[Intraoperative anatomical observation of mesentery morphology of colonic splenic flexure].

Objective: At present, surgeons do not know enough about the mesenteric morphology of the colonic splenic flexure, resulting in many problems in the complete mesenteric resection of cancer around the splenic flexure. In this study, the morphology of the mesentery during the mobilization of the colonic splenic flexure was continuously observed in vivo, and from the embryological point of view, the unique mesenteric morphology of the colonic splenic flexure was reconstructed in three dimensions to help surgeons further understand the mesangial structure of the region. Methods: A total of 9 patients with left colon cancer who underwent laparoscopic radical resection with splenic flexure mobilization by the same group of surgeons in Union Hospital of Fujian Medical University from January 2018 to June 2019 were enrolled. The splenic flexure was mobilized using a "three-way approach" strategy based on a middle-lateral approach. During the process of splenic flexure mobilization, the morphology of the transverse mesocolon and descending mesocolon were observed and reconstructed from the embryological point of view. The lower margin of the pancreas was set as the axis, and 4 pictures for each patient (section 1-section 4) were taken during middle-lateral mobilization. Results: The median operation time of the splenic flexure mobilization procedure was 31 (12-55) minutes, and the median bleeding volume was 5 (2-30) ml. One patient suffered from lower splenic vessel injury during the operation and the bleeding was stopped successfully after hemostasis with an ultrasound scalpel. The transverse mesocolon root was observed in all 9 (100%) patients, locating under pancreas, whose inner side was more obvious and tough, and the structure gradually disappeared in the tail of the pancreatic body, replaced by smooth inter-transitional mesocolon and dorsal lobes of the descending colon. The mesenteric morphology of the splenic flexure was reconstructed by intraoperative observation. The transverse mesocolon was continuous with a fan-shaped descending mesocolon. During the embryonic stage, the medial part (section 1-section 2) of the transverse mesocolon and the descending mesocolon were pulled and folded by the superior mesenteric artery (SMA). Then, the transverse mesocolon root was formed by compression of the pancreas on the folding area of the transverse mesocolon and the descending mesocolon. The lateral side of the transverse mesocolon root (section 3-section 4) was distant from the mechanical traction of the SMA, and the corresponding folding area was not compressed by the tail of the pancreas. The posterior mesangial lobe of the transverse mesocolon and the descending mesocolon were continuous with each other, forming a smooth lobe. This smooth lobe laid flat on the corresponding membrane bed composed of the tail of pancreas, Gerota's fascia and inferior pole of the spleen. Conclusions: From an embryological point of view, this study reconstructs the mesenteric morphology of the splenic flexure and proposes a transverse mesocolon root structure that can be observed consistently intraopertively. Cutting the transverse mesocolon root at the level of Gerota's fascia can ensure the complete resection of the mesentery of the transverse colon.

[Scientific interpretation of membrane anatomy theory and standardized application of membrane anatomy terms].

There has been an upsurge of the theory of membrane anatomy in China, but it is still in the initial stage of establishing preliminary framework. The concept of fasciae in membrane anatomy actually refers to the fasciae constituting the particular plane or the 'holy plane'. Therefore, the membrane anatomy can't simply be defined as the anatomical relationship among fascia. The application of the membrane anatomy is also not just to pursue the avascular plane in the surgical field. Nowadays, nonstandard anatomical terms and diversification of views impede the development of the theory of the membrane anatomy. Fasciae occur in embryonic stage, undergo a series of changes in rotation and fusion, and lose the original features, which bring difficulties in understanding the anatomy of fasciae. In this paper, we restore the origin and continuity of fasciae related to the colorectal surgery by cadaveric study, surgical observation and literature review. Taking the TME for example, we also discuss the core content about the fasciae and plane related to 'mesenteric envelope' and complete mesorectal excision. From the perspective of the fasciae integrity, we illustrate the definitions of important anatomical structure and standardized the terminology of fasciae. To study the origin and architecture of fasciae in the view of embryology, integrity and continuity will contribute to establish the standard theoretical system of membrane anatomy.

[Application of membrane anatomy in key technologies during gastric cancer surgery: guidance and compromise].

