Middle mesenteric artery: contraindication to endovascular repair of an abdominal aortic aneurysm?

Middle mesenteric artery has been described in 1923. We report the observation of a patient with an abdominal aortic aneurysm who had this rare artery arising from the anterior wall of the aneurysmal sac. His inferior mesenteric artery was occluded at its origin from the aorta and the middle and the distal colon was vascularized only by the middle mesenteric artery. Occlusion of this artery would have been necessary before endovascular repair of the aneurysm. We were concerned about the risk of colic ischemia after the occlusion of the middle mesenteric artery, so we abandoned this approach and operated on the patient via a laparotomy. Based on a case report, we here report a literature overview on the repair of abdominal aortic aneurysm in the presence of a middle mesenteric artery.

Stenting of a spontaneous dissection of the superior mesenteric artery: a new therapeutic approach?

Spontaneous dissection of the superior mesenteric artery (SMA) is rare and has been reported only sporadically. Therapeutic options are either a surgical approach, which is the more frequently adopted, or a simple observation. We report a case of spontaneous dissection of the SMA with a review of the literature and present a new therapeutic approach.

Extrahepatic arterioportal fistula: three-dimensional reconstruction of computerized tomodensitometric scan for diagnosis and morphologic assessment.

Arterioportal fistulae (APFs) are rare. An asymptomatic APF was suspected by computed tomography. Multiplanar, maximum intensity projection, and surface shaded display reconstructions showed its anatomy. To our knowledge, this is the first report using such reconstructions to analyze the architecture of an extrahepatic APF. Complete assessment of APF can be achieved noninvasively, and initial endovascular treatment can be planned.

The relationship between multiple mating by queens, within-colony genetic variability and fitness in the ant Lasius niger.

Multiple mating has been suggested to benefit social insect queens because high genetic variation within colonies might decrease the load imposed by sterile diploid males, enhance resistance to parasites and pathogens, and lead to a more effective division of labour and/or a wider range of tolerable environmental conditions. We tested these hypotheses in the ant Lasius niger with three population samples from Switzerland and Sweden. We found no diploid males in young or mature colonies suggesting a lack of diploid male load. Colonies with multiply-mated queens were not larger nor did they produce more sexuals than colonies with singly-mated queens. We did find a significantly lower frequency of multiple mating among newly mated queens than among the queens heading mature colonies in one population sample (Switzerland 1997). However, this result was not repeated in the other study population, or in the following year in the Swiss population.

Surgical treatment of synchronous hepatocellular and esophageal carcinoma: case report and review of literature.

Simultaneous presentation of hepatocellular carcinoma and esophageal carcinoma is rare. Few cases have been reported as surgically curable. We treated a caucasian man of 68 years who presented a voluminous hepatocellular carcinoma in the right lobe of the liver and a superficial squamous cell carcinoma of the middle third of the esophagus. Both tumors seemed curable with surgery. We adopted a treatment consisting of two steps: 1) curative hepatic right trisegmentectomy; 2) three months later transhiatal esophagectomy. Two units of blood were transfused for both operations. Simultaneous hepatectomy and esophagectomy have been published in seven cases. We opted for resecting the tumors in two distinct procedures to lower the operative risk. Because of the large size of the hepatocellular carcinoma and the small size of the esophageal carcinoma, hepatectomy was performed first. The delay between the two interventions did not compromise the prognosis that is actually dependent of the hepatocellular carcinoma.

[Complications of chronic pancreatitis and surgical indications]. / Complications de la pancréatite chronique et indications operatoires.

Chronic pancreatitis may be complicated by the development of pseudocysts or fistulas. Structures surrounding the pancreas such as the bile duct, the duodenum, and peripancreatic vessels may also become altered and cause further complications. Indications and tactics to treat isolated complications are clearly defined in literature. Unfortunately, complications of chronic pancreatitis are rarely isolated and often arise in a context of chronic pain resistant to conservative treatment. Operations aiming at treating these complications in sparing pancreatic tissue should be considered as palliative in the majority of cases. Operations aiming at treating the complications at their origin by resection of the altered pancreas seem to offer definitive treatment to many patients. The treatment of complications of chronic pancreatitis remains controversial.

[Cephalic duodenopancreatectomy with preservation of pancreaticoduodenal arcades in coeliac trunk occlusion]. / Duodénopancréatectomie céphalique respectant les arcades pancréaticoduodénales en cas d'occlusion du tronc coeliaque.

In the case of complete occlusion of the coeliac trunk, the hepatic and splenic arterial blood supply is ensured by the superior mesenteric artery. Interruption of this collateral circulation by pancreaticoduodenectomy carries a risk of hepatic ischaemia and anastomotic leaks. In addition to the various techniques of coeliac trunk revascularization, preservation of the gastroduodenal artery and pancreaticoduodenal arcades may help to preserve the arterial blood supply. The authors report the case of a 58-year-old female with a benign tumour of the pancreatic head and partially corrected coeliac trunk occlusion. Pancreaticoduodenectomy was performed with preservation of the pancreaticoduodenal arcades and gastroduodenal artery.

