Unique multidisciplinary approach in living donor liver transplantation to achieve total physiological revascularization in a patient with complete occlusion of portal vein system with combined chronic and sub-acute thrombosis.

Patients receiving liver transplantation in a setting of complete portal vein (PV) and superior mesenteric vein (SMV) thrombosis (Yerdel grade 4) experience lower outcomes after surgery; prognosis is independently influenced by the portal flow reconstruction technique, showing better outcomes in physiological surgical strategies. We describe a case of living donor liver transplantation in which the patient could not receive common physiological reconstructions pre-operatively due to multiple small collaterals and extensive thrombosis down to 1st branches of SMV. We performed thrombo-endo-venectomy of the portal vein and SMV first, but acute thrombosis developed recurrently even with interposition venous homograft between peri-choledochal collateral vein and proximal recipient portal vein. Immediate after surgery, intervention radiologist performed stenting insertion into 3 stenotic points. Through multidisciplinary approach, complete physiologic recanalization was obtained with normal liver function.

Pancreatoduodenectomy with superior mesenteric vein resection and non-reconstruction for pancreatic head cancer paying particular attention to hemodynamics.

PURPOSE: Locally advanced pancreatic ductal adenocarcinoma (PDAC) with an unreconstructible superior mesenteric vein (SMV) invasion is one of the criteria of unresectability in the National Comprehensive Cancer Network guidelines. Advances in chemotherapy have improved downstaging and conversion surgery outcomes, thereby broadening surgical options for locally advanced PDAC. However, operations for PDAC with an unreconstructible SMV is less well-documented. If the collateral route is well-developed and can be preserved or reconstructed, SMV resection can be performed without reconstruction. In this paper, we detail our surgical technique and the outcomes for patients undergoing pancreatoduodenectomy with SMV resection and non-reconstruction (PD-SMVR-NR). METHODS: All consecutive patients with pancreatic head cancer who underwent PD at Juntendo University Hospital, Japan, between January 2019 and December 2022 were evaluated from a prospectively maintained preoperative database. Demographic data, clinical history, operative record, morbidity, mortality, and pathologic data were reviewed. RESULTS: Over four years at our Institute, 161 patients with pancreatic head cancer underwent PD, and 86 of these patients underwent PD with portal vein (PV) or SMV resection. There were three patients who underwent PD-SMVR-NR. Each patient had well-developed collateral vessels bypassing the obstructed segment of the SMV. All three patients had no hospital mortality with acceptable complications (Clavien-Dindo grade 2). Two patients achieved R0 resection. CONCLUSION: By understanding the hemodynamics of venous flow and preserving collateral vessels, especially the superior right colic vein arcade and porto-mesenterico-splenic confluence, pancreatoduodenectomy with superior mesenteric vein resection and non-reconstruction can be performed safely.

Performance of Prenatal Ultrasound Screening for the Relative Positioning of Mesenteric Vessels.

OBJECTIVES: Abnormal relative positioning of the superior mesenteric artery (SMA) and vein (SMV) can lead to intestinal malrotation that predisposes to midgut volvulus. The aim of this study was to assess the prenatal ultrasound ability to visualize the relative position of SMA and SMV in normal pregnancies. METHODS: Prospective cohort study performed in Montpellier University Hospital Centre, including 80 fetuses during routine 3rd trimester ultrasound scan. For each fetus included, the relative position of the vessels on an axial image was defined as SMV on the right, forward, or on the left of SMA. Doppler imaging was additionally used if necessary. Data were compared to the neonatal abdominal scans performed by pediatric radiologist. RESULTS: The superior mesenteric vessels were identified in 79 fetuses. Prenatal findings showed a usual relative position of the vessels, that is, the vein on the right of the artery, in 96.2%. In 2 cases, the vein was strictly in front of the artery, and in 1 case, the vein was on the left side of the artery. Seventy-four neonates were examined and comparison with prenatal finding showed a perfect agreement (Kappa coefficient of 100%). An intestinal malrotation was postnatally diagnosed corresponding to the case where vein was on the left side of the artery. CONCLUSION: This study showed that the relative position of the SMA and SMV could be assessed using ultrasound prenatal examination with a perfect agreement with postnatal findings. In case of abnormal vessels positioning more examinations should be promote including prenatal MRI and postnatal conventional radiologic examinations to confirm intestinal malrotation.

