Robot-Assisted Pancreaticoduodenectomy with Hemicircumferential Dissection of Nerve Plexus Around the Superior Mesenteric Artery.

BACKGROUND: Pancreatic head cancer with perineural invasion of the superior mesenteric artery (SMA) requires dissection of the nerve plexus around the SMA (PLsma, superior mesenteric nerve plexus) to obtain cancer-free margins.1,2 Technically challenging robot-assisted pancreaticoduodenectomy with PLsma resection is rarely performed owing to the technical limitations of the robot. In this multimedia article, we present our approach to robot-assisted pancreaticoduodenectomy with PLsma dissection.3-5 METHODS: We performed a robot-assisted pancreaticoduodenectomy with resection of the hemicircle of the PLsma in a 78-year-old woman with resectable pancreatic cancer extending to the root of the inferior pancreaticoduodenal artery. In this video, we show how to obtain an optimal view using the multiple scope transition method,4 and technical tips to perform a PLsma dissection with a robot to perform this difficult surgery safely. RESULTS: The operative time was 568 min and 300 mL of blood was lost. The pathological diagnosis was invasive pancreatic ductal carcinoma with lymph node metastasis, and R0 resection was performed. The distance margin from the SMA was 2 mm. The patient was discharged on the 18th postoperative day without postoperative complications. CONCLUSIONS: Robot-assisted pancreaticoduodenectomy with dissection of the hemicircle of the PLsma, which is difficult to perform, can be performed safely with an optimal view using the multiple-scope transition method, and delicate dissection using a robot.

Periarterial and Sub-adventitial Divestment Along with Triangle Operation and RAMPS for Pancreatic Body Cancer.

BACKGROUND: Locally advanced cancers of the pancreatic body can abut or involve the celiac axis, hepatic artery, or superior mesenteric artery. Recent evidence suggests that these tumors are amenable to surgery after neoadjuvant chemotherapy (Hackert et al., Locally advanced pancreatic cancer: neoadjuvant therapy with FOLFIRINOX results in resectability in 60 % of the patients. Ann Surg 264:457-463, 2016; Rangelova et al., Surgery improves survival after neoadjuvant therapy for borderline and locally advanced pancreatic cancer: a single-institution experience. Ann Surg 273:579-86, 2021). An arterial divestment technique can be used for these cancers to get an R0 clearance, thereby avoiding morbid arterial resections (Miao et al., Arterial divestment instead of resection for locally advanced pancreatic cancer (LAPC). Pancreatology 16:S59, 2016; Habib et al., Periadventitial dissection of the superior mesenteric artery for locally advanced pancreatic cancer: surgical planning with the "halo sign" and "string sign." Surgery 169(5):1026-1031, 2021; Diener et al., Periarterial divestment in pancreatic cancer surgery. Surgery 169(5):1026-31, 2020). Two techniques are described for arterial divestment. In the periarterial divestment technique, the plane of the dissection is between the tumor and the adventitia (Habib et al., Periadventitial dissection of the superior mesenteric artery for locally advanced pancreatic cancer: surgical planning with the "halo sign" and "string sign." Surgery 169(5):1026-1031, 2021; Diener et al., Periarterial divestment in pancreatic cancer surgery. Surgery 169(5):1026-31, 2020). In sub-adventitial dissection, the plane of dissection is between the tunica adventitia and the external elastic lamina (Gao et al., Sub-adventitial divestment technique for resecting artery-involved pancreatic cancer: a retrospective cohort study. Langenbecks Arch Surg 406:691-701, 2021). The TRIANGLE operation also is one of the surgical techniques to achieve R0 resection in locally advanced pancreatic cancer (Hackert et al., The TRIANGLE operation: radical surgery after neoadjuvant treatment for advanced pancreatic cancer: a single-arm observational study. HPB Oxford 19:1001-1007, 2017). This multimedia article aims to demonstrate peri-arterial and sub-adventitial divestment techniques as well as the TRIANGLE operation for a locally advanced cancer of the body of the pancreas. The video also highlights the technique of posterior radical antegrade modular pancreato-splenectomy (RAMPS) together with lymph node clearance. PATIENT AND METHODS: A 57-year-old women was detected to have pancreatic body adenocarcinoma with tumor contact of the artery and superior mesenteric artery. After neoadjuvant chemotherapy, she was planned to undergo surgical resection. RESULTS: The surgical technique consisted of peri-arterial and sub-adventitial divestment, the TRIANGLE operation and RAMPS (Fig. 1). The procedure was performed within 240 min and involved blood loss of 250 mL. After the procedure, pancreatic leak (POPF-B), chyle leak and diarrhea developed, which were managed conservatively. The final histopathology showed residual, viable, moderately differentiated adenocarcinoma (ypT2N1M0) with all resection margins free. CONCLUSION: The surgical technique consisting of peri-arterial and sub-adventitial divestment, the TRIANGLE operation and RAMPS helps in R0 resection of locally advanced pancreatic body cancer without any compromise in oncologic outcomes and offers an alternative surgical approach to morbid arterial resection.

