Surgical importance of oblique projection in arteriography for carcinoma of the pancreas.

Oblique projections in celiac and superior mesenteric angiography have been of value in patients with carcinoma arising in various parts of the pancreas. Oblique views allow better perception of the slight and uncertain changes in the pancreatic vessels, which are not discernible on anteroposterior projections because of overlapping with the extrapancreatic vessels and the spine. Anteroposterior and oblique views of both celiac and superior mesenteric arteries are the first, and, therefore, the most essential, step in angiography of lesions of the pancreas.     

Angiographic evaluation of hepatoma for surgical treatment.

Celiac and superior mesenteric arteriography of 60 patients with primary carcinoma of the liver was evaluated retrospectively to select patients properly for hepatic lobectomy, ligation of the hepatic artery or temporary occlusion of the hepatic artery. The angiograms were studied from the viewpoints of origin of the hepatic artery, location of hepatomas, macroscopic type of hepatomas, tumor supplying arteries, patency of the portal vein and coexistence of cirrhosis of the liver. It is stressed that an exact knowledge of these items before operation is important in performing any type of surgical treatment for patients with hepatomas. Resectability of the tumor in the present series of patients was possible in 11 patients, and in the recently seen patients with nonresectable hepatomas, ligation or repeated temporary occlusion of the hepatic artery or both have been performed with postoperative infusion chemotherapy.     

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.     

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.     

Aberrant obturator vessels in minimally invasive pelvic lymph node dissection

The presence of aberrant obturator vessels, arising from the external iliac circulatory system and their lesion during a surgical intervention in the area, may lead to bleeding, which is difficult to control. For a period of 5 years, 133 endoscopic bilateral pelvic lymph node dissections in patients with cervical cancer were performed, and the present aberrant vessels were registered and filmed. Aberrant obturator vessels were present in 58 cases (43.6 %). Eight obturator arteries and 58 obturator veins, branches of the external iliac vascular system, were visualized. Arterial type of obturator variation was found in one (0.07 %) case, venous type—in 50 (37.5 %), and combined (arterial and venous) type—in seven (5.26 %), out of all patients. Of the observed aberrant obturator arteries, three were found to arise from the inferior epigastric artery, and five from the external iliac artery. Of all available 73 veins, 51 (70 %) drained directly into the external iliac vein and 22 (30 %) in the inferior epigastric vein. The frequency of the aberrant obturator veins was 27.44 % (n?=?73), and of the arteries—3 %, related to the investigated pelvic halves (n?=?266). The presence of aberrant obturator vessels is a relatively common anatomic variation, important for the clinical practice.     

Surgical management of difficult wounds of the groin

Coverage of large defects of the soft tissue of the groin present a challenging problem. Exposure of the femoral vessels or prosthetic grafts requires urgent coverage with well vascularized tissue. The medial and lateral femoral circumflex arteries supply the gracilis, sartorius, vastus lateralis, rectus femoris and tensor fascia lata muscles, permitting the use of these muscles or myocutaneous flaps for coverage of groin defects when the femoral artery is intact. With extensive wounds of the groin resulting from trauma, ablation of carcinoma and vascular reconstruction for atherosclerosis involving the femoral vessels, the aforementioned flaps cannot be used. The external iliac artery supplies the rectus abdominis muscle through the deep inferior epigastric artery and the interal oblique muscle through the deep circumflex iliac artery. These muscle flaps are available when the femoral vessels are not intact. If the ipsilateral iliofemoral vessels are not intact, branches of the contralateral iliac artery through deep inferior epigastric artery and deep circumflex iliac artery provide suitable flaps for covering the groin wound. We review our experience with the management of difficult groin wounds (n = 31) and present a systematic approach to reconstruction of the groin based on these anatomic facts.     

Behavior of the portal vein system in man after laparotomy.

At the end of an abdominal operation, a Teflon catheter was inserted into the portal vein, where it remained for nine days. Thus, blood samples could be withdrawn for analyses, and pressures could be recorded. The investigations were carried out in 41 patients who had a gastric or intestinal operation and had an uncomplicated postoperative course. The pressures in the portal vein and the arterioportal oxygen content difference were constant with 7 to 8 millimeters of mercury and by 2 volume per cent, respectively, during the period of all nine postoperative days. The pressure gradient between portal and central veins was about 6 millimeters of mercury. By infusing 350 to 500 milliliters of dextran 60 on day one or two postoperatively, the cardiac output was elevated about one-third, the central venous pressure increased from 0.9 to 4.9 millimeters of mercury and the portal venous pressure increased from 7.8 to 9.7 millimeters of mercury. This means that the pressure difference between the portal and central veins diminished. Simultaneously, the oxygen content difference between the systemic and pulmonary artery decreased from 4.7 to 3.3 volume per cent and between the systemic artery and portal vein, from 1.8 to 1.3 volume per cent. By assuming a constancy of the oxygen consumption in the region of the mesenteric circulation during infusion, it can be calculated from the behavior of the arterioportal oxygen content difference that the flow increase in the portal vein nearly equals that of cardiac output. The physical transhepatic resistance decreased about 50 per cent.     

