Comparison of distal pancreatectomy with celiac axis resection and sub-adventitial divestment technique for locally advanced or borderline resectable pancreatic body cancer / 中华外科杂志

Objective: To compare the outcomes of modified Appleby procedure and sub-adventitial divestment technique for locally advanced or borderline resectable pancreatic body cancer. Methods: A total of consecutive 58 patients(33 males and 25 females) who were diagnosed as locally advanced or borderline resectable pancreatic body cancer and underwent distal pancreatectomy at Pancreas Center, First Affiliated Hospital of Nanjing Medical University between September 2013 and May 2019 were retrospectively reviewed. The age(M(IQR)) was 62(9)years(range: 43 to 79 years). Thirty-one patients underwent distal pancreatectomy with celiac axis resection (DP-CAR) and 27 patients underwent distal pancreatectomy with sub-adventitial divestment technique(SDT). Perioperative parameters and follow-up data of these patients were analyzed. Quantitative data were compared with Wilcoxon test while categorical variables were compared with χ2 test or Fisher's exact test. Survival results were estimated by the Kaplan-Meier survival method with a Log-rank test. Results: There were no differences in age,gender,body mass index,abdominal symptoms,comorbidity or preoperative serum CA19-9 between two groups(all P>0.05). Obvious preoperative weight loss was more common in the group of SDT(48.1%(13/27) vs. 19.4%(6/31),χ²=5.431,P=0.020). Longer operative time(310(123) minutes vs. 254(137)minutes, Z=2.277,P=0.023),higher rate of combined organ resection(41.9%(13/31) vs. 14.8%(4/27),χ²=5.123,P=0.041) and longer postoperative hospital stay(15(10) days vs. 11(5)days,Z=2.292,P=0.022) were observed in the group of DP-CAR. Moreover,rate of overall morbidities was also higher (71.0%(22/31) vs. 29.6%(8/27),χ2=9.876,P=0.003),implicated by clinically relevant postoperative pancreatic fistula(61.3%(19/31) vs. 29.6%(8/27),χ2=5.814,P=0.020) in the DP-CAR group. Tumor size of the DP-CAR group was bigger(4.9(1.5)cm vs. 4.0(1.2)cm,Z=2.343,P=0.019) but no difference was seen between the DP-CAR group and SDT group in R0+R1(<1 mm) resection rate (84.0%(21/25) vs. 90.0%(18/20),P=0.678) and LNR(12.0(23.0)% vs. 9.0(18.0)%,Z=1.238,P=0.216),as well as median disease free survival(11.7 months vs. 11.4 months,Z=0.019,P=0.892) and median overall survival(16.3 months vs. 13.7 months,Z=0.172,P=0.679). Conclusions: Both DP-CAR and distal pancreatectomy with SDT are relatively safe and feasible for locally advanced or borderline resectable pancreatic body cancer. Compared with arterial resection,SDT may contribute to lower rates of postoperative complications and shorter duration of hospitalization,but no significant benefit is seen in long-term survival.

Latest Progresses in Surgical Treatment of Median Arcuate Ligament Syndrome / 中国医学科学院学报

Median arcuate ligament syndrome(MALS)is compression of the celiac trunk by the median arcuate ligament.Median arcuate ligament release is the corner stone for the surgical treatment of MALS.Open surgery,laparoscopic surgery,and robot-assisted surgery have been developed,among which laparoscopic surgery has been proposed as the preferred approach in view of its minimal trauma and short hospital stay.Auxiliary celiac plexus neurolysis could further alleviate the patient's discomfort.Moreover,vascular reconstitution is of vital importance in the case of persistent stenosis in the celiac artery despite of median arcuate ligament decompression.Vascular reconstruction has satisfactory long-term patency rate,while endovascular treatment is less invasive.This article aims to summarize the consensuses and advances and shed light on the surgical treatment of MALS.

