肝圆韧带重建门静脉/肠系膜上静脉的可行性探讨

目的探讨肝圆韧带重建门静脉／肠系膜上静脉的可行性。方法对4例实施胰十二指肠联合门静脉／肠系膜上静脉切除的患者．手术中用肝圆韧带重建切除的静脉。结果静脉切除长度3．5～6．5cm．重建切除静脉时利用肝圆韧带长度4．0～7．0cm,术中门静脉阻断时间30～126min,无手术死亡者。术后随访10～39个月。门静脉／肠系膜上静脉通畅,无血栓形成。结论在胰十二指肠联合门静脉／肠系膜上静脉切除术中利用肝圆韧带重建切除的静脉是可行的。     

肠系膜上静脉胰后干和门静脉干测量的临床意义

目的为提高近端胆管癌和壶腹周围癌的手术切除率，使该区域受肿瘤浸润的血管能一并与肿瘤器官同时切除，并使血管直接重建．方法在实施肝门胆管癌切除术及胰十二指肠切除术中，对肝蒂内门静脉干（portalveintrunk，PV）、胰腺钩突内的肠系膜上静脉子即“胰后干”（post－pancreastrunk，PPT）进行解剖学定位并进行分段测量长度及可以纵向折叠的长度，以此估计可切除的静脉长度及重新再建血管的长度结果测量肝蒂内门静脉干104例，长度男5．8cm±2．0cm，女5．5cm±0．8cm.优势长度大于4.5cm，男56例，占76．7％；女25例，占80．6％胰腺钩突内段肠系膜上静脉子测量54例长度，男3．7cm±0．8cm，女3．5cm±0．6cm；优势长度大于3．0cm者,男28例，占77．6％；女14例，占77.8％．门静脉纵向折叠移动范围1．8cm～4．2cm，平均折叠2．2cm者（1．8～2．4）占66．3％，平均折叠2．8cm（2．5～4．2）占33．7％．切除胰十二指肠后胰腺钩突入肠系膜上静脉段纵向折叠范围平均4．0cm，最长达5．2cm.结论这二类肿瘤切除术合并受浸血管切除在一定范围是可行的，为联合区域性整块切除术提供了临床解剖学支持     

孤立性肠系膜上动脉夹层的诊断与治疗(附3例报告)

孤立性肠系膜上动脉夹层是一种临床罕见的疾病,自1947年Bauertield首次报道该病以来,国内外仅报道百余例。随着人民生活水平的提高,健康意识的加强及医疗技术的发展,近几年来诊断该病的患者数量有上升趋势。我院自2008年以来,共收治孤立性肠系膜上动脉夹层患者3例,现通过对患者临床症状,体征及影像学检查进行回顾性研究,旨在达到尽早明确诊断、减少误诊、对患者进行有效治疗的目的。     

孤立性肠系膜上动脉夹层MSCTA诊断及转归

目的分析孤立性肠系膜上动脉夹层(ISMAD)多层螺旋CT血管造影(MSCTA)表现及转归。方法采用熊江的新ISMAD影像学分型方法,回顾性总结14例孤立性肠系膜上动脉夹层的CT资料。结果 14例患者中,Ⅰ型5例,Ⅱ型1例,Ⅲa型6例,Ⅳ型1例,Ⅴ型1例。保守治疗后随访复查4例,1例Ⅰ型真腔变通畅,1例Ⅰ型无变化,1例Ⅲa型假腔溃疡囊袋状扩大,1例Ⅲa型假腔范围扩大伴真腔进一步受压变窄。结论熊江的新影像学分型法对MSCTA诊断孤立性肠系膜上动脉夹层准确快捷有效,有利于评估孤立性肠系膜上动脉夹层动态变化和转归。     

Extensive mesenteric vein and portal vein thrombosis successfully treated by thrombolysis and anticoagulation

Mesenteric vein thrombosis is generally difficult to diagnose and can be fatal. A case of extensive thrombosis of the mesenteric and portal veins was diagnosed early and successfully treated in a 26-year-old man with Down syndrome who was admitted to hospital because of abdominal pain, severe nausea and high fever. Ultrasonography revealed moderate ascites, and there was minimal flow in the portal vein (PV) on the Doppler examination. Computed tomography (CT) showed remarkable thickening of the walls of the small intestine and extensive thrombosis of the mesenteric, portal and splenic veins. Because neither intestinal infarction nor peritonitis was seen, combined thrombolysis and anticoagulation therapy without surgical treatment was chosen. Urokinase was administered intravenously and later through a catheter in the superior mesenteric artery. Heparin and antibiotics were given concomitantly. The patient's symptoms and clinical data improved gradually. After 10 days, CT revealed that collateral veins had developed and the thrombi in the distal portions of the mesenteric veins had dissolved, although the main trunk of the PV had not recanalized. The only risk factor of thrombosis that was detected was decreased protein S activity.     

