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A quantitative model of stasis-type of venous thrombosis in rats is described. The ligated bowel loop was used after provocation by an injection of kaolin. The mesenteric vessels of the loop were cut in a dish filled with distilled water and the extinction of escaped haemoglobin was measured photometrically. Heparin was highly effective in this model. Vessel wall lesion may be used or inducing thrombosis instead of kaolin.
Antithrombotic effects of different agents including acetylsalicylic acid (Asprocol/Polfa PL/), pentoxifylline (Agapurin/Spofa CS/) and low molecular weight heparin (Antixarin B. Braun, Melsungen, FRG) were studied in the laser-induced rat thrombosis model. The investigations were carried out on male Wistar rats weighing 200-300 g. Thrombus formation was induced in small mesenteric arteries 25-30 microns; using argon laser. An interference contrast system based on a Leitz Orthoplan microscope for the evaluation of thrombus formation was used. The number of laser injuries needed to induce a defined thrombus proved to be a useful way to quantitate the results in this thrombosis mode. All agents showed dose dependent antithrombotic effect in our laser model. Acetylsalicylic acid (ASA) 2 hours after oral administration markedly inhibited thrombus formation in minimal dose 50 mg/kg, pentoxifylline in dose 10 mg/kg 30 min after i.v. injection and low molecular weight heparin (Antixarin) in dose 0.1 mg/kg, 2 hours, after s.c. injection. Antithrombotic effect of administration of minimal effective doses of ASA (orally) and pentoxifylline (i.v.) lasted longer than 4 hours but less then 6 hours. LMW heparin (Antixarin) in minimal effective dose 0.1 mg/kg after s.c. injection inhibited thrombus formation in small mesenteric vessels for more than 12 hours but less than 24 hours.
Intestinal localization of rhabdomyosarcoma is exceptional, this case is the first to be published in the world literature. A 35-year-old patient with abdominal pain, fever, was found to have an infiltrative white-grey tumour, involving 20 cm the jejunoileal wall and also the surrounding mesenterium up to the origin of upper mesenterical vessels and lymph nodes. Histologic examination showed an alveolar type of rhabdomyosarcoma intricated with solid undifferentiated tumoral cells. The presence of multinucleated giant cells and the positivity of protein S 100 reaction was important for differential diagnosis, given the alveolar soft part sarcoma, malignant mesothelioma, malignant melanoma or papillary carcinoma.
An alternative approach to the dissection of the uncinate process during pancreatoduodenectomy is described. This involves mobilisation of the midgut superiorly and bringing the uncinate process into an antero-inferior position within the operative field. Access to, and visualisation of, the posterior aspect of the superior mesenteric vessels is considerably improved. This approach may avoid many of the potential problems associated with freeing of the uncinate process during pancreatic resection.
OBJECTIVE: To explore the clinical value of laparoscopy and laparoscopic ultrasonography (LUS) in judging the resectability of pancreatic head cancer. METHODS: LUS was employed as a prospective diagnosis of tumor staging before exploratory laparotomy in 22 patients diagnosed with pancreatic head cancer to identify whether the liver and peritoneum had small metastases or local invasion to the portal vein, superior mesenteric vessel, aorta, inferior vena cava. RESULTS: In the 22 patients receiving laparoscopy and LUS, we found peritoneal or surface liver metastases (3 patients), hepatic parenchyma metastases (1), and pancreatitis proved by biopsy under ultrasound guidance (1). Laparotomy was avoided in these 5 patients. Of the remaining 17 patients, 8 patients, including 2 patients with portal vein emboli due to tumor metastases had hypertrophic lymph nodes or tumor invasion of local vessels in the peritoneal cavity, retroperitoneum, and omentum and the other 9 patients had resectable tumors shown by LUS. The 17 patients were subjected to exploratory laparotomy, and pancreaticoduodenectomy was successful in 8 patients. CONCLUSIONS: Laparoscopy and LUS can be used to precisely estimate the possibility of resection of pancreatic head cancer, and prevent unnecessary exploratory laparotomy and its complications. It can be used as a routine examination before exploratory laparotomy.