New approach of circumferential lymph node dissection around the superior mesenteric artery for pancreatic cancer during pancreaticoduodenectomy (with video).

PURPOSE: Various approaches have been reported for the resection of the nervous and lymphatic tissues around the superior mesenteric artery (SMA) during pancreaticoduodenectomy (PD) for pancreatic cancer. We developed a new procedure for circumferential lymph node dissection around the SMA to minimize local recurrence. METHODS: We included 24 patients who underwent PD with circumferential lymph node dissection around the SMA (circumferential dissection) and 94 patients who underwent classical mesopancreatic dissection (classical dissection) between 2019 and 2021. The technical details of this new method are described in the figures and videos, and the clinical characteristics and outcomes of this technique were compared with those of classical dissection. RESULTS: The median follow-up durations in the circumferential and classical dissection groups were 39 and 36 months, respectively. The patients' characteristics, including tumor resectability, preoperative and adjuvant chemotherapy rates, postoperative complication rates, and tumor stage, were similar between the two groups. No differences were observed in recurrence-free survival and overall survival between the two groups; however, the classical dissection group tended to have more local recurrences than the circumferential dissection group (8.3% vs. 33.3%, P = 0.168). Although no case of nodular-type recurrence after circumferential dissection was observed, 61.1% of local recurrences after classical dissection were of the nodular-type, and 36.4% were located on the left side of the SMA. CONCLUSIONS: Performing circumferential lymph node dissection around the SMA during PD can be conducted safely with minimal risks of local recurrence and may enhance the completeness of local resection.

Isolated Superior Mesenteric Artery Vasculitis as a Cause of Abdominal Pain.

ABSTRACT: This manuscript demonstrates that although isolated superior mesenteric artery vasculitis that also could be called as localized vasculitis of the gastrointestinal tract was rare entity, it is so significant as differential diagnosis of abdominal pain in addition to idiopathic dissection, infective arteritis, and lymphoma. This case should remind readers to consider isolated superior mesenteric artery vasculitis as a cause of (upper) abdominal pain.

Total laparoscopic radical antegrade modular pancreato-splenectomy with left-posterior superior mesenteric artery first-approach for distal pancreatic cancer: step-by-step technique with a surgical case report (with video).

