Venous anatomy of the right colon: precise structure of the major veins and gastrocolic trunk in 58 cadavers

PURPOSE: This study was designed to describe the precise venous anatomy of the right colon, which is especially important for laparoscopic right hemicolectomy. METHODS: Fifty-eight adult cadavers were dissected to define the three major venous tributaries of the right colon: the ileocolic vein, right colic vein, and middle colic vein. Two or three middle colic veins were often present, and the biggest one was designated as the main middle colic vein. The middle colic vein and the right colic vein occasionally formed a common trunk with the right gastroepiploic vein and/or the pancreaticoduodenal vein. This common trunk was defined as the gastrocolic trunk. RESULTS: All 58 cadavers had a single ileocolic vein. All of the ileocolic veins drained into the superior mesenteric vein. The right colic vein was absent in 56.9 percent (33/58), and the other 43.1 percent had a single right colic vein. The right colic vein joined the superior mesenteric vein directly in 56 percent (14/25) and the gastrocolic trunk in 44 percent (11/25). The middle colic vein was the most variable. A single middle colic vein was present in 37.9 percent (22/58), 2 middle colic veins were present in 50 percent (29/58), and 3 middle colic veins were present in 12.1 percent (7/58). The main middle colic vein drained into the superior mesenteric vein directly in 84.5 percent (49/58), whereas 12.1 percent (7/58) drained into the gastrocolic trunk. In two cadavers, there was anomalous drainage of the main middle colic vein to the splenic vein and the inferior mesenteric vein. Forty-three accessory middle colic veins were present in total. These drained into the superior mesenteric vein in 17 cadavers and into the gastrocolic trunk in 23. The gastrocolic trunk was present in 69 percent (40/58), being formed with the right colic vein in 27.5 percent (11/40; 1 was together with an accessory middle colic vein) and with the middle colic vein in 75 percent (30/40; 7 with the main middle colic vein, 23 with the accessory middle colic vein). CONCLUSION: Venous anatomy of the right colon is highly variable. It is especially important to recognize the lack of direct drainage of the right colic vein to the superior mesenteric vein and the high frequency of the presence of plural middle colic veins and the gastrocolic trunk.     

Total gastrectomy after shunt failure as therapy for recurrent gastric variceal bleeding due to portal and mesenteric vein thrombosis

A 37-yr-old man with portal hypertension due to portal vein thrombosis was referred because of recurrent episodes of variceal hemorrhage. He had previously undergone two portal-systemic shunt procedures. Both of the shunts, as well as the superior mesenteric vein, ultimately thrombosed. Endoscopic variceal sclerotherapy was able to control the bleeding from his esophageal varices, but he repeatedly bled from large gastric varices. The patient underwent a total gastrectomy and has had no further gastrointestinal hemorrhage during a follow-up of 36 months.     

多层螺旋CT对胰源性区域性门静脉高压的诊断价值（附42例报道）

目的 分析胰源性区域性门静脉高压(pancreatogenic segmental portal hypertension,PSPH)的多层螺旋CT(MSCT)表现,探讨MSCT对该病的诊断价值.方法 使用16排螺旋CT对42例PSPH患者行上腹部CT平扫及增强扫描,采用图像后处理技术显示脾静脉及侧枝血管情况.结果 孤立性脾静脉阻塞30例,其侧支血管食管静脉(9.5%)、胃冠状静脉(76.19%)、胃短静脉(85.71%)、胃网膜静脉(95.24%)、胃结肠干(23.81%)曲张;非孤立性脾静脉栓塞12例,其中伴肠系膜上静脉阻塞8例,其属支胃结肠干(19.05%)、结肠右上静脉(16.67%)、结肠中静脉(14.29%)、胰十二指肠前上静脉(19.05%)有不同程度曲张.伴门静脉海绵样变5例.结论 MSCT对PSPH的脾静脉阻塞及其胃周迂曲扩张的侧枝静脉显示具有重要价值.     

Osler-Weber-Rendu disease with esophageal varices and hepatic nodular change

A 72-year-old male visited our hospital for further evaluation of esophageal varices. Telangiectasias were present in the stomach. He had recurrent epistaxis, which was also confirmed in his family's medical history. We diagnosed this case as Osler-Weber-Rendu disease. He had concomitant with hepatic nodular change. Abdominal angiography showed arterio-portal (A-P) shunts, superior mesenteric artery (SMA)-superior mesenteric vein (SMV) shunt, extension of SMV, and dilated and meandering portal vein. Esophageal varices were treated by endoscopic variceral ligation (EVL) and argon plasma coagulation (APC) therapy for prophylaxis of bleeding.     

