Intestinal gangrene due to mesenteric vascular occlusion masquerading as strangulated inguinal hernia

Strangulated inguinal hernia may present with intestinal gangrene. However, mesenteric arterial thrombosis producing massive gangrene of the bowel as content in inguinal hernia is an entity probably not reported in the medical literature. We report a case of inguinal hernia presenting with features of strangulation, which on exploration was found to be a case of massive bowel gangrene due to superior mesenteric artery thrombosis affecting the terminal ileum, cecum, ascending colon and proximal three-fourths of the transverse colon. We think this is the first case report of superior mesenteric artery thrombosis masquerading as strangulated inguinal hernia and present it with a message that while dealing with an inguinal hernia with gangrenous bowel as the content, one should keep in mind a rare possibility of mesenteric thrombo-embolism as the cause.     

急性肠系膜上动脉闭塞的诊断与治疗

目的 探讨急性肠系膜上动脉闭塞的诊断与治疗.方法 对2000-2007年收治的15例急性肠系膜上动脉闭塞患者的临床资料进行回顾性分析.结果 本组15例患者中肠系膜上动脉栓塞11例,肠系膜上动脉血栓形成4例.入院后均行急诊剖腹探查术,其中2例行肠系膜上动脉取栓术,11例行肠系膜上动脉取栓加坏死肠管切除术,2例放弃手术.术后均行肝素等抗凝治疗.4例死亡,总病死率为27%.结论 对于有器质性心脏病的患者,如突然出现腹部疼痛,应警惕肠系膜上动脉闭塞的可能.早期诊断、早期行肠系膜上动脉取栓术是提高治愈率的关键.     

经腹腔干-胃十二指肠弓逆向介入治疗肠系膜上动脉开口处完全闭塞无残端病变1例

目的:探讨逆向入路支架植入治疗肠系膜上动脉(SMA)闭塞的技术。方法:回顾2017年2月1例于复旦大学附属中山医院血管外科行逆向开通SMA闭塞的患者临床资料。结果:患者为47岁女性,诊断为SMA闭塞引起的慢性肠系膜缺血(CMI),行腔内治疗再通SMA。由于SMA开口处完全闭塞性,无残端,经肱动脉和股动脉双侧入路均无法开通病变部位。利用腹腔干和SMA之间的胃十二指肠弓,通过此通路逆向开通SMA闭塞处;肱动脉入路导管和导丝对接后顺利正向通过病变,完成球囊扩张和支架植入术。术后患者CMI症状消失,3个月后随访CTA显示,支架定位良好,远端血管通畅。结论:对于常规血管内介入治疗方法失败的SMA闭塞患者,通过有效的侧支通路进行逆行开通是可行的。     

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目的 探讨急性肠系膜血管闭塞(AMVO)的早期诊断及外科治疗方法。方法 回顾性总结1987年8月至2002年8月收治的24例AMVO，对其临床特征、外科诊断治疗方法及预后进行分析。结果 24例AMVO中肠系膜上动脉栓塞(MAE)9例(37.5％)，肠系膜上静脉血栓形成(MVT)13例(54．2％)，肠系膜上动脉血栓形成(MAT)2例(8．3％)。最常见的临床表现为腹痛(91.7％)。最可靠的诊断方法为肠系膜血管造影(100％)。9例MAE确诊7例。保守治疗3例，急诊手术6例。治愈5例，死亡4例。13例MVT确诊10例。保守治疗7例。介入治疗2例，手术4例。全部治愈。2例MAT均确诊，介入与手术治疗各1例，均治愈。结论 肠坏死发生前早期诊断、积极行介入治疗与剖腹探查为主的外科治疗是提高AMVO疗效的关键。     

