Endovascular revascularization of acute arterial mesenteric ischemia: report of a 3-year experience from an intestinal stroke center unit.

OBJECTIVE: To report the 3-year experience of endovascular revascularization of acute arterial mesenteric ischemia (AMI) from an intestinal stroke center unit (ISCU). METHOD: All data from patients admitted to the ISCU between January 2016 and January 2019 for arterial AMI who underwent endovascular recanalization were prospectively acquired and retrospectively analyzed. Patient demographics, clinical and laboratory characteristics at presentation, and CT scans were reviewed. The type (thrombolysis, thrombectomy, stenting) and the outcome of endovascular procedures (technical success or failure, complications) were noted. Care pathways were described focusing on post-procedural treatments (surgical revascularization, bowel resection) and the mortality rate was evaluated in subgroups. RESULTS: Fifty-eight patients (34 men [59%], mean 69 ± 29 years) were included. Endovascular revascularization was technically successful in 51/58 (88%) patients, and 10 (17%) patients had post-procedural complications. Stenting and in situ thrombolysis were performed in most patients (n = 33 and n = 19, respectively). Thirty-two patients (55%) were recurrence-free and required no further treatment after the procedure, while 9 (16%), 5 (9%), and 5 (9%) patients underwent 2nd-line bowel resection, surgical revascularization, or both. Overall, 46 (79%), 45 (78%), and 34 patients (63%) were alive at 3 months, 1 year, and 3 years. No significant difference in survival was found in care pathways or baseline characteristics. CONCLUSION: Endovascular revascularization is highly feasible for the treatment of arterial AMI, and is associated with an acceptable rate of complications. Results of endovascular revascularization shall only be interpreted as part of a multidisciplinary patient management strategy. KEY POINTS: • Endovascular revascularization is highly feasible for the treatment of arterial AMI, and is associated with an acceptable rate of complications. • Several techniques are available to perform endovascular revascularization, and their use depends on the cause, the location, and the quality of underlying arteries of patients. • Results of endovascular revascularization shall only be interpreted in relation to its role in an integrated multidisciplinary and patient management strategy.

7-Hydroxycoumarin Induces Vasorelaxation in Animals with Essential Hypertension: Focus on Potassium Channels and Intracellular Ca2+ Mobilization.

Cardiovascular diseases (CVD) are the deadliest noncommunicable disease worldwide. Hypertension is the most prevalent risk factor for the development of CVD. Although there is a wide range of antihypertensive drugs, there still remains a lack of blood pressure control options for hypertensive patients. Additionally, natural products remain crucial to the design of new drugs. The natural product 7-hydroxycoumarin (7-HC) exhibits pharmacological properties linked to antihypertensive mechanisms of action. This study aimed to evaluate the vascular effects of 7-HC in an experimental model of essential hypertension. The isometric tension measurements assessed the relaxant effect induced by 7-HC (0.001 µM-300 µM) in superior mesenteric arteries isolated from hypertensive rats (SHR, 200-300 g). Our results suggest that the relaxant effect induced by 7-HC rely on K+-channels (KATP, BKCa, and, to a lesser extent, Kv) activation and also on Ca2+ influx from sarcolemma and sarcoplasmic reticulum mobilization (inositol 1,4,5-triphosphate (IP3) and ryanodine receptors). Moreover, 7-HC diminishes the mesenteric artery's responsiveness to α1-adrenergic agonist challenge and improves the actions of the muscarinic agonist and NO donor. The present work demonstrated that the relaxant mechanism of 7-HC in SHR involves endothelium-independent vasorelaxant factors. Additionally, 7-HC reduced vasoconstriction of the sympathetic agonist while improving vascular endothelium-dependent and independent relaxation.

[Clinical anatomy study of superior mesenteric vessels and its branches].