Different from classical surgical anatomy which only pays attention to the morphology and structure of human organs, modern membrane anatomy focuses on not only the relationship between morphology and structure, but also the biological behavior characteristics of tumors. Membrane antomy is a theoretical system with interpretation on both the structural and disease function, so it has been accepted by more and more gastrointestinal surgeons. However, the theoretical system of gastric membrane anatomy is not mature yet. The stomach and its mesentery have undergone complex rotation and fusion in the process of embryonic development, so that surgeons have different understandings of the gastric membrane anatomy. Therefore, it is easy to cause various confusion and misunderstanding, resulting in deviations between the theory of membrane anatomy and the practice of surgery. In the present study, the mesentery of the stomach is divided into different regions, and the embryonic development process is traced back. The application and compromise encountered in the radical gastrectomy of gastric cancer will be expounded according to the membrane anatomy theory combined with the author's experience of operation.

Distinct roles of VE-cadherin for development and maintenance of specific lymph vessel beds.

Endothelial cells line blood and lymphatic vessels and form intercellular junctions, which preserve vessel structure and integrity. The vascular endothelial cadherin, VE-cadherin, mediates endothelial adhesion and is indispensible for blood vessel development and permeability regulation. However, its requirement for lymphatic vessels has not been addressed. During development, VE-cadherin deletion in lymphatic endothelial cells resulted in abortive lymphangiogenesis, edema, and prenatal death. Unexpectedly, inducible postnatal or adult deletion elicited vessel bed-specific responses. Mature dermal lymph vessels resisted VE-cadherin loss and maintained button junctions, which was associated with an upregulation of junctional molecules. Very different, mesenteric lymphatic collectors deteriorated and formed a strongly hyperplastic layer of lymphatic endothelial cells on the mesothelium. This massive hyperproliferation may have been favored by high mesenteric VEGF-C expression and was associated with VEGFR-3 phosphorylation and upregulation of the transcriptional activator TAZ Finally, intestinal lacteals fragmented into cysts or became highly distended possibly as a consequence of the mesenteric defects. Taken together, we demonstrate here the importance of VE-cadherin for lymphatic vessel development and maintenance, which is however remarkably vessel bed-specific.

Peripheral PDGFRα+gp38+ mesenchymal cells support the differentiation of fetal liver-derived ILC2.

Group 2 innate lymphoid cells (ILC2s) are derived from common lymphoid progenitors (CLPs) via several specific precursors, and the transcription factors essential for ILC2 differentiation have been extensively studied. However, the external factors regulating commitment to the ILC lineage as well as the sites and stromal cells that constitute the optimal microenvironment for ILC2-specific differentiation are not fully defined. In this study, we demonstrate that three key external factors, the concentration of interleukin 7 (IL-7) and strength and duration of Notch signaling, coordinately determine the fate of CLP toward the T, B, or ILC lineage. Additionally, we identified three stages of ILC2 in the fetal mesentery that require STAT5 signals for maturation: ILC progenitors, CCR9+ ILC2 progenitors, and KLRG1- immature ILC2. We further demonstrate that ILC2 development is supported by mesenteric platelet-derived growth factor receptor α (PDGFRα)+ glycoprotein 38 (gp38)+ mesenchymal cells. Collectively, our results suggest that early differentiation of ILC2 occurs in the fetal liver via IL-7 and Notch signaling, whereas final differentiation occurs in the periphery with the aid of PDGFRα+gp38+ cells.

Angiopoietin receptor Tie2 is required for vein specification and maintenance via regulating COUP-TFII.

Mechanisms underlying the vein development remain largely unknown. Tie2 signaling mediates endothelial cell (EC) survival and vascular maturation and its activating mutations are linked to venous malformations. Here we show that vein formation are disrupted in mouse skin and mesentery when Tie2 signals are diminished by targeted deletion of Tek either ubiquitously or specifically in embryonic ECs. Postnatal Tie2 attenuation resulted in the degeneration of newly formed veins followed by the formation of haemangioma-like vascular tufts in retina and venous tortuosity. Mechanistically, Tie2 insufficiency compromised venous EC identity, as indicated by a significant decrease of COUP-TFII protein level, a key regulator in venogenesis. Consistently, angiopoietin-1 stimulation increased COUP-TFII in cultured ECs, while Tie2 knockdown or blockade of Tie2 downstream PI3K/Akt pathway reduced COUP-TFII which could be reverted by the proteasome inhibition. Together, our results imply that Tie2 is essential for venous specification and maintenance via Akt mediated stabilization of COUP-TFII.

Extravascular endothelial and hematopoietic islands form through multiple pathways in midgestation mouse embryos.

