The left gastro-omental vessels are able to maintain the entire spleen blood supply / Os vasos gastromentais esquerdos são capazes de manter o suprimento sanguíneo de todo o baço

Abstract The spleen is supplied by blood flow through the splenic artery and vein. The purpose of this communication is to report an ectopic spleen supplied only by reverse flow through the left gastro-omental vessels. A 14-year-old boy presented with pelvic splenomegaly supplied only by the left gastro-omental artery and veins connected to the inferior polar vessels, which were the only vessels communicating with the spleen. After detorsion of the spleen and splenopexy, the spleen returned to normal dimensions. The patient had uneventful follow-up. In conclusion, the left gastroepiploic vessels are able to maintain the entire spleen blood supply.

Resumo O baço é suprido pelo fluxo sanguíneo da artéria e veia esplênicas. O objetivo desta comunicação é apresentar um baço ectópico suprido apenas pelo fluxo sanguíneo reverso proveniente dos vasos gastromentais esquerdos. Um paciente de 14 anos apresentou esplenomegalia pélvica suprida apenas por artéria e veia gastromentais esquerdas, conectadas aos vasos polares inferiores, que eram os únicos presentes nesse baço. Após a distorção do baço e a esplenopexia, o baço voltou às dimensões normais. Não houve intercorrências no acompanhamento do paciente. Em conclusão, os vasos gastromentais esquerdos são capazes de suprir o fluxo sanguíneo de todo o baço.

A Different Origin of the Right Gastro-omental Artery / Un Origen Diferente de la Arteria Gastro-omental Derecha

The gastro-omental artery is one of the branches of the common hepatic artery. Alterations in the embryonic development of the ventral splanchnic arteries can cause marked variations. A rare variant of the right gastro-omental artery was observed during dissection of a 50-year-old male cadaver. The occurrence of this variant has not been reported in the specialized literature. This case of a different origin of the gastro-omental artery is described in detail in order to provide information that may contribute to upper abdominal surgeries.

La arteria gastro-omental es una de las ramas de la arteria hepática común. Las alteraciones en el desarrollo embrionario de las arterias ventrales pueden causar variaciones marcadas. Se observó una variante rara de la arteria gastro-omental derecha durante la disección de un cadáver de un hombre de 50 años de edad. La presencia de esta variante no se ha informado en la literatura especializada. Este caso de origen diferente de la arteria gastro-omental se describe detalladamente con el fin de proporcionar información que pueda contribuir a la cirugía abdominal superior.

[Epiploic appendagitis: a rare cause of abdominal pain]. / Apendagitis epiploica, causa poco frecuente de dolor abdominal.

BACKGROUND: Epiploic appendagitis is an atypical cause of abdominal pain whose knowledge could avoid diagnostic or treatment errors. Diagnosis has been performed with abdominal ultrasound or tomography with the only treatment being nonsteroidal anti-inflammatory drugs. OBJECTIVE: To analyze patients diagnosed in our hospital. METHODS: We performed a 4-year retrospective and descriptive study (March 2009-March 2013) of patients diagnosed with epiploic appendagitis in our hospital. RESULTS: Seventeen patients were included, 14 females and three males with a median age of 57 years. Symptom delay was 72 h. Abdominal pains were located in the left lower quadrant in 64.7% and right lower quadrant in 35.3% of patients. Blood test demonstrated leukocytes 6,300 (5,000-9,500), neutrophils 61.6% (57-65.8), and C reactive protein 1.5 (0.85-2.92). Diagnosis was confirmed with abdominal ultrasound or tomography in 88.2% and intraoperatively in 11.8%. CONCLUSIONS: Epiploic appendagitis was more frequent in women. Abdominal pain was located in the lower quadrant, more predominant in left than right. Blood tests were normal except for increased levels of C-reactive protein. Diagnosis was made mostly preoperatively due to imaging tests, avoiding unnecessary surgical intervention.