Initial experience with the harmonic scalpel in liver surgery.

BACKGROUND/AIMS: Hepatectomies are generally performed using a crushing clamp or by finger fracture. New instruments such as ultrasonic aspirators or water jet dissectors are increasingly used for precise dissection of intrahepatic structures. An ultrasonically activated scalpel has been introduced, mainly for laparoscopic procedures. The potential of this instrument in liver surgery remains to be defined. METHODOLOGY: In a prospective study, we have tested the harmonic scalpel (Ultracision, Ethicon Endo-surgery) in 16 consecutive patients undergoing liver surgery. The ease of parenchymal dissection and the hemostatic effect of the ultrasonically vibrating blade was assessed in each operation. Blood loss and transfusions were recorded. RESULTS: One patient underwent excision of a liver cyst and 15 patients 16 hepatectomies for colorectal metastases (7 cases), hepatocarcinoma (5 cases) and other benign or malignant conditions (4 cases). The liver was cirrhotic in 4 cases. The performance of the harmonic scalpel for dissection, cutting and hemostasis was good or excellent in 16 operations, and poor in 1 hepatectomy in a cirrhotic liver. Median blood loss was 400 mL (range: 0-1200 mL) and 4 patients received blood transfusions. CONCLUSIONS: The harmonic scalpel allows efficient section of liver parenchyma, precise dissection of intrahepatic structures, good hemostasis and section of small intrahepatic vessels.

[Risks and consequences of tumor seeding after percutaneous fine needle biopsy four diagnosis of hepatocellular carcinoma]. / Risques et conséquences de l'ensemencement tumoral après biopsie percutanée à l'aiguille fine pour diagnostic d'un carcinome hépatocellulaire.

A review of the literature shows that tumour seeding after fine-needle biopsy of a hepatocellular carcinoma is observed in 0.6 to 5.1% of cases. This complication may be detected between one and 72 months after needle biopsy, and the lapse of time between biopsy and diagnosis of recurrence is influenced neither by the tumour grading nor by the diametre of the needle and number of puncture. In most cases, needle biopsy is not necessary to establish the surgical indication and may compromise the result of surgery; it should therefore be restricted to exceptional cases. Because needle-tract seeding may be the sole tumour recurrence, close follow-up of patients who have undergone pre-operative needle biopsy is important for early detection and possible cure.

Sphincter-sparing surgery after preoperative radiotherapy for low rectal cancers: feasibility, oncologic results and quality of life outcomes.

The present study assesses the choice of surgical procedure, oncologic results and quality of life (QOL) outcomes in a retrospective cohort of 53 patients with low-lying rectal cancers (within 6 cm of the anal verge) treated surgically following preoperative radiotherapy (RT, median dose 45Gy) with or without concomitant 5-fluorouracil. QOL was assessed in 23 patients by using two questionnaires developed by the QOL Study Group of the European Organization for Research and Treatment of Cancer: EORTC QLQ-C30 and EORTC QLQ-CR38. After a median interval of 29 days from completion of RT, abdominoperineal resection (APR) was performed in 29 patients (55%), low anterior resection in 23 patients (20 with coloanal anastomosis) and transrectal excision in one patient. The 3-year actuarial overall survival and locoregional control rates were 71.4% and 77.5% respectively, with no differences observed between patients operated by APR or restorative procedures. For all scales of EORTC QLQ-C30 and EORTC QLQ-CR38, no significant differences in median scores were observed between the two surgical groups. Although patients having had APR tended to report a lower body image score (P = 0.12) and more sexual dysfunction in male patients, all APR patients tended to report better physical function, future perspective and global QOL. In conclusion, sphincter-sparing surgery after preoperative RT seems to be feasible, in routine practice, in a significant proportion of low rectal cancers without compromising the oncologic results. However, prospective studies are mandatory to confirm this finding and to clarify the putative QOL advantages of sphincter-conserving approaches.

Evolutionary transition from single to multiple mating in fungus-growing ants.