Pancreatectomía corpo-caudal con resección en bloque de tronco celíaco: reporte de 2 casos / Corporal caudal pancreatectomy with celiac trunk block resection: report of 2 cases

INTRODUCCIÓN: El adenocarcinoma de cuerpo y cola de páncreas corresponde a cerca de un tercio del total de cánceres pancreáticos. Evoluciona en forma silenciosa hasta alcanzar estadios avanzados, llegando a comprometer muchas veces grandes vasos como tronco celíaco y sus ramas, y la arteria mesentérica superior. La resolución quirúrgica parece ser la única alternativa en estos casos. OBJETIVO: Presentar dos casos de adenocarcinoma de cuerpo y cola de páncreas tratados en nuestro hospital con pancreatectomía corpo-caudal y resección en bloque de tronco celíaco (procedimiento de Appleby modificado). DISCUSIÓN: Este procedimiento ha demostrado aumentar la sobrevida de estos pacientes, además de generar un alivio inmediato y duradero del dolor. Sin embargo, corresponde a una intervención con una alta morbilidad, siendo la fístula pancreática y la gastropatía isquémica las complicaciones más frecuentes. La evaluación del flujo de los vasos colaterales es un paso crítico para evitar las complicaciones isquémicas. CONCLUSIONES: La pancreatectomía corpo-caudal con resección en bloque de tronco celíaco, es una alternativa factible en adenocarcinoma de cuerpo y cola de páncreas localmente avanzado. Su indicación debe ser cuidadosa debido a que corresponde a un procedimiento con alta morbilidad.

INTRODUCTION: Adenocarcinoma of the body and tail of the pancreas corresponds to about one third of all pancreatic cancers. It evolves silently to reach advanced stages, often involving large vessels such as the celiac trunk and its branches, and the superior mesenteric artery. Surgical resolution seems to be the only alternative in these cases. AIM: To present two cases of adenocarcinoma of the body and tail of the pancreas treated in our hospital with distal pancreatectomy and celiac trunk en block resection (modified Appleby procedure). DISCUSSION: This procedure has been shown to increase the survival of these patients, in addition to generating immediate and lasting pain relief. However, it corresponds to an intervention with a high morbidity, being the pancreatic fistula and the ischemic gastropathy the most frequent complications. The evaluation of the flow of the collateral vessels is a critical step to avoid ischemic complications. CONCLUSIONS: Distal pancreatectomy with en bloc resection of the celiac trunk is a feasible alternative in locally advanced adenocarcinoma of the body and tail of the pancreas. Its indication must be careful since is a procedure with high morbidity.

Effect of taxifolin on oxidative gastric injury induced by celiac artery ligation in rats

Abstract Purpose: To examine the effect of taxifolin on I/R induced gastric injury in rats using biochemical and histopatholohical methods. Methods: Eighteen albino Wistar male rats equally grouped as; gastric I/R (I/R), 50 mg/kg taxifolin + gastric I/R (TAX+ I/R) and sham operation applied (SHAM). Ischemia induced for 1 hour, and reperfusion induced for 3 hours. Results: Oxidant parameters like, Malondialdehyde (MDA) and Hydroxyguanine (8-OHdG) were higher, whereas total glutathione (tGSH) was lower in the I/R group according to SHAM group, histopathological findings such as marked destruction, edema, and proliferated dilated congested blood vessels were observed severely in the I/R group, whereas there was not any pathological finding except mild dilated congested blood vessels in the TAX+ I/R group. Conclusion: The taxifolin can be clinically beneficial in the treatment of gastric injury due to I/R procedure.

