Manifestations of carcinoma of the uncinate process by means of superior mesenteric arteriography

Identification of carcinoma arising in the uncinate region of the pancreas is difficult because of the peculiar topographic relationship of this lesion with adjacent structures. Among the various diagnostic procedures performed upon ten patients with this malignant lesion, superior mesenteric arteriography provided the most helpful information, including signs of invasion in the main trunk of the superior mesenteric artery and vein and in the proximal portion of the jejunal arteries. A clearer visualization of these vascular involvements was attained in the right posterior oblique projection rather than in the anteroposterior projection. On the contrary, the arterial and portal vessels belonging to the celiac territory, such as superior pancreaticoduodenal arteries, dorsal pancreatic artery, gastroduodenal artery, splenic vein and portal vein, were almost free of involvement. At laparotomy, almost all of the patients had direct extension of the tumor to the superior mesenteric vessels, forming a cancerous core in the root of mesentery. All died of cachexia within six months after a palliative surgical procedure. Serial roentgenograms of superior mesenteric artery, especially taken in the oblique projection, are the best means of confirming carcinoma of the uncinate process, for which only a few available methods have been established to evaluate the clinical aspects.     

Combined hepatic and pancreaticoduodenal procurement for transplantation

We have used a procurement method whereby both the liver and whole pancreas grafts are procured from the same donor and successfully transplanted. During the combined procurement, the hepatic artery is completely mobilized; the splenic artery is transected from the hepatic artery and the gastroduodenal artery is ligated from the hepatic artery. The portal vein is mobilized 2 centimeters from the head of the pancreas. The whole pancreas graft includes the splenic artery and the superior mesenteric artery, which are reconstructed. The hepatic graft includes the entire length of the hepatic artery with the celiac axis, and no further reconstruction is required. Using this technique, we have performed nine combined hepatic and whole pancreas procurements; only one liver was not transplanted because of technical complications. When a replaced right hepatic artery is identified from the superior mesenteric artery, we have abandoned the pancreatic retrieval. All combined retrievals have included successful renal retrieval, and the majority have been associated with cardiac retrieval also. Combined hepatic and whole pancreas procurement is feasible with minimal technical complications with the liver or the pancreatic graft and should be standard in most procurements.     

Hypoglycemia due to high positioning of umbilical artery catheters

Three neonates with umbilical artery catheters positioned at the eighth and tenth thoracic vertebrae experienced hypoglycemia that resolved rapidly upon withdrawal of the catheters to low positions between the third and fourth lumbar vertebrae. Streaming of glucose to the celiac and superior mesenteric arteries is a possible cause of this hypoglycemia.     

Retropancreatic control of the suprarenal aorta

An alternative approach to occluding the suprarenal abdominal aorta involves a Kocher maneuver and isolation of the retropancreatic aorta between the origins of the celiac axis and the superior mesenteric artery. The use of this approach is supported by operative dissections upon cadavers, as well as upon two patients in whom it was used without difficulty.     

A simple technique for resection of the uncinate process during pancreatectomy

Difficulty in resection of the uncinate process of the pancreas often results in significant hemorrhage. Partial vascular occlusion of the superior mesenteric vein with resection of the lateral wall allows complete removal of all pancreatic tissue with minimal blood loss.     

Echogenic bowel in intrauterine growth restriction fetuses: does this jeopardize the gut?