INTRODUCTION: Left-sided pancreatic cancers are uncommon but seem more aggressive than tumors of pancreatic head. Radical antegrade modular pancreato-splenectomy (RAMPS) was proved to have safe and effective advantages while comparing with standard retrograde pancreato-splenectomy (SRPS) in recent systematic literature reviews and meta-analyses. Laparoscopic SMA first-approach RAMPS was recently proceeded with optimistic perioperative outcomes. CASE PRESENTATION: Our patient is a 67-year-old female with a medical history of diabetes and hypertension, recruited because of upper left quadrant abdominal pain. She was referred for pancreato-splenectomy because of a 3-cm-sized mass in distal pancreas. We use 5 trocars and the patient placed in a Trendelenburg position. The retroperitoneum is opened at the left-posterior side of the meso-pancreato-duodenum along to the inframesocolic space, so that the anterior surface of the aorta (AO), inferior vena cave (IVC), left renal vein (LRV), left adrenal grand (LAG), and kidney are completely exposed. The inferior border of the pancreas had been dissected and separated from the superior mesenteric vein (SMV) below the pancreatic isthmus, removed the lymph nodes (LNs) groups 14v and 17. Then, dissect of LNs groups 7,8,9,11p,12 en bloc at the superior side of the pancreas. Dissection of LNs group 14p, d or SMA LNs after transecting the pancreas. The operation time was 240 min, the estimated blood loss was 200 ml. With no postoperative complications as well as no diarrhea, the patient was discharged on the POD10 uneventfully. Pathological result: pancreatic ductal adenocarcinoma with T2N1 staging and negative margin (R0). CONCLUSIONS: This technique was safe and effective to perform precise and complete lymphadenectomy and negative posterior resection in total laparoscopic left-posterior SMA first-approach RAMPS for distal pancreatic cancer.

CT Radiomic Features of Superior Mesenteric Artery Involvement in Pancreatic Ductal Adenocarcinoma: A Pilot Study.

Background Current imaging methods for prediction of complete margin resection (R0) in patients with pancreatic ductal adenocarcinoma (PDAC) are not reliable. Purpose To investigate whether tumor-related and perivascular CT radiomic features improve preoperative assessment of arterial involvement in patients with surgically proven PDAC. Materials and Methods This retrospective study included consecutive patients with PDAC who underwent surgery after preoperative CT between 2012 and 2019. A three-dimensional segmentation of PDAC and perivascular tissue surrounding the superior mesenteric artery (SMA) was performed on preoperative CT images with radiomic features extracted to characterize morphology, intensity, texture, and task-based spatial information. The reference standard was the pathologic SMA margin status of the surgical sample: SMA involved (tumor cells ≤1 mm from margin) versus SMA not involved (tumor cells >1 mm from margin). The preoperative assessment of SMA involvement by a fellowship-trained radiologist in multidisciplinary consensus was the comparison. High reproducibility (intraclass correlation coefficient, 0.7) and the Kolmogorov-Smirnov test were used to select features included in the logistic regression model. Results A total of 194 patients (median age, 66 years; interquartile range, 60-71 years; age range, 36-85 years; 99 men) were evaluated. Aside from surgery, 148 patients underwent neoadjuvant therapy. A total of 141 patients' samples did not involve SMA, whereas 53 involved SMA. A total of 1695 CT radiomic features were extracted. The model with five features (maximum hugging angle, maximum diameter, logarithm robust mean absolute deviation, minimum distance, square gray level co-occurrence matrix correlation) showed a better performance compared with the radiologist assessment (model vs radiologist area under the curve, 0.71 [95% CI: 0.62, 0.79] vs 0.54 [95% CI: 0.50, 0.59]; P < .001). The model showed a sensitivity of 62% (33 of 53 patients) (95% CI: 51, 77) and a specificity of 77% (108 of 141 patients) (95% CI: 60, 84). Conclusion A model based on tumor-related and perivascular CT radiomic features improved the detection of superior mesenteric artery involvement in patients with pancreatic ductal adenocarcinoma. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Do and Kambadakone in this issue.

The Medial Border of Laparoscopic D3 Lymphadenectomy for Right Colon Cancer: Results from an Exploratory Pilot Study.

