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。     

肠系膜下动脉解剖分型在肠系膜下动脉结扎方式选择中的应用

目的探讨肠系膜下动脉（IMA）各种解剖分型及血管长度差异的相关因素,为结直肠癌低位结扎IMA提供参考。 方法前瞻性收集温州医科大学附属第一医院2019年7月至2020年4月因乙状结肠癌及直肠癌接受根治性手术治疗的患者的病例资料,术前使用增强CT对IMA进行重建,对IMA分型进行统计分析。并选取温州医科大学解剖教研室10具成人尸体,进行IMA解剖。 结果共纳入172例血管充盈可,重建效果佳的患者数据,纳入统计。按照Murono分型标准,其中Ⅰ型88例,Ⅱ型66例,Ⅲ型16例,Ⅳ型患者2例（不纳入后续统计分析）。170例患者中,IMA主干长（42.96±6.78）mm,体重是IMA主干长的主要影响因素（系数=0.253,P＜0.05）,IMA主干长度=23.12+0.253×体重（R²=0.181）。体重每增加一个单位（kg）,长度平均增加0.253个单位（mm）。 结论对IMA术前行增强CT可以了解IMA分型,有助于低位结扎位置的选择。可通过体重对IMA血管长度进行预估,从而选择最合适的血管处理方式。     

Preoperative assessment of vascular anatomy of inferior mesenteric artery by volume-rendered 3D-CT for laparoscopic lymph node dissection with left colic artery preservation in lower sigmoid and rectal cancer

AIM:To determine the distance between the branch-ing point of the left colic artery(LCA)and the inferiormesenteric artery(IMA)by computed tomography(CT)scanning,for preoperative evaluation before laparoscopiccolorectal operation.METHODS:From February 2004 to May 2005,100patients(63 men,37 women)underwent angiographyperformed with a 16-scanner multi-detector row CT unit(Toshiba,Aquilion 16).All images were analyzed on aworkstation (AZE Ltd,Virtual Place Advance 300).Thedistance from the root of the IMA to the bifurcation ofthe LCA was measured by curved multi-planar recon-struction on a workstation.RESULTS:The IMA could be visualized in all the cases,but the LCA was missing in two patients.The mean dis-tance from the root of the IMA to the root of the LCAwas 42.0 mm(range,23.2-75.0 mm).There were nodifferences in gender,arterial branching types,bodyweight,height,and body mass index.CONCLUSION:Volume-rendered 3D-CT is helpful toassess the vascular branching anatomy for laparoscopicsurgery.     

Radical lymph node dissection and assessment:Impact on gallbladder cancer prognosis

AIM: To investigate the lymph node metastasis patterns of gallbladder cancer(GBC) and evaluate the optimal categorization of nodal status as a critical prognostic factor.METHODS: From May 1995 to December 2010,a total of 78 consecutive patients with GBC underwent a radical resection at Liaocheng People’s Hospital.A radical resection was defined as removing both the primary tumor and the regional lymph nodes of the gallbladder.Demographic,operative and pathologic data were recorded.The lymph nodes retrieved were examined histologically for metastases routinely from each node.The positive lymph node count(PLNC) as well as the total lymph node count(TLNC) was recorded for each patient.Then the metastatic to examined lymph nodes ratio(LNR) was calculated.Disease-specific survival(DSS) and predictors of outcome were analyzed.RESULTS: With a median follow-up time of 26.50 mo(range,2-132 mo),median DSS was 29.00 ± 3.92 mo(5-year survival rate,20.51%).Nodal disease was found in 37 patients(47.44%).DSS of node-negative patients was significantly better than that of nodepositive patients(median DSS,40 mo vs 17 mo,χ2= 14.814,P < 0.001),while there was no significant difference between N1 patients and N2 patients(median DSS,18 mo vs 13 mo,χ2= 0.741,P = 0.389).Optimal TLNC was determined to be four.When node-negative patients were divided according to TLNC,there was no difference in DSS between TLNC < 4 subgroup and TLNC ≥ 4 subgroup(median DSS,37 mo vs 54 mo,χ2 = 0.715,P = 0.398).For node-positive patients,DSS of TLNC < 4 subgroup was worse than that of TLNC ≥ 4 subgroup(median DSS,13 mo vs 21 mo,χ2= 11.035,P < 0.001).Moreover,for node-positive patients,a new cut-off value of six nodes was identified for the number of TLNC that clearly stratified them into 2 separate survival groups(< 6 or ≥ 6,respectively;median DSS,15 mo vs 33 mo,χ2= 11.820,P < 0.001).DSS progressively worsened with increasing PLNC and LNR,but no definite cut-off value could be identified.Multivariate analysis revealed hist     

