Anatomical variations of portal venous system: importance in surgical clinic / Variações anatômicas do sistema venoso porta: importância em clínica cirúrgica

ABSTRACT - BACKGROUND: Knowledge of the portal system and its anatomical variations aids to prevent surgical adverse events. The portal vein is usually made by the confluence of the superior mesenteric and splenic veins, together with their main tributaries, the inferior mesenteric, left gastric, and pancreaticoduodenal veins; however, anatomical variations are frequent. AIM: This article presents a literature review regarding previously described anatomical variations of the portal venous system and their frequency. METHODS: A systematic review of primary studies was performed in the databases PubMed, SciELO, BIREME, LILACS, Embase, ScienceDirect, and Scopus. Databases were searched for the following key terms: Anatomy, Portal vein, Mesenteric vein, Formation, Variation, Variant anatomic, Splenomesenteric vein, Splenic vein tributaries, and Confluence. RESULTS: We identified 12 variants of the portal venous bed, representing different unions of the splenic vein, superior mesenteric vein, and inferior mesenteric vein. Thomson classification of the end of 19th century refers to the three most frequent variants, with type I as predominant (M=47%), followed by type III (M=27.8%) and type II (M=18.6%). CONCLUSION: Thomson classification of variants is the most well-known, accounting for over 90% of portal venous variant found in clinical practice, inasmuch as the sum of the three junctions are found in over 93% of the patients. Even though rarer and accounting for less than 7% of variants, the other nine reported variations will occasionally be found during many abdominal operations.

RESUMO - RACIONAL: O conhecimento do sistema porta e de suas variações anatômicas contribui para prevenir acidentes cirúrgicos. Usualmente, a veia porta é formada pela confluência das veias mesentérica superior e esplênica, junto com suas principais tributárias: as veias mesentérica inferior, gástrica esquerda e pancreaticoduodenal. Entretanto, variações anatômicas são frequentes. OBJETIVO: Este artigo apresenta uma revisão da literatura em relação às variações anatômicas previamente descritas do sistema venoso porta e sua frequência. MÉTODOS: Foi realizada revisão sistemática de estudos primários nas bases de dados PubMed, Scielo, BIREME, LILACS, Embase, Science Direct e Scopus. As bases de dados foram pesquisadas pelas seguintes palavras-chave: Anatomia, Veia porta, Veia mesentérica, Formação, Variação, Variante anatômica, Veia esplenomesentérica, Veia esplênica, tributárias e Confluência. RESULTADOS: Foram identificadas doze variantes do sistema venoso portal, representando diferentes formações da veia esplênica, veia mesentérica superior e veia mesentérica inferior. A classificação de Thomson, do final do século XIX, refere três variantes mais frequentes, com predomínio do tipo I (M = 47%), seguido do tipo III (M = 27,8%) e do tipo II (M = 18,6%). CONCLUSÃO: A classificação de variantes de Thomson é a mais conhecida e responde por mais de 90% da variante venosa portal encontrada na prática clínica, na medida em que a soma das três junções é encontrada em mais de 93% dos pacientes. Embora mais raras e representando menos de 7% das variantes, as outras nove variações relatadas ocasionalmente serão encontradas durante muitas cirurgias abdominais.

Risk factors of primary acute mesenteric venous thrombosis in plateau area / 中华普通外科杂志

Objective:To explore the risk factors of primary acute mesenteric venous thrombosis (AMVT) in plateau area.Methods:Data of 54 primary AMVT cases admitted to the People's Hospital of Tibet Autonomous Region between Jan 2015 and Jul 2021 were retrospectively analyzed. There were 42 males and 12 females, aged from 29-79 years. One hundred and ninty matched volunteers severed as control. Logistic multivariate regression analysis was used to screen out independent risk factors. The receiver operating characteristic (ROC) curve and the area under the curve are used to evaluate the value of each indicator and model prediction.Results:Univariate analysis showed that the two groups were significantly different in gender, smoking history, drinking history, and hemoglobin concentration ( P<0.05); there was no significant difference in age, altitude of residence, uric acid and BMI ( P>0.05). Logistic multivariate regression analysis showed that male ( OR=2.466, 95% CI: 1.166-5.212, P=0.018), elevated hemoglobin levels ( OR=2.761, 95% CI: 1.411-5.403, P=0.003) were independent risk factors for primary AMVT. The area under the ROC curve of the two predictors and prediction model are 0.639 (95% CI: 0.559-0.719), 0.650 (95% CI: 0.563-0.737), 0.697 (95% CI: 0.618-0.776). Conclusion:Male and elevated hemoglobin levels are independent risk factors for primary AMVT in plateau areas.