ANTECEDENTES: la apendagitis epiploica es una causa poco frecuente de dolor abdominal cuyo conocimiento podría evitar errores diagnósticos y terapéuticos. El diagnóstico suele establecerse mediante ecografía o tomografía abdominal; el tratamiento es sintomático, con antiinflamatorios. OBJETIVO: analizar los casos diagnosticados en nuestro centro. MATERIAL Y MÉTODOS: estudio retrospectivo y descriptivo de pacientes con diagnóstico de apendagitis epiploica durante 4 años (marzo 2009 a marzo 2013). RESULTADOS: se incluyeron 17 pacientes, 14 mujeres y 3 hombres, con una mediana de edad de 57 años. El periodo de latencia de los síntomas fue 72 horas. En 64.7% de los pacientes el dolor abdominal se localizó en el cuadrante inferior izquierdo y en 35.3% en el derecho. Laboratorio: leucocitos 6,300 (5,000-9,500), neutrófilos 61.6% (57- 65.8), proteína C reactiva 1.5 (0.85-2.92). El diagnóstico se confirmó mediante ecografía o tomografía abdominal en 88.2%, e intraoperatorio en 11.8%. CONCLUSIONES: la apendagitis epiploica fue más frecuente en mujeres. La clínica fue dolor abdominal en los cuadrantes inferiores, más frecuente en el lado izquierdo, con RESULTADOS de laboratorio normales, excepto la elevación de la proteína C reactiva. En la mayoría de los casos el diagnóstico se estableció preoperatoriomente, gracias al uso de pruebas radiológicas que evitó las intervenciones quirúrgicas innecesarias.

[Strangulated inguinal hernia]. / La hernia inguinal estrangulada.

BACKGROUND: Strangulated inguinal hernia (SIH) has an overall prevalence of 1.3% in adults, affecting mainly senilepatients, with a high incidence of morbidity and mortality. There are more than 13 different surgical techniques for treatment,but none has proven to be more effective than the others. METHODS: The present observational, longitudinal and prospective study carried out at Hospital General, Centro MedicoLa Raza in Mexico City proposes a new surgical technique to treat SIH. Between December 2000 and August 2010,43 adult patients with SIH were consecutively subjected to preperitoneal mesh repair and exploratory laparotomy (PPMRand ELAP), a personal modification by the author to the Stoppa-Rives technique. Several variables were studied. RESULTS: There was zero mortality. There were no cases of inguinal recurrence or reintervention. One patient developeda granuloma at the surgical site. There were three cases of superficial wound infection, six cases of inguinoscrotal seroma,and one case of incisional hernia. DISCUSSION: There is no international consensus on the treatment of SIH although it is interesting to analyze the studiespublished during the last two decades and to observe the results. Studies that propose a preperitoneal approach withmesh demonstrate the best results by reducing morbidity and mortality. CONCLUSIONS: Preperitoneal mesh repair and exploratory laparotomy reduce the rate of morbidity and mortality in thetreatment of SIH. Inguinal hernias must be repaired at the time of diagnosis to avoid strangulation.

A morphometric study of the intestinal mucosa of rats submitted to omentoenteropexy.

CONTEXT: The omentoenteropexy technique was developed as an alternative method for intestinal neovascularization, due to the angiogenic properties of factors from the omentum. OBJECTIVES: This study investigated changes in intestinal villi heights and crypts depths due to surgical techniques: seromiotomy with and without omentoenteropexy. METHOD: Thirty rats were operated on, after being divided into three groups, namely GI, GII and GIII with 10 rats each. In the GI rats were submitted to omentoenteropexy; rats in GII were submitted only to a seromiotomy, and in the GIII only laparotomy. Sixty days after the first surgery, the animals were sacrificed and a segment of intestine was removed for histology using Masson's trichrome technique and morphometric study of intestinal mucosa. RESULTS: The histological findings showed that seromiotomy with or without omentoenteropexy increased the length of intestinal villi when compared with GIII (only laparotomy) (analysis of variance: P = 0.0068; GI 38.88 ± 4.17; GII 39.41± 6.33; GIII 31.85 ± 5.56; GI = GII P>0.05; GII>GIII P<0.05; GI>GIII P<0.001). CONCLUSION: No differences were demonstrated in relation to crypt depths between the groups (P = 0.60). Ongoing studies are being set forth by our group to add more data on the role of omentopexy as a tool to promote neovascularization and intestinal mucosal growth.