First jejunal vein oriented mesenteric excision for pancreatoduodenectomy

Background

Dissection of the pancreatic head from the superior mesenteric vein (SMV) and artery (SMA) are major points of bleeding in pancreaticoduodenectomy (PD) because of congestion of the pancreatic head. The “SMA-first” approach, which involves ligating the artery from the SMA first, can be used to solve this problem. However, the SMA-first approach has problematic anatomical issues. We applied a new surgical approach, first jejunal vein oriented mesenteric excision (FME), for PD. This study aimed to clarify the effect of FME on reduction of bleeding during PD.

Methods

The jejunal vein, the most frequent source of bleeding during dissection of the mesoduodenum, was identified at the beginning of dissection of the pancreatic head from SMV and SMA. The mesoduodenum, including plural IPDAs, was completely divided before dissection of the pancreatic head from the SMV. The perioperative outcomes of two groups, patients who underwent FME-based PD and patients who underwent standard PD, were compared. Additionally, the spatial characteristics of the first jejunal vein (FJV) were analyzed using computed tomography.

Results

FME-based PD significantly reduced intraoperative blood loss compared with conventional PD (569 vs. 1094 ml, P = 0.0315). The median distance of the FJV was 0 mm from the middle colic artery and 0 mm from the third portion of the duodenum. The FJV was posterior to the SMA in the majority of the patients but was anterior to the SMA in 16.7 % of patients.

Conclusions

FME is useful for reducing intraoperative bleeding.     

Vascular relationships in right colectomy for cancer: clinical implications

Aims The study aim was to provide data on pattern and length of crossing of the ileocolic artery (ICA) and right colic artery (RCA) with the superior mesenteric vein (SMV). Methods Specimens from 30 fresh human cadavers underwent corrosion casting. Methylacrylate was injected into the SMV and superior mesenteric artery (SMA). Length of crossing was measured with a scaleable ruler and copper wire. Values are mean (SD; range). Results ICA was present in all specimens and crossed posterior to the SMV in 19 (63.33%) of 30 specimens. Length of crossing was 17.01 (7.84; 7.09–42.89) mm. RCA was present in 19 (63.33%) of 30 specimens. RCA crossed anterior to SMV in 16 (84.21%) of 19 specimens. Length of crossing was 20.63 (8.09; 6.3–35.7) mm. Conclusions ICA was always present, crossed posterior to SMV in 60% of specimens with a crossing length of 17 mm. RCA was present in 63% of specimens, crossed anterior to the SMV in 84% of specimens with a crossing length of 20 mm. Clinical implications include arterial length left behind with main nodes, arterial bleeding and safety of laparoscopic access.     

Surgical anatomy of the pancreas for limited resection

The fusion fascia of the head of the pancreas is called the "fusion fascia of Treitz" and that of the body and tail of the pancreas is termed the "fusion fascia of Toldt". The fusion fascia is histologically composed of a loose connective tissue membrane. All of the important pancreaticoduodenal arcades of arteries and veins are situated on this membrane, i.e., between this membrane and the pancreatic parenchyma. The topography of the head of the pancreas shows that, after departing from the gastroducodenal artery, the anterior superior pancreaticoduodenal artery runs toward a point 1.5 cm below the papilla of Vater, then turns to the posterior aspect of the pancreas to join the anterior inferior pancreaticoduodenal artery. For preserving the duodenum, the artery toward the papilla is very important. The artery toward the papilla of Vater runs along the right side of the common bile duct after departing from the posterior superior pancreaticoduodenal artery. The gastrocolic trunk of Henle has been reported to be found in about 60% of individuals. It is possible that the gastroepiploic vein and anterior superior pancreaticoduodenal vein (ASPDV) can be divided at pancreaticoduodenectomy, with preservation of the superior right colic vein, if this area is free of carcinoma. The ASPDV and anterior inferior pancreaticoduodenal vein form an arcade on the anterior surface of the pancreas. However, arcade formation was not found between the posterior superior pancreaticoduodenal vein and posterior inferior pancreaticoduodenal vein in many of the individuals examined. The vein joined by the inferior mesenteric vein was also investigated.     