The de novo generation of hematopoietic cells occurs during midgestation when a population of endothelial cells called hemogenic endothelium transitions into hematopoietic progenitors and stem cells. In mammalian embryos, the newly formed hematopoietic cells form clusters in the lumens of the major arteries in the embryo proper and in the vascular plexus of the yolk sac. Small clusters of hematopoietic cells that are independent of the vasculature (referred to here as extravascular islands) were shown to form in the mesentery during vascular remodeling of the vitelline artery. Using three-dimensional imaging of whole mouse embryos we demonstrate that extravascular budding of hematopoietic clusters is a more widespread phenomenon that occurs from the vitelline and the umbilical arteries both proximal to the embryo proper and distal in the extraembryonic yolk sac and placenta. Furthermore, we show that there are several mechanisms by which hematopoietic clusters leave the arteries, including vascular remodeling and extrusion. Lastly, we provide static images suggesting that extravascular islands contribute to the formation of new blood vessels. Thus, extravascular islands may represent a novel mechanism of vasculogenesis whereby established vessels contribute endothelial and hematopoietic cells to developing vascular beds.

Bone morphogenetic protein 9 (BMP9) controls lymphatic vessel maturation and valve formation.

Lymphatic vessels are critical for the maintenance of tissue fluid homeostasis and their dysfunction contributes to several human diseases. The activin receptor-like kinase 1 (ALK1) is a transforming growth factor-ß family type 1 receptor that is expressed on both blood and lymphatic endothelial cells (LECs). Its high-affinity ligand, bone morphogenetic protein 9 (BMP9), has been shown to be critical for retinal angiogenesis. The aim of this work was to investigate whether BMP9 could play a role in lymphatic development. We found that Bmp9 deficiency in mice causes abnormal lymphatic development. Bmp9-knockout (KO) pups presented hyperplastic mesenteric collecting vessels that maintained LYVE-1 expression. In accordance with this result, we found that BMP9 inhibited LYVE-1 expression in LECs in an ALK1-dependent manner. Bmp9-KO pups also presented a significant reduction in the number and in the maturation of mesenteric lymphatic valves at embryonic day 18.5 and at postnatal days 0 and 4. Interestingly, the expression of several genes known to be involved in valve formation (Foxc2, Connexin37, EphrinB2, and Neuropilin1) was upregulated by BMP9 in LECS. Finally, we demonstrated that Bmp9-KO neonates and adult mice had decreased lymphatic draining efficiency. These data identify BMP9 as an important extracellular regulator in the maturation of the lymphatic vascular network affecting valve development and lymphatic vessel function.

Peritoneal and retroperitoneal anatomy and its relevance for cross-sectional imaging.

It is difficult to identify normal peritoneal folds and ligaments at imaging. However, infectious, inflammatory, neoplastic, and traumatic processes frequently involve the peritoneal cavity and its reflections; thus, it is important to identify the affected peritoneal ligaments and spaces. Knowledge of these structures is important for accurate reporting and helps elucidate the sites of involvement to the surgeon. The potential peritoneal spaces; the peritoneal reflections that form the peritoneal ligaments, mesenteries, and omenta; and the natural flow of peritoneal fluid determine the route of spread of intraperitoneal fluid and disease processes within the abdominal cavity. The peritoneal ligaments, mesenteries, and omenta also serve as boundaries for disease processes and as conduits for the spread of disease.

Fetal intrahepatic gallbladder and topographical anatomy of the liver hilar region and hepatocystic triangle.

The fetal gallbladder (GB) is embedded in a deep fossa surrounded by the liver parenchyma. Using 15 specimens with intrahepatic GB (crown-rump length 45-92 mm; approximately 9-13 weeks of gestation), we assessed the fetal topographical anatomy of the hepatocystic triangle and the porta hepatis. The cystic duct displayed a long upward course (0.9-4.5 mm along the supero-inferior axis) from the GB, along the duodenum, to the common bile duct in the hepatoduodenal ligament, via an independent mesentery separated from liver parenchyma by a recess of the peritoneal cavity. Notably, the course varied in length among specimens, not among stages. At the porta hepatis, we were able to distinguish the supraportal course of the posterior right hepatic duct overriding a portal vein branch to segment 8 (6/15) from the other, infraportal course (9/15). In the latter type, the portal vein bifurcation was superior to the cystic duct course. Two margins of the hepatocyctic triangle were very long in fetuses because of the inferiorly located intrahepatic GB. Thus, the triangle seems to be difficult to identify in prenatal ultrasound. During changes in location after 9 weeks, the GB fundus remains attached to the liver because the cystic artery was often embedded in the liver parenchyma. A failure in the embedding and re-exposure process of the GB may result in anomalous peritoneal folds around the GB.