Objective: To examine the anatomical relationships of tributaries to superior mesenteric artery and vein in surgical procedures. Methods: A prospectively designed observational trial, registried to Chinese Clinical Trial Registry, ChiCTR 1800014610, was conducted in Department of General Surgery, Peking Union Medical College Hospital from July 2016 to Decmeber 2018 to record the relationships of ileocolic artery and vein, right colic artery and vein, middle colic artery and vein, and combinations to assemble Henle's trunk, during the laparoscopic operation of radical right colectomy for right colon malignancies. The length of middle colic artery, length of Henle's trunk, and distance from Henle's trunk to the inferior margin of pancreatic head to duodenum were measured during operation. A total of 100 patients, 52 male and 48 female, with right colon cancer, who underwent radical right colectomy, were enrolled in present study from July 2016 to December 2018, with age of (61.0±12.3) years (range: 31 to 82 years), and body mass index of (23.3±3.5) kg/m(2) (range: 16.0 to 34.2 kg/m(2)). Results: The ileocolic artery and vein presented as rates of 97.0% (97/100, 95%CI: 91.5% to 99.4%, the same below) and 98.0% (98/100, 93.0% to 99.8%), respectively. The ileocolic vein ran ventrally in 51 of 97 patients (52.6%, 42.7% to 62.5%). The right colic artery, which raised from superior mesenteric artery directly, was found in 42 of 100 patients (42.0%, 32.3% to 51.7%); and the right colic vein drained directly into superior mesenteric vein in 19 of 100 patients (19.0%, 11.3% to 26.7%). The presence of middle colic artery and vein were 95.0% (95/100, 90.7% to 99.3%) and 90.0% (90/100, 84.1% to 95.9%) respectively. The average length of middle colic artery, from its origin to bifurcation into right and left branches, was (2.6±1.6) cm (range: 0.1 to 7.2 cm). All the dissected middle colic vein drained into superior mesenteric vein (87.8% (79/90), 81.0% to 94.6%) and Henle's trunk (12.2% (11/90), 5.4% to 19.0%). Henle's trunk was found in 93 of 100 patients (93.0%, 88.0% to 98.0%), with average length of (1.0±0.6) cm (range: 0.1 to 2.4 cm). The distance between Henle's trunk to the inferior margin of pancreatic head was (2.7±0.7) cm (range: 1.3 to 4.5 cm). More than half of the Henle's trunk were composed of 3 tributaries (54.8% (53/93), 40.8% to 61.2%). The most frequently discovered tributaries to form Henle's trunk were right gastroepiploic vein (98.0% (98/100), 93.0% to 99.8%), superior right colic vein (82.0% (82/100), 74.5% to 89.5%), and superior anterior pancreaticoduodenal vein (78.0% (78/100), 69.9% to 86.1%). In present study, the right branch of middle colic vessels was often found to run closely with Henle's trunk, veins drained from small intestine could be found to run over superior mesenteric artery to converge into superior mesenteric vein. There were 2 incidences, injuries to Henle's trunk and middle colic vein, happened during the operation, which were overcomed by bipolar coagulation and dividing the vessels. Conclusions: Ileocolic vessels and middle colic vessels could be used as landmarks for laparoscopic surgery based on their constant anatomical existence. In contrast, the chances are rare for the presence of right colic artery or right colic vein. Nearly half of the Henle's trunk was consisted of right gastroepiploic vein, superior right colic vein and superior anterior pancreaticoduodenal vein. Exceptional cautions should be made for the variations of the Henle's trunk during the operation.

[Acute right-sided upper abdominal pain in a 46-year-old woman]. / Akute rechtsseitige Oberbauchschmerzen bei einer 46-Jährigen.

A 46-year-old woman presented with acute abdominal pain in the right upper quadrant. Esophagogastroduodenoscopy revealed a duodenal stenosis within the horizontal part of the duodenum. Based on the findings of abdominal computed tomography (CT), endosonography, Doppler duplex sonography and angiography, the diagnosis of an aneurysm of a branch of the inferior pancreaticoduodenal artery was established. This arterial branch was part of a collateral circulation between the superior mesenteric artery and the proper hepatic artery caused by obturation of the celiac artery. The symptomatic duodenal stenosis was the result of a local hematoma due to prior rupture of an aneurysm. After successful coiling of the afferent vessels to the aneurysm follow-up examinations showed progredient resorption of the hematoma and the patient was free of complaints.

Endovascular Management of Superior Mesenteric Artery (SMA) Aneurysm - Adequate Access is Essential for Success - Case Report.