OBJECTIVE: To investigate the association between intrauterine growth restriction (IUGR) fetuses with echogenic bowel and high resistance in the umbilical artery and increased risk of developing neonatal necrotizing enterocolitis. METHODS: We analyzed two groups: group 1, singleton IUGR fetuses with echogenic bowel or reversed diastolic flow in the umbilical artery, and group 2, neonates who were diagnosed as having neonatal necrotizing enterocolitis. In group 1, the pulsatility index of the superior mesenteric artery and celiac trunk were determined. In group 2, a retrospective analysis was carried out from the medical records of the neonates. RESULTS: Fifteen fetuses with echogenic bowel and severe IUGR were evaluated by Doppler studies, and 21 neonates with neonatal necrotizing enterocolitis were reviewed. In group 1, none of the IUGR fetuses developed neonatal necrotizing enterocolitis, whereas in group 2, only one neonate was defined as IUGR. The mean gestational age at delivery did not differ statistically between the two groups (28.8 +/- 2.3 weeks versus 30.1 +/- 3.3 weeks), whereas the mean birth weight was significantly lower in the first group (700 +/- 200 g versus 1431 +/- 466 g in the second group, P <.001). The mean pulsatility index +/- standard deviation in the superior mesenteric artery and celiac trunk of the IUGR fetuses were 1.5 +/- 0.14 and 1.2 +/- 0.17, respectively, both being found significantly lower than those of normal, appropriate controls (1.9 +/- 0.15 and 1.7 +/- 0.1, respectively, P <.005). CONCLUSION: Fetal echogenic bowel in IUGR fetuses is not associated with development of neonatal necrotizing enterocolitis. In these fetuses, vasodilatation in the superior mesenteric artery and celiac trunk have been demonstrated.     

Application of streptokinase in peripheral vascular thromboembolism

To assess the efficacy of and the complications associated with streptokinase in clinical use, we administered this drug prospectively to 9 patients with thromboembolism of the peripheral vessels from August 1984 to January 1987. The involved vessels included the renal artery, superior mesenteric artery and vessels of the lower extremities. During the course of treatment, thrombin time (TT), prothrombin time (PT), and partial thromboplastin time (PTT) were monitored regularly. Complications such as fever, chills, liver function abnormalities and hematuria were managed effectively. One patient experienced anaphylactic shock and required immediate discontinuation of streptokinase. Good results were obtained in all other patients. According to the results of our study, streptokinase offers the advantages of rapid lysis and complete resolution of clots in peripheral thromboembolic disease. The complications can be minimized if clinical and laboratory responses are monitored appropriately and patients are carefully selected.     

Colonoscopic diagnosis of angiodysplasias of the gastrointestinal tract

We have reviewed our experience with colonoscopy in the diagnosis of angiodysplastic lesions of the colon. In 14 of the patients in our series, the lesions in the colon were diagnosed colonoscopically, confirming arteriographic findings in many but being the only diagnostic modality facilitating the diagnosis in three of the patients. Results of our experience indicate that colonoscopy is an effective means of diagnosing or confirming the diagnosis of angiodysplastic lesions of the right colon. It should be part of the evaluation along with superior and inferior mesenteric angiography of every patient with occult gastrointestinal tract bleeding or iron deficiency anemia, or both, for whom no diagnosis can be made with standard barium contrast techniques.     

Improvement of mesenteric superior artery Doppler velocimetry by amnio-infusion in fetal gastroschisis.

This study aimed to analyse the influence of amnio-infusion on superior mesenteric Doppler velocimetry and to correlate Doppler data with outcome in fetuses presenting with gastroschisis. Umbilical and intra- and extra-abdominal superior mesenteric artery Doppler velocimetry was measured prospectively before and after amnio-infusion in fetuses with gastroschisis. Doppler index values and changes were correlated with the following outcome parameters: importance of fibrous coating, duration of hospitalization in the neonatal intensive care unit, total duration of hospitalization, duration of parenteral feeding, duration of ventilatory assistance, and the interval to initiation of oral feeding. A significant improvement of diastolic flow was observed in the extra-abdominal superior mesenteric artery with amnio-infusion. No similar change was seen in the intra-abdominal superior mesenteric or in the umbilical artery. Pre-amnioinfusion extra-abdominal mesenteric Doppler index was correlated with maximal diameter of exteriorized bowel and slightly with duration of hospitalization in the neonatal intensive care unit, but no other relation between Doppler index and outcome parameter could be ascertained. Amnio-infusion induces modifications in the vascularization of exteriorized bowel in gastroschisis. This could partly explain the beneficial effect of this procedure on fetal gut.     