Anatomical variations of the celiac trunk: a systematic review / Variações anatômicas do tronco celíaco: uma revisão sistemática

ABSTRACT Introduction: The celiac trunk (CT) is one of the abdominal portion branches of the aortic artery and, together with the superior mesenteric and inferior mesenteric arteries, participates in the abdominal viscera vascularization through a series of anastomoses. Absence of CT or variation in the number of terminal branches implies in varied abdominal arteries origins, which may have implication in surgical approaches. Objective: To analyze the anatomical variations of the celiac trunk and possible associated surgical clinical implications. Methods: It is a systematic review of articles indexed in the PubMed, Lilacs, SciELO, Springerlink, Scienc Direct and Latindex databases from August to September 2017. Original articles involving the anatomical variations of the celiac trunk in humans were included. The presence/absence of the celiac trunk, the number of terminal branches and the place of origin of its branches in variant cases of the normal anatomical pattern, were considered for this study. Results: At the end of the research, 12 articles were selected, characterized by sample, anatomical structure evaluation method and main results. The normal anatomical pattern was the most prevalent in most studies (75.0%). CT was absent in 41.7% of the findings. The most prevalent anatomical variation was the presence of CT with bifurcation (66.7%). It was also observed the origin of the common and splenic hepatic arteries from the mesenteric arteries (25.0%). The presence of only one branch (16.7%) and quadrifurcation (8.33%) were other findings. Conclusion: CT variations are not uncommon findings, with different anatomic variants being reported. Thus, the importance of knowing the possible variations of this structure is emphasized, which may have implications for surgical interventions and imaging studies related to the abdominal region.

RESUMO Introdução: O tronco celíaco (TC) surge da aorta abdominal e juntamente com as artérias mesentérica superior e mesentérica inferior participa da vascularização de vísceras abdominais por meio de uma série de anastomoses. Ausência do TC ou variação no número de ramos terminais implica em origens variadas das artérias abdominais, o que pode ter implicação em abordagens cirúrgicas. Objetivo: Analisar as variações anatômicas do TC e as possíveis implicações clínico/cirúrgicas associadas. Métodos: Trata-se de uma revisão sistemática de artigos indexados nas bases de dados PubMed, Lilacs, SciELO, Springerlink, Scienc Direct e Latindex, no período de agosto a setembro de 2017. Foram incluídos artigos originais envolvendo as variações anatômicas do TC em humanos. Considerou-se para este estudo a presença/ausência do TC, o número de ramos terminais e o local de origem de seus ramos em casos variantes do padrão anatômico normal. A coleta foi realizada por dois revisores independentes. Resultados: Ao final da busca foram selecionados 12 artigos, caracterizados quanto à amostra, método para avaliar a estrutura anatômica e principais resultados. O padrão anatômico normal foi o mais prevalente na maioria dos trabalhos (75,0%). O TC foi ausente em 41,7% dos achados. A variação anatômica mais prevalente foi a presença do TC com bifurcação (66,7%). Observou-se, ainda, a origem das artérias hepática comum e esplênica a partir das artérias mesentéricas (25,0%). A presença de apenas um ramo (16,7%) e quadrifurcação (8,33%) foram outros achados presentes. Conclusão: Variações do TC não são achados incomuns, sendo relatados diferentes variantes anatômicas. Desse modo, ressalta-se a importância sobre o conhecimento das possíveis variações dessa estrutura, o que pode ter implicação em intervenções cirúrgicas e exames de imagem relacionados à região abdominal.

Síndrome ligamento arcuato medio / Median arcuate ligament syndrome

Background: Median arcuate ligament syndrome (SLAM) is caused by extrinsic compression of the celiac artery by fibrous bands of this ligament and periaortic lymph node tissue. Case report: We report a 59 years old man with a history of weight loss, epigastric pain and a postprandial murmur. The syndrome was diagnosed by CT angiography. The patient was operated, performing a midline laparotomy and releasing the extrinsic compression. An early and sustained remission of symptoms was achieved.

Introducción: El síndrome del ligamento arcuato medio (SLAM), es causado por la compresión extrínseca del tronco celíaco por bandas fibrosas de este ligamento y tejido ganglionar periaórtico. Caso clínico: Reportamos el caso de un hombre de 59 años con historia de baja de peso, dolor postprandial y soplo epigástrico, al cual se le diagnostica SLAM por medio de angioTC. Se realiza abordaje quirúrgico, con laparotomía media y liberación de la compresión extrínseca, logrando remisión de los síntomas de forma inmediata y sostenida. El SLAM es una causa infrecuente de dolor abdominal, requiere estudio por imágenes para su diagnóstico, la resolución quirúrgica constituye su tratamiento.