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.     

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.     

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.     

Internal jugular venous autograft in extrahepatic portal hypertension.

A 26 year old female with repeated episodes of upper gastrointestinal bleeding, secondary to extensive extrahepatic portal and superior mesenteric venous obstruction, was surgically treated by interposing an internal jugular vein autograft between a collateral channel and the inferior vena cava. The follow-up observation during a seven and one-half year period has shown no recurrence of bleeding, disappearance of esophageal varices and a widely patent graft with normal portal vascular pressures. The internal jugular vein is a readily accessible autogenous graft of adequate caliber that can maintain patency under rigorous conditions. Its use is recommended in constructing portal-systemic venous shunts in those instances of extrahepatic portal hypertension in which conventional shunts cannot be established or, if they can be established, are liable to closure.     

Transduodenopancreatic interposition mesocaval shunt using an internal jugular vein autograft.

In 26 interposition mesocaval shunts using an internal jugular vein autograft which has been performed since 1970, four patients had important abnormalities in the superior mesenteric vein, making impossible the usual subduodenal position of the jugular vein graft. In these four patients, a small pancreatectomy was performed between the transverse portion of the duodenum and the right aspect of the superior mesenteric vein, placing the interposition mesocaval shunt in a transduodenopancreatic position. No patient has had any bleeding after the operation nor have esophageal varices been found at the time of the last examination. During this period, all patients showed a remarkable tolerance to proteins, so that no patient has been on a low protein diet.     

Successful pregnancy in a patient with portal hypertension secondary to portal vein thrombosis due to essential thrombocythaemia: a rare case

Essential thrombocythaemia (ET) is a disease characterized by an increased platelet count, megakaryocytic hyperplasia and a hemorrhagic or thrombotic tendency. Pregnancy in patients with ET can have a favorable outcome. However, ET has also been reported to complicate pregnancy by recurrent abortions, intrauterine death, and fetal growth retardation due to placental infarctions. ET has an unusual prevalence of intraabdominal (hepatic, portal and mesenteric) vein thrombosis, especially in young patients, which can lead to portal hypertension. There are ample cases in the literature of both essential thrombocytosis complicating pregnancy and portal hypertension complicating pregnancy, but the coincidence of both conditions appears to be unique. In this case report, we report a successful pregnancy in a patient with a prior diagnosis of essential thrombocytosis with remote secondary portal vein thrombosis and portal hypertension (PH).     

True clinical entity of vascular compression of the duodenum in adolescence

Thirteen pediatric patients were diagnosed with superior mesenteric artery syndrome (SMAS) at our institution between 1974 and 1986. Four were successfully treated with nasojejunal feedings only, and nine underwent a derotation procedure designed to alleviate the problem of compression of the duodenum by the superior mesenteric artery. Of the nine patients who were operated upon, only one required a gastrojejunostomy to bypass a persistent obstruction. Therapy was aimed specifically toward the problem of duodenal occlusion at the mesenteric root. Because this therapy was successful in all of the patients, we conclude that SMAS exists as a treatable entity and must be considered in any adolescent patient who presents with symptoms of obstruction of the upper part of the gastrointestinal tract and failure to thrive.     

The significance of elevated peritoneal fluid phosphate level in intestinal infarction

Early diagnosis seems mandatory if the mortality of mesenteric vascular occlusion is to be altered. A model has been developed in which intestinal infarction has been produced by ligation of either the superior mesenteric vein or the superior mesenteric artery. Results of earlier work, using this model, have shown a significant rise in the serum inorganic phosphate level and an associated severe metabolic acidosis. This article has confirmed these results as being statistically significant. In this experiment, a significant rise in the inorganic phosphate level of the peritoneal fluid has been shown in the same model. We suggest that, in the patient with possible intestinal infarction, an elevated serum phosphate level, elevated peritoneal fluid phosphate level, base deficit and leukocytosis may be useful in making an earlier diagnosis of this disease. If an earlier diagnosis is accomplished, the morbidity and mortality of this lethal disease hopefully will be reduced.     