Early diagnosis of pancreatic trauma has always been challenging because of the lack of correlation between the initial clinical symptomatology, radiologic and laboratory findings, and the severity of the injury. Thanks to the improved performance of spiral CT scanning and magnetic resonance pancreatography, it is now often possible to make an early diagnosis of pancreatic contusion, to localize the site of the injury, and (most importantly) to identify injury to the main pancreatic duct which has major implications for the management of the case. When the trauma victim is unstable, radiologic work-up may be impossible and urgent laparotomy is required. Control of hemorrhage is the primary concern here and a damage control approach with packing may be appropriate; if the pancreatic head has been destroyed, a pancreaticoduodenectomy with delayed reconstruction may be required. If the trauma victim is stable, the treatment strategy will be governed by a variety of parameters--age, clinical condition, associated local anatomic findings (pancreatitis, injury to the duodenum or biliary tract), involvement of the pancreatic duct, and localization of the injury within the gland (to right or left of the mesenteric vessels).
The authors describe an experimental laparoscopic sigmoid colon resection performed in the porcine model. The operation begins with the introduction of the laparoscope via an umbilical trocar. Five other trocars are then placed allowing different maneuvers. The sigmoid colon is grasped in order to gain access to its mesenteric vessels which are clipped and divided, carrying out the dissection of the entire sigmoid colon. Two modified Endo-GIA are then fired both cranially and caudally, in order to obtain a closed sigmoid specimen and to maintain patent the lumen of the descending colon and rectum. The sigmoid is removed transanally. A P-CEEA stapler is introduced via the rectum and its detached anvil is put into the lumen of the descending colon. A purse-string is applied and closed around the anvil rod. The P-CEEA is retracted, and the rectal stump closed with another Endo-GIA. After reintroducing the trocar-loaded stapler, the trocar is advanced through the suture line of the rectum and removed via a port. The stapler is then reassembled, fired and extracted through the anus. Taking into account the oncologic criteria, we think that this mini-invasive technique could be applied, after an adequate training period on the animal model, to humans also.
Late clinical outbreak in patients with right colon cancer translates into very advanced stage of the tumour. Nevertheless, long term results of radical surgery are favourable, even if susceptible of improvements. While earlier diagnoses are not easy to achieve, a greater surgical radicality can be obtained both by extending resections to the surrounding structures and organs, and by enlarging lymphadenectomy to all the inframesocolic compartment and to the main lymph nodes located at the level of superior mesenteric vessels. A series of 60 right hemicolectomies performed from 1968 to 1990 to treat right colonic cancer is presented. Intraoperative mortality was of 4 cases (6.6%). Lymph node "mapping" was drawn, and in 26 cases (43%) metastases were found. Paracolic nodes were involved in 96% of cases, intermediate in 42%, and principal ones in 34%. Forty four patients, surgically treated up to 1985 and eligible for a 5 year follow up, were all verified. Overall free of disease survival was assessed in 28 cases (63.6%). Survival in relation to Dukes staging was 81.8% (9/11) in C. According to presence (LN+) or absence (LN-) of lymphatic spread, 5 year survival was found to be 70.3% (19/27) in LN-, and 52.9 (9/17) in LN+. Difference between the two groups is 17.4%, much smaller than the mean one of 45% reported by world literature. This figure, together with the finding of a 12, 10 and 5 year survival in patients with principal nodes involvement, suggests that extended lymphadenectomy might play a principal role in improving long term survival rates of advanced right colon cancer.
