Anemia to Median Nerve Palsy.

Mesenteric angina has a high mortality rate. Occlusion of the superior mesenteric artery is the most common cause. Increasingly, it is managed endovascularly instead of by open revascularization. Despite the lower risk of complications in minimally invasive procedures, it is important to be mindful of long-term sequelae of minor complications. Patient education regarding risks and complications is paramount for better clinical outcomes. The risks of transbrachial angiography procedures are low. Postprocedural vigilance for interventionists and written educational advice to patients are paramount in all minimally invasive endovascular procedures, especially because most of these patients with a complication require urgent operative correction.

Thick mesopancreas is a novel predictor of surgical outcomes of patients who undergo pancreaticoduodenectomy.

PURPOSE: Mesopancreas resection is a crucial but difficult procedure when performing pancreaticoduodenectomy. This study evaluated the influence of mesopancreas thickness on surgical outcomes in patients undergoing pancreaticoduodenectomy. METHODS: We measured the thickness of the fat tissue on the right side of the superior mesenteric artery from the dorsal margin of the confluence of the superior mesenteric vein and portal vein to the ventral margin of the left renal vein on preoperative contrast-enhanced computed tomography and defined it as the mesopancreas thickness. We evaluated the correlation between mesopancreas thickness and intraoperative and postoperative variables in 357 patients who underwent pancreaticoduodenectomy. RESULTS: Multivariate analysis revealed that a thick mesopancreas was significantly associated with a long operative time (ß = 10.361; 95% confidence interval, 0.370-20.353, p = 0.042), high estimated blood loss (ß = 36.038; 95% confidence interval, -27.192-99.268, p = 0.013), and a low number of resected lymph nodes (ß = -1.551; 95% confidence interval, -2.662--0.439, p = 0.006). This analysis further revealed that thick mesopancreas was a significant risk factor for overall morbidity (odds ratio 2.170; 95% confidence interval 1.340-3.520, p = 0.002), major morbidity (odds ratio 2.430; 95% confidence interval 1.360-4.340, p = 0.003), and a longer hospital stay (ß = 2.386; 95% confidence interval 0.299-4.474, p = 0.025). CONCLUSION: A thick mesopancreas could predict a longer operation time, higher estimated blood loss, fewer resected lymph nodes, more frequent overall and major morbidities, and a longer hospital stay in patients who underwent pancreaticoduodenectomy more precisely than the body mass index.

Feasibility of middle colic artery as a landmark for superior mesenteric artery - first approach in laparoscopic pancreatoduodenectomy: a prospective study.

BACKGROUND: SMA-first approach in pancreatoduodenectomy (PD) has been widely applied in open surgery as well as laparoscopy. Finding the superior mesenteric artery (SMA), inferior pancreatoduodenal artery (IPDA), first jejunal artery (J1A) has become a great challenge in laparoscopic PD (LPD). Meanwhile, exposing the midde colic artery (MCA) might be a feasible approach to determine SMA, IPDA, and J1A. Our study aims to find the anatomical correlation between MCA and SMA, IPDA, J1A, especially in SMA-first approach LPD from the left. METHODS: Uncontrolled clinical trial with 33 patients undergoing LPD had preoperative contrast abdominal CT scan to analyze the anatomical relevance between MCA and SMA, J1A, IPDA. The operation was performed starting with exposing MCA in advance to find SMA, J1A and IPDA. The data was analyzed by SPSS 25.0. RESULTS: 90.9% of MCA started at 12-3 o'clock from SMA, the mean distance from the SMA root to the MCA and J1A was 56.4 mm and 37.4 mm, respectively. The distance between SMA and J1A was 19 mm. 72.7% J1A started at 9-12 o'clock, 69.7% J1A and IPDA had a common trunk. 78.8% IPDA started at 3-6 o'clock. 100% of the cases had J1A controlled intraoperatively, 81.8% for IPDA when approached from the left, 3% had MCA injury. The mean time to approach from the left was 98 min, median blood loss was 100 ml. CONCLUSION: Exposing MCA first helps determine SMA, J1A and IPDA safely, efficiently and faciliates SMA-first approach LPD from the left and complete dissection of the mesopancreas and lymph nodes.

Impact of Breathing Control Training Program on sonographic quantification of abdominal vasculature.

OBJECTIVES: To compare vascular scanning parameters (vessel diameter, peak systolic velocity, end-diastolic velocity, and resistive index) and scanning time before and after breathing control training program for selected abdominal vessels. METHODS: This study was pre and post quasi-experimental. The researchers designed a breathing training program that gives participants instructions through a video describing breathing maneuvers. Data were collected at the ultrasound laboratory/College of Health and Rehabilitation Sciences in Princess Nourah bint Abdul Rahman University, Riyadh, Saudi Arabia from January 2023 to November 2023. About 49 volunteers at the university participated in the study. Scanning was performed two times for the right renal artery, upper abdominal aorta, inferior vena cava, and superior mesenteric artery. Scanning time was measured before and after the program as well. A paired sample t-test was used to compare the parameters means and time before and after the program. RESULTS: The program had a significant effect on the following parameters: right renal artery peak systolic velocity (p=0.042), upper abdominal aortic peak systolic velocity, and resistive index (p=0.014, p=0.014 respectively), superior mesenteric artery and inferior vena cava diameters (p=0.010 and p=0.020). The scanning time was reduced significantly (p<0.001). CONCLUSION: The breathing training program saves time and improves ultrasound measurement quality. Hospitals and health centers should consider the importance of breathing control training programs before abdominal scanning.