Rare deep vein thrombosis in pregnancy and puerperium 3 case series; upper extremities vein thrombosis, ovarian vein thrombosis, portal and superior mesenteric vein thrombosis.

Pregnancy induces a hypercoagulable state, elevating thrombosis risk by 5-6 times compared to non-pregnant conditions. Predominantly affecting the left lower extremity due to anatomical and hematological factors, deep vein thrombosis can escalate into pulmonary embolism, impacting mortality. The authors aim to report rare incidents of thrombosis beyond the norm, including upper extremity vein thrombosis, right ovarian vein thrombosis, and portal vein and superior mesenteric vein thrombosis, highlighting their significance. Obstetricians should be mindful that thrombosis can occur not only in the lower extremities but also in other areas. Especially when symptoms such as fever unresponsive to antibiotics, atypical pain, and an abnormally high C-reactive protein level are present. Considering the possibility of a rare thrombosis is crucial. Understanding these less common thrombotic events during pregnancy and the postpartum period can contribute to the improvement of timely diagnosis and management strategies.

First jejunal vein, jejunal trunk, and pancreatico-duodenectomy: resolving the literature conundrum.

A detailed knowledge of the surgical anatomy of tributaries of the superior mesenteric vein, especially proximal jejunal venous anatomy (first jejunal vein and jejunal trunk), is a key prerequisite for performing a safe pancreatico-duodenectomy. However, the available literature on the anatomical course and surgical relevance of these vessels is scarce, the nomenclature across the articles is heterogeneous, and the resulting evidence is confusing to interpret. Standardized terminology and an in-depth review of these vessels with regard to their course, termination, vascular relations, and variations will help the surgeons in planning and performing this complex surgery safely, especially when a venous resection and reconstruction is planned in cases of borderline resectable pancreatic cancer. A uniform nomenclature and a unifying classification are proposed in this review for these two tributaries to help resolve the literature conundrum. This standardized terminology and anatomical description will assist the radiologists in reporting pancreatic protocol-computed tomography scans and surgeons in selecting the appropriate steps for the different anatomical orientations of these tributaries for the performance of safe pancreatic surgery. This will also help future researchers communicate in well-defined terms in reference to these tributaries so as to avoid confusion in future studies.

Pediatric hypereosinophilic syndrome associated with liver damage, portal vein, splenic vein and superior mesenteric vein thromboses: a case report.

BACKGROUND: The hypereosinophilic syndrome (HES) is a group of rare blood disorders characterized by persistent eosinophilia and damage to multiple organs. HES can be either primary, secondary or idiopathic. Secondary HES are commonly caused by parasitic infections, allergic reactions or cancer. We described a pediatric case of HES associated with liver damage and multiple thrombi. A 12-year-old boy with eosinophilia was complicated with severe thrombocytopenia, liver damage, portal vein, splenic vein, and superior mesenteric vein thromboses. The thrombi recanalized after treatment with methylprednisolone succinate and low molecular weight heparin. No side effects appeared after 1-month. CONCLUSIONS: Corticosteroids should be used at an early stage of HES to prevent further damage to vital organs. Anticoagulants should be recommended only in cases with thrombosis which should be actively screened as a part of evaluation of end organ damage.

Long Term Results of Pancreatectomy With and Without Venous Resection: A Comparison of Safety and Complications of Spiral Graft, End-to-End and Tangential/Patch Reconstruction Techniques.