Leiomyosarcoma of the superior mesenteric vein: a diagnostic and therapeutic challenge

We report here a case of a very rare entity, a leiomyosarcoma of the mesentericoportal trunk, which was initially misdiagnosed as an unresectable pancreatic cancer invading the mesenteric vein, and which was finally treated by pancreatectomy with mesentericoportal reconstruction. The pitfalls of diagnosis and modalities of resection are discussed.     

肠系膜上动脉置管溶栓联合全身抗凝治疗急性广泛门静脉血栓2例报告

<正>急性门静脉血栓形成(acute portal vein thrombosis,APVT)是一种少见且临床表现复杂的急腹症,约占肠道血管性疾病的5%~15%[1]。急性广泛门静脉血栓形成(acute extensive portal vein thrombosis,AEPVT)是指门静脉、脾静脉、肠系膜上静脉、肠系膜下静脉中有2条或2条以上血管急性血栓形成[2],在临床更为罕见,治疗上也更为棘手。本文报道2例肠系膜上     

Ultrasound imaging in diagnosis of superior mesenteric artery syndrome

OBJECTIVES: We screened a cohort of subjects affected by various degree of dyspepsia to reveal if they presented a reduction of the aorto-mesenteric angle and to diagnose suspected cases of superior mesenteric artery (SMA) syndrome. DESIGN: Controlled, prospective, study. SETTING: Subjects were studied as outpatients. SUBJECTS: The study investigated a total of 3622 subjects referred to our department by their general practitioners for dyspepsia and/or abdominal pain. Interventions. Abdominal ultrasonography with power colour Doppler, gastroduodenoscopy, hypotonic duodenography, contrast-enhanced spiral computerized tomography were performed. MAIN OUTCOME MEASUREMENT AND RESULTS: Color Doppler revealed a significant reduction of the SMA angle in 29 of 950 subjects; gastroscopy showed duodenal compressive pulsation in 14 of 29 patients and X-ray revealed compression of the third segment of the duodenum in 28 of 29 patients. CT confirmed the presence of a reduced angle and various degrees of duodenal compression in all patients. Ultrasonography and CT examinations gave overlapping results (P > 0.05) in diagnosing pathological aorto-mesenteric angle. CONCLUSION: The authors believe that the incidence of reduced aorto-mesenteric angle and SMA syndrome might be underrated. Ultrasound power colour Doppler imaging is useful in epidemiological screening of reduced aorto-mesenteric angle to diagnose suspected cases of SMA syndrome.     

Effects of nifedipine on hepatic venous pressure gradient and portal vein blood flow in patients with cirrhosis

Abstract We investigated the effects of nifedipine on splanchnic haemodynamics in 13 patients with cirrhosis and portal hypertension, and in 10 control subjects using hepatic venous catheterization and pulsed Doppler ultrasound. There were no significant changes in systemic or splanchnic haemodynamics in control patients. In contrast, systemic vascodilatation, evidenced by significant decreases in mean arterial pressure and systemic vascular resistance, was observed in patients 20 min after sublingual application of 10 mg nifedipine. Moreover, hepatic venous pressure gradient and portal vein blood flow significantly increased after nifedipine administration. There was a significant correlation between the percentage increases in portal vein blood flow and in hepatic venous pressure gradient. However, no correlation was found between the percentage change in cardiac output and that in portal vein blood flow. Thus the increase in portal vein blood flow appears to be related to splanchnic arterial vasodilatation by nifedipine. Consequently, nifedipine has deleterious effects on portal haemodynamics in patients with cirrhosis. As nifedipine may potentially increase the risk of variceal haemorrhage in patients with less advanced varices, this drug should be used with caution in patients with chronic liver disease.     