BACKGROUND: Opinions vary on the medial border of D3 lymphadenectomy for right colon cancer. Most surgeons place the medial border along the left side of the superior mesenteric vein, but some consider the left side of the superior mesenteric artery as the medial border. OBJECTIVES: This study investigated the clinical outcomes of laparoscopic D3 lymphadenectomy for right colon cancer with the medial border along the left side of superior mesenteric artery. DESIGN: This was a retrospective study. SETTINGS: The study was conducted in specialized colorectal cancer department of 5 tertiary hospitals. PATIENTS: Patients receiving laparoscopic D3 lymphadenectomy for right colon cancer from January 2013 to December 2018 were included. MAIN OUTCOME MEASURES: After propensity score matching, 307 patients receiving laparoscopic D3 lymphadenectomy along the left side of the superior mesenteric artery were assigned to the superior mesenteric artery group and 614 patients were assigned to the superior mesenteric vein group. Univariate, multivariate, and Kaplan-Meier analyses were performed to assess the clinical data. RESULTS: The short-term outcomes were similar between the 2 groups; however, the superior mesenteric artery group had a higher rate of chylous leakage (p < 0.001). More lymph nodes were harvested from the superior mesenteric artery group than from the superior mesenteric vein group (p = 0.001). The number (p = 0.005) of metastatic lymph nodes and the lymph node ratio (p = 0.041) in main nodes were both higher in the superior mesenteric artery group. The 2 groups had similar long-term survival, but the superior mesenteric artery group tended to show better disease-free survival in patients with stage disease III (p = 0.056). LIMITATIONS: This was a retrospective, nonrandomized study. CONCLUSION: Laparoscopic D3 lymphadenectomy along the left side of the superior mesenteric artery, except for a higher rate of chylous leakage, had short-term outcomes comparable to the superior mesenteric vein group. The superior mesenteric artery group tended to achieve better disease-free survival in patients with stage III disease, but further study is required to better elucidate differences in these approaches because risks/benefits do exist.

Natural History of Asymptomatic Superior Mesenteric Arterial Stenosis Depends on Coeliac and Inferior Mesenteric Artery Status.

OBJECTIVE: The benefit of preventive treatment for superior mesenteric artery (SMA) stenosis remains uncertain. The latest European Society for Vascular Surgery (ESVS) guidelines remain unclear given the lack of data in the literature. The aim of this study was to evaluate asymptomatic SMA stenosis prognosis according to the presence of associated coeliac artery (CA) and/or inferior mesenteric artery (IMA) stenosis. METHODS: This was a single academic centre retrospective study. The entire computed tomography (CT) database of a single tertiary hospital was reviewed from 2009 to 2016. Two groups were defined: patients with isolated > 70% SMA stenosis (group A) and patients with both SMA and CA and/or IMA > 70% stenosis (group B). Patient medical histories were reviewed to determine the occurrence of mesenteric disease (MD) defined as development of acute mesenteric ischaemia (AMI) or chronic mesenteric ischaemia (CMI). RESULTS: Seventy-seven patients were included. Median follow up was 39 months. There were 24 patients in group A and 53 patients in group B. In group B, eight (10.4%) patients developed MD with a median onset of 50 months. AMI occurred in five patients with a median of 33 months and CMI in three patients with a median of 88 months. Patients of group B developed more MD (0% vs. 15.1%; p = .052). The five year survival rate was 45% without significant difference between groups. CONCLUSION: Patients with SMA stenosis associated with CA and/or IMA seem to have a higher risk of developing mesenteric ischaemia than patients with isolated SMA stenosis. Considering the low life expectancy of these patients, cardiovascular risk factor assessment and optimisation of medical treatment is essential. Preventive endovascular revascularisation could be discussed for patients with non-isolated > 70% SMA stenosis, taking into account life expectancy.

Reduced Relaxant Response to Adenine in the Superior Mesenteric Artery of Spontaneously Hypertensive Rats.