Damage control in abdominal vascular trauma

In patients with abdominal trauma who require laparotomy, up to a quarter or a third will have a vascular injury. The venous structures mainly injured are the vena cava (29%) and the iliac veins (20%), and arterial vessels are the iliac arteries (16%) and the aorta (14%). The initial approach is performed following the ATLS principles. This manuscript aims to present the surgical approach to abdominal vascular trauma following damage control principles. The priority in a trauma laparotomy is bleeding control. Hemorrhages of intraperitoneal origin are controlled by applying pressure, clamping, packing, and retroperitoneal with selective pressure. After the temporary bleeding control is achieved, the compromised vascular structure must be identified, according to the location of the hematomas. The management of all lesions should be oriented towards the expeditious conclusion of the laparotomy, focusing efforts on the bleeding control and contamination, with a postponement of the definitive management. Their management of vascular injuries includes ligation, transient bypass, and packing of selected low-pressure vessels and bleeding surfaces. Subsequently, the unconventional closure of the abdominal cavity should be performed, preferably with negative pressure systems, to reoperate once the hemodynamic alterations and coagulopathy have been corrected to carry out the definitive management.

En pacientes con trauma de abdomen que requieren laparotomía, hasta una cuarta o tercera parte, habrán sufrido una lesión vascular. Las estructuras venosas principalmente lesionadas son la vena cava y las iliacas, y de vasos arteriales, son las iliacas y la aorta. El abordaje de este tipo de heridas vasculares se puede ser difícil en el contexto de un paciente hemodinámicamente inestable ya que requiera medidas rápidas que permita controlar la exanguinación del paciente. El objetivo de este manuscrito es presentar el abordaje del trauma vascular abdominal de acuerdo con la filosofía de cirugía de control de daños. La primera prioridad en una laparotomía por trauma es el control de la hemorragia. Las hemorragias de origen intraperitoneal se controlan con compresión, pinzamiento o empaquetamiento, y las retroperitoneales con compresión selectiva. Posterior al control transitorio de la hemorragia, se debe identificar la estructura vascular comprometida, de acuerdo con la localización de los hematomas. El manejo de las lesiones debe orientarse a la finalización expedita de la laparotomía, enfocado en el control de la hemorragia y contaminación, con aplazamiento del manejo definitivo. Lo pertinente al tratamiento de las lesiones vasculares incluyen la ligadura, derivación transitoria y el empaquetamiento de vasos seleccionados de baja presión y de superficies sangrantes. Posteriormente se debe realizar el cierre no convencional de la cavidad abdominal, preferiblemente con sistemas de presión negativa, para consecutivamente reoperar una vez corregidas las alteraciones hemodinámicas y la coagulopatía para realizar el manejo definitivo.

Várices yeyunales secundarias a trombosis de la vena mesentérica superior: una causa inusual de sangrado del intestino delgado / Jejunal varices secondary to superior mesenteric vein thrombosis: an unusual cause of bleeding from the small intestine

RESUMEN Las várices del intestino delgado, usualmente, están relacionadas con hipertensión portal. Las várices ectópicas secundarias a trombosis crónica aislada de la vena mesentérica superior son muy infrecuentes. El sangrado digestivo secundario a éstas representa un reto diagnóstico, dada la baja prevalencia y sospecha clínica, y terapéutico por la escasa evidencia científica existente con respecto a las opciones de tratamiento. Presentamos el caso de un hombre de 56 años, con sangrado digestivo secundario a várices yeyunales por trombosis crónica de la vena mesentérica superior, asociada a trombofilia; diagnosticadas mediante video cápsula endoscópica (VCE) y enterografía por tomografía (entero TC), sin posibilidades de manejo endoscópico ni radiológico dado el compromiso extenso, intervenido quirúrgicamente con éxito.

