Tromboembolismo de la arteria mesentérica inferior con necrosis del territorio de la arteria rectal superior / Thromboembolism of the inferior mesenteric artery with necrosis of the territory of the superior rectal artery

RESUMEN Fundamento: la elevada mortalidad de la isquemia intestinal obliga a llevar a cabo un esfuerzo de coordinación a todos los niveles al actuar con celeridad. Las isquemias segmentarias son menos comunes y lo son, aún más, las del territorio de la arteria mesentérica inferior. Objetivo: exponer un caso poco frecuente de isquemia de la unión rectosigmoidea, provocado por un embolismo de la arteria mesentérica inferior y subsiguiente necrosis del territorio de la rectal superior. Presentación de caso: paciente femenina 76 años de edad ingresada desde hacía 31 días con diagnóstico de enfermedad cerebrovascular tipo infarto cerebral, que el día que se decide su egreso presenta un cuadro sincopal, presentando luego; dolor, distensión y contractura abdominal en cuadrante inferior izquierdo por lo que es intervenida quirúrgicamente, se encontró una necrosis del recto superior y sigmoides bajo (unión rectosigmoidea). Conclusiones: el embolismo de la arteria mesentérica inferior con necrosis segmentaria es una presentación muy rara de esta afección, en la literatura los casos reportados son escasos, esto se debe a las consideraciones anatómicas de las arterias y venas mesentéricas, cuando ocurre la oclusión de las arteria mesentérica inferior suele ser lenta y progresiva con revascularización o si es de forma abrupta la arteria mesentérica superior suple las necesidades de este territorio mediante la arteria de Drummont, lo cual ocurrió en esta paciente pero no con su arteria terminal (punto crítico de Sudeck) necrosándose el rectosigmoides.

ABSTRACT Background: the high mortality of intestinal ischemia requires an effort of coordination at all levels, requiring prompt action. Segmental ischemias are less common and, more so, those of the territory of the inferior mesenteric artery. Objective: to present a rare case of ischemia of the rectosigmoid junction, caused by an embolism of the inferior mesenteric artery and subsequent necrosis of the upper rectal territory. Case presentation: 76-year-old female patient admitted for 31 days with a diagnosis of cerebral infarction-type cerebrovascular disease, which on the day her discharge is decided presents a syncopal picture, presenting later; pain, abdominal distension and contracture in the lower left quadrant, so she undergoes a surgery finding a necrosis of the upper rectum and low sigmoid (recto-sigmoid union). Conclusions: the embolism of the inferior mesenteric artery with segmental necrosis is a very rare presentation of this affection, in the literature the cases reported are scarce, this is due to the anatomical considerations of the mesenteric arteries and veins, when occlusion of the inferior mesenteric artery occurs is usually slow and progressive with revascularization or if abruptly the superior mesenteric artery supplies the needs of this territory through the Drummont artery, which occurred in this patient but not with her terminal artery (Sudeck's critical point) recto-sigmoid necrosis.

The angiographic anatomy of the inferior mesenteric artery in elder / 中华外科杂志

To examine the characteristics of the digital subtraction angiography of inferior mesenteric artery (IMA) in elderly Chinese patients over 65 years old. Totally 64 cases who underwent angiography of IMA were selected from the Department of General Surgery, Xuanwu Hospital of Capital Medical University, including 42 males and 22 females, aging (70.9±5.1) years (range: 60 to 88 years). The origin, diameter and trunk length of IMA were analyzed. The distribution of IMA branching and the relationship between LCA and IMV at the level of IMA opening position were revealed. Also, the range of IMA perfusion, Riolan arch and IMA occlusion were observed. All 64 patients underwent IMA angiography successfully. The diameter of IMA was (3.2±0.5) mm (range: 2.6 to 4.4 mm), and the trunk length was (3.8±1.0) cm (range: 1.1 to 7.0 mm). According to IMA classification standard, there were 26 patients with type Ⅰ (40.6%), 24 patients with type Ⅱ (37.5%), 12 patients with type Ⅲ (18.8%), 2 patients with type Ⅳ(3.1%). The horizontal distance between IMV and LCA was less than 0.5 cm in 58 cases (90.6%) and more than 0.5 cm in 6 cases (9.4%). IMA perfusion was interrupted at the splenic flexure in elderly patients in 14 cases (21.9%), including 11 cases terminated at splenic flexure and 3 cases terminated at descending colon. Riolan arch was found in only 4 of 64 patients (6.2%). Two patients (3.1%) had IMA or its branch occlusion, the arterial perfusion were compensated by Drummond arch without Riolan arch. The anatomy of IMA should be taken attention seriously in laparoscopic left-colorectal cancer radical resection. IMA shape, type, blood supply range and the relationship between LCA and IMV could be considered by the angiography or other examination, which can help to determine the ligation position of blood vessels, which could optimize the operation strategy.