Spontaneous isolated dissection of the superior mesenteric artery

A case of a 63-year-old man with isolated dissection of the superior mesenteric artery (SMA), demonstrated by enhanced computed tomography (CT) and abdominal angiography, was admitted to our hospital. The severity of this disease varies from mild to severe; the severe cases require surgery. But the mild cases, like the one presented here, only need conservative therapy. This case demonstrated the usefulness of anticoagulation therapy and the indications for surgical and radiological intervention.     

A scoring system to predict inferior mesenteric artery lymph node metastasis and prognostic value of its involvement in rectal cancer

Purpose

The aim of this study is to establish a prediction scoring system for inferior mesenteric artery (IMA) lymph node metastasis and to assess the prognostic impact of dissection of positive IMA node on patients with stage III rectal cancer.

Methods

A retrospective study was performed in 264 patients with stage III rectal cancer undergoing curative surgery. Clinicopathological, survival, and recurrence data were compared between 29 patients with positive IMA nodes and 235 patients with negative IMA nodes. Clinicopathological data which were found to be significantly associated with IMA nodal status were incorporated into a scoring system.

Results

In the training samples, tumor differentiation and preoperative serum CEA were significant predictors of IMA node metastasis in multivariate analysis, which were incorporated into a scoring system. Using receiver operating characteristic curve analysis, we determined a cutoff value of 46.5 for scores, at which the system's sensitivity was 86 % and specificity 61 %. When applied to testing sample, the sensitivity was 80 % and specificity 60 %. Survival analysis showed that 5-year disease-free survival rate (5-DFS) and 5-year overall survival (5-OS) in the positive IMA node group (24.4 and 27.6 %, respectively) were significantly lower than in the negative IMA node group (61.8 and 71.3 %, respectively) (P?<?0.001). Furthermore, multivariate analysis indicated that IMA lymph node metastasis was an unfavorable independent prognostic factor for 5-DFS and 5-OS.

Conclusions

IMA lymph node metastasis is an independent poor prognostic factor for stage III rectal cancer. The prediction scoring system for IMA node metastasis would be beneficial in determining the appropriate level of IMA ligation.     

High tie of the inferior mesenteric artery in distal colorectal resections —a safe vascular procedure

Division of the inferior mesenteric artery flush with the aorta (high tie) allows a tension-free anastomosis in distal colorectal resections but may also diminish the blood supply. Tissue oxygen tension was measured proximal to the resection margin before and after either low or high division of the inferior mesenteric artery in 62 patients undergoing elective colorectal resections. Oxygenation was maintained or improved when the transverse (median change after vs before resection for low tie +9 mmHg (P<0.05), high tie+8 mmHg (P=0.3)) and descending colon (low tie +7 mmHg (p<0.01), high tie +1 mmHg (p=0.67)) were used for the anastomosis but diminished for sigmoid anastomoses (low tie-4 mmHg (P=0.42), high tie-9 mmHg (P<0.05)). Change in oxygenation was significantly affected by location of proximal resection site but not by choice of high or low tie. These results suggest that the marginal artery provides a more than adequate vascular supply to the transverse and descending colon, but that the sigmoid colon is not suitable for anastomosis. We conclude that the sigmoid colon be sacrificed and there should be no hesitation in performing a high tie to avoid tension in low pelvic anastomoses.