Síndrome de compresión del tronco celíaco por el ligamento arcuato mediano: Tratamiento laparoscópico

El síndrome del ligamento arcuato medio (SLAM), o síndrome de compresión del tronco celíaco, es causado por la compresión extrínseca del ligamento arcuato medio, bandas fibrosas prominentes y tejido ganglionar periaórtico. En muchas ocasiones es asintomático, pero puede manifestarse con síntomas como dolor abdominal postprandial o durante el ejercicio, náuseas, vómitos y pérdida de peso. Mediante técnicas poco invasivas, como la ecografía doppler color y la angiotomografía preoperatoria, es posible obtener resultados diagnósticos comparables a los de la arteriografía. La cirugía constituye el tratamiento de elección, siendo la vía laparoscópica una técnica segura y eficaz Se presenta un caso sintomático atípico que requirió tratamiento quirúrgico laparoscópico, con mejoría clínica e imagenológica luego del procedimiento.

Median arcuate ligament syndrome (MALS), or celiac trunk compression syndrome, is caused by extrinsic compression of median arcuate ligament, prominent fibrous bands and periaortic nodal tissue. In many cases is asymptomatic, but it may manifests with symptoms such as postprandial abdominal pain or during exercise, nauseas, vomiting and weight loss. Trough less invasive diagnostic techniques, such as doppler ultrasound for screening and preoperative angiotomograhpy, it is possible to obtain good results, comparable to those with arteriography. Surgical treatment by laparoscopic approach is a safe and effective technique. A symptomatic case that required surgical treatment, a laparoscopic approach, with clinical and imaging improvement after the procedure, is presented.

Surgical treatment of Dunbar syndrome / Tratamento cirúrgico da síndrome de Dunbar

Dunbar syndrome or celiac artery compression syndrome is an infrequently described clinical condition with poorly defined diagnostic criteria and an obscure pathophysiology. It is usually associated with an extrinsic compression upon the celiac axis near its takeoff from the aorta by fibrous diaphragmatic bands or sympathetic neural fibers. The authors report the case of a 70-year-old male patient presenting with nausea, epigastric pain, and weight loss. An aortography showed a compression of the celiac trunk. A preliminary attempt at percutaneous transluminal angioplasty and stenting proved unsuccessful. The patient became asymptomatic and his clinical condition improved after surgical release of the celiac trunk by partial section of the arcuate ligament of the diaphragm and with resection of the neural, fibrotic, and lymphatic tissues surrounding the aortic and visceral vessels. The purpose of this report is to discuss the indications and the therapeutic options of this syndrome.

A síndrome de Dunbar ou compressão do tronco celíaco é uma condição clínica infrequente, com poucos critérios para diagnóstico e com patofisiologia obscura. Está usualmente associada à compressão extrínseca do tronco celíaco por banda fibrosas do diafragma e fibras neurais simpáticas, próximo a sua emergência da aorta. Os autores relatam um caso de um paciente de 70 anos de idade com quadro de náuseas, dor epigástrica e perda de peso. Uma arteriografia mostrou compressão do tronco celíaco. Uma primeira tentativa de angioplastia com stent foi realizada em outro serviço, mas sem sucesso. Após o tratamento cirúrgico que consistiu de secção parcial do ligamento arqueado do diafragma com ressecção dos tecidos fibróticos, neurais e linfáticos que circundavam a aorta e as artérias viscerais, o paciente obteve melhora clínica e tornou-se assintomático. O objetivo deste estudo é discutir as indicações e opções terapêuticas desta síndrome.