ABSTRACT Small bowel varices are usually associated with portal hypertension. Ectopic varices caused by isolated chronic superior mesenteric vein thrombosis are exceedingly rare. Gastrointestinal bleeding secondary to these represents a diagnostic challenge, given the low prevalence and clinical suspicion, and therapeutic dilemma due to the limited scientific evidence available regarding treatment options. We present the case of a 56-year-old man with gastrointestinal bleeding from jejunal varices due to chronic superior mesenteric vein thrombosis, associated with thrombophilia; diagnosed by video capsule endoscopic (VCE) and computed tomography enterography (CTE), with no possibility of endoscopic or radiological management given the extensive involvement, who underwent successful surgery.

Superior mesenteric vein-identified middle line approach in patients of colonic cancer (T4b) undergoing right hemicolectomy combined with pancreaticoduodenectomy / 中华普通外科杂志

Objective To explore the safety and efficacy of middle line approach identified with superior mesenteric vein in the right hemicolectomy combined with pancreaticoduodenectomy for colonic carcinoma involing liver and duodenun.Methods Clinical data of 13 patient's with right colonic cancer (T4b) undergoing right hemicolectomy combined with pancreaticoduodenectomy from Jan 2016 to Jul 2019 in He'nan Provincial Tumor Hospital were retrospectively analyzed.The superior mesenteric vein was used to mark the medial border of tumor resection.Vertical cutline was made to transverse mesocolon and all the way done to the root of superior mesenteric vein,the pancreas was cut in front of superior mesenteric vein,superior mesenteric artery and the affiliated lymph nodes were dissected.The stomach and pancreas were transected,the specimen was removed.Then the GI tract was reconstructed.Results Surgery was successful in all 13 patients.The operation time was (249 ± 27) min,blood loss was (442 ± 129) ml,2 cases suffered pancreatic fistula,there was no biliary fistula,and 1 case of delayed gastric emptying.There were no other major complications.The number of lymph node dissection was (20 ± 4) and hospital stay was (23.2-± 9.4) d.Conclusions It is safe and feasible to use the superior mesenteric vein-identified middle line approach in patients of right colonic cancer undergoing right hemicolectomy plus pancreaticoduodenectomy.

Índice vena/arteria de vasos mesentéricos en casos de gastrosquisis: nueva herramienta pronóstica

Objective: To evaluate the flow of the superior mesenteric artery and vein both by Doppler flowmetry and simultaneously, in normal controls and in cases of gastroschisis, as additional prognostic criteria. Methods: The venous/arterial index was determined by Doppler flowmetry; reference values for the superior mesenteric vessels were obtained from a group of 60 healthy fetuses of 30 to 34 weeks and 15 cases of gastroschisis. The flow rate wave (FRW) was obtained simultaneously from both the superior mesenteric artery and vein with an angle of insonation less than 60°; the vein velocity was divided by the systolic peak of the artery and the percentage index was calculated based on the velocity of both vessels. The equipment used was a Mylab™Twice from Esaote with a 3.5 MHz convex probe. Results: The superior mesenteric venous/arterial index value in the control group was 26% ± 6 (2SD). In 12 cases of gastroschisis, the index remained within the reference values, with favorable prognosis for primary reduction (9 with Svelitza technique and 3 with immediate neonatal primary reduction). In three cases, the venous/arterial index was below 20% (1%, 14% and 16% respectively), with unfavorable results; the worst case, where no venous flow was detected, required wide resection, presented short bowel syndrome and died at 6 months. Conclusions: The perfusion index of the eviscerated bowel, studied by the percentage between vein velocity and maximum mesenteric artery velocity, could have prognostic value for the flow conditions of afferent and efferent intestinal loops in gastroschisis.