BACKGROUND: An aneurysm of the superior mesenteric artery (SMA) with a diameter of 2.2 cm was found incidentally on an ultrasound (US) examination in a 26-year-old woman. The only known risk factor was an intracranial aneurysm that was found on her grandmother's autopsy. Based on pregnancy planning and the current literature, endovascular management with a covered stent was proposed. CASE REPORT: Self-expandable, covered stent (Bard, Fluency®) was implanted using a single transfemoral approach. A stiff guidewire and a large sheath distorted the anatomy, which resulted in an incomplete aneurysmal neck covering. In the absence of additional covered stents, the procedure was terminated. Two weeks later, computed tomographic angiography (CTA) confirmed persistent aneurysmal perfusion due to the incomplete neck coverage. A multidisciplinary board opted for a second endovascular attempt, this time with a longer covered stent via the transaxillary approach in order to reduce anatomical distortion. Balloon, expandable, cobalt-chrome covered stent (Jotec, E-ventus BX®) was implanted in the SMA, covering the aneurysmal neck and overlapping the previously implanted covered stent. Angiography confirmed a complete exclusion of the aneurysm. A control US performed three weeks later confirmed a patent covered stent and complete aneurysmal exclusion. There was a mild median nerve damage periprocedurally that resolved in three months. The most recent US control examination, performed eleven months after the procedure, showed an excluded aneurysm and a patent covered stent. There were no clinical signs of bowel ischaemia during the follow-up period. CONCLUSIONS: Endovascular management of SMAA proved to be safe and efficient. The "access from above" is probably safer and should be considered in the majority of cases with acceptable sizes of access vessels. Mid-term results in our patient are good and life-long follow-up is planned to prevent late complications.

Rupture of an Aneurysm of a Small Branch of the Superior Mesenteric Artery: A Case Report.

BACKGROUND: Superior mesenteric artery aneurysm (SMAA) is an uncommon vascular disorder. Complications such as rupture have been reported. Once complication has been encountered both surgical and endovascular treatment techniques can be considered. CASE REPORT: We present a case of 68-year old male patient with SMAA rupture treated by endovascular modality. CONCLUSIONS: Endovascular therapy is an effective and less invasive option for rupture of superior mesenteric artery aneurysm.

Spontaneous Isolated Celiac Artery and Superior Mesenteric Artery Dissections: A Rare Case.

BACKGROUND: Arterial dissection is defined as the cleavage of the arterial wall by an intramural hematoma. Reports of dissection of the celiac and/or superior mesenteric artery are rare; as far as we know, only 24 cases of spontaneous isolated celiac trunk dissection, and 71 cases of spontaneous isolated superior mesenteric artery dissection have been reported. CASE REPORT: The case presents a 48-year-old male with a sudden-onset epigastric pain. A Computed Tomography Angiography of the thoracoabdominal aorta was applied and dissections of both the celiac artery and SMA were determined. A conservative therapeutic approach was preferred and the patient was discharged with anticoagulant and antihypertensive therapy. CONCLUSIONS: Although rare, spontaneous isolated celiac artery and superior mesenteric artery dissections must be kept in mind in the differential diagnosis of the epigastric pain in the emergency room. Contrast-enhanced Computed Tomography Angiography examination is the method of choice in the diagnosis.

Common hepatic artery originating from superior mesenteric artery with replaced right hepatic artery.

We found a variational case relating to the arteries distributed to the liver and pancreas during the routine cadaver dissection course. The common hepatic artery originated from the superior mesenteric artery as the first branch. The common hepatic artery was soon divided into the left and right hepatic arteries and distributed to the left and right lobe of the liver. The superior pancreaticoduodenal artery arose from the gastroduodenal artery, a branch of the left hepatic artery. The inferior pancreaticoduodenal artery originated from the superior mesenteric artery. Besides, two posterior branches of the right hepatic artery supplied the duodenum and the head of the pancreas. The arterial arcades were formed behind the head of the pancreas among the superior pancreaticoduodenal artery and these two posterior branches of the right hepatic artery. In conclusion, this case can be considered a rare case in which the replaced common hepatic artery and replaced right hepatic artery occurred simultaneously. The coexisting of these two replaced arteries suggests that the developmental processes to form these variations are independent.