RECURRING ENCEPHALOPATHY ABOLISHED BY GASTRORENAL SHUNT LIGATION IN A DIABETIC HEMODIALYSIS PATIENT

A 57-year-old man was admitted to our hospital for hepatic encephalopathy. He previously had undergone a partial gastrectomy for gastric ulcer, and also had been on maintenance hemodialysis because of diabetic nephropathy. Despite treatment with branched-chain amino acids and lactulose, encephalopathy occurred repeatedly. The findings of his laboratory examinations, computed tomography, and liver biopsy were not suggestive of chronic liver damage. Angiography revealed a portal-systemic shunt from the superior mesenteric vein via the left gastric vein to the left renal vein. A ligation of the gastrorenal shunt was performed. After the shunt ligation, hepatic encephalopathy no longer recurred, and no medication was required to prevent it. The insulin requirements also decreased, the plasma ammonia concentration then decreased, and serum concentration of several amino acids related to the ammonia metabolism also decreased. The molar ratio of branched-chain amino acids to aromatic amino acids increased. The ligation of the portal-systemic shunt was thus considered to be the key to the successful treatment of hepatic encephalopathy in this unusual case.     

Surgical treatment for recurrent tumors of primary malignant melanoma of the esophagus: a case report and review of the literature

The purpose of this communication is to present a case of resection performed for local recurrent tumors of primary malignant melanoma of the esophagus (PMME) and to review the relevant literature. The patient was a 54 year-old man who had received an intraabdominal esophagectomy with a total gastrectomy for primary malignant melanoma of the abdominal esophagus in another hospital, in November 1995. After the initial operation, he was treated as an outpatient. In August 1997, computed tomography and ultrasonography revealed recurrent tumors in the dorsal pancreatic lymph node and in the right adrenal gland. The recurrent tumor of the dorsal pancreas directly invaded the dorsal pancreas parenchyma and occluded the superior mesenteric vein and splenic vein, and the other metastatic tumor in the right adrenal gland existed in the absence of circumference invasion. Metastases of the PMME were confirmed in the dorsal pancreas, the superior mesenteric vein, splenic vein, and right adrenal gland, and were removed by a total pancreatectomy on October 7, 1997. By immunohistochemical staining, we found that the focal areas expressed S-100 protein and HMB-45 antibody. Currently (February 1998), the patient is alive and disease-free. PMME is an extremely rare tumor with a poor prognosis for survival. Only 2 cases of removal of recurrent tumors, including the present case, have been reported. The treatment of choice is surgical resection, even in cases of recurrence, because radiotherapy and/or chemotherapy have not been proven to be beneficial; however, they may play a palliative role if surgery is not possible.     

Non-Familial Double Malignancy of the Colon and Ampulla of Vater: A Case Report and Review of Literature

Apart from their association in familial and hereditary cancer syndromes, sporadic double malignancies of the gastrointestinal tract involving the ampulla of Vater and colon are extremely rare. Although synchronous resection of the two by adding a colectomy to a pancreaticoduodenctomy can be accomplished with minimal increase in the surgical morbidity, a few patients, however, are best managed by a staged resection. We report a case of sporadic double malignancy of the ampulla of Vater and right colon who despite the best attempts continued to bleed and remained malnourished and was successfully managed by staged right hemicolectomy followed by a pancreaticoduodenectomy.     

Successful resection of cholangiocellular carcinoma with tumor thrombus in the main trunk of the portal vein

A space-occupying lesion in the right hepatic lobe, with dilated peripheral bile ducts, was observed by ultrasonography and computed tomography in a 50-year-old man with right upper quadrant abdominal pain. One month later, this lesion evidenced rapid growth and a tumor thrombus, which completely occluded the main trunk and the left primary branch of the portal vein, had developed. The tumor was diagnosed as a cholangiocellular carcinoma with an unusual pattern of intravascular extension. The primary tumor and the portal tumor thrombus were resected via a right hepatic trisegmentectomy combined with resection of the portal vein and extrahepatic bile duct, using a superior mesenteric vein—left femoral vein catheter bypass (SMV—FV bypass). The SMV—FV bypass was found to effectively reduce intraoperative hemorrhage.     

Pancreatoduodenectomy after coronary artery bypass grafting using the right gastroepiploic artery: a case report

We herein report the case of an advanced ampullary cancer developed 80 months after coronary artery bypass grafting (CABG) using the right gastroepiploic artery (RGEA) and successfully treated by pancreaticoduodenectomy (PD) with revascularization using the great saphenous vein. A 69-year-old Japanese male was admitted for examination with one-month history of nausea and appetite loss. He underwent three vessel CABG, involving bypassing between the right coronary artery and RGEA about 80 months before. The preoperative diagnosis with CT scan and gastric endoscope was carcinoma of the papilla of Vater. Preoperative abdominal angiography showed the RGEA graft remained well patent. He underwent PD with regional lymph node dissection after revascularization of the RGEA. The postoperative clinical course was uneventful. The histopathological examinations of the resected specimen revealed adenocarcinoma of the ampulla, pT2, pN0, M0 stage IB. The patient is currently alive without any further signs of ischemic heart disease several months after his operation. This case report demonstrates that the radical PD with revascularization using other vein graft can be safely performed after CABG using the RGEA.     