Vomiting during pregnancy due to midgut volvulus with duodenal obstruction

An interesting case of severe vomiting with dehydration and weight loss due to midgut volvulus with duodenal obstruction during pregnancy is reported. The patient was an 18-year-old primipara in the third month of pregnancy. She had experienced symptoms which were similar, but much less severe, for many years. The obstruction occurred at the level of the third portion of the duodenum and was produced by the torsion and tightening of the overlying superior mesenteric vessels. These vessels were the only support for an other-wise unattached small intestine. Complete and continuing relief of the patient's symptoms was achieved by operative by-pass of the area of obstruction by means of a duodenojejunostomy. The episode of obstruction and its operative management did not influence the normal course and termination of the pregnancy. The importance of an awareness of the possible occurrence of intestinal volvulus during pregnancy is emphasized.     

Pregnancy in the tubal interstitium and tubal remnants

The stages of intestinal rotation and mesenteric fixation are outlined.A case of superior mesenteric syndrome resulting from acute pelvic inflammatory disease and congenital absence of mesenteric fixation is presented.     

Nonimmune hydrops fetalis associated with congenital small bowel atresia--a case study

Nonimmune hydrops fetalis is observed with the frequency of 1:3000 cases diagnosed pre- and postnatally. In the following paper the authors analyzed the course of pregnancy complicated by fetal ascites and polyhydramnios with the appearance of colonic ileus and they presented the postnatal condition of the baby The preliminary diagnosis was confirmed after birth and the newborn was operated in the second day of his life. The congenital small bowel atresia was qualified as a III B type (Grossfeld qualification), which is called the "pagoda" syndrome [3]. The colonic atresia is located then around the superior mesenteric vessels, which leads to colonic necrosis (Figure 1).     

Superior mesenteric artery blood flow velocity in small for gestational age infants of very low birth weight during the early neonatal period

In order to elucidate intestinal blood flow after birth in infants with intrauterine growth retardation, we measured superior mesenteric artery blood flow velocity in uncomplicated small for gestational age infants with a birth weight of < 1500 g by pulsed Doppler ultrasound in days 1 to 7 of life. Peak systolic blood flow velocity, time-averaged mean blood flow velocity and end-diastolic blood flow velocity in the superior mesenteric artery significantly increased with time. The resistance index and relative vascular resistance in the superior mesenteric artery significantly decreased after birth. Compared with gestational age matched appropriate for gestational age infants and birth weight matched appropriate for gestational age ones, peak systolic blood flow velocity, time-averaged mean blood flow velocity and end-diastolic blood flow velocity in the superior mesenteric artery were lower in the small for gestational age infants. The difference between the small for gestational age group and the gestational age matched appropriate for gestational age group was statistically significant. The resistance index and relative vascular resistance in the superior mesenteric artery tend to be higher in the small for gestational age group than in the appropriate for gestational age groups. In conclusion, although intestinal blood flow velocity in infants with intrauterine growth retardation increases after birth, it is lower than appropriate for gestational age infants during the early neonatal period.     

Angiography in acute gastrointestinal bleeding.

Angiography in patients with acute gastrointestinal bleeding is a necessary adjunct to fiberoptic endoscopy to identify the site of the bleeding, especially if it is from the small or large intestine. Clinically, a bleeding rate of 3 milliliters per minute is associated with perceptible extravasation of the contrast medium, venous bleeding excluded. Although celiac or mesenteric arteriography is preferred, abdominal aortography can be useful as the selective examination.     

Neonatal hepatic hemangioendothelioma identified by real-time ultrasound: report of a case

Sonographic findings emphasizing vascular imaging in the identification of a resectable huge hepatic hemangioendothelioma in a 1-day-old neonate are reported. The prominent sonographic features consisted of dilated hepatic veins, enlarged celiac trunk and hepatic artery, indicating arteriovenous shunting, in addition to the complex echo pattern of the mass itself. Moreover, sonographic visualization of marked caliber discrepancy between hepatic and splenic arteries at their origin from the celiac trunk readily provided another subjective evidence of hepatic artery dilatation, further reflecting the hypervascularity of this hepatic mass. Hence meticulous ultrasonic study of such hepatic masses with special attention to their enlarged feeding and draining vessels can provide a simple and noninvasive approach for early recognition of this vascular hepatic tumor in the immediate newborn period.     