We investigated the vascular response to nucleobase adenine using freshly isolated superior mesenteric arteries of spontaneously hypertensive rats (SHR) and its control, Wistar Kyoto (WKY) rats. Endothelium-dependent and endothelium-independent relaxations were assessed in isolated segments in an organ bath. The releases of the metabolites of thromboxane A2 and prostaglandin I2 were also detected. Adenine induced vasorelaxation in both the endothelium-intact and endothelium-denuded arteries in a concentration-dependent manner. In the SHR group, the adenine-induced relaxation was slightly but significantly reduced in the endothelium-intact rings when compared with that in the WKY group. However, the relaxation in the endothelium-denuded rings were similar between the two groups. The difference in the adenine-mediated relaxation in the superior mesenteric arteries between the SHR and WKY groups was eliminated by endothelial denudation and a nitric oxide (NO) synthase inhibitor. In the absence and presence of adenine, SHR tended to have higher levels of metabolites of thromboxane A2 and prostaglandin I2 compared with WKY. However, adenine did not induce the release of these substances in the arteries in both the SHR and WKY groups. These results suggest that the reduced adenine-mediated relaxation in the superior mesenteric arteries in SHR is due to a lack of contribution from the endothelium-derived NO and not from the release of prostanoids.

Extraordinary first jejunal arterial variation associated with annular pancreas undergoing pancreaticoduodenectomy for pancreatic cancer: a case report.

PURPOSE: Annular pancreas encountered in adults and jejunal arterial variations are rare. Anatomical variations can cause conflicts between oncology and surgical safety. METHODS: Case report of a 68-year-old man suffering from vomiting because of an annular pancreas and a ductal adenocarcinoma of the pancreas head invading the second portion of the duodenum. RESULTS: Contrast-enhanced computed tomography showed multiple arterial variations describing the absence of the coeliac trunk such that the left gastric artery (LGA), splenic artery and superior mesenteric artery (SMA) were arising separately from the aorta. The accessory left hepatic artery arose from the LGA; and both the common hepatic artery and combined trunk of the replaced right hepatic artery with the higher replaced first jejunal artery separately arose close to the root of the SMA. The patient underwent curative pancreaticoduodenectomy which achieved 3 years of recurrence-free survival. CONCLUSION: This was an extraordinary case of annular pancreas with first jejunal arterial variation detailing an embryological interpretation as well as considerations for balancing short- and long-term outcomes.

The 'TRIANGLE Operation' by Laparoscopy: Radical Pancreaticoduodenectomy with Major Vascular Resection for Borderline Resectable Pancreatic Head Cancer.

BACKGROUND: It has recently been shown that the 'triangle operation'1 may be associated with margin-free resection in selected patients with borderline resectable pancreatic cancer after neoadjuvant chemotherapy. Such a procedure consists of en bloc removal, following the adventitial plane of the whole mesopancreas from the triangular space delimited by the superior mesenteric artery, hepatic artery, and portal vein.2-11 In this video, we show how to safely perform this procedure by laparoscopy. METHODS: A 70-year-old male with persistent back pain and significant loss of weight underwent a computed tomography that showed a 3 cm mass of the uncinate process of the pancreas with involvement of the superior mesenteric artery and venous axis. The biopsy, performed at the time of endoscopic retrograde cholangiopancreatography, showed an adenocarcinoma of the pancreas. Cancer antigen (CA) 19-9 was in the normal range. The patient received eight cycles of neoadjuvant chemotherapy (FOLFIRINOX). The chemotherapy induced a major tumoral radiological response with tumoral shrinkage, however the preoperative computed tomography showed persistent infiltration of the mesopancreas behind the superior mesenteric artery and venous axis. A radical laparoscopic pancreaticoduodenectomy with portal vein resection was performed, including the complete clearing of the superior mesenteric artery and the right side of the celiac trunk, as in the 'triangle operation'. Venous reconstruction was achieved with an end-to-end 5/0 polypropylene running suture with growth factor, while intestinal reconstruction was achieved with an end-to-side hepaticojejunal anastomosis, a double purse-string pancreaticogastrostomy, and side-to-side mechanical linear gastrojejunostomy. The specimen was removed via a short Pfannenstiel incision. RESULTS: Operative time was 7 h and 15 min, and blood loss was 150. Frozen sections of the superior mesenteric artery margins were negative for tumoral cells. On postoperative day 5, the patient had a hematemesis with bleeding from the pancreaticogastrostomy, which was treated endoscopically. Hospital stay was 16 days. Histopathological examination showed a well-differentiated adenocarcinoma of the pancreas [ypT3 N1 (3/36) R0]. CONCLUSION: The 'triangle operation' for borderline resectable pancreatic head cancer can be achieved safely by laparoscopy in carefully selected patients.1-11 Proven experience in both open and laparoscopic pancreatic surgery is mandatory.