A morphometric study of the intestinal mucosa of rats submitted to omentoenteropexy / Estudo morfométrico da mucosa intestinal de ratos submetidos a omentoenteropexia

CONTEXT: The omentoenteropexy technique was developed as an alternative method for intestinal neovascularization, due to the angiogenic properties of factors from the omentum. OBJECTIVES: This study investigated changes in intestinal villi heights and crypts depths due to surgical techniques: seromiotomy with and without omentoenteropexy. METHOD: Thirty rats were operated on, after being divided into three groups, namely GI, GII and GIII with 10 rats each. In the GI rats were submitted to omentoenteropexy; rats in GII were submitted only to a seromiotomy, and in the GIII only laparotomy. Sixty days after the first surgery, the animals were sacrificed and a segment of intestine was removed for histology using Masson's trichrome technique and morphometric study of intestinal mucosa. RESULTS: The histological findings showed that seromiotomy with or without omentoenteropexy increased the length of intestinal villi when compared with GIII (only laparotomy) (analysis of variance: P = 0.0068; GI 38.88 ± 4.17; GII 39.41± 6.33; GIII 31.85 ± 5.56; GI = GII P>0.05; GII>GIII P<0.05; GI>GIII P<0.001). CONCLUSION: No differences were demonstrated in relation to crypt depths between the groups (P = 0.60). Ongoing studies are being set forth by our group to add more data on the role of omentopexy as a tool to promote neovascularization and intestinal mucosal growth.

CONTEXTO: a omentoenteropexia foi desenvolvida como técnica alternativa para a neovascularização intestinal, devido às propriedades angiogênicas de fatores provenientes do omento. OBJETIVO: Investigar as alterações nas alturas vilositárias e profundidades de cripta na mucosa intestinal de ratos submetidos a seromiotomia com e sem omentopexia. MÉTODOS: Trinta ratos foram operados após serem divididos em três grupos com 10 animais cada um. No grupo I (GI) os ratos foram submetidos seromiotomia seguida por omentoenteropexia; no grupo II (GII) foi realizada apenas a seromiotomia, e no grupo III (GIII) apenas a laparotomia. após 60 dias, os animais foram sacrificados e seus intestinos examinados histologicamente, corados pelo tricrômio de Masson, sendo realizado também estudo morfométrico da mucosa intestinal. RESULTADOS: O estudo mostrou que a altura vilositária é maior nos grupos submetidos a seromiotomia, com ou sem omentopexia, do que no grupo em que se realizou laparotomia apenas, porém entre os dois primeiros grupos não houve diferença significante (análise de variância: P = 0,0068; GI 38,88 ± 4,17; GII 39,41 ± 6,33; GIII 31,85 ± 5,56; GI = GII P>0,05; GII>GIII P<0,05; GI>GIII P<0,001). CONCLUSÕES: Não foram demonstradas diferenças quanto às profundidades de criptas entre os grupos (P = 0,60). Novos estudos estão sendo realizados por este grupo para acrescentar mais dados sobre o papel da omentopexia como forma de promover neovascularização e crescimento da mucosa intestinal.

Adipocyte morphometric evaluation and angiogenesis in the omentum transposed to the breast: a preliminary study.

OBJECTIVE: The purpose of this study was to describe the probable mechanism of the volume increase of laparoscopically harvested omentum flaps used to treat breast deformities. METHODS: A histological analysis of omentum samples was performed to study the volume increase of laparoscopically harvested omentum flaps. Samples were harvested immediately after the transposition of the omentum from the abdominal cavity to the breast region and during the second surgical procedure for breast symmetrization of eight patients submitted to the transposition of the omentum flap. Changes in the morphometric measurements of the adipocytes (perimeter, diameter, and area), microvascular density (as measured by the CD31 endothelial marker), and immunohistochemical expression of VEGF were documented. RESULTS: The increases in adipocyte size and microvascular density were statistically significant (P < 0.012). The expression levels of VEGF were lower in the second set of samples when compared to the first set, but the differences were not statistically significant (P < 0.093). CONCLUSION: These results demonstrate an increase in cellular volume as measured by adipocyte perimeter, diameter, and area. Moreover, the increase in the number of vessels in the second set of samples suggests that neoangiogenesis was stimulated by the initial increase in VEGF expression levels observed in the first set of samples. The increase in VEGF expression in the flap may have been caused by adipocyte hypertrophy resulting from neoangiogenesis.