Interventional treatment for symptomatic acute-subacute portal and superior mesenteric vein thrombosis

AIM: To summarize our methods and experience with interventional treatment for symptomatic acute-subacute portal vein and superior mesenteric vein thrombosis (PV-SMV) thrombosis. METHODS: Forty-six patients (30 males, 16 females,aged 17-68 years) with symptomatic acute-subacute portal and superior mesenteric vein thrombosis were accurately diagnosed with Doppler ultrasound scans, computed tomography and magnetic resonance imaging.They were treated with interventional therapy, including direct thrombolysis (26 cases through a transjugular intrahepatic portosystemic shunt; 6 through percutaneous transhepatic portal vein cannulation) and indirect thrombolysis (10 through the femoral artery to superior mesenteric artery catheterization; 4 through the radial artery to superior mesenteric artery catheterization).RESULTS: The blood reperfusion of PV-SMV was achieved completely or partially in 34 patients 3-13 d after thrombolysis. In 11 patients there was no PV-SMV blood reperfusion but the number of collateral vessels increased significantly. Symptoms in these 45 patients were improved dramatically without severe operational complications. In 1 patient, the thrombi did not respond to the interventional treatment and resulted in intestinal necrosis, which required surgical treatment.In 3 patients with interventional treatment, thrombi re-formed 1, 3 and 4 mo after treatment. In these 3 patients, indirect PV-SMV thrombolysis was performed again and was successful.CONCLUSION: Interventional treatment, including direct or indirect PV-SMV thrombolysis, is a safe and effective method for patients with symptomatic acutesubacute PV-SMV thrombosis.     

Epidemiology of Familial Adenomatous Polyposis in Sweden: Changes over Time and Differences in Phenotype between Males and Females

Background: The Swedish Polyposis Registry was set up in Sweden in the late 1950s to promote screening of familial adenomatous polyposis (FAP). The aim of this study was to examine the epidemiology of FAP in Sweden, including the influence of screening on morbidity and mortality in colorectal cancer (CRC). Methods: Four hundred and thirty-one patients (213 males and 218 females) with FAP from 145 families recorded by the Swedish Polyposis Registry were investigated. The effect of screening on morbidity and mortality in CRC was evaluated by comparing the 216 probands with the 215 call-up patients. Three different periods were studied: the pre-screening period (1912-1956), the first screening period (1957-1976), and the second screening period (1977-1996). Results: The mean annual incidence rates during the three periods were 0.2, 1.38, and 0.86 per million, respectively. The birth frequency was calculated to be 1 in 18,000 between 1947 and 1966, and the prevalence was 32 per million at the end of 1996. The proportion of new mutants among the FAP patients born between 1927 and 1966 was estimated to be 11%. The median age at diagnosis of probands was 39 (range, 11-71) years and did not change over time, although an increase was seen in the subgroup with CRC at diagnosis (P = 0.02). In the call-up group the median age at diagnosis was 22 (range, 3-65) years. Sixty-seven per cent of the probands and 3.3% of the call-up patients had CRC at diagnosis, and the corresponding mortality figures were 44% and 1.9%. The risk among probands of having CRC at diagnosis decreased from 81% to 49% (P = 0.0006). Female probands were diagnosed with symptoms (P = 0.03) and CRC (P = 0.04) earlier than male probands. Conclusions: A nationwide screening program facilitates detection and early diagnosis of FAP. A decrease in CRC morbidity among probands contributed to the improved prognosis. An earlier onset of symptoms and CRC in females indicate that the course of FAP is influenced by sex.     

Successful therapy with argatroban for superior mesenteric vein thrombosis in a patient with congenital antithrombin deficiency

A 38-year-old woman was admitted with superior mesenteric vein (SMV) thrombosis, which was refractory to anticoagulation therapy. The plasma antithrombin activity was decreased and hardly compensated by concentrated antithrombin preparation due to high consumption rate. However, successful anticoagulation was achieved by administration of direct thrombin inhibitor, argatroban. Family studies of antithrombin activity revealed that she had type I congenital antithrombin deficiency. A novel heterozygous mutation in the gene for antithrombin (single nucleotide T insertion at 7916 and 7917, Glu 272 to stop in exon 4) was identified. Argatroban administration would be effective in the treatment of congenital antithrombin deficiency with SMV thrombosis.     