Predictive value of the Ki67 index for lymph node metastasis of small non-functioning pancreatic neuroendocrine neoplasms.

BACKGROUND: We evaluated the clinicopathological factors associated with lymph node metastasis in patients with non-functioning pancreatic neuroendocrine neoplasms (PanNENs), focusing on the risk factors and range of lymph node metastasis for tumors ≤ 2 cm in diameter. METHODS: The subjects of this study were patients with PanNENs consecutively diagnosed at our hospital between January, 2000 and June, 2018. We analyzed 69 patients who underwent R0 resection of a non-functioning sporadic PanNEN with no distant metastasis, as well as 43 patients with tumors ≤ 20 mm in radiological diameter. RESULTS: Nineteen patients (27.5%), including 7 (16.3%) with a small PanNEN, had lymph node metastasis. A large radiological diameter, a high Ki67 index, and cyst formation correlated significantly with positive lymph node metastasis. In patients with tumors ≤ 20 mm in diameter, a high Ki67 index correlated significantly with lymph node metastasis. When we set the cut-off Ki67 index as 3.3%, 2 of 43 patients had lymph node metastasis. Tumors in the uncinate process readily metastasized to the region around the superior mesenteric artery. CONCLUSIONS: These findings suggest that a high Ki67 index indicates a risk of lymph node metastasis for tumors ≤ 20 mm in diameter and that lymphadenectomy should be performed in the region spatially adjacent to the primary tumor.

Arterial resection and reconstruction in pancreatectomy: surgical technique and outcomes.

BACKGROUND: The outcomes in patients with pancreatic or ampulla tumors remain unsatisfactory, especially with invasion into the hepatic artery (HA) or the superior mesenteric artery (SMA). In this setting, pancreatectomy combined with arterial resection and reconstruction may offer the possibility of an en-block resection with negative margins and acceptable morbidity and mortality. METHODS: A six year retrospective review of pancreatectomies performed at our institution, included 21 patients that underwent a pancreatectomy combined with arterial resection and reconstruction. Arterial reconstruction was performed under an operating microscope. The types of arterial reconstruction included direct anastomosis, arterial transposition, and arterial bypass with a vascular graft. RESULTS: The surgical procedures consisted of 19 pancreaticoduodenectomies and 2 total pancreatectomies. The tumors were located at the pancreatic head (n = 10), whole pancreas (n = 2), distal common bile duct (n = 5), ampulla (n = 2) and retroperitoneum with pancreatic head involvement (n = 2). All operations achieved R0 resection successfully, with no intraoperative complication. Eighteen patients recovered without complications while three patients died from intra-abdominal hemorrhage due to a pancreatic fistula, though notably the bleeding was not at the arterial anastomosis site. All reconstructed arteries showed adequate patency at follow-up. The median postoperative survival was 11.6 months in all the 11 patients with pancreatic adenocarcinoma. CONCLUSION: Pancreatectomy combined with arterial resection and reconstruction is a feasible treatment option. The microsurgical technique is critically important to achieving a successful and patent arterial anastomosis.

Pathological Margin Clearance and Survival After Pancreaticoduodenectomy in a US and European Pancreatic Center.