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Résumé La section de l'artère mésentérique inférieure à ras de l'aorte permet une anastomose colo-rectale distale sans tension mais peut entraîner une diminution du débit sanguin. La tension en oxygène tissulaire a été mesurée à proximité des tranches de section distale avant et après section haute ou basse de la mésentérique inférieure chez 62 patients soumis à une résection colo-rectale élective. L'oxygénation était maintenue ou même améliorée lorsque le côlon transverse (valeur moyenne avant vs après résection pour une ligature basse +9 mmHg (P<0.05), ligature haute +8 mmHg (P<0.3) et le côlon descendant (ligature basse: +7 mmHg (P<0.01), ligature haute +1 mmHg (P<0.67) était utilisé pour confectionner l'anastomose mais l'oxygénation a été diminuée lors d'anastomose sigmoïdienne (section basse-4 mmHg (P=0.42), ligature haute-9 mmHg (P<0.05)). Des changements dans l'oxygénation tissulaire étaient significativement modifiés selon la position de la trache de section proximale mais ne l'étaient pas selon que la ligature était haute ou basse. Ces résultats suggèrent que l'artère marginale assure une vascularisation plus qu'adéquate sur le côlon transverse et le côlon descendant mais que le côlon sigmoïdien n'est pas adéquat pour une anastomose. Nous en concluons que le côlon sigmoïde doit être sacrifié et qu'il ne doit y avoir aucune hésitation à réaliser une ligature haute de la mésentérique inférieure pour réduire le risque de tension dans des anastomoses pelviennes basses.

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N.R. Hall is in receipt of an Imperial Cancer Research Fund clinical fellowship.     

Management of isolated superior mesenteric artery dissection

AIM:To evaluate our experience of the clinical management of spontaneous isolated superior mesenteric artery dissection(ISMAD).METHODS:From January 2008 to July 2013,18 patients with ISMAD were retrospectively analyzed,including 7 patients who received conservative therapy,9patients who received reconstruction with bare stents,and 2 patients who underwent surgical treatment.The decision to intervene was based on anatomic suitability,patient comorbidities and symptoms.RESULTS:Intestinal ischemia-related symptoms completely resolved in 7 patients who received conservative therapy.Stent placement was successful in 9patients.Of the 9 patients who received endovascular stenting,abdominal pain was alleviated after the procedure and gradually disappeared within 3 d.Followup computed tomography and computed tomography angiography were available in all patients during the first month and the first year after the procedure,which revealed patent stent and patent involved superior mesenteric artery branches with complete obliteration of the dissection lesion.In the 2 patients who underwent surgical treatment,good clinical efficacy was also observed.CONCLUSION:ISMAD may be managed successfully in a variety of ways based on the clinical symptoms.ISMAD should be treated by conservative management as the first-line option,however,in those with bowel necrosis or imminent arterial rupture during conservative therapy,endovascular or surgical therapy is indicated.     

Indication for using high ligation of the inferior mesenteric artery in rectal cancer surgery

PURPOSE: In surgery for rectal cancer, it is unclear whether the inferior mesenteric artery should be ligated at a high or low position. The study contained herein was undertaken to clarify the indications for high ligation of the inferior mesenteric artery. METHODS: Subjects included 198 patients with rectal cancer who underwent resection with high ligation of the inferior mesenteric artery. Nodal metastases were examined by the clearing method. RESULTS: The incidence of metastases to the lymph nodes surrounding the origin of the inferior mesenteric artery (root nodes) was 8.6 percent. Inferior mesenteric artery root nodal metastases occurred more frequently with pT3 and pT4 cancer. The five-year survival rate in patients with inferior mesenteric artery root nodal metastases was 38.5 percent; this rate was significantly lower than in those without inferior mesenteric artery root nodal metastases (73.4 percent). CONCLUSIONS: Although the five-year survival rate in patients with inferior mesenteric artery root nodal metastases was lower than in those without metastases, inferior mesenteric artery root nodal dissection should be performed after high ligation of the inferior mesenteric artery for patients with pT3 and pT4 cancers.     