Percutaneous endovascular treatment for isolated spontaneous superior mesenteric artery dissection: Report of two cases and literature review

Isolated spontaneous superior mesenteric artery (SMA) dissection is a rare and sporadically reported condition. Therapeutic options include medical treatment, surgery, and endovascular treatment. However, the optimal treatment strategy has still not been established. We herein present two patients with acute abdomen due to isolated spontaneous SMA dissection, in whom symptoms remained despite initial anticoagulation therapy. Percutaneous endovascular treatment with stenting of the dissected main trunk to achieve complete coverage of the entry site and balloon angioplasty for the distally involved side branches were performed successfully and resulted in complete resolution of the symptoms. According to our experience and previous case reports, early (within 1 week) elective percutaneous endovascular intervention with background anticoagulation therapy is a feasible and effective treatment strategy for symptomatic patients with isolated SMA dissection. © 2009 Wiley‐Liss, Inc.     

Physical hemodynamic interaction between portal venous and hepatic arterial blood flow in humans.

OBJECTIVE: The hepatic arterial end-diastolic velocity (HAEDV) is normally equal to portal vein peak velocity (PVPV). However, there is no report of quantitative measurement that HAEDV was equal to PVPV. We investigated the interaction in PVPV and HAEDV in both chronic and acute hepatic hemodynamic changes. METHODS: One hundred and nineteen patients (54 with cirrhosis, 23 with chronic hepatitis, and 42 with no diffuse liver disorder) were enrolled. We investigated the differences in PVPV and HAEDV among the patients with and without liver disorder. In addition, we measured the intraindividual changes in HAEDV when PVPV was mechanically changed by percutaneous isolated hepatic perfusion in six patients and by percutaneous transhepatic portal embolization (PTPE) in six more. RESULTS: HAEDV was nearly equal to PVPV not only in patients with both normal and hepatitis but also in those with cirrhosis (PVPV-HAEDV = 3.0 +/- 5.2, 2.2 +/- 5.4, 2.3 +/- 6.5 cm/s, respectively). In the intraindividual study, both PVPV and HAEDV decreased during hepatic mechanical perfusion and HAEDV was equal to PVPV (8.2 +/- 2.8, 10.5 +/- 1.5 cm/s, respectively). After PTPE, PVPV was increased and hepatic arterial peak systolic velocity was reciprocally decreased. However, HAEDV was nearly equal to PVPV 7 days after PTPE (PVPV-HAEDV = 5.9 +/- 5.1 cm/s). CONCLUSIONS: Since arterial end-diastolic velocity depends on the downstream vascular resistance, lower HAEDV in patients with cirrhosis was considered to reflect a high outflow resistance. If there is no collateral pathway, we consider that HAEDV may actually reflect sinusoidal resistance to the same degree as PVPV.     

Influence of isosorbide dinitrate on superior mesenteric artery impedance in humans

Summary In a randomized, double-blind, placebo-controlled crossover study the acute effect of isosorbide dinitrate (ISDN) on the superior mesenteric artery velocity waveform was studied in 10 healthy subjects (mean age 48.2 years) over a 10-minute period. The superior mesenteric artery pulsatility index (PI), which quantifies the blood velocity waveform, increased from the second minute following sublingual administration of 5 mg ISDN (basal PI 4.88±0.32) and reached its upper level (8.22±1.38) from the fourth minute on. In comparison with placebo, the significant rise of PI (second minute) occurred before the significant decrease of systolic blood pressure (ninth minute) and before the significant increase in the heart rate (fourth minute). Diastolic and mean arterial blood pressures remained unchanged. These observations suggest an immediate vasoconstrictive effect of ISDN on the resistance vessels of the vascular bed of the superior mesenteric artery.     

Intraoperative portal vein blood flow predicts allograft and patient survival following liver transplantation

Background:

We hypothesized that operative variables might predict survival following liver transplantation.

Methods:

We examined perioperative variables from 469 liver transplants carried out at the University of Washington during 2003–2006. Logistic regression determined the variables'' contributions to survival at 30, 90 and 365 days.

Results:

Portal vein blood flow (>1 l/min) was significant to patient survival at 30, 90 and 365 days. Complete reperfusion was only a significant predictor of survival at 30 days. This provided model receiver operating characteristic (ROC) area under the curve (AUC) statistics of 0.93 and 0.87 for 30 and 90 days, respectively. At 365 days, hepatic artery blood flow (>250 ml/min) combined with portal vein blood flow was significantly predictive of survival, with an AUC of 0.74. A subset analysis of 110 transplants demonstrated improved 1-year survival with more aggressive vascular revisions.