Objetivo. Evaluar mediante flujometría Doppler y de manera simultánea el flujo de la arteria y vena mesentérica superior en casos normales y en aquellos portadores de gastrosquisis, como criterio adicional en el pronóstico. Métodos. Se determinó mediante flujometría Doppler el índice venoso/arterial, obteniendo los valores de referencia de los vasos mesentéricos superiores, en un grupo de 60 fetos sanos con 30 a 34 semanas de gestación y 15 casos portadores de gastrosquisis. Se obtuvo la onda de velocidad de flujo (OVF) simultáneamente de la arteria y de la vena mesentérica superior, con ángulo de insonación menor a 60°; la velocidad de la vena fue dividida entre el pico sistólico de la arteria y calculado el índice porcentual entre las velocidades de ambos vasos. El equipo utilizado fue un MyLab Twice de Esaote con transductor convexo de 3,5 MHz. Resultados. El valor del índice veno/arterial de los vasos mesentéricos superiores en el grupo control fue 26% ± 6 (2DE). En 12 casos de gastrosquisis, el índice se mantuvo dentro de los valores de referencia y con índice pronóstico favorable para reducción primaria (9 con técnica de Svelitza y 3 con reducción primaria neonatal inmediata) y, en tres casos, el índice porcentual veno/arterial se encontró por debajo del 20%, (1%, 14% y 16%), con resultados desfavorables. En el caso con mayor compromiso, no pudo detectarse flujo venoso y requirió de resección amplia, con síndrome de intestino corto y fallecimiento a los 6 meses. Conclusiones. El índice de perfusión de las asas intestinales evisceradas, estudiado mediante la relación porcentual entre las velocidades de la vena y velocidad máxima de la arteria mesentérica superior, podría ser considerada como un complemento pronóstico en las condiciones de flujos aferentes y eferentes en que se encuentran dichas asas, en los casos de gastrosquisis.

Duodenopancreatectomia com ressecção venosa: análise de morbidade e mortalidade em 30 dias / Pancreaticoduodenectomy with venous resection: an analysis of 30-day morbidity and mortality

ABSTRACT BACKGROUND: Pancreaticoduodenectomy (PD) with the resection of venous structures adjacent to the pancreatic head, even in cases of extensive invasion, has been practiced in recent years, but its perioperative morbidity and mortality are not completely determined. OBJECTIVE: To describe the perioperative outcomes of PD with venous resections performed at a tertiary university hospital. METHODS: A retrospective study was conducted, classified as a historical cohort, enrolling 39 individuals which underwent PD with venous resection from 2000 through 2016. Preoperative demographic, clinical and anthropometric variables were assessed and the main outcomes studied were 30-day morbidity and mortality. RESULTS: The median age was 62.5 years (IQ 54-68); 55% were male. The main etiology identified was ductal adenocarcinoma of the pancreas (82.1%). In 51.3% of cases, the portal vein was resected; in 35.9%, the superior mesenteric vein was resected and in the other 12.8%, the splenomesenteric junction. Regarding the complications, 48.7% of the patients presented some type of morbidity in 30 days. None of the variables analyzed was associated with higher morbidity. Perioperative mortality was 15.4% (six patients). The group of individuals who died within 30 days presented significantly higher values for both ASA (P=0.003) and ECOG (P=0.001) scores. CONCLUSION: PD with venous resection for advanced pancreatic neoplasms is a feasible procedure, but associated with high rates of morbidity and mortality; higher ASA e ECOG scores were significantly associated with a higher 30-day mortality.

RESUMO CONTEXTO: A duodenopancreatectomia (DP) com ressecção de estruturas venosas adjacentes à cabeça do pâncreas, mesmo em casos de invasão extensa, tem sido praticada nos últimos anos, mas sua morbidade e mortalidade perioperatórias não são completamente determinadas. OBJETIVO: Descrever os resultados perioperatórios de DP com ressecções venosas realizadas em um hospital terciário universitário. MÉTODOS: Foi realizado estudo retrospectivo, classificado como coorte histórica, envolvendo 39 indivíduos submetidos à DP com ressecção venosa entre 2000 e 2016. Foram estudadas variáveis demográficas, clínicas e antropométricas pré-operatórias e os desfechos principais foram a morbidade e mortalidade em 30 dias. RESULTADOS: A mediana de idade foi 62,5 anos (IQ 54-68), sendo 55% dos indivíduos do sexo masculino. A principal etiologia identificada foi o adenocarcinoma ductal de pâncreas (82,1%). Em 51,3% dos casos, a veia porta foi submetida à ressecção; em 35,9%, a veia mesentérica superior foi ressecada e nos outros 12,8%, a junção esplenomesentérica. Em relação às complicações, 48,7% dos pacientes apresentaram algum tipo de morbidade em 30 dias. Nenhuma das variáveis analisadas associou-se à maior morbidade. A mortalidade perioperatória foi 15,4% (seis pacientes). O grupo de indivíduos que cursou com mortalidade em 30 dias apresentou escores significativamente mais altos de ASA (P=0,003) e ECOG (P=0,001). CONCLUSÃO: A DP com ressecção venosa para neoplasias avançadas do pâncreas é um procedimento factível, porém que se acompanha de altos índices de morbidade e mortalidade; escores de ASA e ECOG altos são fatores significativamente associados à maior mortalidade.