BACKGROUND: The optimal definition of a margin-negative resection and its exact prognostic significance on survival in resected pancreatic adenocarcinoma remains unknown. This study was designed to assess the relationship between pathological margin clearance, margin type, and survival. METHODS: Patients who underwent pancreaticoduodenectomy with curative intent at two academic institutions, in Amsterdam, the Netherlands, and Boston, Massachusetts, between 2000 and 2014 were retrospectively evaluated. Overall survival, recurrence rates, and progression-free survival (PFS) were assessed by Kaplan-Meier estimates and multivariate Cox proportional hazards analysis, according to pathological margin clearance and type of margin involved. RESULTS: Of 531 patients identified, the median PFS was 12.9, 15.4, and 24.1 months, and the median overall survival was 17.4, 22.9, and 27.7 months for margin clearances of 0, < 1, and ≥1 mm, respectively (all log-rank p < 0.001). On multivariate analysis, patients with a margin clearance of ≥1 mm demonstrated a survival advantage relative to those with 0 mm clearance [hazard ratio (HR) 0.71, p < 0.01], whereas survival was comparable for patients with a margin clearance of < 1 mm versus 0 mm (HR: 0.93, p = 0.60). Patients with involvement (0 or < 1 mm margin clearance) of the SMV/PV margin demonstrated prolonged median overall survival (25.7 months) relative to those with SMA involvement (17.5 months). CONCLUSIONS: In patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma, a margin clearance of ≥1 mm correlates with improved survival relative to < 1 mm clearance and may be a more accurate predictor of a complete margin-negative resection in pancreatic cancer. The type of margin involved also appears to impact survival.

Homocysteine up-regulates ETB receptors via suppression of autophagy in vascular smooth muscle cells.

The change of autophagy is implicated in cardiovascular diseases (CVDs). Homocysteine (Hcy) up-regulates endothelin type B (ETB) receptors in vascular smooth muscle cells (VSMCs). However, it is unclear whether autophagy is involved in Hcy-induced-up-regulation of ETB receptors in VSMCs. The present study was designed to examine the hypothesis that Hcy up-regulates ETB receptors by inhibiting autophagy in VSMCs. Hcy treated the rat superior mesenteric artery (SMA) without endothelium in the presence and absence of AICAR, rapamycin or MHY1485 for 24 h. The contractile responses to sarafotoxin 6c (S6c) (an ETB receptor agonist) were studied using a sensitive myograph. Levels of protein expression were determined using Western blot analysis. Punctate staining of LC3B was exanimated by immunofluorescence using confocal microscopy. The results showed that Hcy inhibited AMPK, and activated mTOR, followed by impairing autophagy, and increased the levels of ETB receptor protein expression and the ETB receptor-mediated contractile responses to S6c in SMA without endothelium. However, these effects were reversed by AICAR or rapamycin. Additionally, MHY1485 up-regulated the AICAR-inhibited ETB receptor-mediated contractile response and the levels of ETB receptor protein expression in presence of Hcy. In conclusion, this suggested that Hcy up-regulated ETB receptors by inhibiting autophagy in VSMCs via AMPK/mTOR signaling pathway.

Abdominal near-infrared spectroscopy in a piglet model of gastrointestinal hypoxia produced by graded hypoxia or superior mesenteric artery ligation.

BackgroundAbdominal near-infrared spectroscopy (aNIRS) may detect gastrointestinal hypoxia before necrotizing enterocolitis develops. We sought to validate aNIRS during splanchnic hypoxia and hypoperfusion in neonatal piglets.MethodsAnesthetized piglets underwent systemic hypoxia or 3 h superior mesenteric artery (SMA) ligation with aNIRS monitoring.ResultsDuring progressive hypoxia, gastrointestinal tissue oxyhemoglobin saturation measured by aNIRS decreased linearly with oxyhemoglobin saturation measured directly in the portal vein. Correlation coefficients were 0.94-0.99 in each of 10 piglets, the average regression slope of 0.73 (95% confidence interval: 0.57, 0.89) differed from one (P<0.004), and the intercept on the aNIRS axis of 9.5% (4.4, 14.6) differed from zero (P<0.0025). Umbilical venous oxyhemoglobin saturation also correlated strongly with the portal vein oxyhemoglobin saturation (r=0.83-0.99), with a slope not different from one. SMA ligation caused ileal blood flow to decrease by ~50%, and produced a sustained decrease in aNIRS oximetry from approximately 60 to 30%.ConclusionaNIRS can detect abrupt and sustained gastrointestinal hypoperfusion associated with arterial occlusion in a neonatal model. The highly linear relationship of portal venous oxyhemoglobin saturation with aNIRS and umbilical vein saturation during graded hypoxia implies that these measures can accurately track tissue oxygenation trends over a wide range in individual subjects.