The angiographic anatomy of the inferior mesenteric artery in elder / 中华外科杂志

Objective@#To examine the characteristics of the digital subtraction angiography of inferior mesenteric artery (IMA) in elderly Chinese patients over 65 years old.@*Methods@#Totally 64 cases who underwent angiography of IMA were selected from the Department of General Surgery, Xuanwu Hospital of Capital Medical University, including 42 males and 22 females, aging (70.9±5.1) years (range: 60 to 88 years). The origin, diameter and trunk length of IMA were analyzed. The distribution of IMA branching and the relationship between LCA and IMV at the level of IMA opening position were revealed. Also, the range of IMA perfusion, Riolan arch and IMA occlusion were observed.@*Results@#All 64 patients underwent IMA angiography successfully. The diameter of IMA was (3.2±0.5) mm (range: 2.6 to 4.4 mm), and the trunk length was (3.8±1.0) cm (range: 1.1 to 7.0 mm). According to IMA classification standard, there were 26 patients with type Ⅰ (40.6%), 24 patients with type Ⅱ (37.5%), 12 patients with type Ⅲ (18.8%), 2 patients with type Ⅳ(3.1%). The horizontal distance between IMV and LCA was less than 0.5 cm in 58 cases (90.6%) and more than 0.5 cm in 6 cases (9.4%). IMA perfusion was interrupted at the splenic flexure in elderly patients in 14 cases (21.9%), including 11 cases terminated at splenic flexure and 3 cases terminated at descending colon. Riolan arch was found in only 4 of 64 patients (6.2%). Two patients (3.1%) had IMA or its branch occlusion, the arterial perfusion were compensated by Drummond arch without Riolan arch.@*Conclusions@#The anatomy of IMA should be taken attention seriously in laparoscopic left-colorectal cancer radical resection. IMA shape, type, blood supply range and the relationship between LCA and IMV could be considered by the angiography or other examination, which can help to determine the ligation position of blood vessels, which could optimize the operation strategy.

High ligation versus low ligation of the inferior mesenteric artery and lymph node dissection in laparoscopic rectal cancer surgery / 中华普通外科杂志

Objective To evaluate the surgical complications and root vascular lymph node dissection by high versus low ligation the inferior mesenteric artery (IMA) retaining left colonic artery (LCA) in laparoscopic radical resection of rectal cancer.Methods Clinical data of 357 cases of rectal cancer in our center from Jan 2015 to Dec 2016,were retrospectively analyzed,including 247 cases in high ligation group,110 cases of low ligation group.Results There was no statistically significant difference in operative time and intraoperative blood loss between the two groups [(105 ± 10)min vs.(113 ±9)min,t =0.138,P =0.092;(96 ± 21) ml vs.(99 ± 23) ml,t =0.171,P =0.118].Nor that in the incidence of anastomotic leakage between the two groups (7.3％ vs.4.5％,x2 =0.949,P =0.330).The incidence of low anterior resection syndrome in the two groups was statistically significant (21％ vs.12％,x2 =4.358,P =0.037).There was no significant difference in the total number of lymph nodes dissected between the two groups ([(14.5±4.3) vs.(13.6±3.5),t=1.851,P=0.065].Conclusion Low ligation of IMA with preservation of LCA in laparoscopic radical operation for rectal cancer provides better blood supply for proximal colon,while achieving same radical clearance of lymph nodes as with high ligation of IMA.