Queens of leafcutter ants exhibit the highest known levels of multiple mating (up to 10 mates per queen) among ants. Multiple mating may have been selected to increase genetic diversity among nestmate workers, which is hypothesized to be critical in social systems with large, long-lived colonies under severe pressure of pathogens. Advanced fungus-growing (leafcutter) ants have large numbers (104-106 workers) and long-lived colonies, whereas basal genera in the attine tribe have small (< 200 workers) colonies with probably substantially shorter lifespans. Basal attines are therefore expected to have lower queen mating frequencies, similar to those found in most other ants. We tested this prediction by analysing queen mating frequency and colony kin structure in three basal attine species: Myrmicocrypta ednaella, Apterostigma collare and Cyphomyrmex longiscapus. Microsatellite marker analyses revealed that queens in all three species were single mated, and that worker-to-worker relatedness in these basal attine species is very close to 0.75, the value expected under exclusively single mating. Fungus growing per se has therefore not selected for multiple queen mating. Instead, the advanced and highly productive social structure of the higher attine ants, which is fully dependent on the rearing of an ancient clonal fungus, may have necessitated high genetic diversity among nestmate workers. This is not the case in the lower attines, which rear fungi that were more recently derived from free-living fungal populations.

[Closed injuries of the intrahepatic bile ducts--clinical presentation, diagnosis and treatment]. / Traumatismes fermés des voies biliaires intrahépatiques--présentation clinique, diagnostic et traitement.

Two cases of blunt trauma of the intrahepatic bile ducts are described: one illustrates the difficulty to establish a diagnosis that is often delayed, the other emphasizes the usefulness of the peroperative cholangiography to precise the diagnosis and define the treatment. In the two cases a simple drainage either perihepatic or of the common bile duct resulted in complete healing of the biliary wound. When liver rupture and bleeding complicates a biliary injury, efficient packing allows to reoperate the patient under better conditions the next day. According to the extent and location of the biliary injury, simple drainage, direct suture, bilio-digestive anastomosis and even hepatectomy in rare cases will be indicated.

Risk factors for rebleeding and death from peptic ulcer in the very elderly.

BACKGROUND: Ageing populations are increasing in many countries and bleeding peptic ulcers in patients older than 60 years carry a greater risk of rebleeding and death. This study aimed to identify the risk factors for rebleeding and death in very elderly patients with peptic ulcer bleeding. The efficacy of treatment in preventing recurrent bleeding and death in this group of patients was also studied by means of prospective data collection and analysis. METHODS: Data relating to 1744 patients treated between September 1985 and January 1994 for peptic ulcer bleeding were collected prospectively and analysed. Patients were stratified by age to one of three groups: group 1 (less than 60 years, n = 833), group 2 (60-79 years, n = 706) and group 3 (80 or more years, n = 205). RESULTS: Univariate and multivariate analyses of 21 factors possibly affecting either rebleeding or death identified age greater than 80 years as one of the factors significantly affecting rebleeding and death. In a comparison of groups 1, 2 and 3, the likelihood of rebleeding and death was significantly greater in group 3. Univariate and multivariate analyses for rebleeding and death were performed for each group. The severity of initial bleeding had a marked bearing on subsequent rebleeding rates for all three groups. In group 3, however, large ulcer size and impaired liver function were additional factors which correlated significantly with final outcome. No rebleeding or morbidity occurred when endoscopic treatment was performed early for patients in group 3 but there was a significantly greater risk of further recurrent haemorrhage and treatment-related morbidity when treatment was performed after the onset of rebleeding. CONCLUSION: Patients aged 80 years or greater had the highest risk of rebleeding and death. For patients below 80 years of age, significant factors related to a fatal outcome included co-morbid illness, complications and the need for mechanical ventilation. For patients aged 80 years or older, the significant factors were ulcer size greater than 2 cm and admission with serum bilirubin level above 20 mmol/l. Endoscopic treatment for the very elderly was effective if carried out early.

[Surgical therapy of complicated sigmoid diverticulitis: single stage or multi-stage operation?]. / Chirurgische Therapie der komplizierten Sigmadivertikulitis: einzeitig oder mehrzeitig?

Surgical tactics for the teatment of complicated diverticulitis are in constant evolution and remain a subject of controversy. Amongst 53 patients operated on for complicated sigmoid diverticulits over a 10 year period in our hospital, 29 underwent a Hartmann's procedure (3 Hinchey's stage II, 19 stage III and 7 stage IV). Only 11 out of 20 having survived the operation underwent restoration of bowel continuity (55%). This experience is in line with the literature. Surgeons have become conscious that in reality the colostomy was permanent in a significant proportion of patients who were poor candidates for a second operation. Therefore there is a tendency to perform as far as possible a resection of the sigmoid and a colo-rectal anastomosis in a one-stage procedure. In the absence of prospective randomized studies and objective criteria, the decision to resect the sigmoid in a one-stage or in a multi-stage procedure is based on consensus and clinical judgement.

The arterioportal fistula syndrome: clinicopathologic features, diagnosis, and therapy.