Resección de tronco celíaco en cáncer de cuerpo y cola de páncreas / Celiac axis resection in cancer of the pancreas body and tail

Antecedentes: La resecabilidad del cáncer de cuerpo de páncreas es baja. Históricamente la invasión al tronco celíaco era considerada una contraindicación para la resección. Series recientes, sin embargo, muestran la factibilidad y utilidad de la esplenopancreatectomía con resección del tronco celíaco en cáncer de cuerpo de páncreas. Objetivo: Presentar dos pacientes con tumor de cuerpo de páncreas e invasión al tronco celíaco tratados mediante resección con intento curativo. Lugar de aplicación: Centro terciario de referencia. Diseño: Retrospectivo. Población: Dos pacientes con diagnóstico anatomapatológico de adenocarcinoma de páncreas e invasión del tronco celíaco tratados mediante esplenopancratectomía y resección del tronco celíaco. Método: Análisis retrospectivo de una base de datos de resecciones plancreáticas. Resultados: La estadificación preoperatoria se realizó mediante TAC dinámica. En ambos pacientes se comprobó la invasión al tronco celíaco y se realizó esplenopancreatectomía con resección del tronco celíaco sin reconstrucción arterial. En un paciente, por invasión directa del tumor al estómago, se realizó gastrectomía total. No se registraron complicaciónes mayores ni mortalidad. En los dos pacientes la resección fue RO. Ambos pacientes recibieron tratamiento adyuvante con quimioradioterapia y actualmente se encuentran sin evidencia de recurrencia a los 11 y 7 meses de cirugía. No requieren analgésicos en el postoperatorio alejado. Conclusiones: En pacientes con cáncer de cuerpo de páncreas e invasión aislada al tronco celíaco es posible la resección con intento curativo. La resección del tronco celíaco se puede realizar sin reconstrucción arterial ni resección gastrointestinal. En centros con alto volumen, esta cirugía se puede realizar con aceptable morbimortalidad.

A review on the celiac trunk compression syndrome: some anatomic clinical-surgical aspects / Una revisión del síndrome de compresión del tronco celíaco: algunos aspectos anatómicos clínicos-quirúrgicos

The objective of this study was to review some celiac trunk compression syndrome aspects such as: symptom-posture relationship; absence of symptoms; syndrome-age relationship; angiographic study on anatomy of the celiac trunk stenosis; congenital or acquired origin; invasive diagnostic tests; surgical and postoperative results.

El objetivo de este estudio fue hacer una revisión del síndrome de compresión del tronco celíaco, en cuanto a aspectos tales como: relación síntoma-postura; ausencia de síntomas; relación síndrome-edad; estudio angiográfico sobre la anatomía de la estenosis del tronco celíaco; origen congénito o adquirido; tests diagnósticos no invasivos; resultados quirúrgicos y post-quirúrgicos.

Tratamiento quirúrgico de la isquemia mesentérica crónica: Caso clínico / Surgical treatment of chronic mesenteric ischemia: Report of one case

Although the classic therapy for chronic mesenteric ischemia is surgical revascularization, endovascular therapy is a new therapeutic option. We report a 55 year-old female, with a 2 years history of post prandial abdominal pain, diarrhoea, and weight loss, with occlusion of both mesenteric arteries and critical stenosis of the celiac artery. The initial treatment consisted in angioplasty and celiac artery stent placement in two occasions, with a brief symptomatic relief. Finally, a visceral artery bypass was performed, with good post operative outcome and complete symptomatic resolution at one year follow up. In our opinion endovascular therapy is a good therapeutic option for chronic mesenteric ischemia in high surgical risk patients, specially when dealing with stenotic injuries. It may also be a complement for patients who need to recover their nutritional status prior to revascularization surgery. On the other hand, due to the long term patency and symptomatic relief, surgical treatment is a good option in low risk patients.