Human fetal lymphoid tissue-inducer cells are interleukin 17-producing precursors to RORC+ CD127+ natural killer-like cells.

The human body contains over 500 individual lymph nodes, yet the biology of their formation is poorly understood. Here we identify human lymphoid tissue-inducer cells (LTi cells) as lineage-negative RORC+ CD127+ cells with the functional ability to interact with mesenchymal cells through lymphotoxin and tumor necrosis factor. Human LTi cells were committed natural killer (NK) cell precursors that produced interleukin 17 (IL-17) and IL-22. In vitro, LTi cells gave rise to RORC+ CD127+ NK cells that retained the ability to produce IL-17 and IL-22. Postnatally, similar populations of LTi cell-like cells and RORC+ CD127+ NK cells were present in tonsils, and both secreted IL-17 and IL-22 but no interferon-gamma. Our data indicate that lymph node organogenesis is controlled by an NK cell precursor population with adaptive immune features and demonstrate a previously unappreciated link between the innate and adaptive immune systems.

The chirality of gut rotation derives from left-right asymmetric changes in the architecture of the dorsal mesentery.

We have investigated the structural basis by which the counterclockwise direction of the amniote gut is established. The chirality of midgut looping is determined by left-right asymmetries in the cellular architecture of the dorsal mesentery, the structure that connects the primitive gut tube to the body wall. The mesenchymal cells of the dorsal mesentery are more condensed on the left side than on the right and, additionally, the overlying epithelium on the left side exhibits a columnar morphology, in contrast to a cuboidal morphology on the right. These properties are instructed by a set of transcription factors: Pitx2 and Isl1 specifically expressed on the left side, and Tbx18 expressed on the right, regulated downstream of the secreted protein Nodal which is present exclusively on the left side. The resultant differences in cellular organization cause the mesentery to assume a trapezoidal shape, tilting the primitive gut tube leftward.

Steel factor controls midline cell death of primordial germ cells and is essential for their normal proliferation and migration.

During germ-cell migration in the mouse, the dynamics of embryo growth cause many germ cells to be left outside the range of chemoattractive signals from the gonad. At E10.5, movie analysis has shown that germ cells remaining in the midline no longer migrate directionally towards the genital ridges, but instead rapidly fragment and disappear. Extragonadal germ cell tumors of infancy, one of the most common neonatal tumors, are thought to arise from midline germ cells that failed to die. This paper addresses the mechanism of midline germ cell death in the mouse. We show that at E10.5, the rate of apoptosis is nearly four-times higher in midline germ cells than those more laterally. Gene expression profiling of purified germ cells suggests this is caused by activation of the intrinsic apoptotic pathway. We then show that germ cell apoptosis in the midline is activated by down-regulation of Steel factor (kit ligand) expression in the midline between E9.5 and E10.5. This is confirmed by the fact that removal of the intrinsic pro-apoptotic protein Bax rescues the germ-cell apoptosis seen in Steel null embryos. Two interesting things are revealed by this: first, germ-cell proliferation does not take place in these embryos after E9.0; second, migration of germ cells is highly abnormal. These data show first that changing expression of Steel factor is required for normal midline germ cell death, and second, that Steel factor is required for normal proliferation and migration of germ cells.

Elevated vascular endothelial cell growth factor affects mesocardial morphogenesis and inhibits normal heart bending.

Signaling by means of vascular endothelial cell growth factor (VEGF) and its receptors (VEGFRs) is required for cardiovascular development. To examine how VEGF/VEGFR receptor signaling affects early endocardial cell behavior, embryonic quail hearts were subjected to elevated VEGF165 levels (five- to nine-somite stage). Primitive embryonic hearts microinjected with recombinant human (rh)VEGF165 exhibit several distinct malformations compared with hearts in untreated embryos: the endocardial tube is malformed with tortuous cords and folds surrounded by a diminished cardiac jelly space, and the lumens of affected hearts are conspicuously reduced. Furthermore, the embryonic heart fails to loop properly. Inhibition of bending is accompanied by an apparent failure of the dorsal mesocardium to atrophy--an event thought to be necessary for heart bending. Instead of atrophy, VEGF-treated mesocardia exhibit a marked increased in the number of resident endothelial cells. Collectively, the data suggest that the abnormally robust mesocardia in VEGF-treated hearts impede the mechanical deformation required for normal heart bending. We conclude that the excessive VEGF signaling culminates in a physical or biomechanical mechanism that acts over a wide, tissue-level, length scale to cause a severe developmental defect--failure of heart bending.