OBJECTIVE: Roughly 10% - 20% of pancreatic cancer patients are candidates for curative intent surgical treatment. In the 2000s, many studies showed similar survival rates comparing pancreatic surgery with or without vein resection and reconstruction. The aim was to identify the best method of venous reconstruction. METHODS: This was a retrospective cohort study. A total of 1 375 patients undergoing pancreatectomy between 2005 and 2018 were identified. Patients undergoing a combined pancreatic resection and venous reconstruction were included retrospectively. When tumour infiltration to the portal/superior mesenteric vein was detected, excision and reconstruction with tangential suturing/patch, end to end anastomosis, or a spiral graft from the great saphenous vein was performed. Next, 90 day and long term survival and outcomes across reconstruction techniques were analysed. RESULTS: Overall, 198 patients had venous involvement visible in pre-operative scans or detected during surgery, broken down as follows: 171 (86%) pancreaticoduodenectomy, 12 (6%) total pancreatectomy, and 15 (8%) distal pancreatectomy. In total, 69 (35%) spiral graft reconstructions, 77 (39%) end to end anastomoses, and 52 (26%) tangential/patch reconstructions were performed. Tumour histology revealed pancreatic adenocarcinomas in 162 (82%) patients, intraductal mucinous pancreatic neoplasia in 14 (7%), cholangiocarcinoma in five (3%), neuro-endocrine neoplasia in nine (5%), and eight other diagnoses. Overall, 183 (92%) were malignant and 15 (8%) benign. Two patients died within 90 days, one in hospital and one on post-operative day 38 due to thrombosis of the superior mesenteric vein and intestinal necrosis, a Clavien-Dindo grade 5 complication. In addition, 50 (23%) patients had Clavien-Dindo grade 3 - 4 complications. No differences in complications comparing vein reconstruction techniques or in the long term survival of pancreatectomy patients with or without venous reconstruction were detected. CONCLUSION: The spiral graft technique, used when more advanced venous infiltration occurs, does not increase complications, with outcomes mirroring those accompanying shorter venous resections.

Portal vein reconstruction with cryopreserved vascular grafts: A two-edged sword.

BACKGROUND: Portal vein anastomotic complications related to size discrepancy are important causes of morbidity and mortality in pediatric liver transplantation. Interposed vascular grafts in portal vein anastomosis can solve this problem. The aim of this study is to evaluate the results of pediatric liver transplantations performed using cryopreserved interposed vascular grafts between graft portal vein and superior mesenteric vein (SMV)-splenic vein (SpV) confluence. METHODS: Twenty-nine pediatric patients received liver transplantation using cryopreserved venous grafts in our Liver Transplant Institute between 2013 and 2020 were included in this study. Demographic, clinical, and operative characteristics and postoperative follow-up were analyzed. RESULTS: Sixteen patients (55.2%) had portal hypoplasia and five patients (17.2%) had portal vein thrombosis. In total, six patients (20.6%) suffered portal vein thrombosis in the early postoperative period. Three patients (10.3%) experienced portal vein thrombosis in the late postoperative period. Late portal vein thrombosis rate was significantly higher in patients with early portal vein thrombosis (3/6 patients [50%] versus 0/23 patients [0%]; p = .034). Lack of portal flow was significantly higher in patients with both early (50% versus 0%; p = .002) and late portal vein thrombosis (66.7% versus 6.7%; p = .03). CONCLUSION: Preoperative portal vein thrombosis and insufficient flow are important factors affecting success of liver transplant in children. The use of interposed vein grafts in problematic portal anastomoses can overcome portal flow problems.

Is the ileocolic artery crossing pattern related to oncological outcomes of right-sided colon cancer?