Relative factors of transmural intestinal necrosis in acute superior mesenteric vein thrombosis / 中华外科杂志

Objective@#To examine the relative factors of transmural intestinal necrosis(TIN) during multidisciplinary stepwise management facilitating the decision making in patients with acute superior mesenteric vein thrombosis (ASMVT).@*Methods@#Clinical data of patients with ASMVT admitted to Department of General Surgery, Jinling Hospital from January 2009 to June 2017 were reviewed retrospectively. There were 52 males and 37 females, aging (45.9±12.6) years (range: 20 to 69 years). According to the postoperative pathological results and follow-up, the patients were divided into TIN group (n=31) and non-TIN group(n=58, including 18 cases of intestinal stricture). The related factors were compared between ASMVT patients with TIN and patients without TIN by univariate analysis using t test, U test and χ2 test accordingly, and factors with statistically significance were subsequently submitted to binary Logistic regression analysis. The predictive value and cut-off point of factors were evaluated by receiver operator characteristic(ROC) curve and area under the curve.@*Results@#In univariate analysis, smoking, hypertension, peritonitis, white blood cell count,haemoglobin, international normalized ratio, blood albumin, thrombosis of superior mesenteric branches vein, free intraperitoneal fluid, decrease of bowel wall enhancement and pneumatosis intestinalis were TIN risk factors (all P<0.05). According to the binary Logistic regression analysis, white blood cell count (OR=1.093, 95%CI: 1.010 to 1.182, P=0.027), thrombosis of the superior mesenteric branches vein (OR=11.519, 95%CI: 1.906 to 69.615, P=0.008), pneumatosis intestinalis (OR=11.140, 95%CI: 2.360 to 52.585, P=0.002) were independent relative factors of TIN in patients with AMI, and the area under the ROC curve of the above factors and predictive model was 0.759 (95%CI: 0.647 to 0.871), 0.745 (95%CI: 0.641 to 0.848), 0.737 (95%CI: 0.621 to 0.854), 0.909 (95%CI: 0.847 to 0.971), respectively. The cutoff value of white blood cell count was 18.1×109/L.@*Conclusion@#White blood cell levels, superior mesenteric vein branch thrombosis and pneumatosis intestinalis are independent predictors of TIN in ASMVT.

Clinical management of acute superior mesenteric vein thrombosis / 中华普通外科杂志

Objective To evaluate the diagnosis and treatment of acute superior mesenteric venous thrombosis (ASMVT).Methods Clinical data of 36 ASMVT patients admitted to our department from Jan 2014 to Oct 2017 were retrospectively analyzed,the differences of the clinical data and prognosis of nonsurgical group and surgical group were studied.Results All patients received anticoagulation therapy immediately after diagnosis,and recanalization rate was 42％.Surgical group included 21 cases,of which 9 cases received emergency surgery,12 cases received delayed bowel resection.There was significant difference between non-surgical group and surgical group (P ＞ 0.05) in hemoglobin level at admission (124 ±29)g/L vs.(93 ± 13) g/L,t =3.880,P =0.006.Compared with delayed bowel resection group emergency surgery group had longer bowel resection (65 ± 58) cm vs.(13 ± 6) cm,t =2.700,P =0.035,more loop ileostomy (6 vs.1,x2 =7.875,P =0.016),more postoperative complication rate (56％ vs.8％,x2 =5.619,P =0.046),but there was no significant difference in hospitalization time,hospitalization cost,postoperative recurrence and mortality rate (P ＞ 0.05).Conclusions Early anticoagulantion therapy is advised for ASMVT patients to avoid bowel resection or reduce the length of intestinal resection.It is advisable for those who can be tided over to delayed bowel resection with intestinal obstruction.