Aortomesenteric bypass using autogenous saphenous vein graft for superior mensenteric artery aneurysm: report of a case

We report a 62-year-old man who had symptoms of abdominal angina and was diagnosed preoperatively with a superior mesenteric artery (SMA) aneurysm. The findings of the CT scan and angiography revealed a 3 X 4 cm saccular aneurysm at the proximal site of the SMA. During abdominal exploration, a weak pulsation of the SMA branches distal to the aneurysm was felt. The aneurysmal cavity was full of old thrombi. Brisk retrograde bleeding from the orifices of the connecting collaterals was seen after removal of the thrombi. Our operative procedures included endoaneurysmorrhaphy, proximal ligation, and distal interruption of the aneurysm. Vascular reconstruction by an aortomesenteric bypass using a segment of autogenous saphenous vein graft was also done. After creating the vein graft bypass, the weak pulsation of the distal SMA branches became normalized. The patient enjoyed an uneventful postoperative course and did not complain of abdominal pain on clinical follow up. Four months later, he received an evaluation including angiography and CT scan, which confirmed that the vein graft was patent and without deformity.     

Angiography of trophoblastic tumors. Analysis of pelvic angiography correlated with microangiography and histopathological examination of uterine specimens.

Pelvic angiography of 61 patients with trophoblastic disease was studied. Twenty-four patients were studied in detail correlating direct 4-fold magnification angiography, microangiography, and histopathological examination. Increased myometrial vessels, central vascular pooling, and central avascularity on pelvic angiograms were confirmed by magnification angiography or microangiography, but the diagnosis of tumor vessels by pelvic angiography was often disproved by microangiography.It is usually possible to detect and diagnose established malignant tumors with pelvic angiography, but there were exceptions which impose limitations to pelvic angiography. Differential diagnosis of chorionepithelioma and destructive mole is not always possible. Central vascular pooling is more suggestive of destructive mole than chorionepithelioma, because diffuse infiltration of contrast media into intervillous spaces which were found on destructive mole were represented as central vascular pooling on pelvic angiograms.     

Fetal superior mesenteric artery blood flow velocimetry in normal and high-risk pregnancy

THE AIM: To record blood flow velocimetry in the fetal superior mesenteric artery in normal pregnancy and to evaluate if blood flow recordings in the vessel might predict adverse outcome in high-risk pregnancy. METHODS: The fetal superior mesenteric artery blood velocimetry was recorded in a cross sectional manner in 75 normal pregnancies between 27 and 41 weeks of gestation. Reference curves were performed for pulsatility and resistance indices. The superior mesenteric artery was also located in 48 singleton pregnancies complicated by pregnancy-induced hypertension and/or intra-uterine growth retardation. Middle cerebral artery, umbilical artery and vein and uterine artery velocimetry were also recorded. RESULTS: Superior mesenteric artery PI and RI values expressed an increase in resistance to blood flow with gestational age after 32 weeks of gestation. In all except eight high-risk pregnancies the fetal mesenteric artery PI values were within normal range. Among the pregnancies with absent or reversed blood flow in the umbilical artery, all had abnormal mesenteric artery pulsatility index (PI) (> 97.5th percentiles), one fetus died intrauterine and two others died after delivery due to prematurity, growth retardation and necrotizing enterocolitis. In the remaining fetuses with increased mesenteric artery PI, necrotizing enterocolitis was diagnosed in three cases. CONCLUSIONS: Increased vascular resistance in the mesenteric artery might be a late sign of fetal circulation redistribution and frequently related to necrotizing enterocolitis in the newborn.     

Collateral mesenteric circulation

The origins of historical terms, such as "Arc of Riolan" and "marginal artery of Drummond" are traced herein with emphasis on the inherent confusion caused when these terms are used. Basic mesenteric anatomy is briefly mentioned and pathologic anatomy with its altered direction of blood flow induced by atherosclerosis is stressed. The significance of the meandering mesenteric artery as the main collateral vessel between the superior and inferior mesenteric artery is emphasized along with preoperative and intraoperative ways to ascertain whether or not the origin of this latter vessel can be safely ligated. Specific operations, such as abdominal aortic aneurysmorrhaphy and sigmoid colectomy, which can potentially interfere with blood flow in the meandering mesenteric artery, are discussed in an attempt to prevent postoperative necrosis of any portion of the intestine that may have deficient mesenteric blood flow.