BACKGROUND: Complete mesocolic excision + D3 lymphadenectomy for right-sided colon cancer is standard procedure in Japan. A postmortem study has shown that in patients with the ileocolic artery (ICA) crossing posterior to the superior mesenteric vein (SMV), D3 lymphadenectomy may be potentially inadequate due to anatomical difficulties in lymphadenectomy of the ventral and lateral areas of the ICA. However, whether the ICA crossing pattern is associated with oncologic outcomes of right-sided colon cancer remains unclear. This study aimed to clarify whether differences in ICA crossing patterns are associated with disease-free survival and overall survival. METHODS: In this retrospective study, we searched a prospectively maintained database to identify medical records of patients with right-sided colon cancer who underwent right hemicolectomy and D3 lymphadenectomy. We classified patients into two groups based on the ICA crossing pattern: ICA crossing anterior to the SMV (group A) and ICA crossing posterior to the SMV (group P). We compared oncologic outcomes between the two groups. RESULTS: A total of 336 patients were included in the final analytic cohort: 175 in group A and 161 in group P. There was no significant difference in the number of harvested lymph nodes between the two groups. The two groups did not differ in 5-year overall survival within any disease stage. Similarly, the 5-year disease-free survival rates did not differ significantly between the two groups within any disease stage. We performed univariate and multivariate analyses, which showed the ICA crossing pattern had no clinical relevance. CONCLUSION: Our study did not show an association between the ICA crossing pattern and oncologic outcomes in patients with right-sided colon cancer who underwent right hemicolectomy with D3 lymphadenectomy.

Anatomy of the vitelline vein remnant in human embryos and fetuses.

PURPOSE: To demonstrate the entire course of the human vitelline vein (VV) in specimens after degeneration of the yolk sac. METHODS: Sagittal and horizontal histological sections from 8 embryos and 19 fetuses (gestational age approximately 6-12 weeks; crown-rump length 11-61 mm) were examined. RESULTS: Two types of VV remnants were observed: a long VV on the right superior side of the mesentery of the jejunum (VV1) and a short VV on the left inferior side of the mesentery (VV2). The VV1, observed in 12 specimens, was 20-30 microns in diameter and ran dorsally between the right liver lobe and the jejunum, subsequently merging with an initial superior mesenteric vein on the pancreatic head immediately below the superior portion of the duodenum. The VV2, observed in four specimens, passed dorsally between loops of the ileum on the left side of the mesentery of the ileum and connected to the mesentery. Many of the VVs did not originate from the umbilical cord but suddenly started in the sack of physiological herniation. At 10-12 weeks, after herniation, the VVs originated from the umbilicus and were involved by the expanding greater omentum. CONCLUSIONS: The right-sided and left-sided VVs seemed to correspond to right and left VV remnants, respectively, and both took an upstream course outside the mesentery of the jejunum and ileum. The right VV upstream portion was likely to disappear later than the left one, but the timing of degeneration varied greatly among individuals, depending on the topographical relationship between the right liver lobe and the jejunum.

Unusual contribution of the first jejunal vein in the formation of the portal vein.

Jejunum is drained into superior mesenteric vein through a series of jejunal veins. The way in which the first jejunal vein terminates is of great importance in upper abdominal surgery and radiological procedures. Knowledge of its variations is particularly important in surgical procedures like orthotropic hepatic transplantation, hepatic vein reconstruction, pancreatic surgery and surgical procedures of duodenojejunal junction. We saw a first jejunal vein opening directly into the portal vein. Further, the inferior mesenteric vein drained into the first jejunal vein. This case could be useful to gastroenterologists, general surgeons and radiologists.

A Rare Case of Malrotation and Midgut Volvulus with Whirlpool Sign.

We report a rare case of midgut malrotation and volvulus with "whirlpool sign" in a new-born infant. The "whirlpool sign" is an imaging characteristic of midgut volvulus and has a high predicting value for volvulus. Malrotation or malrotation with volvulus can be effectively diagnosed based on these characteristics. Ultrasound diagnosis has the advantage of no radiation exposure. Color Doppler documenting the reversal or aberrant superior mesenteric vein/superior mesenteric artery axis is not only predictive but also diagnostic of malrotation of gut. The rapid and accurate diagnosis of volvulus by ultrasound helps to establish the diagnosis of malrotation in time and thus allows for urgent surgical intervention to avoid bowel necrosis.

Splenic Vein as an Autologous Graft in Traumatic SMV Injuries: A Missed Valuable Alternative.