OBJECTIVE: To investigate the factors related to curable resection of pancreatic cancer and to obtain better efficacy. METHODS: A uniform questionnaire survey on the clinical epidemiology of pancreatic cancer was conducted by the Society of Pancreatic Cancer, Chinese Anti-cancer Association from January 1, 1990 to December 31, 2000 on a total of 2340 the patients with pancreatic cancer confirmed clinically or pathologically in 14 hospitals in China. Survival analysis was conducted for selected patients with complete data. Cox regression was used to screen out single and multiple risk factors. Cumulative survival rate was calculated by life table and Gehan score test. RESULTS: Cox single factor analysis showed that the significant variables at alpha = 0.05 level included age, occupation, duration of disease, location of neoplasm, operation type, postoperative pancreatic fistula, postoperative hepatic failure, chemotherapy, TNM stage, immunotherapy, liver metastasis, and invasion of the superior mesenteric vessel. Cox multifactor analysis revealed that the significant variables at alpha = 0.05 level included age, surgical procedures, postoperative pancreatic fistula, postoperative hepatic failure, chemotherapy, and immunotherapy. These were independent factors for the prognosis of patients with pancreatic carcinoma. Among these factors, age less than 70 years, radical operation, chemotherapy and immunotherapy were all protective factors. 92.9% of the patients were aged more than 40 years, and only 7.09% were less than 40 years. The median survival time of patients after radical resection of carcinoma of the pancreatic head was 17.11 months and the 1-year survival rate was 54.36%. The 3 and 5-year survival rates were 13.47% and 8.47%. CONCLUSION: For early diagnosis, an effective way to screen population older than 40 years is really an effective way to detect patients early and promptly. And comprehensive therapy is conducive to better quality of life and longer survival time.
Endoscopic examination of the stomach and duodenum with microscopic examination of biopsy material was performed in 66 patients with lower limbs chronic ischemia before reconstructive surgeries on aorto-ilio-femoral segment. High incidence (30.3%) of erosive-ulcerous diseases of the stomach and duodenum was revealed, 12% of the patients had undergone surgeries on the stomach and duodenum due to peptic ulcer. Hemodynamic studies of mesenteric vessels showed some increase of their diameter, slight increase of blood velocity, decrease of pulsation indices and circulatory resistance which may be regarded as the phenomenon of blood shunting and reduced blood flow in terminal branches of visceral vessels. Erosive-ulcerous diseases of the stomach and duodenum are more severe in patients with lower limbs critical ischemia.
Total mesorectal excision (TME) is a precise dissection of the rectum and all pararectal lymph nodes within an oncologic package: the mesorectal envelope. This article is a brief description of the technical aspects of the dissection, illustrated by cadaver dissection. Here the TME dissection is organized into 6 steps to facilitate learning: (1) left retroperitoneum; (2) superior rectal and inferior mesenteric vessels; (3) upper mesorectum; (4/5) right and left mid-mesorectum; and (6) distal mesorectum and anorectal junction. The relationship of the autonomic nerves, blood vessels and adjacent organ structures are described at each step. The 6 steps are recommended for learning and performing TME dissection in cadavers and patients.
BACKGROUND: The aim of this study was to investigate the involvement of angiotensin II and oxidative stress on cardiovascular damage induced by chronic subcutaneous aldosterone infusion in the absence of salt loading. METHODS: Sprague-Dawley rats were infused with d-aldosterone (0.75 microg/h subcutaneously) for 6 weeks. Blood pressure was measured with the tail-cuff method. Small arteries were investigated on a pressurized myograph. Cardiovascular and renal collagen was evaluated by Sirius red staining. Systemic oxidant excess was measured with plasma 8-isoprostane by ELISA and by measurement of thiobarbituric acid-reactive substances. Vascular reactive oxygen species were studied using hydroethidine and NADPH-generated superoxide anion measured by lucigenin chemiluminescence. RESULTS: After 6 weeks of treatment, systolic blood pressure was significantly increased in aldosterone-infused rats (170+/-8 v 123+/-2 mm Hg in controls, P < .05). Progression of hypertension was partially prevented by co-administration of losartan (AT1 receptor blocker) or tempol (superoxide dismutase mimetic): 140+/-4 and 149+/-6 mm Hg, respectively, P < .05 versus the aldosterone group. Aldosterone induced renal but not cardiac hypertrophy, which was not prevented by losartan or by tempol. Moreover, losartan and tempol failed to prevent vascular hypertrophy of resistance mesenteric vessels. However, losartan (0.77%+/-0.05%) and tempol (0.65%+/-0.10%) prevented cardiac fibrosis in the midmyocardium in the aldosterone group (1.03%+/-0.12% v 0.68%+/-0.07% positive staining per area in control, P < .05). In the kidney, collagen accumulation of aldosterone-infused rats was also significantly decreased by losartan (-77%) and tempol (-60%). Similar effects were obtained on aortic fibrosis. Aldosterone increased serum 8-isoprostane levels.This increase was blunted by losartan and tempol. Losartan and tempol totally prevented vascular, cardiac, and renal increase of NADPH-induced superoxide production stimulated by aldosterone. CONCLUSIONS: Our data suggest that the profibrotic but not the hypertrophic action of aldosterone are mediated at least in part by reactive oxygen species generation and involve an interaction with the renin-angiotensin system.