Celiac trunk compression syndrome: a review / Una Revisión del Síndrome de Compresión del Tronco Celíaco

La presente revisión tiene por objetivo conocer tanto los aspectos anatómicos como clínicos y quirúrgicos relacionados con el síndrome de compresión del tronco celíaco causado por el ligamento arqueado mediano del diafragma. Se revisan los principales descubrimeinos del síndrome, tanto en el plano anatómico durante la disecación de cadáveres, como en la clínica-quirúrgica de la estenosis del tronco celíaco. Además, se revisa la relación de esta estenosis con los síntomas del paciente y cura después de la descompresión del tronco celíaco. Por otra parte, se explican los métodos no invasivos e invasivos utilizados en la descompresión; el efecto estenótico de los mecanismos fisiológicos del desplazamiento del ligamento arqueado mediano, aorta y tronco celíaco durante la respiración; anatomía del canal aórtico y plexo celíaco; el ligamento arqueado mediano y el plexo celíaco como agentes constrictores; la esquelotopía del tronco celíaco y del ligamento arqueado mediano y la predisposición para el síndrome. Finalmente, se hace una asociación del síndrome del tronco celíaco con anomalías morfológicas y metabólicas.

The purpose of the present review is to report the anatomic and the clinical-surgical aspects involved in the celiac trunk compression syndrome by the median arcuate ligament of the diaphragm, reviewing the major findings of the syndrome in the anatomic field during dissection of cadavers, followed by clinical-surgical findings of stenosis of the celiac trunk, the relationship of this stenosis with the patient's symptoms and healing after decompression of that artery; invasive and non-invasive methods used to diagnose compression; the stenotic effect of physiologic mechanisms of the median arcuate ligament, aorta and celiac trunk displacement during respiration; anatomy of the aortic channel and celiac plexus; the median arcuate ligament and the celiac plexus as constrict agents; skeletopy of the celiac trunk, the median arcuate ligament and predisposition to syndrome; association of the syndrome with morphological and metabolic aspects.

Management of visceral artery aneurysms

Objective: Visceral artery aneurysms, despite being uncommon, are important vascular diseases, since they frequently are life threatening, and often fatal emergencies. The purpose of this study is to review our experience with treatment of visceral artery aneurysms. Method: Between 1988 and June, 2004, 37 visceral artery aneurysms were treated in 35 patients (17 male and 18 female) with average age of 56 mais ou menos 14 years. The most common locations were the splenic artery (18), the hepatic artery (10) and the superior mesenteric artery (four), 22 patients were asymptomatic, 13 patients were symptomatic. Emergency surgery was performed on three patients, elective open surgery on 20 patients, and endovascular treatment onseven patients. Results: Perioperative mortality rate was 3,1 por cento in the surgical group. The perioperative mobidity rate was 5,7 por cento: one case of respiratory distress and one case of bilious fistula were...

Management of celiac artery aneurysm: a case report.

A case of CAA in a 68-year-old male patient is reported. The patient had vague abdominal pain for 1 year. Physical examination revealed a pulsatile abdominal mass on the epigastrium. Abdominal ultrasonography and visceral arteriography confirmed the diagnosis of CAA. Aneurysmectomy with direct implantation was performed transabdominally.

Celiac-superior mesenteric artery anastomosis in pancreatic transplantation: a new technique

En el trasplante total de pancreas, la anastomosis es hecha rutinariamente con la vena porta y un "patch" de la aorta conteniendo el tronco celíaco y la arteria mesentérica superior. Una nueva técnica se describe en dos casos donde se anastomosa en forma térmico-lateral la arteria mesentérica superior con la arteria ilíaca externa y luego se anastomosa el tronco celíaco a la parte próximo-terminal de la arteria mesentérica superior

Aneurismas del tronco celíaco / Celiac trunk aneurysms

En la literatura mundial se han publicado 81 casos de aneurima del tronco celíaco, solamente 41 casos han sido operados. Se presenta un caso operado con éxito en 1984. Las causas más frecuentes de aneurisma del tronco celíaco son la aterosclerosis y la fibrodisplasia. Las formas clínicas de presentación son muy variables. La ecografía y angiografía son los pilares del diagnóstico. El tratamiento es siempre quirúrgico. Preferimos la vía supraumbilical para el abordaje. La revascularización hepática es de suma importancia, no así la conservación del flujo esplénico y de la arteria coronaria estomáquica. Se presenta un caso resuelto con resección aneurismática y revascularización hepática por "bypass" aorto hepático