Traumatic superior mesenteric artery (SMA) and vein (SMV) injuries are rare but often lethal. The ideal management options of traumatic SMV injury are still controversial. Management options include venous repair and ligation. Splenic vein turndown procedure (SVTP) is a rare procedure that has been described in only 6 cases in the literature. Here, we reviewed the literature on the usage of the splenic vein turndown procedure (SVTP) as an alternative option in patients with traumatic SMV injury. METHODS: We performed a narrative review for the available literature on the usage of the splenic vein as an autologous graft in the management of the SMV injury. We included all studies of SVTP in traumatic SMV injuries only. RESULTS: We included only 5 studies. In total, 7 patients underwent SVTP. Five patients presented with a penetrating abdominal vascular trauma (AVT) and 2 patients with a blunt AVT. The advantages of the SVTP include no need for additional incisions to harvest potential autologous grafts, minimally increased operative time, and 1 less anastomotic site compared to other conduit options. CONCLUSIONS: In cases of traumatic SMV injuries with associated splenic or pancreatic injuries that need distal pancreatosplenectomy, surgeons may consider SVTP as an ideal management option rather than primary repair or ligation.

Direct splenic vein reconstruction combined with resection of the portal vein/superior mesenteric vein confluence during pancreaticoduodenectomy.

PURPOSE: Splenic vein (SV) ligation combined with portal vein (PV)/superior mesenteric vein (SMV) confluence resection during pancreaticoduodenectomy (PD) is reported to cause left-side portal hypertension (LPH). The purpose of this study was to present our technique of the SV reconstruction and to evaluate the surgical outcomes with/without SV ligation during PD. METHODS: Twenty-four patients undergoing PD with PV and/or SMV resection and being followed over 4 months after surgery between March 2013 and December 2019 in our hospital were evaluated. Resection of the PV/SMV confluence were performed in 14, and SV reconstruction was successfully performed in 3. Presence of LPH was assessed by examining changes in splenic volume, newly venous collateral formation, and platelet counts before and 4-8 months after PD. Surgical technique is the direct anastomosis between SV and PV. RESULTS: Splenic volume ratio was significantly higher in the SV ligation group (n = 11) than in the SV preservation group (n = 13) (median (range) 1.11 (0.57-1.62) vs. 1.68 (1.05-2.22), p < 0.01), but no significant differences were found in the incidence of newly formed venous collaterals or platelet counts between groups. CONCLUSION: SV ligation may represent the cause of LPH after PD combined with resection of PV/SMV confluence. Our simple procedure may help decrease the incidence of LPH.

Superior Mesenteric Arterial and Venous Thrombosis in COVID-19.

BACKGROUND: Patients with coronavirus disease 2019 (COVID-19) commonly present with fever, constitutional symptoms, and respiratory symptoms. However, atypical presentations are also well known. Though isolated mesenteric arterial occlusion associated with COVID-19 has been reported in literature, combined superior mesenteric arterial and venous thrombosis is rare. We report a case of combined superior mesenteric arterial and venous occlusion associated with COVID-19 infection. CASE REPORT: We report a case of a 45-year-old man who was a health care worker who presented to the emergency department with severe abdominal pain. The clinical examination was unremarkable, but imaging revealed acute mesenteric ischemia caused by superior mesenteric artery and superior mesenteric vein occlusion. Imaging of the chest was suggestive of COVID-19 infection, which was later confirmed with reverse transcription polymerase chain reaction of his nasopharyngeal swab. To date, only 1 case of combined superior mesenteric artery and superior mesenteric vein thrombosis caused by COVID-19 has been reported. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: During the COVID-19 pandemic it is important to keep mesenteric ischemia in the differential diagnosis of unexplained abdominal pain. Routinely adding high-resolution computed tomography of the chest to abdominal imaging should be considered in patients with acute abdomen because it can help to identify COVID-19 immediately. © 2020 Elsevier Inc.

Propensity-score-matched analysis of short- and long-term outcomes in patients with an ileocolic artery crossing anterior vs posterior to the superior mesenteric vein during curative resection for right-sided colon cancer.