急性肠系膜上静脉血栓形成合并肠坏死诊断及手术治疗体会

目的总结急性肠系膜上静脉血栓形成(SMVT)合并肠坏死的诊断及手术治疗经验。方法回顾性分析2010年6月1日至2016年7月1日收治的12例SMVT合并肠坏死的临床资料。结果 12例患者术前影像学检查有9例均明确诊断,3例剖腹探查术中证实。出院前行门静脉肠系膜上静脉CT和计算机断层摄影术血管造影(CTA)复查,未见新的血栓形成,血管通畅。平均住院时间14~20 d。2例患者术后继发短肠综合征,无手术死亡及再次手术。全部患者得到随访,随访6个月~1年无1例复发。结论 SMVT合并肠坏死早期及时诊断和围手术期治疗的规范化处理,可避免再手术或形成继发性短肠综合征,尤为重要。     

肝硬化患者肠系膜上动脉血流动力学变化的观测

目的 通过肝硬化肠系膜上动脉（SMA）血流动力学观测，探讨肝硬化腹水形成机理。方法 采用彩色多普勒超声对50例对照组和80例肝硬化组SMA血流动力学进行测定。结果 肝硬化代偿期患、失代偿期患SMA的脉动指数（PI）和阻力指数（RI）均较正常对照组明显降低，但有腹水的肝硬化又较不伴腹水PI显降低，且有随食道静脉曲张的加重而降低的趋势。结论 肝硬化患早期即有内脏血流阻力的减低，SMA的高动力与腹水的形成、食道静脉曲张有关。     

经腹小切口超声引导系膜穿刺逆向开通治疗肠系膜上动脉开口全堵病变

背景与目的：对于肠系膜上动脉（SMA）闭塞患者,尤其是存在开口处动脉粥样硬化性无残端病变,开腹逆行肠系膜动脉支架置入术（ROMS）是一种有效的治疗方法,但该手术创伤较大,一些身体条件差的患者并不适合。笔者通过报告1例SMA全堵病变病例的治疗过程介绍一种改良的微创ROMS技术,以期为临床治疗方法的选择提供参考。 方法：回顾复旦大学附属中山医院厦门医院血管外科2019年10月收治的1例SMA全堵病变患者的临床资料。患者为64岁女性,诊断为SMA闭塞引起的慢性肠系膜缺血,行杂交手术再通SMA。 结果：患者SMA开口处为无残端完全闭塞病变且无侧支血管与腹腔干动脉及脾动脉沟通,顺行或逆行血管腔内开通均无法进行。因患者全身条件较差,难以耐受开放血运重建手术和传统的ROMS。遂做腹部做小切口,超声引导下经系膜穿刺SMA远端建立通路,导丝顺利逆向通过SMA闭塞处进入降主动脉;右侧肱动脉入路导管和逆向导丝对接后顺利正向通过病变,完成球囊扩张和支架置入术。术后患者恢复良好,症状消失,3个月后随访CTA示,支架形态、位置良好,血流通畅。 结论：对于血管腔内治疗失败且全身条件较差的SMA闭塞患者,通过经腹小切口超声引导系膜穿刺逆向开通SMA是可行的。     

肝脏血流阻断方法及评价

Hepatectomy is the main option of treatment for liver cancer,and how to control the blood loss is an important issue for the recovery of patients.Continuous hepatic vascular occlusion(Pringle maneuver)is the oldest and simplest way for vascular occlusion and still used in clinical practice.But continuous hepatic vascular occlusion often gives rise to postischemic reperfusion injury due to clamping the portal vein and the hepatic artery in the hepatic pedicle.So intermittent clamping or hemihepatic vascular occlusion is recommended in complex liver resections or for patients with liver cirrhosis.Total hepatic vascular exclusion has the advantages of occlusion of vascular inflow and outflow of the liver,and is mainly used for patients with tumors invading the caval veins.Major hepatic veins and limited inferior vena cava reconstruction has been also achieved under inflow occlusion with extraparenchymal control of major hepatic veins.It is crucial to know how to select the optimal methods of hepatic vascular occlusion according to the specific conditions.Focusing on this issue,we have reviewed and evaluated various methods and relevant researches in this paper.     

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.     

