,but was limited to an adult population(18 years and above).The search period was between January 1,2000 and February 28,2019.The review was registered in the PROSPERO database:CRD42018116825.Bias was assessed using the ROBINS-I tool.Results:A total of 7989 studies were identified,resulting in 19 observational studies being analyzed.Eighteen studies reported on anti-coagulation,1 reported on anti-coagulation plus endovascular thrombectomy,9 reported on thrombolysis,and 10 reported on the role of surgery.Bias assessment showed that confounding was a significant area of potential bias.This review has reported that the management of SMV thrombosis is centered around a patients’perceived hemodynamic stability.If there is evidence of perforation or peritonism then surgical intervention is advocated.Otherwise,anti-coagulation or thrombolysis is preferred.Conclusions:The data reported were compared with,and added to,that presented by the European Society for Vascular Surgery 2017 guidelines.Overall the source data were heterogenous,with multiple sources of bias and statistical comparison was not achievable.

Pancreatic cancer surgery with vascular resection: current concepts and perspectives

Pancreatic cancer is a devastating disease and resection at an early disease stage is the best chance of cure. Less than 20% of all patients present with a resectable tumor, while another 20% to 30% have locally advanced pancreatic cancer and the majority of the patient suffer from metastatic disease. Recently, it has been recognized that there is a 4th group of patients with so-called borderline resectable disease. Here, the tumor approaches or infiltrates the vascular axis (superior mesenteric vein/portal vein and/or superior mesenteric/hepatic artery/celiac trunk). While a large number of tumors with suspected venous infiltration can be resected with concomitant venous resection and reconstruction, arterial infiltration has been considered a contraindication to resection. Neoadjuvant treatment with combination chemotherapy protocols with or without radiotherapy has allowed for higher resection rates even in patients with arterial invasion. Here, we review the contemporary literature on extensive pancreatic cancer surgery with vascular resection and reconstruction.