Comparison of Mesenteric Lengthening Techniques in IPAA: An Anatomic and Angiographic Study on Fresh Cadavers.

BACKGROUND: The IPAA technique restores anal functionality in patients who have had the large intestine and rectum removed; however, 1 of the most important reasons for pouch failure is tension on the anastomosis. OBJECTIVE: The aim of this study was to compare technical procedures for mesenteric lengthening used for IPAA to reduce this tension. DESIGN: After randomization, 4 different techniques for mesenteric lengthening were performed and compared on fresh cadavers. SETTING: This was a cross-sectional cadaveric study. MAIN OUTCOME MEASURES: In the first group (n = 5), stepladder incisions were made on the visceral peritoneum of the mesentery of the small intestine. In the second and third groups, the superior mesenteric pedicle was divided, whereas the ileocolic pedicle (n = 7) or marginal vessels (n = 6) were preserved during proctocolectomy. In the fourth group (n = 7), the superior mesenteric pedicle was cut without preserving any colic vessels. Mesenteric lengthening was analyzed. Angiography was performed to visualize the blood supply of the terminal ileum and pouch after mesenteric lengthening. RESULTS: Average mesenteric lengthening was 5.72 cm (± 1.68 cm) in group 1, 3.63 cm (± 1.75 cm) in group 2, 7.03 cm (± 3.47 cm) in group 3, and 7.29 cm (± 1.73 cm) in group 4 (p = 0.011 for group 2 when compared with the others). LIMITATIONS: The study was limited by nature of being a cadaver study. CONCLUSIONS: Stepladder incisions through superior mesenteric pedicle trace are usually sufficient for mesenteric lengthening. In addition, division of the superior mesenteric pedicle with either a preserving marginal artery or without preserving ileocolic and marginal arteries leads to additional mesenteric lengthening.

Outcomes of Spontaneous Isolated Superior Mesenteric Artery Dissection Without Antithrombotic Use.

OBJECTIVES: This study aimed to show the intention to treat results of treatment for spontaneous isolated superior mesenteric artery dissection (SISMAD) without anticoagulation or antiplatelet agents and the follow-up results of SISMAD according to the configuration on computed tomography (CT) scans. DESIGN: Retrospective, observational single centre study METHODS: All cases of SISMAD were enrolled consecutively from 2006 onwards. There were 25 symptomatic and four asymptomatic patients in whom SISMAD was found incidentally. The SISMAD patients were treated using a consistent therapeutic strategy without antithrombotics. SISMAD was categorized into four types based on the configuration on CT scans by Yun's classification. Follow-up CT was performed at 3 months, 6 months, and yearly thereafter. RESULTS: The median follow-up duration was 57 months (13-129 months). Improvement or complete resolution on CT scans, with no symptom recurrence, was seen in 27 patients. The non-invasive approach failed in three cases and two patients underwent further intervention. No patient died during the follow-up. CONCLUSIONS: Weighing the risks versus benefits of antithrombotics and considering the benign nature of SISMAD, conservative treatment without antithrombotics might be sufficient in patients without evidence of bowel ischaemia or infarction on initial CT scan.

Laparoscopic Resection of a Middle Colic Artery Aneurysm.

We report herein the successful laparoscopic resection of an asymptomatic 3-cm middle colic artery aneurysm in a young woman. Endovascular treatment represents nowadays the first-line option facing visceral artery aneurysm, but in this case, embolization was excluded because of hostile anatomy. Advantages of laparoscopic approach were the safe resection of the aneurysm with immediate evaluation of the bowel tolerance and the possibility of a histological examination of the arterial wall, without the disadvantages of laparotomy.