Surgical approaches for unresectable primary carcinoma of the hepatic hilus

Thirteen patients with proximal malignant obstruction of the biliary tract secondary to primary cholangiocarcinoma are presented. Seven of these patients had bilateral involvement of the major vessels of the porta hepatis, and 12 had bilateral involvement of the main hepatic ducts up to the level of segmental bifurcation. Resection of the tumor was carried out in all of the patients. Extensive resection of the liver with resection of the regional vascular structures was done in six. Another six underwent resection of the liver without resection of the regional vascular structures. The remaining patient underwent resection of the tumor and of the regional revascular structures alone. Vascular resection included resection and reconstruction of both the portal vein and hepatic artery in four patients or only of the portal vein in three. Biliary drainage was carried out by intrahepatic cholangiojejunostomies between segmental hepatic ducts and a Roux-en-Y loop. Two patients died and ten are alive. The quality of postoperative life is satisfactory and the patients are free of sequelae and symptoms secondary to operation or disease. This approach is recommended for the management of a number of patients with bilateral vascular or biliary involvement secondary to primary cholangiocarcinoma of the porta hepatis. For those patients, this approach offers a promising alternative.     

Perfusion scan in pulmonary tumor microembolism: report of a case.

A 76-year-old male patient was admitted to our hospital with the chief complaint of dyspnea. A chest CT scan showed pericardial effusion, mediastinal lymphadenopathy and a tumor in the right ventricle with invasion to the main trunk of the pulmonary artery. A 99mTc MAA perfusion lung scan revealed multiple small subsegmental peripheral defects and a "fissure sign", while the 133Xe ventilation scan was normal. After the chest CT scan and scans of both lungs, tumor microembolism was highly suspected. Open chest surgery was performed. A huge tumor in the right ventricle involving the main trunk of the pulmonary artery was found. In addition, multiple tumor thrombi in the pulmonary arteries and veins were also noted. The pathology was metastatic squamous cell carcinoma. Thereafter, the primary lesion was found by bronchoscopy. The final diagnosis was squamous cell carcinoma of the right lower lobe bronchus with metastases to the right ventricle and pulmonary vessels, and in association with pulmonary tumor microembolism. We present this uncommon case and describe the pulmonary perfusion pattern of the tumor microembolism.     

In vivo use of human umbilical vessels and the ductus venosus arantii.

Clinical use of umbilical vessels in the neonate is commonplace. In the adult, surgical reopening of the umbilical vein is feasible in the majority of patients, providing direct access to the portal circulation. Umbilical vein catheterization allows for portal manometry in the intact, unanesthetized state. Prolonged catheterization has served to facilitate physiologic and pharmacologic studies hitherto unavailable. Selective splanchnic catheterization with hepatoportography permits roentgenographic studies, important in the evaluation of patients with hepatobiliary diseases. Clinically, the umbilical vein has been used in the study of portal hemodynamics, portal decompression and hemofiltration, portal arterialization and in evaluating hepatic trauma. This method of access to the portal circulation has provided a route for study of the effects of drugs, hormones and other biologic materials on the portal circulation and for administration of antibiotics and other chemotherapeutic agents into the portal system. The procedure of umbilical vein catheterization is simple and repeated catheterization is possible. The ductus venosus, on the other hand, is not clinically usable and pertinent information has been reviewed. The ex vivo use of neonatal umbilical veins as vascular conduits is not included in this review.     

Type II single umbilical artery (persistent vitelline artery) in an otherwise normal fetus

A single umbilical artery resulting from absence of the umbilical arteries and persistence of the vitelline artery that arises directly from the abdominal aorta has been described only in malformed fetuses with sirenomelia or caudal regression. Such an aberrant artery was suggested to be the etiology of sirenomelia caused by a 'steal' mechanism of blood flow from the caudal end of the embryo. We present a case in which prenatal ultrasound showed a similar aberrant single artery arising from the abdominal aorta in an otherwise normal fetus with a normal course of pregnancy. This vessel, a continuation of the superior mesenteric artery (SMA), corresponds to a persistent vitelline artery assuming the function of the umbilical arteries. The etiology of such a finding and its possible consequences are discussed.     

腹主动脉旁淋巴结切除术在子宫内膜癌治疗中的临床意义

目的探讨子宫内膜癌患者腹主动脉旁淋巴结切除范围及其临床意义。方法回顾四川大学华西第二医院709例患者的临床-病理资料,随访217例行腹主动脉旁淋巴结切除患者的生存情况。结果多因素分析发现：淋巴脉管浸润及盆腔淋巴结转移是发生腹主动脉旁淋巴结转移的独立高危因素（P〈0.05）。腹主动脉旁淋巴结取样组,切除至肠系膜下血管水平组以及肾血管水平组术后10月生存率分别为：98.6%,94.3%和100.0%。结论中低分化、淋巴脉管转移、特殊病理类型、以及晚期子宫内膜癌患者建议切除腹主动脉旁淋巴结,其切除范围应至肾血管水平。