BACKGROUND AND OBJECTIVES: Laparoscopic-assisted colectomy for colon and rectal cancer causes less surgical trauma than does open colectomy. However, current methods are more costly and require highly skilled staff. In addition, the technique for lymphadenectomy has yet to be standardized. We developed a technique that uses a nylon suture to elevate the colon. This method reduces costs without compromising the completeness of the resection. METHODS: Three trocars are introduced and a 1-0 nylon suture is passed into the abdominal cavity and through the mesocolon. The colon is retracted anteriorly and is fixed by this suture to the abdominal wall. The main mesenteric vessels are under tension, and lymph node dissection is performed easily. This method requires only 2 surgeons, an operator, and a scopist, because the colon is fixed to the abdominal wall. In addition, the working space is more stable because the colon is fixed to the abdominal wall. The procedure is relatively independent of the skill of the first assistant. RESULTS: From April 2000 to August 2002, this method was performed in 52 patients. The mean number of dissected lymph nodes was 16.9+/-9.0 (range, 6 to 41). Nine patients had lymph node metastases (17.3%). One patient developed hepatic recurrence; all patients are alive. No complication occurred that was related to lifting the colon. CONCLUSIONS: Using a suture to lift the colon is a useful method for performing laparoscopic-assisted colectomy with lymphadenectomy. This method reduces the number of surgical staff and the expense of the procedure.
Blunt abdominal trauma with intraperitoneal injury commonly presents with shock or acute abdomen. It infrequently presents later as bowel obstruction. Injury to mesenteric vessels or subclinical perforation are possible pathophysiologic mechanisms. Few and mainly anecdotal cases appear in the medical literature. One patient with this pathology is described herein.
BACKGROUND: Acute transient ischaemic colitis gives abdominal pain and blood per rectum; the symptoms disappear in the course of a few days. The diagnosis is made by clinical signs and symptoms, endoscopy and histology. MATERIAL AND METHODS: During the last tree years this diagnosis has been made in 12 patients in our department. In an attempt at evaluating the extent to which transabdominal ultrasonography could give diagnostic information, the patients were examined in the acute state and at control a few days later; then the data were compared. RESULTS: At admission the bowel wall echotexture was non-stratified; proximal to the ischaemic damage was fluid or air within the bowel lumen in all patients. During the observation period the thickness of the bowel wall was reduced from 9.0 +/- 1.7 to 4.2 +/- 0.7 mm (p < 0.0005). At the same time, mural resistive index was reduced from 0.72 +/- 0.08 to 0.62 +/- 0.09 (p = 0.010), while systolic acceleration time was reduced from 0.144 +/- 0.054 to 0.070 +/- 0.023 ms (p = 0.001), the same value as was found in the great mesenteric vessels (p = 0.969). INTERPRETATION: In acute transient ischaemic colitis, transabdominal ultrasonography may reveal pathological haemodynamic conditions and bowel wall thickness, both of which normalise within a few days.