BACKGROUND: Colorectal cancer is one of the most common malignant diseases worldwide. However, laparoscopic lymph node dissection is technically demanding and time-consuming in right-sided colon cancer surgery because of variable vessel anatomy. We evaluated whether the ileocolic artery (ICA) crossing anterior to the superior mesenteric vein (SMV) was associated with better intraoperative parameters and survival compared with the ICA crossing posterior to the SMV, following laparoscopic curative resection for right-sided colon cancer. METHODS: This was a propensity-score-matched retrospective study including data for 540 patients with right-sided colon cancer undergoing laparoscopic curative resection (299 with the ICA crossing anterior to the SMV (group A) and 241 with the ICA crossing posterior to the SMV (group B). We compared propensity-matched scores between the two groups to evaluate surgical and oncological outcomes. RESULTS: We found no significant difference in 5-year overall survival rates between groups for any disease stage (0-III). However, 5-year disease-free survival (DFS) rates did differ significantly between groups (p = 0.011), especially in patients with stage III disease (p = 0.013). We then performed univariate and multivariate analyses to determine the associations between DFS and ICA location and tumor-node-metastasis (UICC) stage. ICA location and UICC stage had a poor association with DFS on univariate analysis: ICA hazard ratio (HR) 2.52, CI 1.19-5.78, p = 0.014 vs HR 3.18, CI 1.08-9.46, p = 0.03, and on multivariate analysis: HR 2.48, CI 1.17-5.69, p = 0.016 vs HR 3.86, CI 1.90-7.96, p = 0.0002. CONCLUSION: Our results showed that an ICA crossing posterior to the SMV was associated with worse DFS compared with an ICA crossing anterior to the SMV. We recommend careful laparoscopic technique in patients with an ICA crossing posterior to the SMV, during lymph node resection in right-sided colon cancer surgery.

Serial Doppler velocimetry of mesenteric and portal flow in very-low-birth-weight preterm neonates with and without patent ductus arteriosus.

BACKGROUND: Very-low-birth-weight (VLBW) preterm neonates are vulnerable to patent ductus arteriosus (PDA), which might be related to high-resistance flow in the superior mesenteric artery (SMA), with decreased diastolic flow in situations of marked intestinal hypoperfusion. No previous studies have evaluated the portal vein and superior mesenteric vein (SMV) parameters to assess the PDA hemodynamic repercussions. OBJECTIVE: To assess mesenteric and portal flow in VLBW preterm neonates with or without PDA using serial Doppler ultrasonography (US). MATERIALS AND METHODS: We conducted a prospective longitudinal study on 61 VLBW preterm neonates submitted to 161 Doppler US exams, from 2 days to 20 days of age. RESULTS: All infants exhibited a progressive daily increase in the mean of the SMA diameter and systolic velocity, the portal vein diameter, the peak velocity, the mean velocity and the flow volume and of SMV diameter (P<0.05). The incidence of PDA was 37.7% (n=23) and infants with the disease revealed a smaller diameter, greater systolic velocity, lower diastolic velocity, and higher resistivity and pulsatility indices on SMA compared to those without PDA (P<0.05). Additionally, 47.8% (n=11) of infants with PDA exhibited absent or reversed end-diastolic flow in the SMA, and its resolution was seen among 54.5% (n=6) of these. Infants with PDA also exhibited lower values of portal vein diameter and flow volume and of SMV diameter (P<0.01). CONCLUSION: Doppler US enhances the understanding of mesenteric and portal flow, including the effects of PDA. The study of SMV and portal vein flow is proposed as a new parameter in PDA evaluation.

Factors associated with metastasis in superior mesenteric vein lymph node in subtotal gastrectomy for gastric cancer: Retrospective case control study.