Three-dimensional computed tomography in laparoscopic surgery for colorectal carcinoma

AIM: To evaluate the usefulness of three-dimensional computed tomography (3DCT) in laparoscopic surgery for colorectal carcinoma. METHODS: Seventy-two patients with colorectal cancer who underwent curative operation at our hospital were enrolled in this study. They were classified into two groups by operative procedures. Sixteen patients underwent laparoscopic surgery, laparoscopic group (LG), while 56 patients underwent conventional open surgery, open group (OG). At our institution, contrast-enhanced CT is routinely performed as part of intra-abdominal screening and the 3D images of the major regional vessels are described. We have previously described about the preoperative visualization of the inferior mesenteric artery (IMA) by 3DCT. This time we newly acquired 3D images of the superior mesenteric artery (SMA)/superior mesenteric vein (SMV), ileocecal artery (ICA), middle colic artery (MCA), and inferior mesenteric vein (IMV). We have compared our two study groups with regard to five items, including clinical anastomotic leakage. We have discussed here the role of 3DCT in laparoscopic surgery for colorectal carcinoma. RESULTS: The mean length of the incision in LG was 4.625+/-0.89 cm, which was significantly shorter than that in OG (P<0.001). The association between ICA and SMV and SMA was described in the right-sided colectomy. The preoperative imaging of IMA and IMV was created in the rectosigmoidectomy. There was no significant difference in anastomotic leakage between the two groups, but no patients in LG experienced anastomotic leakage. CONCLUSION: Most of the patients are satisfied with the shorter incisional length following laparoscopic surgery. Preoperative visualization of the major regional vessels may be helpful for the secure treatment of the anastomosis in laparoscopic surgery for colorectal carcinoma.     

Histamine-producing neuroendocrine tumor of the ampulla of Vater

Neuroendocrine tumors of the ampulla of Vater are rare (less than 100 cases reported). We report here a new case characterized by histamine secretion, a hitherto unreported feature. Clinical presentation is similar to that of other tumors of the ampulla of Vater. In our observation, the patient had noticed urticaria on the right forearm for several months. Tumor of the ampulla was confirmed by endoscopic ultrasonography, while neuroendocrine characterization was assessed on biopsies after endoscopic sphincterotomy. Histamine concentration in blood was the only elevated neuroendocrine marker and returned to normal after surgical resection. Histology showed a neuroendocrine tumor with extension to lymph nodes. On immunohistochemical analysis, production of histamine was confirmed, and the diagnosis of mastocytoma was eliminated. In view of the literature, neuroendocrine tumors of the ampulla of Vater are associated with a good prognosis (5 year-survival rate: 90%) despite early lymph node involvement.     

Devascularization of the superior mesenteric vein without reconstruction during surgery for retroperitoneal liposarcoma: A case report and review of literature

A 61-year-old female patient with chronic hepatitis B virus infection was diagnosed with liposarcoma in a community hospital. Fine needle aspiration biopsy confirmed the diagnosis of well-differentiated liposarcoma. Abdominal computed tomographic angiography(CTA) showed that the mass adhered to and constricted the main trunk and branch of the superior mesenteric vein(SMV), especially the ileocolic vein, and collateral circulation was observed during the vascular reconstruction scan. The abdominal liposarcoma was resected. Because of the collateral circulation, devascularization of the SMV was attempted, and we resected the eroded SMV. The condition of the blood vessels was evaluated 20 d after surgery using CTA, which showed that the SMV had disappeared. Significant improvements in SMV collateral circulation and the inferior mesenteric vein were observed after vascular reconstruction. The patient had an uneventful postoperative course except for transient gastroplegia. Twenty months after surgery, the patient had a recurrence of liposarcoma. She underwent tumor resection to remove the distal small intestine and right hemicolon. We learned that(1) direct devascularization of the main SMV trunkwithout a vein graft is possible. The presence of collateralcirculation can increase the success rate of patientsundergoing radical surgery and prevent the occurrence ofserious postoperative complications. In addition,(2) thiscase demonstrated the clinical value of 3 D reconstruction.     