Gradient treatment of acute superior mesenteric venous thrombosis: clinical analysis of 68 cases / 中华外科杂志

Objective@#To investigate the effect of Gradient treatment for acute superior mesenteric venous thrombosis (ASMVT).@*Methods@#Clinic data of 68 patients of ASMVT admitted in Department of General Surgery, Jinling Hospital, Medical School of Nanjing University from January 2009 to December 2014 were analyzed retrospectively. There were 50 male and 18 female patients with a mean age of (45±12) years. These patients were conducted by the stepwise treatment model (endovascular treatment-damage control surgery-surgical intensive care-intestinal rehabilitation treatment). Clinical outcomes and complications were compared during the follow-up period. Differences about bowel resection length of endovascular treatment and surgical procedures were evaluated with t test.@*Results@#In the 68 cases, 24 cases were cured simply by endovascular treatment, 19 cases received surgical procedures alone (group surgery). Twenty-five patients received endovascular treatment combined with surgical procedures (group combined), including 6 cases temporary abdominal closure. The overall mortality rate was 2.9% (2/68) during hospitalization. The range of bowel resection of group combined significantly reduced compared with group surgery ((92±14) cm vs. (162±27) cm, t=-2.377, P=0.022). During 1-year follow-up period, 4 cases suffered from short bowel syndrome, whom underwent surgery alone.@*Conclusions@#Early diagnosis and treatment is the key to treatment of ASMVT, the rapid improvement of intestinal ischemia is particularly important for prognosis. Combination therapy significantly save more residual small intestine and avoid short bowel syndrome. The selection of early gradient treatment can significantly reduce the mortality and improve the prognosis of ASMVT patients.

Recurrent Abdominal Pain after Laparoscopic Appendectomy / 대한소화기학회지

Laparoscopic surgical approaches, compared with open surgical approaches, provide comparable clinical outcomes, but lower complications. Unfortunately, a rare complication―portomesenteric vein thrombosis―had been reported after laparoscopic surgery. A 42-year-old woman was referred our hospital for recurrent abdominal pain after laparoscopic appendectomy from acute appendicitis. It was determined that abdominal pain was due to postoperative superior mesenteric vein thrombus. A six-month anticoagulation therapy is an excellent treatment for superior mesenteric vein thrombus . Therefore, physicians should be aware of portomesenteric vein thrombosis in patients with newly developed abdominal pain after successful laparoscopic surgical management.

Mechanical thrombectomy-assisted thrombolysis for acute symptomatic portal and superior mesenteric venous thrombosis

Acute portal vein and mesenteric vein thrombosis (PVMVT) can cause acute mesenteric ischemia and be fatal with mortality rate of 37%-76%. Therefore, early diagnosis and prompt venous revascularization are warranted in patients with acute symptomatic PVMVT. Due to advances in catheter-directed treatment, endovascular treatment has been used for revascularization of affected vessels in PVMVT. We report two cases of symptomatic PVMVT treated successfully by transhepatic percutaneous mechanical thrombectomy-assisted thrombolysis.

Idiopathic Phlebosclerotic Colitis: A Rare Entity of Chronic Ischemic Colitis / 대한소화기학회지

Colonic wall thickening is frequently encountered in various conditions, from acute or chronic inflammatory disease to colorectal carcinoma. Colonic wall thickening may be accompanied by calcifications in mucinous adenocarcinoma of the colon, leiomyosarcoma of the colon, schistosomiasis japonica, and phlebosclerotic colitis. Phlebosclerotic colitis is a rare entity of chronic ischemic colitis associated with sclerosis and fibrosis of mesenteric veins. Although its development is usually insidious, and, thus its diagnosis can be delayed, characteristic findings in phlebosclerotic colitis are calcifications of mesenteric veins as well as colonic wall thickening with calcifications. We report on a 71-year-old woman who presented with chronic diarrhea and intermittent hematochezia, who was first misdiagnosed as mucinous adenocarcinoma of the colon, but finally diagnosed as a rare entity of chronic ischemic colitis, phlebosclerotic colitis. Differential points of phlebosclerotic colitis from other diseases, including leiomyosarcoma and schistosomiasis japonica, are also described.