BACKGROUND & AIMS: Arterioportal fistulas (APFs) are rare vascular disorders of the mesenteric circulation. The aim of this study was to determine the etiology, anatomical location, and main symptom at presentation of APFs, and analyze the various modes of treatment. METHODS: The etiology, clinical presentation, radiographs, and treatment of 12 patients with APFs are reported in detail, and another 76 cases published since 1980 are reviewed. RESULTS: APFs result from trauma (n = 25, 28%), iatrogenic procedures (n = 14, 16%), congenital vascular malformations (n = 13, 15%), tumor (n = 13, 15%), aneurysm (n = 12, 14%), and other causes (n = 11, 12%). The origin of APFs is the hepatic artery in the majority of patients (n = 56, 65%). The main symptoms at presentation are lower or upper gastrointestinal bleeding (n = 29, 33%), ascites (n = 23, 26%), heart failure (n = 4.5%), or diarrhea (n = 4.5%). Radiological intervention provides definitive treatment in 42% (n = 33) of patients, whereas the remainder are treated by surgery alone (n = 27, 31%) or a combination of radiological intervention and surgery (n = 8, 9%). CONCLUSIONS: APFs result in a protean syndrome variously combining portal hypertension and other hemodynamic imbalances (heart failure, intestinal ischemia). Single or multiple interventional radiological procedures using arterial and/or venous approaches allow definitive treatment of most APFs. With increasing technological advances, it is anticipated that surgery will only be indicated in rare instances after failure of radiological intervention(s).

Changes in hepatic portal resistance and in liver morphology during regeneration: in vitro study in rats.

OBJECTIVE: To study the effects of liver regeneration on hepatic portal resistance and on the morphology of liver sinusoids. DESIGN: Experimental in vitro study. SETTING: University laboratory, Hong Kong. ANIMALS: 10 Groups of 6 male Sprague Dawley rats each. INTERVENTIONS: Two thirds hepatectomy, with subsequent re-hepatectomy for measurements 0, 1, 3, 7, 21 and 56 days later. Perfusion of isolated livers and histomorphometry. MAIN OUTCOME MEASURES: Hepatic portal resistance and measurement of width and length of sinusoids. RESULTS: Liver weight was restored within 7 days of hepatectomy. Hepatic portal resistance/g of liver increased, reaching a maximum at 3 and 7 days of hepatectomy, and subsequently returned to initial values after 56 days. Width of sinusoids decreased to a minimum within 3 to 7 days of hepatectomy, and subsequently returned close to initial values within 56 days of hepatectomy. The changes in hepatic portal resistance occurred in phase with the changes in the width of liver sinusoids. CONCLUSIONS: There is a transient increase in hepatic portal resistance/g of liver during regeneration; transient narrowing of sinusoids may contribute to this change.

Thoracoscopic vagotomy for recurrent ulcer after previous gastric operation.

BACKGROUND: Recurrent peptic ulcer after previous gastric operation is a difficult surgical problem and abdominal re-operation is associated with significant morbidity, mortality and recurrence rate. METHODS: The authors report on five patients with recurrent ulcers who, after previous gastric operation, were treated with thoracoscopic vagotomy. RESULTS: All patients tolerated the procedure well without complications, and the median hospital stay was 5 days. Endoscopy confirmed healing of the ulcers in all patients. Pre-operative and postoperative gastric acid studies showed a significant postoperative reduction in both basal and maximal acid output (P < 0.05). In a follow-up period of 18-33 months, one patient had a recurrent ulcer presenting with bleeding. Gastric biopsy revealed presence of Helicobacter pylori and repeated gastroscopy after a course of H. pylori eradication treatment showed a healed ulcer. The other four patients were asymptomatic. CONCLUSIONS: We conclude that thoracoscopic vagotomy is a simple and safe procedure for the treatment of recurrent ulcers after previous gastric operation, but the long-term results need further assessment.

Long-term survival after gastrectomy for advanced bleeding or perforated gastric carcinoma.

OBJECTIVE: To find out whether massive bleeding or free perforation of advanced gastric carcinoma affect long term survival after gastrectomy. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Teaching hospital, Hong Kong. INTERVENTIONS: Gastrectomy. MAIN OUTCOME MEASURES: Long term survival. RESULTS: Data of 50 patients with gastric carcinoma that had penetrated the serosa (pT3) and who were operated on between 1985 and 1990 were analysed. A total of 17 patients with tumour free perforation and 10 with massive bleeding underwent emergency gastrectomy, and 23 patients with comparable uncomplicated tumours had elective gastrectomy. Twelve variables that could have influenced survival including malignant perforation, bleeding, or the absence of complications were analysed using the Cox's proportional hazards model. Survival was influenced only by proliferative cell nuclear antigen (PCNA) index and not by perforation, bleeding, or the uncomplicated nature of the tumour. CONCLUSIONS: These findings suggest that perforation or bleeding from advanced gastric carcinomas do not significantly affect long term survival after gastrectomy.