Feasibility evaluation on preservation of left colonic artery in dealing with inferior mesenteric artery in laparoscopic anterior resection of rectal carcinoma / 中国医师进修杂志

Objective To explore the feasibility and value of preservation of left colonic artery (LCA) in dealing with inferior mesenteric artery (IMA) in laparoscopic anterior resection of rectal carcinoma.Methods The clinical data of 72 cases of laparoscopic anterior resection of rectal carcinoma from April 2010 to October 2013 were retrospectively analyzed including 32 cases with preservation of LCA (observation group) and 40 cases without preservation of LCA (control group).The blood loss,operative time,postoperative exhaust time,terminal ileum stoma,the number of lymph nodes removed around the root of IMA,the rate of lymph node metastasis around the root of IMA and prognosis were compared between two groups.Results There was no significant difference in the blood loss,operative time,postoperative exhaust time,terminal ileum stoma,the number of lymph nodes removed around the root of IMA,the rate of lymph node metastasis around the root of IMA between two groups (P ＞ 0.05).No case in observation group needed to free the splenic flexure of colon and to make the terminal ileum stoma,while 3 cases in control group needed to free splenic flexure of colon because of blood supply disorder in the proximal intestine (P =0.046),and 4 cases underwent terminal ileum stoma following anastomosis (P =0.042).No anastomotic leakage occurred in observation group,while 2 cases of anastomotic leakage occurred in control group(P =0.090).After followed up for 6-48 months,no significant difference was found in local recurrence and liver metastasis in two groups (P ＞ 0.05).Conclusion Laparoscopic anterior resection of rectal carcinoma with preservation of LCA in dealing with IMA can effectively retain the blood supply of proximal intestine.

Comparative study on effects of different treatments on inferior mesenteric artery in resection of rectal cancer / 国际外科学杂志

Objective To evaluate the clinical significance of low ligation and high ligation of inferior mesenteric artery (IMA) and lymph nodes dissection on radical resection for rectal cancer.Methods One hundred and fifty-six patients who were diagnosed rectal cancer in our hospital between May 2007 and May 2008 were divided into low ligation group (80 cases)and high ligation group (76 cases).The low ligation group was treated with low ligation of IMA and lymph nodes dissection,the high ligation group was cured by high ligation of IMA and lymph nodes dissection.cases.The IMA lymph nodes metastasis,number of lymph nodes,cancer recurernce rate,5-year survival rate,complication rate were compared and analyzed.Results The rate of lymph nodes metastasis around the origin of inferior mesenteric artery was 15.0％ in the low ligation group,the rate of lymph nodes metastasis around the origin of inferior mesenteric artery was 14.5％ in the high ligation group,and the difference was not statistically significant (P ＞ 0.05).Compared two groups of postoperative recurrence rate,5-year survival rate,anastomotic leakage rate,sexual dysfunction rate and urinary retention rate,there was no significant differences (P ＞ 0.05).The intestinal function recovery time and low anterior resection syndrome incidence of the low ligation group were lower than the high ligation group,there were significant differences (P ＜ 0.05).Conclusions Low ligation of inferior mesenteric artery and lymph nodes dissection can achieve radical resection for rectal cancer.Compared with traditional high ligation of inferior mesenteric artery,there were no differences for patients on recurrence rate,5-year survival rate and complication rate.

Lymph node metastasis around the root of inferior mesenteric artery in rectal cancer / 中华普通外科杂志