Small Bowel Infarction by Mesenteric Venous Thrombosis due to Methylenetetrahydrofolate Reductase Gene Mutation

Acute mesenteric venous thrombosis (MVT) is an uncommon form of intestinal ischemia with high mortality and usually occurs in the setting of preexisting comorbidities including thrombophilia and abdominal inflammatory conditions. Hyperhomocysteinemia has been known to be a risk factor for thromboembolism, often located on an unusual site. Considering that homocysteine metabolism is determined genetically to a high degree, a mutant of methylenetetrahydrofolate reductase (MTHFR) C677T causes hyperhomocysteinemia, leading to thrombophilia. Until now, there have been few reports of MVT associated with MTHFR gene mutation. We, herein, report a case of small bowel infarction associated with MVT by MTHFR gene mutation in an adult without any other risk factors of thrombophilia.

Trombosis inusuales y trombofilia Un problema difícil de abordar. Experiencia de cuatro años / Unusual thrombosis and thrombophilia A difficult problem to approach. Experience of four years

Resumen Existen territorios vasculares denominados sitios inusuales que pueden presentar eventos trombóticos: senos venosos, miembros superiores y lecho esplácnico, con consecuencias clínicas que pueden ser catastróficas. Se encuentran vacíos de conocimiento en el estudio de los factores involucrados en estas entidades. Objetivo: escribir la frecuencia de trombofilia en pacientes que consultan por trombosis en sitios inusuales al servicio de hematología del Hospital San José, entre enero 2007 y diciembre 2011. Se describe la población en términos demográficos, género, edad, recurrencia, tratamientos empleados y complicaciones asociadas. Métodos: es un estudio descriptivo serie de casos, se incluyeron las historias clínicas de pacientes mayores de 18 años con primer evento trombótico que compromete trayecto vascular en sitio inusual, asistentes a la consulta externa de hematología durante el periodo de estudio, los datos fueron extraídos de las historias clínicas de forma retrospectiva. Resultados: en el estudio ingresaron 73 pacientes, mayoría mujeres (65.8%), la localización de la trombosis fue: senos venosos (47.9%), miembro superior (27.4%), lecho esplácnico (24%). Los factores de riesgo de mayor frecuencia fueron: embarazo (12.5%), consumo de anovulatorios orales (10.4%), tabaquismo (9.6%), puerperio (4.2%). Se encontró trombofilia en 57% de los pacientes con trombosis en sitios inusuales, siendo la más frecuente el síndrome antifosfolípidos. Conclusiones: existe una frecuencia alta para trombofilia en pacientes con trombosis en sitio inusual, siendo el síndrome antifosfolípidos la causa más frecuente en nuestra serie. (Acta MedColomb 2013; 38: 132-137).

Abstract There are vascular territories called unusual sites which may present thrombotic events: venous sinuses, upper limbs and splanchnic bed, with clinical consequences that can be catastrophic. Knowledge gaps are found in the study of the factors involved in these entities. Objective: To describe the frequency of thrombophilia in patients who consult to the Hematology Service of San Jose Hospital due to thrombosis in unusual sites between January 2007 and December 2011. We describe the population in terms of demographics, gender, age, recurrence, treatments used and associated complications. Methods: A case series descriptive study. We included the medical records of patients older than 18 years with first thrombotic event compromising a vascular unusual site, attending the outpatient hematology service during the study period. Data were extracted retrospectively from medical records. Results: 73 patients entered the study; most were women (65.8%). Localization of thrombosis was: venous sinuses (47.9%), upper limb (27.4%), splanchnic bed (24.0%). The most frequent risk factors were: pregnancy (12.5%), use of oral contraceptives (10.4%), smoking (9.6%), postpartum (4.2%). Thrombophilia was found in 57% of patients with thrombosis in unusual sites. The most frequent diagnosis was antiphospholipid syndrome. Conclusions: There is a high frequency of thrombophilia in patients with thrombosis in unusual site, being antiphospholipid syndrome the most common cause in our series. (Acta Med Colomb 2013;38: 132-137).