OBJECTIVE: The revised Japanese treatment guideline for gastric cancer recommends dissection of the superior mesenteric vein lymph node (No. 14v LN) if there is metastasis in infrapyloric lymph node (No. 6 LN). However, it is still controversial whether LN dissection is necessary. The aim of this study was to investigate the factors associated with metastasis in No. 14v LN. METHODS: Patients who underwent D2 lymphadenectomy between 2003 and 2010 were included. We excluded patients who underwent total gastrectomy, had multiple lesions, or had missing data about the status of metastasis in the LNs that were included in D2 lymphadenectomy. Clinicopathologic characteristics and the metastasis in regional LNs were compared between patients with No. 14v LN metastasis (14v+) and those without (14v-). RESULTS: Five hundred sixty patients were included in this study. Univariate analysis showed that old age, larger tumor size, tumor location, differentiation, lymphatic invasion, venous invasion, perineural invasion, T classification, and N classification were related to metastasis in No. 14v LN. Multivariate analysis showed differentiation (P=0.027) and N classification (P<0.001) were independent related factors. Metastasis in infrapyloric lymph node (No. 6 LN) and proxiaml splenic lymph node (No. 11p LN) was independently associated with metastasis in No. 14v LN. CONCLUSIONS: Differentiation and N classification were independent factors associated with No. 14v LN metastasis, and No. 6 and No. 11p LN metastasis were independent risk factors for No. 14v LN metastasis.

Length of Stay and ICU Stay Are Increased With Repair of Traumatic Superior Mesenteric Vein Injury.

BACKGROUND: Traumatic superior mesenteric vein (SMV) injury is rare, and the ideal treatment is controversial. We compared the outcomes of ligation versus repair of SMV injury using the National Trauma Databank. MATERIALS AND METHODS: All adult patients who suffered from traumatic SMV injury were identified from the National Trauma Databank (2002-2014) by International Classification of Diseases (ICD) codes. Patients were stratified by treatment modality into no repair, ligation, and surgical repair using ICD procedure codes. Patient characteristics were compared between ligation and surgical repair groups using the Kruskal-Wallis test for continuous variables and Fisher's exact test for categorical variables. Outcomes, including mortality, rates of small bowel resection, length of stay (LOS), and ventilation days were compared using logistic regression. RESULTS: Among 952 patients with SMV injury, 192 patients (20.2%) had ligation, 428 (50%) underwent surgical repair, and 332 patients (34.9%) had neither repair nor ligation of the SMV. Overall hospital mortality was 32%. Age, gender, injury severity score (ISS), and Glasgow Coma Scale (GCS) were similar between groups that underwent ligation and surgical repair. Although the mortality rate (29.4% versus 36.5%, P = 0.20) and bowel resection rate (4% versus 3%, P = 0.12) were similar, patients who underwent repair had significantly longer hospital LOS (19.4 ± 24.8 versus15.2 ± 24.4 d, P < 0.001) and ICU LOS (13 ± 17.1 versus 9.3 ± 11.8 d, P = 0.02) compared to ligation. Similar results were observed in multivariable analysis when adjusted for race, associated vascular injuries, and other associated injuries. CONCLUSIONS: In patients with traumatic SMV injury, surgical repair does not appear to confer a significant survival advantage over ligation and can be associated with greater LOS and ICU LOS. Ligation may be an acceptable option for management of a traumatic SMV injury, especially when surgical repair cannot be performed, without compromising patient mortality or bowel resection rates.

Successful kidney transplantation in a small child with end-stage renal disease due to angiotensin receptor blocker fetopathy and atretic inferior vena cava.

Kidney transplantation is the treatment of choice in pediatric patients with end-stage renal disease. This population presents technical challenges particularly in those less than 20 kg due to anomalous anatomy, vascular access issues prior to transplantation, and a generally small size for age. Standard allograft outflow is usually achieved utilizing the iliac veins or IVC. When use of the iliocaval system is not feasible, alternative anastomosis must be considered. Herein, we report a case of a pediatric kidney transplantation where successful allograft outflow was achieved using the SMV when he was found to have an atretic IVC intraoperatively. In this setting, use of the portal system was required to achieve adequate allograft outflow. We created a donor iliac graft for added length to anastomose the renal vein with the SMV. In the setting of IVC occlusion with poor drainage, we utilized a patent vessel with larger caliber for outflow to reduce the risk of high venous pressures, allograft failure, venous rotation, and thrombosis. We conclude that the SMV may serve as an alternative outflow tract in the small pediatric patient and provides the vessel caliber needed to reduce the risks of complications.