Superior Mesenteric Artery Thrombosis for Emergency Laparotomy in Covid-19 Patient: A Case Report.

The novel coronavirus disease 2019 (COVID-19) pandemic has caused significant morbidity and mortality worldwide. The most common symptoms include fever, cough, and shortness of breath (predominantly involving pulmonary function). However, there are lesser-known presentations that affect other systems too. Vascular complications have been reported in the literature focusing on venous thrombosis, which appears to be more common than arterial thrombosis. Among arterial thrombosis, mainly lower limb involvement is reported so far. Here, we report an unusual presentation in COVID-19, which presented with acute abdomen due to superior mesenteric artery thrombosis without respiratory symptoms. We report this case as a varied form of coronavirus complication presentation and highlight the need for eternal vigilance and a reactive approach for early diagnosis.

Damage control in abdominal vascular trauma.

In patients with abdominal trauma who require laparotomy, up to a quarter or a third will have a vascular injury. The venous structures mainly injured are the vena cava (29%) and the iliac veins (20%), and arterial vessels are the iliac arteries (16%) and the aorta (14%). The initial approach is performed following the ATLS principles. This manuscript aims to present the surgical approach to abdominal vascular trauma following damage control principles. The priority in a trauma laparotomy is bleeding control. Hemorrhages of intraperitoneal origin are controlled by applying pressure, clamping, packing, and retroperitoneal with selective pressure. After the temporary bleeding control is achieved, the compromised vascular structure must be identified, according to the location of the hematomas. The management of all lesions should be oriented towards the expeditious conclusion of the laparotomy, focusing efforts on the bleeding control and contamination, with a postponement of the definitive management. Their management of vascular injuries includes ligation, transient bypass, and packing of selected low-pressure vessels and bleeding surfaces. Subsequently, the unconventional closure of the abdominal cavity should be performed, preferably with negative pressure systems, to reoperate once the hemodynamic alterations and coagulopathy have been corrected to carry out the definitive management.

En pacientes con trauma de abdomen que requieren laparotomía, hasta una cuarta o tercera parte, habrán sufrido una lesión vascular. Las estructuras venosas principalmente lesionadas son la vena cava y las iliacas, y de vasos arteriales, son las iliacas y la aorta. El abordaje de este tipo de heridas vasculares se puede ser difícil en el contexto de un paciente hemodinámicamente inestable ya que requiera medidas rápidas que permita controlar la exanguinación del paciente. El objetivo de este manuscrito es presentar el abordaje del trauma vascular abdominal de acuerdo con la filosofía de cirugía de control de daños. La primera prioridad en una laparotomía por trauma es el control de la hemorragia. Las hemorragias de origen intraperitoneal se controlan con compresión, pinzamiento o empaquetamiento, y las retroperitoneales con compresión selectiva. Posterior al control transitorio de la hemorragia, se debe identificar la estructura vascular comprometida, de acuerdo con la localización de los hematomas. El manejo de las lesiones debe orientarse a la finalización expedita de la laparotomía, enfocado en el control de la hemorragia y contaminación, con aplazamiento del manejo definitivo. Lo pertinente al tratamiento de las lesiones vasculares incluyen la ligadura, derivación transitoria y el empaquetamiento de vasos seleccionados de baja presión y de superficies sangrantes. Posteriormente se debe realizar el cierre no convencional de la cavidad abdominal, preferiblemente con sistemas de presión negativa, para consecutivamente reoperar una vez corregidas las alteraciones hemodinámicas y la coagulopatía para realizar el manejo definitivo.

Vascular changes of the superior mesenteric artery (SMA): A new component of the hypovolemic shock complex (HSC).