Overexpression of the Del1 gene causes dendritic branching in the mouse mesentery.

In the present study, we established transgenic mice overexpressing Del1, a ligand of integrins, to examine the effect of overexpression of Del1 on vascular morphogenesis. In the wild-type mouse, mesenteric vessels are shaped like rakes consisting of a long stalk and short branches at the periphery. In contrast, those in transgenic mice showed typical dendritic architecture consisting of a few large primary branches with smaller spreading branches. The phenotype of mice overexpressing Del1 suggests the existence of a tissue-specific mechanism for branching morphogenesis in the mesentery.

Laparoscopic repair of a right paraduodenal hernia.

BACKGROUND: Laparoscopic repair of a right paraduodenal hernia has never been described in the literature. A 24-year-old woman was admitted after 2 weeks of intermittent abdominal pain associated with nausea and vomiting. Physical examination was normal. Laboratory studies and upper endoscopy were normal. Computed tomography revealed that the small bowel was on the right side of the abdomen and the colon on the left, suspicious for malrotation. Subsequent upper gastrointestinal series with small bowel follow-through revealed the ligament of Treitz on the right with the small bowel encased within a probable hernia sac. A presumptive diagnosis of a right paraduodenal hernia was made. METHODS AND RESULTS: Initial access was obtained with a 10-mm infraumbilical port followed by placement of 5-mm ports in the right and left upper and lower quadrants. The duodenum was identified and the small bowel was found encased within a hernia sac, which was opened widely from the duodenum to the pelvis. The hernia sac was opened laterally to avoid injury to the superior mesenteric vessels. The small bowel was then released from the sac into the peritoneal cavity. The entire bowel was inspected and no other abnormalities were noted. The patient had resolution of her abdominal pain and her postoperative course was uncomplicated. She was discharged home on postoperative day 3 and has since done exceptionally well. CONCLUSIONS: Paraduodenal hernia, a rare cause of small bowel obstruction, can present a diagnostic challenge. However, when the diagnosis is made preoperatively, a laparoscopic repair is a feasible and practical option.

Congenital mesenterico-portal (Rex) shunt.

Congenital anomalies of the portal and umbilical-venous system are rare, with few reported cases. We describe a case where the native umbilical vein had acquired mesenteric venous outflow to bypass an in-utero portal-vein (PV) obstruction and restore normal venous return to the liver. This is analogous to the recently described Rex shunt procedure used in some cases of extrahepatic portal hypertension due to PV occlusion.

Stromal cells from murine embryonic aorta-gonad-mesonephros region, liver and gut mesentery expand human umbilical cord blood-derived CAFC(week6) in extended long-term cultures.

The first definitive long-term repopulating hematopoietic stem cells (HSCs) emerge from and undergo rapid expansion in the embryonic aorta-gonad-mesonephros (AGM) region. To investigate the presumptive unique characteristics of the embryonic hematopoietic microenvironment and its surrounding tissues, we have generated stromal clones from subdissected day 10 and day 11 AGMs, embryonic livers (ELs) and gut mesentery. We here examine the ability of 19 of these clones to sustain extended long-term cultures (LTCs) of human CD34(+) umbilical cord blood (UCB) cells in vitro. The presence of in vitro repopulating cells was assessed by sustained production of progenitor cells (extended LTC-CFC) and cobblestone area-forming cells (CAFC). The embryonic stromal clones differed greatly in their support for human HSCs. Out of eight clones tested in the absence of exogenous cytokines, only one (EL-derived) clone was able to provide maintenance of HSCs. Addition of either Tpo or Flt3-L + Tpo improved the long-term support of about 50% of the tested clones. Cultures on four out of 19 clones, ie the EL-derived clone mentioned, two urogenital-ridge (UG)-derived clones and one gastrointestinal (GI)-derived clone, allowed a continuous expansion of primitive CAFC and CFU-GM with over several hundred-fold more CAFC(week6) produced in the 12th week of culture. This expansion was considerably higher than that found with the FBMD-1 cell line, which is appreciated by many investigators for its support of human HSCs, under comparable conditions. This stromal cell panel derived from the embryonic regions may be a powerful tool in dissecting the factors mediating stromal support for maintenance and expansion of HSCs.