Adipocyte morphometric evaluation and angiogenesis in the omentum transposed to the breast: a preliminary study

OBJECTIVE: The purpose of this study was to describe the probable mechanism of the volume increase of laparoscopically harvested omentum flaps used to treat breast deformities. METHODS: A histological analysis of omentum samples was performed to study the volume increase of laparoscopically harvested omentum flaps. Samples were harvested immediately after the transposition of the omentum from the abdominal cavity to the breast region and during the second surgical procedure for breast symmetrization of eight patients submitted to the transposition of the omentum flap. Changes in the morphometric measurements of the adipocytes (perimeter, diameter, and area), microvascular density (as measured by the CD31 endothelial marker), and immunohistochemical expression of VEGF were documented. RESULTS: The increases in adipocyte size and microvascular density were statistically significant (P < 0.012). The expression levels of VEGF were lower in the second set of samples when compared to the first set, but the differences were not statistically significant (P < 0.093). CONCLUSION: These results demonstrate an increase in cellular volume as measured by adipocyte perimeter, diameter, and area. Moreover, the increase in the number of vessels in the second set of samples suggests that neoangiogenesis was stimulated by the initial increase in VEGF expression levels observed in the first set of samples. The increase in VEGF expression in the flap may have been caused by adipocyte hypertrophy resulting from neoangiogenesis.

Prefabricated flap composed by skin and terminal gastromental vessels. Experimental study in rabbits.

BACKGROUND: The angiogenic induction property of the omentum makes it a promising pedicle for prefabricating flaps. Therefore, the objective of this paper is to establish the abdominal area to be prefabricated by the omental pedicle and to analyse the prefabricated potential (PP) according to the time delay between the pedicle introduction and the flap release. METHODS: Forty-four rabbits were divided into four groups (A, B, C and D). In group A, a piece of skin, subcutaneous tissue and abdominal cutaneous muscle was fully released and sutured again in place. In the other groups, a 9-cm2 omental pedicle containing the gastromental vessels distally tied was transposed and sutured to abdominal cutaneous muscle. A second procedure, consisting of incision and release of the flap that contained skin, subcutaneous and cutaneous abdominal muscle pediculated only by the omentum, was carried out. The only variation was the time delay between the two procedures: 7, 21 and 56 days for groups B, C and D, respectively. The flaps were inspected 15 days after the last procedure. The pieces of viable area were immunostained using anti-CD31 for estimation of the microvascular density. RESULTS: The mean and maximum viable areas in group D were 45.29 and 99.37cm2, respectively (average PP=5.03 and maximum PP=11.04). There was no significant difference between the viable areas in groups C and D. The mean microvascular densities of groups B, C and D were 24.54, 33.20 and 27.03 vessels/mm2, respectively. CONCLUSION: The omental tissue has great potential for prefabrication of flaps, and the delay time for the second procedure should be at least 21 days.

Omental infarction in children.

OBJECTIVES: To analyze the clinical presentation, radiologic features, management, and outcome in children diagnosed with omental infarction. STUDY DESIGN: This was a retrospective chart review of patients diagnosed with omental infarction in a tertiary care pediatric emergency department. Images and reports of the radiologic investigations were re-examined by a staff radiologist and analyzed for sensitivity. RESULTS: A diagnosis of omental infarction was made in 19 children (mean age, 9.3 +/- 3.5 years). The presentation was acute right lower quadrant pain in 47% of the children and associated gastrointestinal symptoms in 63%. The sensitivity of abdominal ultrasound (US) to detect omental infarction at our institution was 64%, and the sensitivity of abdominal computed tomography was 90%. Fourteen children were treated conservatively without complications after an accurate diagnosis of omental infarction done by imaging examination. Only 5 children underwent surgery based on clinical suspicion of appendicitis. CONCLUSIONS: Early identification of omental infarction by abdominal US appears to prevent unjustified surgical procedures and reduce the length of hospital stay.