PURPOSE: To assess the type and frequency of vascular changes in the superior mesenteric artery (SMA) associated with the hypovolemic shock complex (HSC). METHODS: Twenty-six patients (14 males, 70.6 ±â€¯11.2 years) meeting the criteria for hypovolemic shock complex in computed tomography were examined for the presence of angiographic signs of non-occlusive mesenteric ischemia (NOMI) in the SMA: the string of sausages sign and spasms of the arcades of mesenteric arteries on coronal maximum intensity projection images (MIP). Interrater agreement was assessed using weighted kappa (κ). RESULTS: Vascular changes of the SMA were visible in almost all of the patients with HSC with a frequency of 88.5 %-96.2 %. Intraclass correlation coefficients indicated a substantial to almost perfect interrater agreement. CONCLUSIONS: Using computed tomography, it is possible to reliably and reproducibly detect vascular changes in SMA known from angiography in the context of hypoperfusion. The pathological vascular changes also occur more frequently than other classic signs of a CT hypoperfusion complex. Since the qualitative assessment of the SMA requires only a small amount of time, it is suitable as a further criterion for the presence of the CT hypoperfusion complex.

Coil Embolization of an Iatrogenic Arteriovenous Fistula between the Superior Mesenteric Artery and Vein: A Case Report.

Superior mesenteric arteriovenous fistulae are rare. A 32-year-old woman presented with abdominal pain. The angiography showed that the superior mesenteric vein was aneurysmal. The patient underwent coil embolization, during which a balloon catheter was inflated before the fistula for the protection of coil migration with a high blood flow. After the balloon inflation, one 8-mm and two 7-mm coils were deployed at the fistula site. The final angiography showed successful embolization with no visualization of the fistula and the aneurysmal vein.

Celiomesenteric trunk: New classification based on multidetector computed tomography angiographic findings and probable embryological mechanisms.

BACKGROUND: In previous studies, celiomesenteric trunk (CMT) was narrowly defined as a hepato-gastro-spleno-mesenteric (HGSM) trunk, but other possible types were ignored. With the widespread use of multidetector computed tomography (MDCT) angiography, it is easy to collect a large sampling of data on arterial anatomy of the abdomen in daily radiological practice. A new classification system for CMT may be created based on its MDCT angiographic findings and variation patterns. AIM: To identify the spectrum and prevalence of CMT according to a new classification based on MDCT angiographic findings, and discuss the probable embryological mechanisms to explain the CMT variants. METHODS: A retrospective study was carried out on 5580 abdominal MDCT angiography images. CMT was defined as a single common trunk arising from the aorta and its branches including the superior mesenteric artery and at least two major branches of the celiac trunk. Various types of CMT were investigated. RESULTS: Of the 5580 patients, 171 (3.06%) were identified as having CMT. According to the new definitions and classification, the CMT variants included five types: I, II, III, IV and V, which were found in 96 (56.14%), 57 (33.33%), 4 (2.34%), 3 (1.75%) and 8 (4.68%) patients, respectively. The CMT variants also were classified as long type (106 patients, 61.99%) and short type (65 patients, 38.01%) based on the length of single common trunk. Further CMT classification was based on the origin of the left gastric artery: Type a (92 patients, 53.80%), type b (57 patients, 33.33%), type c (11 patients, 6.43%) and type d (8 patients, 4.68%). CONCLUSION: We systematically classified CMT variants according to our new classification system based on MDCT angiographic findings. Dislocation interruption, incomplete interruption and persistence of the longitudinal anastomosis could all be embryological mechanisms of various types of CMT variants.

Síndrome de Wilkie como reto diagnóstico en obstrucción intestinal: reporte de caso / Wilkie syndrome as a diagnostic challenge in intestinal obstruction: case report

RESUMEN El síndrome de Wilkie es una patología poco frecuente que genera un cuadro de obstrucción intestinal, debido a la disminución del ángulo aortomesentérico comprometiendo la tercera porción del duodeno. Describimos el caso de una paciente de 18 años de edad, diagnosticada con síndrome de Wilkie, con cuadro clínico de obstrucción intestinal y pérdida de peso. El diagnóstico se realizó con tomografía abdominal. El síndrome de Wilkie es una patología rara, que se vuelve un reto diagnóstico, por presentar un cuadro similar a otras patologías más comunes. Recomendamos que se sospeche ante un cuadro de obstrucción duodenal.

ABSTRACT Wilkie syndrome is a rare pathology that generates intestinal obstruction due to a decrease of the aortomesenteric angle compromising the third portion of the duodenum. We describe a case of an 18-year-old female patient, diagnosed with Wilkie syndrome, with clinical symptoms of intestinal obstruction and weight loss. The diagnosis was made with abdominal CT. Wilkie syndrome is a rare pathology, which becomes a diagnostic challenge because it presents a similar picture to other more common pathologies. We recommend that it should be suspected in the presence of duodenal obstruction.