Aneurysm of the inferior mesenteric artery associated with occlusion of the celiac axis and superior mesenteric artery

The authors report a case of aneurysm of the inferior mesenteric artery encountered in a 38-year-old man, associated with occlusion of the celiac axis, the superior mesenteric artery and the inferior mesenteric artery distal to the aneurysm. All three arteries were revascularized. In spite of failure in the bypass of the superior mesenteric artery, the patient remained symptom free until his demise four years later, from a probable myocardial infarction. Only 11 cases of aneurysms of the inferior mesenteric artery have been reported in the literature. The causes, diagnosis and treatment of these uncommon lesions are discussed. When occlusion of the celiac axis is associated with that of the superior mesenteric artery, a complete mesenteric revascularization should be attempted whenever possible.     

Ischemia-reperfusion injury following superior mesenteric artery occlusion and strangulation obstruction

BACKGROUND: Intestinal ischemia-reperfusion injury (IRI) is a serious and common clinical entity resulting in severe tissue injury. This study was designed to compare IRI in superior mesenteric artery (SMA) occlusion and strangulation obstruction (SO). MATERIALS AND METHODS: Thirty Wistar-Albino rats were assigned randomly to three groups. In the control group, a sham operation was performed. In the SMA occlusion group, a vascular clamp was placed across the SMA to occlude arterial circulation. In the SO group, a 15-cm segment of small intestine was looped to prevent venous circulation. Sixty minutes of ischemia was followed by 60 min of reperfusion. Following reperfusion, biopsies of small intestine were taken to assess morphologic damage, tissue levels of malonyldialdehyde (MDA) as an index of lipid peroxidation reflecting oxygen free radicals (OFR) were determined, and serum biochemical analyses were performed. RESULTS: The levels of tissue MDA were significantly higher in the SO group than in the SMA occlusion group (P < 0.05). Biochemical parameters of SO and SMA occlusion groups were higher than those in the control group and there was a significant difference between the SMA occlusion and the SO models, except for ALP levels. Histopathologically, transmural intestinal damage were present in seven cases of SO and in six cases in the SMA occlusion group. CONCLUSIONS: Despite no significant difference between the two groups in terms of intestinal tissue damage, OFR-induced injury was higher in the strangulation obstruction group.     

A new approach for acute embolus occlusion of the superior mesenteric artery

Acute embolus occlusion of the superior mesenteric artery (SMA) either demonstrates a poor prognosis, or forces the patients to endure miserable postoperative dietary lives. Recently, we developed a new successful technique which reduced the length of the intestinal segment that had to be removed. The technique was as follows: (1) the distal end of the SMA was ligated to avoid perfusion of the necrotic segment, and (2) a Fogarty balloon catheter was inserted from the distal end of the SMA and then passed proximally to remove any remaining clots. Using the above-described technique on 3 cases from 1992 to 1994, we were thus able to shorten the length of the intestine that had to be removed and thereby greatly improve the patients' postoperative dietary lives.     

血管腔内技术与手术治疗锁骨下动脉闭塞症

目的探讨血管腔内技术与手术治疗锁骨下动脉闭塞症的临床效果及合适的治疗程序。方法1997年6月至2004年5月采取血管腔内技术与手术治疗锁骨下动脉闭塞症39例。26例患者采用血管腔内治疗,置入27枚支架,14例经股动脉途径,12例经肱动脉逆行支架置入,其中8例在彩色多普勒超声定位下穿刺肱动脉。13例未能行支架置入,行血管旁路转流术。9例伴有颈动脉或椎动脉严重狭窄者行支架置入。结果39例患者术后患侧与健侧血压差<10mmHg(1mmHg=0.133kPa),患侧/健侧血压指数由术前的平均0.62±0.11提高至0.98±0.04(t=4.738,P<0.01);腔内治疗患者与手术患者平均血管通畅时间分别为(57.6±3.7)和(60.2±7.2)个月。结论血管腔内治疗与手术治疗锁骨下动脉闭塞症疗效相当,由于血管腔内治疗的微创性和安全性,应优先选择血管腔内治疗。     