Objective To investigate factors affecting the metastasis of lymph nodes around the root of inferior mesenteric artery(IMA) in rectal cancer,and the significance of root lymph nodes dissection of IMA in radical surgery for rectal cancer.Methods Clinicopathological data of 105 rectal cancer patients undergoing root lymph node dissection of IMA during radical resection in Peking University First Hospital from January 2005 to December 2008 were analyzed retrospectively.Rectal cancer patients without root lymph node dissection of IMA during the same period served as control.Results were compared between these two groups for survival and local recurrence rates.Results The rate of lymph node metastasis around the origin of IMA was 9.5％ (10/105).The five-year survival rate in patients with IMA root nodal dissection was 71.3％,and that without was 70.6％ (P =0.995),while the local recurrence was respectively 1.9％ and 7.4％ (P ＜ 0.05).In multivariate analyses,IMA root nodal metastasis occurred more frequently in patients with pT3 and pT4 tumor(Wald =5.764,P ＜ 0.05) and poorly differentiated tumor(Wald =7.818,P ＜ 0.05).Conclusions Root lymph nodes dissection of IMA could not increase five-year survival rate,but it could reduce local recurrence rate in patients with rectal cancer.In radical surgery of rectal cancer,lymphadenectomy of IMA root should be performed in patients with T3 and T4 tumor with poorly differentiated tumor,so as to reduce local recurrence rate.

A Case of Inferior Mesenteric Arterial Thrombosis with Bowel Infarction Successfully Treated by Conservative Treatment / 대한내과학회지

Acute mesenteric thrombosis accounts for 25-30% of acute mesenteric ischemia and occurs usually alongside severe atherosclerotic disease. Acute mesenteric thrombosis primarily affects the superior mesenteric artery; thus, inferior mesenteric arterial thrombosis is an extremely rare form of the condition. Surgical treatment is mandatory to resolve impending or overt bowel infarction in acute mesenteric ischemia patients. However, here we report a case of colonic infarction caused by acute inferior mesenteric thrombosis successfully treated by conservative management.

A Case of the Inferior Mesenteric Artery Arising from the Superior Mesenteric Artery in a Korean Woman

Anatomical variations of the inferior mesenteric artery are extremely uncommon, since the inferior mesenteric artery is regularly diverged at the level of the third lumbar vertebra. We found a rare case in which the inferior mesenteric artery arose from the superior mesenteric artery. The findings were made during a routine dissection of the cadaver of an 82-yr-old Korean woman. This is the tenth report on this anomaly, the second female and the first Korean. The superior mesenteric artery normally arising from abdominal aorta sent the inferior mesenteric artery as the second branch. The longitudinal anastomosis vessels between the superior mesenteric artery and inferior mesenteric artery survived to form the common mesenteric artery. This anatomical variation concerning the common mesenteric artery is of clinical importance, performing procedures containing the superior mesenteric artery.

Estudio anatómico de la arteria mesentérica inferior en el hombre / Anatomic study of the inferior mesenteric artery in man

En el presente trabajo se estudió la morfología de la arteria mesentérica inferior y sus ramas, así como su forma de distribución, grosor y cantidad de divisiones y arcadas en el hombre. Para ello se utilizó una muestra de 15 preparaciones anatómicas, obtenidas por el método de macro y macromicrodisección, se realizaron mediciones de los distintos elementos, y se procesaron luego estos datos estadísticos. El sistema de la arteria mesentérica inferior posee un esquema general que va de formas más simples a más complejas según el nivel de desarrollo. Tiene un vaso visceral impar que termina en el borde mesocólico del intestino grueso mediante vasos rectos. Las ramas terminales y las arcadas simples constituyen los elementos que hacen más complejo el árbol vascular intestinal de los mamíferos, pero que alcanzan su desarrollo más elevado en su representante superior: el hombre. Las ramas secundarias en los sitios de emergencia o dicotomización presentan grosores semejantes, así como los vasos rectos que penetran en la pared intestinal, lo que garantiza de esta forma una irrigación uniforme en el órgano.

In this work, morphology of the inferior mesenteric artery and its branches is studied as well as its distribution form, thickeness, and quantity of divisions and arches in man. For this, a sample of 15 anatomic preparations obtained for the microdisecction method, was used. Messurements of different elements were performed , and afterwards these statistical data were processed. The system of the level of developmen. It has and old visceral vessel which ends in the mesocholic border of the large bowel through direct vessels. Ending branches and simple arches are the elements which make more complex the intestinal vascular tree of mammals, but they reach their highest development in its superior representant:man Secondary branches in the emergency sites or dicotomization present similar thickeness, as well as disect vessels that penetrate into the intestinal wall which guarantees a uniform irrigation to the organ.