Effective balloon-occluded retrograde transvenous obliteration of the superior mesenteric vein–inferior vena cava shunt in a patient with hepatic encephalopathy after living donor liver transplantation

Balloon-occluded retrograde transvenous obliteration (BRTO) has become a common and effective procedure for treating hepatic encephalopathy due to a portosystemic shunt related to cirrhosis of the liver. However, this method of treatment has rarely been reported in patients after liver transplantation. Here, we report the case of a 52-year-old patient who underwent living donor liver transplantation (LDLT) due to hepatitis C virus-infected hepatocellular carcinoma that was complicated with portal vein thrombosis and a large portosystemic shunt between the superior mesenteric vein (SMV) and inferior vena cava (IVC). The SMV–IVC shunt was not obliterated during LDLT because there was sufficient portal flow into the graft after reperfusion. However, the patient was postoperatively complicated with encephalopathy due to the portosystemic shunt. BRTO was performed and was demonstrated to have effectively managed the encephalopathy due to the SMV–IVC shunt, while preserving the hepatic function after LDLT.     

Lengthening of the mesentery using the marginal vascular arcade of the right colon as the blood supply to the ileal pouch

PURPOSE: Creation of a safe ileal pouch requires a tension-free anastomosis. The aim of this study was to evaluate a technical procedure that increases the length of the mesentery while preserving the blood supply to the ileal pouch. HYPOTHESIS: Preservation of the marginal vascular arcade (MVA) of the right colon will allow ligation of more mesenteric vessels and increase the mesenteric length. METHODS: Six fresh cadavers were dissected. Measurement of the apex of the terminal ileum was done in relation to the pubic symphysis. Measurements were taken after 1) complete mobilization of the terminal ileum, right colon, and hepatic flexure; 2) vascular ligation between colon wall and the MVA, preserving the latter from the right branch of the middle colic artery to the ileal branch of the ileocolic artery (ICA); 3) ligation of the distal third of the superior mesenteric artery; 4) ligation of the ICA at its origin; 5) ligation of the right colon artery; and 6) division of the terminal ileal mesentery. RESULTS: This technique enabled complete division of the terminal ileal mesentery, adding a mean additional 3.6 (range, 2.5–5.0) cm (36.5±16.5 percent) in length to the mesentery, compared with superior mesenteric artery, ICA, and right colic artery ligation. CONCLUSION: Patients who have a shorter mesentery and concern of excessive mesenteric tension should have colectomy performed, preserving the MVA from the middle colic artery to the ileal branch of the ICA. The preserved MVA can be a reliable alternative blood supply to the pouch if more mesenteric vessel ligations are necessary.     

Synchronous double primary cancer of the esophagus and ampulla of Vater successfully treated by a two-stage operation: report of a case

A 68-year-old man was diagnosed with local recurrent cancer of the ampulla of Vater by follow-up endoscopy 3 years after an endoscopic papillectomy. A screening endoscopy found superficial middle thoracic esophageal cancer. The patient required an esophagectomy and pancreatoduodenectomy. We chose a two-stage operation for the esophageal cancer and the local recurrent cancer of the ampulla of Vater, both to reduce surgical invasiveness and to circumvent the lower curability. The first-stage operation consisted of a right transthoracic subtotal esophagectomy with mediastinal and cervical lymph node dissection, external esophagostomy of the neck, and gastrostomy. Forty days after the first surgery, a gastroduodenal artery- and right gastroepiploic vessel-preserving pancreatoduodenectomy with Child’s reconstruction was performed as the second-stage surgery. Esophageal reconstruction was achieved using a gastric tube via the percutaneous route with vascular anastomosis.     

Delayed rupture of the middle colic artery secondary to blunt abdominal trauma.

The case of a 46-year-old man complaining of acute abdominal discomfort is presented. The patient fell 3 ft and injured his abdomen in the right upper quadrant four days before his emergency department visit. The complete workup revealed an acutely ruptured middle colic artery. The presenting symptoms, laboratory work, differential diagnosis, computed tomography scan, treatment, and follow-up are reviewed. This case is unusual in that delayed rupture of the middle colic artery secondary to blunt abdominal trauma had not been described previously.     

A case of ampullary cancer with pancreas divisum treated by endoscopic papillectomy

A 60's man underwent a medical check-up and esophagogastroduodenoscopy revealed an exposed-type tumor at the ampulla of Vater. Endoscopic ultrasonography and intraductal ultrasonography showed a hypoechoic mass limited to the ampulla of Vater. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a slightly dilated ventral pancreatic duct not connected to the dorsal duct. Endoscopic papillectomy was performed without pancreatic stent placement and his postprocedural course was uneventful. The specimen was histologically diagnosed as well-differentiated adenocarcinoma limited to the mucosa of the ampulla of Vater. Endoscopic papillectomy without pancreatic stent placement can be performed without a risk of post-ERCP pancreatitis for ampullary tumor limited to the mucosa of the ampulla of Vater associated with pancreas divisum.