Novel surgical reconstruction of a mycotic abdominal aortic aneurysm using cryopreserved femoral arterial allograft from the NHS tissue bank: a new resource for UK vascular surgeons

The treatment of mycotic abdominal aortic aneurysms remains a significant surgical challenge associated with significant morbidity and mortality. In the following case report, we describe our successful management of a patient with a mycotic abdominal aortic aneurysm using two cryopreserved superficial femoral artery allografts (available from the UK NHS tissue bank) to create a Y-shaped allograft to permit immediate aortic reconstruction after surgical debridement. To our knowledge, this is the first time such a reconstruction has been reported in the literature.     

急性原发性肠系膜上静脉血栓形成的临床诊治：附19例报告

目的：探讨急性原发性肠系膜上静脉血栓形成（APSMVT）的诊断与治疗。方法：回顾性分析近3年收治的19例APSMVT的临床资料。结果：术前诊断疑为APSMVT的仅7例。19例均行手术治疗, 其中2次手术3例。治愈17例, 死亡2例。17例随访0.5~4年, 均健在。结论：该病诊断缺乏特异性, Doppler彩超、CT、选择性血管造影有助于早期诊断。手术切除坏死肠管、术后抗凝是防止复发、降低病死率的关键。     

Hybrid endovascular repair with reconstruction of superior mesenteric and celiac arteries for thoracoabdominal and abdominal aortic aneurysms

A 79-year-old woman presented with sustained thoracolumbar back pain. Contrasted computed tomography (CT) showed a thoracoabdominal aortic aneurysm (TAAA: type I of Crawford classification) and an abdominal aortic aneurysm (AAA) that were not ruptured. Considering her age, the placement of an endovascular stent graft was performed for TAAA at the possible sacrifice of the celiac (CA) and superior mesenteric arteries (SMA). In order to prevent ischemic events, it was necessary that blood supply to the CA and SMA was maintained by placing a graft to each artery from the Y-shaped graft for replacement of AAA. Actually, only CA was sacrificed and coil embolization of CA was needed because of type 2 endoleak. The patient was discharged 17 days after surgery. A hybrid technique, endovascular repair with reconstruction of abdominal branches for TAAA and AAA, can be an alternative procedure for such high-risk operation with multiple aortic aneurysms including TAAA.     

结肠肝曲癌右半结肠联合胰十二指肠切除术九例报道

目的探讨右半结肠(RH)联合胰十二指肠切除(PD)的必要性及疗效。方法对9例RH联合PD手术患者采用child方式重建;右半结肠切除采用回肠末端与横结肠对端吻合,胰肠吻合以嵌入式捆绑吻合的治疗及随访结果分析。结果本组无围手术期死亡,其中胆肠瘘,切口感染2例;胆肠瘘,胰瘘1例;切口感染1例,均经静脉营养,抑制胰酶分泌等综合治疗而痊愈,3例患者平均存活23个月后死亡,另6例患者平均存活15.8个月,仍在随访中。结论RH联合PD手术需严格掌握其适应证,其患者远期预后则取决于肿瘤分期和手术的完整切除。     

Postshock mesenteric lymph drainage ameliorates vascular reactivity and calcium sensitivity through RhoA

Background

Vascular hyporeactivity plays an important role in the pathogenesis of severe shock. Previous studies have shown that postshock mesenteric lymph (PSML) blockage ameliorates the vascular reactivity and calcium sensitivity, and RhoA is involved in the regulation of vascular reactivity after hemorrhagic shock. Therefore, the present study tested whether small GTPase RhoA mediates the improvement of the vascular reactivity and calcium sensitivity in superior mesenteric artery (SMA) of rats with PSML drainage.

Materials and methods

The hemorrhagic shock model (blood pressure to 40 ± 2 mm Hg) was established, and PSML was drained from immediate hypotension for 3 h, after which SMA was isolated, and the vascular reactivity and calcium sensitivity were tested in the presence of RhoA agonist (U-46619) or inhibitor (C3 transferase). The protein expressions of small GTPase RhoA and phospho-RhoA were also examined in SMA.