Surgical and interventional therapy in patients with acute superior mesenteric vein thrombosis / 中华普通外科杂志

Objective To evaluate the surgical and interventional therapy in patients with acute superior mesenteric vein thrombosis.Methods In this series,31 acute superior mesenteric vein thrombosis(SMVT) cases were reviewed from Oct 2006 to Feb 2012.According to varied clinical presence,patients received superior mesenteric vein thrombectomy with necrotic bowel resection or indirected catheter thrombolysis through superior mesenteric artery.Results 6 of 9 cases undergoing surgery were cured and other 3 still complained abdominal distension when discharged for not being able to bear anticoagulation and thrombolysis after operation due to alimentary tract hemorrhage,and residual thrombus was shown in superior veins by venography.17 of 22 treated by interventional therapy gained obvious relief within 72 hours after intervention,others gained symptomatic relief in 5-7 days.Indirected catheter thrombolysis were interrupted in 2 due to alimentary tract hemorrhage.One patient was shifted to surgery 48 hours after catheter thrombolysis due to deterioration.Mean duration of follow-up after hospital discharge was (19 ± 5) months in 25 cases,20 had no abdominal distension and pain,3 with postcibal abdominal distension.Conclusions Indirected thrombolytic therapy by way of the superior mesenteric artery is a technically simple,safe and effective therapy for patients with acute SMVT.

A Case of Massive Portal Venous Gas Caused by Fatal Intestinal Infarction

Hepatic portal venous gas (HPVG), a rare radiologic finding, is associated in some cases with severe or lethal conditions requiring urgent surgical intervention. Computed tomography has recently demonstrated a wider range of clinical conditions associated with HPVG, some of which are benign and do not necessarily require surgery. However, HPVG remains an ominous sign in cases of bowel ischemia or necrosis. We report on a case of massive HPVG caused by a fatal intestinal infarction, which showed rapid disease progression, eventually resulting in death due to septic shock. The HPVG in this case was huge and could therefore be confused with an air-biliarygram.

O papel dos exames de imagem no diagnóstico de trombose das veias esplâncnicas: relato de dois casos / The role of imaging exams in the diagnosis of thrombosis of the splanchnic veins: Report of two cases

Objetivos: apresentar dois casos de trombose de veias esplâncnicas, que é considerada uma causa potencialmente fatal de isquemia intestinal, sendo as veias porta e mesentérica superior as mais acometidas. Discutir as possíveis etiologias e realçar a importância do uso de exames de imagem no diagnóstico dessa afecção.Descrição dos Casos: duas pacientes com trombose venosa esplâncnica apresentaram manifestações clínicas inespecíficas. No primeiro caso as principais manifestações foram dor abdominal, diarréia sanguinolenta, distensão abdominal e náuseas. No segundo caso, a paciente apresentava dor abdominal vaga, inapetência e hipotensão arterial. Nos dois casos o diagnóstico foi firmado por tomografia computadorizada.Conclusões: considerando as manifestações clínicas vagas da trombose de veias esplâncnicas, os exames de imagem, em especial a tomografia computadorizada, apresentam papel fundamental no seu diagnóstico.

Aims: To present two cases of thrombosis of the splanchnic veins, which is considered a possible fatal cause of intestinal ischemia, with the portal and superior mesenteric veins being the most affected. To discuss the etiological possibilities and emphasize the importance of using imaging exams for the definitive diagnosis.Case Description: Two women with splanchnic venous thrombosis showed nonspecific clinical manifestations. In the first case, the main symptoms were abdominal pain, bloody diarrhea, abdominal distension and nausea. In the second case, the patient presented with vague abdominal pain, anorexia and hypotension. In both cases the diagnosis was established by computed tomography. Conclusion: Considering the nonspecific clinical manifestations of splanchnic veins thrombosis, the imaging exams, especially the computed tomography, play a major role in its definitive diagnosis.

Pylephlebitis: Report of a Case Secondary to Appendicitis and Review of Cases Reported in Korea

Pylephlebitis occurs secondary to infection in the region drained by the portal venous system. We described a case of pylephlebitis which developed as a complication of appendicitis and reviewed 22 cases of pylephlebitis, including the current case, reported in Korea. Appendicitis, followed by diverticulitis, was the most common infection associated with pylephlebitis. Fever and abdominal pain were the most common presenting symptoms. Bacteremia was present in 60% of cases. Streptococci, enteric gram-negative bacilli, and Bacteroides fragilis were common organisms isolated from the blood. Liver abscess was identified in 3 cases. All patients survived regardless of anticoagulation therapy. Although pylephlebitis is a rare disease, it should be included in the differential diagnosis in patients with fever of unknown origin who present with nonspecific abdominal symptoms or abnormal liver function test.