[Development of blood vessels of the greater omentum in the hepatic lobe after vascular ligation. An experimental model in the rats]. / Desenvolvimento de vasos sanguíneos do omento maior no lobo hepático após ligadura vascular. Modelo experimental em ratos.

PURPOSE: To verify the development of blood vessels between the greater omentum and the liver in the presence of distinct liver blood intake blockages. METHODS: Two hundred and eighty conventional male Wistar rats were used, divided into 5 groups: control (n=35), laparotomy (n=35); hepatic artery ligature (n=70), ligature of the right-hand branch of the portal vein (n=70); and ligature of both blood vessels (n=70). The last three groups were divided into two subgroups each (n=35), according to the presence or absence of the transposition of the greater omentum onto the right hepatic lobe. The postoperative periods were 1, 3, 7, 15, 30, 60 and 90 days. At the end of each period, the greater omentum and right hepatic lobe were collected for histopathological examination. The presence of blood vessels between the referred tissues was verified by the administration of Indian ink as a marker of vascular lumen. RESULTS: Macroscopic and microscopic observation and the dye marker demonstrated the distribution of blood vessels between the greater omentum and liver tissues. CONCLUSION: The greater omentum was capable of developing blood vessels when fixed to the parenchyma of the liver after the suppression of hepatic blood flow.

Development of blood vessels of the greater omentum in the hepatic lobe after vascular ligation: an experimental model in the rats

PURPOSE: To verify the development of blood vessels between the greater omentum and the liver in the presence of distinct liver blood intake blockages. METHODS: Two hundred and eighty conventional male Wistar rats were used, divided into 5 groups: control (n=35), laparotomy (n=35); hepatic artery ligature (n=70), ligature of the right-hand branch of the portal vein (n=70); and ligature of both blood vessels (n=70). The last three groups were divided into two subgroups each (n=35), according to the presence or absence of the transposition of the greater omentum onto the right hepatic lobe. The postoperative periods were 1, 3, 7, 15, 30, 60 and 90 days. At the end of each period, the greater omentum and right hepatic lobe were collected for histopathological examination. The presence of blood vessels between the referred tissues was verified by the administration of Indian ink as a marker of vascular lumen. RESULTS: Macroscopic and microscopic observation and the dye marker demonstrated the distribution of blood vessels between the greater omentum and liver tissues. CONCLUSION: The greater omentum was capable of developing blood vessels when fixed to the parenchyma of the liver after the suppression of hepatic blood flow.

OBJETIVO: Verificar o desenvolvimento de vasos sanguíneos entre o omento maior e o fígado em presença de diferentes bloqueios do aporte sanguíneo hepático. MÉTODOS: Foram utilizados 280 ratos machos, Wistar, convencional, divididos em 5 grupos: controle (n = 35), com laparotomia (n = 35), com ligadura da artéria hepática própria (n = 70), com ligadura do ramo direito da veia porta (n = 70) e com ligadura de ambos vasos sanguíneos (n = 70). Os três últimos grupos foram divididos em dois subgrupos (n = 35), de acordo com a transposição ou não do omento maior no lobo direito do fígado. Os períodos de pós-operatório foram de 1, 3, 7, 15, 30, 60 e 90 dias. Em cada período foram coletados o omento maior e o lobo direito do fígado para exame histopatológico. Presença de vasos sanguíneos entre os referidos tecidos foi verificada pela administração da tinta nanquim como marcador de lúmen vascular. RESULTADOS: As observações macroscópicas, microscópicas e do marcador tintorial demonstraram a distribuição dos vasos sanguíneos entre o omento maior transposto e o tecido hepático. CONCLUSÃO: O omento maior foi capaz de desenvolver vasos sanguíneos quando fixado junto ao parênquima do fígado, após supressão do fluxo sanguíneo hepático.

Omental infarction in children: color Doppler sonography correlated with surgery and pathology findings.

OBJECTIVE: The objective of our report is to describe color Doppler sonography findings of omental infarction and correlate them with surgical and pathology findings. Ten children underwent preoperative gray-scale and color Doppler sonographic examinations; omental infarction was confirmed at surgery. CONCLUSION: Color Doppler sonography findings were reviewed and correlated with surgical and pathology findings. Color Doppler sonography features of idiopathic omental infarction differ from those of infarction secondary to omental torsion.