Aneurisma de arteria mesentérica superior: causa muy rara de epigastralgia

Se describe el primer caso de tratamiento quirúrgico exitoso de un aneurisma de arteria mesentérica superior en el Hospital Regional III Honorio Delgado de Arequipa. El paciente presentó dolor epigástrico de 18 meses de evolución que fue diagnosticado mediante tomografía y angiotomografía computarizada. Fue sometido a laparotomía para resección de aneurisma y se realizó un bypass de arteria mesentérica superior utilizando un injerto de politetrafluoroetileno. El paciente tuvo una recuperación rápida y sin complicaciones y ha evolucionado adecuadamente hasta la fecha. Este tipo de aneurisma es raro, no contamos con incidencias reportadas en Perú. El tratamiento quirúrgico requiere una planificación cuidadosa debido al alto riesgo de ruptura y mortalidad. El apoyo tecnológico es primordial en la aproximación quirúrgica de este tipo de pacientes, lo cual muchas veces es un reto en hospitales públicos no especializados.

The first successful case of surgical treatment of a superior mesenteric artery aneurysm is described at the Honorio Delgado Regional Hospital III in Arequipa. The case report involved a patient who had experienced 18 months of epigastric pain and was diagnosed with computed tomography and computed tomography. The patient underwent laparotomy for aneurysm resection and a bypass of the superior mesenteric artery was performed using a polytetrafluoroethylene graft. The patient had a rapid and uncomplicated recovery and has since progressed well. This type of aneurysm is rare, with no epidemiological data in Peru. Surgical treatment requires careful planning due to the high risk of rupture and mortality. Technological support is essential in the surgical approach of these patients, which is often a challenge in non-specialized public hospitals.

Downregulation of Endothelial Transient Receptor Potential Vanilloid Type 4 Channel and Small-Conductance of Ca2+-Activated K+ Channels Underpins Impaired Endothelium-Dependent Hyperpolarization in Hypertension.

Endothelium-dependent hyperpolarization (EDH)-mediated responses are impaired in hypertension, but the underlying mechanisms have not yet been determined. The activation of small- and intermediate-conductance of Ca2+-activated K+ channels (SKCa and IKCa) underpins EDH-mediated responses. It was recently reported that Ca2+ influx through endothelial transient receptor potential vanilloid type 4 channel (TRPV4) is a prerequisite for the activation of SKCa/IKCa in endothelial cells in specific beds. Here, we attempted to determine whether the impairment of EDH in hypertension is attributable to the dysfunction of TRPV4 and S/IKCa, using isolated superior mesenteric arteries of 20-week-old stroke-prone spontaneously hypertensive rats (SHRSP) and age-matched Wistar-Kyoto (WKY) rats. In the WKY arteries, EDH-mediated responses were reduced by a combination of SKCa/IKCa blockers (apamin plus TRAM-34; 1-[(2-chlorophenyl)diphenylmethl]-1H-pyrazole) and by the blockade of TRPV4 with the selective antagonist RN-1734 or HC-067047. In the SHRSP arteries, EDH-mediated hyperpolarization and relaxation were significantly impaired when compared with WKY. GSK1016790A, a selective TRPV4 activator, evoked robust hyperpolarization and relaxation in WKY arteries. In contrast, in SHRSP arteries, the GSK1016790A-evoked hyperpolarization was small and relaxation was absent. Hyperpolarization and relaxation to cyclohexyl-[2-(3,5-dimethyl-pyrazol-1-yl)-6-methyl-pyrimidin-4-yl]-amine, a selective SKCa activator, were marginally decreased in SHRSP arteries compared with WKY arteries. The expression of endothelial TRPV4 and SKCa protein was significantly decreased in the SHRSP mesenteric arteries compared with those of WKY, whereas function and expression of IKCa were preserved in SHRSP arteries. These findings suggest that EDH-mediated responses are impaired in superior mesenteric arteries of SHRSP because of a reduction in both TRPV4 and SKCa input to EDH.