Results

The hemorrhagic shock resulted in a significant decrease in the SMA reactivity and calcium sensitivity, which was enhanced by the application of U-46619 to the SMA. In contrast, the PSML drainage ameliorated the deleterious effect of the hemorrhagic shock on the SMA. This beneficial effect of the PSML drainage was abolished by C3 transferase. Western blotting revealed that the expressions of the RhoA and phospho-RhoA in SMA tissue obtained from the shock group were significantly decreased, and the PSML drainage markedly enhanced these protein expressions.

Conclusions

RhoA is an important contributor to the PSML drainage-induced amelioration of the vascular reactivity and calcium sensitivity in rats with hemorrhagic shock.     

肝总动脉闭塞后经侧支循环行TACE治疗肝癌

目的 探讨肝总动脉(CHA)闭塞后经动脉化疗栓塞(TACE)治疗原发性肝癌(PLC)的可行性及效果.方法 回顾性分析9例PLC患者CHA闭塞后经侧支循环行TACE治疗的临床及影像学资料.结果 本研究入组1 782例PLC患者,共行4 771次TACE治疗,平均2.7次/人.9例患者出现CHA脉闭塞,发生率为0.5％(按人数计算)、0.19％(按TACE次数计算).第一、二、三、四、五、六次TACE后出现CHA闭塞者分别为1例、1例、2例、2例、2例、1例.9例发生CHA闭塞的患者平均行TACE 3.7次/人,明显高于总体的2.7次/人(P＜0.05).7例CHA存在不同程度的迂曲.CHA闭塞与术中使用5F导管、CHA迂曲及TACE次数有关.9例患者均经侧支循环行TACE治疗.术后4～6周复查CT均提示碘油沉积良好,达到了有效控制肿瘤的目的.结论 对于CHA闭塞的PLC患者,经侧支循环行TACE治疗是安全、可行的,具有与CHA途径行TACE治疗同样的疗效.     

Risk factor analysis and treatment outcome of patients with spontaneous isolated celiac axis or superior mesenteric artery dissection

BackgroundSpontaneous isolated mesenteric artery (celiac axis or superior mesenteric artery [SMA]) dissection (IMAD) is a rare clinical entity. The aim of the present study was to examine the patient demographics, comorbidities, clinical and radiologic features, management, and prognosis and to identify the risk factors predictive of symptoms.MethodsWe performed a single-center, retrospective review from November 2005 to November 2021 of prospectively collected data from patients with a diagnosis of IMAD. The clinical data and radiologic images were reviewed, and statistical analysis was performed to compare the symptomatic and asymptomatic groups.ResultsA total of 78 patients were identified. Of the 78 patients, 24 (31%) had had celiac dissections, 51 (65%) had had SMA dissections, and 3 (4%) had had both celiac and SMA dissections. The mean age was 57.7 years (range, 36-84 years), with a male predominance (86%). More than one half (55%) of the patients had had hypertension. In addition, 29 patients (37%) were symptomatic, and 24 (31%) had been admitted to the hospital. The symptomatic patients with celiac axis dissections were more likely to have thrombosis (P = .02), significant stenosis (P = .01) or branch extension (P = .02). The symptomatic patients with SMA dissections were more likely to have a smaller artery diameter (P = .07), a longer dissection length (P = .05), thrombosis (P < .001), significant stenosis (P < .001), or branch extension (P = .003). The symptomatic patients were more likely to have been treated with antiplatelet or anticoagulant therapy (P < .001). Only three patients had undergone an intervention. Seven patients (9%) had died of unrelated causes. The Kaplan-Meier survival analysis showed a 5-year survival rate of 96% and 10-year survival rate of 91%.ConclusionsIMAD is an uncommon disease entity with a risk of visceral ischemia. Nonetheless, most of these patients can be treated conservatively with medication, with only a small minority requiring emergency surgery.