Clinical study of dissection of the superior mesenteric artery]

Six patients with dissection of the superior mesenteric artery (SMA) who were treated at our hospital between 1993 and 1999 were studied. Hypertension was considered significant as a risk factor. The clinical features were characterized by severe abdominal pain which radiated posteriorly, back pain, weak bowel sounds and exacerbation by eating. An ultrasonographic examination and a computed tomographic scan of the abdomen were useful for diagnosis. Four cases showed full recovery under conservative management with anticoagulant or antiplatelet drugs. Two cases without recovery should be considered intervention if they have progressive courses. This disease should be kept in mind on differential diagnosis of abdominal pain, because it may be overlooked without a correct diagnosis.     

Procedure for lymph node dissection around splenic artery in proximal gastric cancer

BACKGROUND/AIMS: The effect of lymph node metastasis around the splenic artery on the prognosis of proximal gastric cancer patients is not confirmed. The aim of this study is to clarify the optimal procedure for lymph node dissection along the splenic artery in proximal gastric cancer. METHODOLOGY: Proximal gastric cancer patients who underwent total gastrectomy with pancreaticosplenectomy were examined. The anatomical location of lymph nodes and the metastases around the pancreas were also studied in pancreatic cancer patients who underwent total pancreatectomy. RESULTS: Multivariate analysis of lymph node metastasis around the splenic artery showed that No. 11 lymph node metastasis was affected by No.10 lymph node that was predicted by depth of invasion. Multivariate analysis of prognostic variables by Cox's proportional hazard regression revealed that No. 10 lymph node metastasis was the significant factor affecting prognosis. No lymph node metastasis infiltrating the pancreatic parenchyma was observed in the pancreatic body or the tail. CONCLUSIONS: Total gastrectomy preserving the pancreas and spleen is the optimal procedure in proximal T2 gastric cancer. Total gastrectomy with splenectomy is appropriate in T3 cases, and distal pancreatectomy should be additionally done only in cases of direct invasion by the lymph node and/or the tumor to the pancreas.     

Isolated dissection of the main trunk of the superior mesenteric artery

A 47-year-old male with sudden onset of abdominal pain was diagnosed as having a tight stenosis and a long irregular narrowing of the main trunk of the superior mesenteric artery (SMA), which induced transient ileus. The patient was successfully treated by a patch angioplasty using an autologous saphenous vein. An intraoperative finding revealed the isolated dissection of the SMA, and a histological examination confirmed the dissection of the SMA, in which false lumen was thrombosed.     

Injection of methylene blue solution into the inferior mesenteric artery of resected rectal specimens for rectal cancer as a method for increasing the lymph node harvest

Background

The aim of the present study was to determine whether the injection of methylene blue solution into the inferior mesenteric artery could improve the lymph node harvest in rectal specimens of rectal cancer patients treated with rectal resection with total mesorectal excision.

Methods

The study group consisted of 20 randomly selected fresh rectal specimens from patients with stages I-III rectal cancer treated at the Surgery Clinic at the Institute of Oncology of Vilnius University during the period from February 2008 to December 2010, and 20 specimens were selected under the same conditions to serve as the control group. The patients underwent conventional rectal resection with total mesorectal excision and coloanal anastomosis for low rectal cancer performed by the same surgeon, did not receive preoperative radiotherapy and had no distant metastases. After the removal of the specimen, 30?ml of 0.5% methylene blue solution was injected into the inferior mesenteric artery of the specimens in the study group (methylene blue group). The specimens from both the methylene blue and control groups were examined using the standards established by the Lithuanian National Centre of Pathology. The pathologist was not required to make any special macroscopic preparations. A retrospective analysis of clinical and histopathological records was performed.

Results

Comparison of the mean lymph node harvest showed a significant difference between methylene blue and control groups with average lymph node numbers per specimen of 18?±?5 and 14?±?6, respectively (p?=?0.025). The specimens from 12 of the 20 patients in the methylene blue group and the specimens from 7 of the 20 patients from the control group had positive nodes.

Conclusions

Injecting methylene blue solution into the inferior mesenteric artery is an efficient and simple method for improving the lymph node harvest in the histopathological examination of rectal specimens of rectal cancer patients treated with rectal resection with total mesorectal excision.     

Totally intracorporeal colorectal anastomosis after segmental sigmoid resection with inferior mesenteric artery preservation for deep infiltrating endometriosis

Techniques in Coloproctology -