Síndrome de Wilkie. Diagnóstico por imágenes / Wilkie syndrome. Imaging diagnosis

RESUMEN El síndrome de Wilkie representa una rara causa de obstrucción intestinal por compresión externa de la tercera porción duodenal por la arteria mesentérica superior. Se presenta una mujer de 68 años que fue a consulta por presentar vómitos biliosos frecuentes, con distensión abdominal, y marcada pérdida de peso. Mediante estudios radiográficos baritados con control fluoroscópico y tomografía axial computarizada con contraste vía oral y endovenosa, se evidenció compresión duodenal extrínseca en la tercera porción; se diagnosticó un síndrome de Wilkie y se instauró un tratamiento conservador, el cual cursó favorablemente. El síndrome de Wilkie, a pesar de su baja incidencia, debe considerarse como diagnóstico diferencial en cuadros de obstrucción intestinal alta.

ABSTRACT Wilkie syndrome represents a rare cause of intestinal obstruction due to external compression of the third duodenal portion by the superior mesenteric artery. We present a 68-year-old woman who came to the consultation for frequent bilious vomiting, abdominal distension and marked weight loss. Extrinsic duodenal compression was evidenced in its third portion by means of barium radiographic studies with fluoroscopic control and computerized axial tomography with oral and intravenous contrast; Wilkie syndrome was diagnosed and conservative treatment was instituted, which progressed favorably. Wilkie syndrome, despite its low incidence, should be considered as a differential diagnosis in cases of upper intestinal obstruction.

Damage control in abdominal vascular trauma

In patients with abdominal trauma who require laparotomy, up to a quarter or a third will have a vascular injury. The venous structures mainly injured are the vena cava (29%) and the iliac veins (20%), and arterial vessels are the iliac arteries (16%) and the aorta (14%). The initial approach is performed following the ATLS principles. This manuscript aims to present the surgical approach to abdominal vascular trauma following damage control principles. The priority in a trauma laparotomy is bleeding control. Hemorrhages of intraperitoneal origin are controlled by applying pressure, clamping, packing, and retroperitoneal with selective pressure. After the temporary bleeding control is achieved, the compromised vascular structure must be identified, according to the location of the hematomas. The management of all lesions should be oriented towards the expeditious conclusion of the laparotomy, focusing efforts on the bleeding control and contamination, with a postponement of the definitive management. Their management of vascular injuries includes ligation, transient bypass, and packing of selected low-pressure vessels and bleeding surfaces. Subsequently, the unconventional closure of the abdominal cavity should be performed, preferably with negative pressure systems, to reoperate once the hemodynamic alterations and coagulopathy have been corrected to carry out the definitive management.

En pacientes con trauma de abdomen que requieren laparotomía, hasta una cuarta o tercera parte, habrán sufrido una lesión vascular. Las estructuras venosas principalmente lesionadas son la vena cava y las iliacas, y de vasos arteriales, son las iliacas y la aorta. El abordaje de este tipo de heridas vasculares se puede ser difícil en el contexto de un paciente hemodinámicamente inestable ya que requiera medidas rápidas que permita controlar la exanguinación del paciente. El objetivo de este manuscrito es presentar el abordaje del trauma vascular abdominal de acuerdo con la filosofía de cirugía de control de daños. La primera prioridad en una laparotomía por trauma es el control de la hemorragia. Las hemorragias de origen intraperitoneal se controlan con compresión, pinzamiento o empaquetamiento, y las retroperitoneales con compresión selectiva. Posterior al control transitorio de la hemorragia, se debe identificar la estructura vascular comprometida, de acuerdo con la localización de los hematomas. El manejo de las lesiones debe orientarse a la finalización expedita de la laparotomía, enfocado en el control de la hemorragia y contaminación, con aplazamiento del manejo definitivo. Lo pertinente al tratamiento de las lesiones vasculares incluyen la ligadura, derivación transitoria y el empaquetamiento de vasos seleccionados de baja presión y de superficies sangrantes. Posteriormente se debe realizar el cierre no convencional de la cavidad abdominal, preferiblemente con sistemas de presión negativa, para consecutivamente reoperar una vez corregidas las alteraciones hemodinámicas y la coagulopatía para realizar el manejo definitivo.