Discussion:

Portal vein blood flow is a significant predictor of survival after liver transplantation. Initially, the liver''s survival is based on portal vein blood flow; however, subsequent biliary problems and patient demise result from both poor portal vein and inadequate hepatic artery blood flow.     

Signiifcance 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 su-perior mesenteric or portal vein so as to obtain a margin nega-tive 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 signiifcance 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 histopatho-logical venous invasion by PDAC are limited and recent stud-ies 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 conlficting studies do exist on the subject. Some stud-ies also relate the depth of venous invasion to prognosis after surgical resection of PDAC.
CONCLUSIONS: Frank/‘histopathological’ invasion of supe-rior mesenteric/portal venous and R1 resection indicate a very poor survival. Such patients may be given the opportunity of beneift of neoadjuvant treatment.     

Circadian rhythm of fasting and postprandial portal blood flow in cirrhosis

Objective. To examine the relationship of both the unstimulated and the postprandial portal blood flow (PVF) to the time of day and to determine its intra-individual reproducibility over time in patients with liver cirrhosis. Material and methods. In 24 cirrhotic patients, 27 PVF measurements were performed during 24?h on day 0 and day 7 using Doppler ultrasound. Three standard liquid meals were given orally. On day 7, the baseline hepatic venous pressure gradient (HVPG) was also measured. Results. Circadian area under the time curve of PVF was highly reproducible within individuals (r=0.959, p<0.001). It did not correlate with HVPG. Cosinor analysis showed a significant circadian rhythm of PVF (acrophase at 11:44 and amplitude of 9.44%). Maximal postprandial increase in PVF was significantly higher in the morning than at noon or in the evening. Conclusions. PVF is subject to a circadian rhythm and postprandial portal hyperemia shows a diurnal variability. Both are highly reproducible.     

Portal and mesenteric vein thrombosis after portal vein embolization in a patient with protein S deficiency

Portal vein embolization can be performed safely, and so far no major complications have been reported. We report an extremely rare complication of portal vein embolization, a case of portal and mesenteric thrombosis in a 65-year-old patient with protein S deficiency. Right portal vein embolization was carried out prior to extended right hepatectomy for advanced gallbladder carcinoma involving the hepatic hilus. Computed tomography 14 days after embolization revealed massive thrombosis of the portal and the superior mesenteric veins. A protein S deficiency was found by means of an extensive workup for hypercoagulable state. Portal vein embolization may have triggered a cascade of events that was expressed as portal and mesenteric vein thrombosis resulting from deficiency of protein S. It may be better to determine the concentrations of such coagulation regulators prior to portal vein embolization.     

Three-dimensional studies on the structure of the tissue surrounding the superior mesenteric artery

The anatomy and topography of tissue surrounding the superior mesenteric artery were examined histopathologically, and the structure surrounding the superior mesenteric artery (SMA) was reconstructed with data from histologic examination and three-dimensional analyses. Specimens were obtained from three autopsy cases without abnormalities, two surgically resected cases of cancer of the pancreatic head, and one autopsy case of cancer of the pancreatic head. The endothelium or basal membrane of blood and lymph vessels were identified immunohistochemically, and the distribution of lymph nodes, blood vessels, lymph vessels, and collagen fibers was determined. The superior mesenteric plexus was found to be a relatively dense structure with a thickness of about 2 mm, composed of collagen fibers and connective tissue, which concentrically enveloped the small arteries, the superior mesenteric artery, nerve bundles, and capillaries. Lymph vessels larger than a few micrometers in diameter were often found outside of the plexus, and this plexus contained no lymph nodes in any sections. The three-dimensional study of the modes of spread along the superior mesenteric artery of pancreatic cancer revealed two types of spread: the tumor extends mainly by neural invasion, and the tumor extends mainly by lymph node metastases. These morphologic features suggest that lymphatic flow in the vicinity of the superior mesenteric artery passes primarily outside of the plexus, and complete excision of lymph nodes close to the superior mesenteric artery with preservation of the superior mesenteric plexus is feasible if there is no neural invasion into retropancreatic tissues.