BACKGROUND/AIMS: Up to 40% of the patients with pancreatic carcinoma are not fit for curative resection due to the locally advanced nature of the disease in the form of vascular involvement. In recent years a more aggressive approach of vascular resection with pancreaticoduodenectomy (PD) has resulted in the increase in resectability rate and survival in this group of patients. The most important determinant of survival in these patients is negative resection margins. The aim of the present study is to present our experience of vascular resection using a modified technique, in patients with pancreatic cancer. METHODOLOGY: This is a retrospective study of 48 patients who underwent portal vein/superior mesenteric vein (PV/SMV) resection along with PD using the modified technique of resection, during 1982-2004. The principle modification is the initial extensive retroperitoneal dissection for the assessment of the extent of tumor involvement of the superior mesenteric vessels and division of retroperitoneal margin before the division of the pancreas. All patients also underwent extended lymphadenectomy. RESULTS: The subtotal PD was done in 26 and total PD in 22 patients, with resection of the PV/SMV in all of them. The end-to-end anastomosis was possible after adequate mobilization of the PV and SMV in 40 patients. In 4 patients reconstruction was able to be done with the use of a graft. The portal vein occlusion time was 8-15 minutes. Histopathological examination showed negative margins in all the resected specimens. Postoperative complications occurred in 16.66% with reoperation rate of 8.33%, and mortality of 6.25%. After a mean follow-up of 110 months, mean survival was 40 months with the range of 18-250 months. The five-year and 10-year survival was 18% and 10% respectively. The venous patency rate was 100% at three years. CONCLUSIONS: In conclusion, PD with en bloc resection of the PV/SMV confluence can safely be done with morbidity and mortality similar to that of standard PD. The survival advantage is directly related to the attainment of negative resection margins. The modified technique is a useful way of doing vascular resection with the least amount of bowel congestion and securing negative resection margins.
A total of 119 Japanese patients with pancreas head carcinoma were treated in the Department of Surgery I, Kyushu University Faculty of Medicine, Fukuoka, Japan, from January 1976 to December 1991. Three of the 119 patients had carcinoma in the uncinate process, with a 2.5% incidence of pancreas head carcinoma. Those three cases consisted of two men, one 55 and one 72 yr old, and one 62-yr-old woman. Two patients developed abdominal pain, whereas another was vomiting; no patients were icteric. Hypotonic duodenography showed an irregular mucosa of the inner area of the third portion of the duodenum in two and an obstruction of the duodenum in one. Drip infusion cholangiography and/or endoscopic retrograde cholangiopancreatography revealed no abnormality of the biliary tract or pancreatic ducts in any of the three. Ultrasonography showed a hypoechoic mass in the uncinate process in three, and computed tomography showed a low-density mass in the uncinate process in two with a displacement of the superior mesenteric vessels toward the anterior. Angiography showed encasement of the pancreatoduodenal arcade in three, the dorsal pancreatic artery in two, and the middle colic artery in two. No neovascularity or tumor staining was present. Two patients underwent a pancreatoduodenectomy, and the other had a bypass operation (gastrojejunostomy). The histopathologic diagnosis was well-differentiated adenocarcinoma, mucinous carcinoma, and adenosquamous carcinoma, respectively. Two patients died from local recurrence and/or distant metastasis 5 and 6 months after a radical resection, and the other died 3 months after clinical diagnosis. Peculiar clinicopathologic features of these patients with pancreas carcinoma arising in the uncinate process are reported herein, and the clinical problems of this disorder are briefly discussed.
The paper reports on the clinical observation of a patient with mechanical jaundice in which the biliary obstruction was caused by an ampulla of Vater. Cephalic duodenopancreatectomy with preservation of the pylorus was used. Distally the duodenum was excised to its intersection with the mesenteric vessels. For recovery of the digestive circuits, a loop excluded "en Y" à la Roux ascending transmesocolically was used. The anastomoses had the following stages: choledochojejunostomy (T-T) the most proximal; pancreatic-jejunal anastomosis (T-L); and the most distal, the duodeno-jejunal one (T-L). After surgery, the evolution was good, and the patient left the hospital with the wound cured. Starting from this observation, the authors discuss aspects connected with the technique of cephalic duodenopancreatectomy with or without preservation of the pylorus.