Splenic Artery Originating from the Superior Mesenteric Artery: An Unusual but Important Anatomic Variant.

BACKGROUND: Variations in the origin, course, and branching of visceral arteries, particularly those of the celiac artery and superior mesenteric artery (SMA), are well documented in medical literature. Identifying any variation is necessary prior to abdominal surgery. CASE REPORT: A 72-year-old male presented after a pancreatic body mass was incidentally found on abdominal computed tomography (CT). The CT revealed an anatomic anomaly of the splenic artery. The patient's splenic artery originated from his SMA rather than from his celiac artery. CONCLUSION: Accounting for this anatomic anomaly prior to performing an open distal pancreatectomy and splenectomy was essential to the surgery's success. Ligation of the splenic vein followed by early ligation of the splenic artery allowed for minimal splenic congestion. Preoperative planning and understanding the patient's unique anatomy minimized the risk of an adverse outcome.

Anatomical variations of the superior mesenteric artery and its clinical and surgical implications in humans / Variações anatômicas da artéria mesentérica superior e suas implicações clínicas e cirúrgicas em humanos

ABSTRACT Introduction: Superior mesenteric artery (SMA) usually arises from the abdominal aorta, just below the celiac trunk and it supplies the midgut-derived embryonic structures. Anatomical variations in this vessel contribute to problems in the formation and/or absorption of this part of the intestine and its absence has been recognized as the cause of congenital duodenojejunal atresia. Objective: To analyze SMA anatomical variations in humans and the possible associated clinical and surgical implications. Methods: This is a systematic review of papers indexed in PubMed, SciELO, Springerlink, Science Direct, Lilacs, and Latindex databases. The search was performed by two independent reviewers between September and December 2018. Original studies involving SMA variations in humans were included. SMA presence/absence, level, place of origin and its terminal branches were considered. Results: At the end of the search, 18 studies were selected, characterized as for the sample, method to evaluate the anatomical structure and main results. The most common type of variation was when SMA originated from the right hepatic artery (6.13%). Two studies (11.11%) evidenced the inferior mesenteric artery originating from the SMA, whereas other two (11.11%) found the SMA sharing the same origin of the celiac trunk. Conclusion: SMA variations are not uncommon findings and their reports evidenced through the scientific literature demonstrate a great role for the development of important clinical conditions, making knowledge about this subject relevant to surgeons and professionals working in this area.

RESUMO Introdução: A artéria mesentérica superior (AMS), normalmente, tem sua origem a partir da aorta abdominal, um pouco abaixo do tronco celíaco e é responsável pela irrigação das estruturas derivadas, embrionariamente, do intestino médio. Variações anatômicas nesse vaso contribui para defeitos na formação e/ou absorção dessa parte do intestino e a sua ausência tem sido reconhecida como a causa da atresia duodenojejunal congênita. Objetivo: Analisar as variações anatômicas dela em humanos e as possíveis implicações clínicas e cirúrgicas associadas. Métodos: Trata-se de uma revisão sistemática de artigos indexados nas bases de dados PubMed, SciELO, Springerlink, Scienc Direct, Lilacs e Latindex. A busca ocorreu por dois revisores independentes entre setembro e dezembro de 2018. Foram incluídos artigos originais envolvendo as variações da AMS em humanos. Considerou-se para este estudo a presença/ausência da AMS, o nível, local de origem e seus ramos terminais. Resultados: Ao final da busca foram selecionados 18 artigos, caracterizados quanto à amostra, método para avaliar a estrutura anatômica e principais resultados. O tipo de variação mais comum foi aquele cuja AMS se originou da artéria hepática direita (6,13%). Dois estudos (11,11%) evidenciaram a artéria mesentérica inferior originando-se a partir da AMS, enquanto outros dois (11,11%) constataram ser ela compartilhada na mesma origem do tronco celíaco. Conclusão: Variações na AMS não são achados incomuns e seus relatos evidenciados através da literatura científica demonstram grande importância para o desenvolvimento de condições clínicas importantes, tornando o conhecimento sobre esse assunto relevante para os cirurgiões e profissionais atuantes nesta área.