Spontaneous isolated gastric intramural hematoma combined with spontaneous superior mesenteric artery intermural hematoma: a rare case.

BACKGROUND: Gastric intramural hematoma is a rare disease. Here we report a case of spontaneous isolated gastric intramural hematoma combined with spontaneous superior mesenteric artery intermural hematoma. CASE PRESENTATION: A 75-years-old man was admitted to our department with complaints of abdominal pain. He underwent a whole abdominal computed tomography (CT) scan in the emergency department, which showed extensive thickening of the gastric wall in the gastric body and sinus region with enlarged surrounding lymph nodes, localized thickening of the intestinal wall in the transverse colon, localized indistinct demarcation between the stomach and transverse colon, and a small amount of fluid accumulation in the abdominal cavity. Immediately afterwards, he was admitted to our department, and then we arranged a computed tomography with intravenously administered contrast agent showed a spontaneous isolated gastric intramural hematoma combined with spontaneous superior mesenteric artery intermural hematoma. Therefore, we treated him with anticoagulation and conservative observation. During his stay in the hospital, he was given low-molecular heparin by subcutaneous injection for anticoagulation therapy, and after discharge, he was given oral anticoagulation therapy with rivaroxaban. At the follow-up of more than 4 months, most of the intramural hematoma was absorbed and became significantly smaller, and the intermural hematoma of the superior mesenteric artery was basically absorbed, which also confirmed that the intramural mass was an intramural hematoma. CONCLUSION: A gastric intramural hematoma should be considered, when an intra-abdominal mass was found to be attached to the gastric wall. Proper recognition of gastric intramural hematoma can reduce the misdiagnosis rate of confusion with gastric cancer.

No difference in postprandial mesenteric blood flow between healthy younger and elderly individuals.

We recently used phase-contrast magnetic resonance imaging (PC-MRI) to demonstrate an attenuated postprandial blood flow response in the superior mesenteric artery (SMA) in patients with Parkinson's disease compared to age- and sex-matched healthy controls. Since both groups showed substantial inter-individual variations, we extended the cohort of controls with a group of young individuals to investigate possible age-related effects. Seventeen healthy young subjects aged < 30 years and 17 elderly subjects aged > 50 years underwent serial PC-MRI to measure the postprandial blood flow response in the SMA after ingestion of a standardized liquid test meal (∼400 kcal). Postprandial blood flow dynamics in SMA did not differ between young and elderly subjects. A noticeable inter-individual variation in postprandial intestinal blood flow increase was found, and approximately 30% of the variation could be explained by the preprandial blood flow. Regardless of age, some subjects showed a remarkable transient SMA blood flow increase immediately after meal intake. This study provides tentative evidence that postprandial blood flow dynamics in SMA in healthy young and elderly subjects do not substantially differ, indicating that age is without impact on vascular response in SMA as an indicator for regulation of mesenteric perfusion in response to food intake.

Endovascular treatment of traumatic pseudoaneurysm of the ileal branch of the superior mesenteric artery in a 9-year-old girl: Case report and literature review.

RATIONALE: Visceral artery aneurysm is a rare and potentially fatal vascular condition that typically affects the superior mesenteric or inferior mesenteric arteries, the splenic, hepatic, and celiac arteries, as well as their branches. Visceral artery aneurysms can usually be treated using endovascular intervention, open surgery, or percutaneous thrombin injection. PATIENT CONCERNS: A 9-year-old girl was admitted to our trauma center with abdominal and bilateral leg pain after a car accident involving a head-on collision. DIAGNOSIS: Abdominal computed tomography (CT) showed bowel herniation through a muscle defect in the left lateral abdominal wall. There was a small amount of fluid around the liver and spleen, mild thickening of the small bowel wall, and infiltration in the small bowel mesentery, indicating the possibility of small bowel injury. INTERVENTIONS: Emergent exploratory laparotomy was performed. After resection of the ischemic parts of the terminal ileum and sigmoid colon, intestinal continuity was reestablished. Primary repair was performed on a traumatic left lateral abdominal wall hernia. She recovered well postoperatively without any complications. A follow-up abdominal CT scan after 2 months showed a pseudoaneurysm of the ileal branch of the superior mesenteric artery. Despite the absence of any gastrointestinal symptoms, the pseudoaneurysm was treated by endovascular intervention using numerous coils because of the significant risk of delayed rupture or massive bleeding. OUTCOMES: Follow-up abdominal CT scan after 6 months showed complete occlusion and resorption of the pseudoaneurysm. LESSONS: Although it is technically challenging, endovascular coil embolization may be a feasible technique in children with traumatic visceral artery pseudoaneurysms without complications.

Exploring celiac trunk parameters in median arcuate ligament syndrome: A CT study.

PURPOSE: To assess anatomical variations in the celiac trunk (Ct) in patients with Median Arcuate Ligament Syndrome (MALS) using computed tomography (CT). The primary objectives were to investigate the celiac trunk angle (CtA), origin level, length (CtL), and their relationships with the superior mesenteric artery (SMA) in MALS patients. Additionally, the study intended to evaluate gender differences in these parameters and explore correlations between variables. METHODS: Retrospectively, reports of abdominal CT scans taken between January 2018, and Sepmtember 2021, in the hospital image archive were screened vey two observers independently for MALS diagnosis. Parameters such as CtA, CtL, Ct-SMA distance, SMA angle (SMAA), and median arcuate ligament thickness (MALT) were measured. Statistical analyses were conducted using SPSS software. RESULTS: Among the 81 patients (25 females, 56 males), significant differences were observed in MALT between genders (p = 0.001). CtA showed a negative correlation with CtL and Ct-SMA (p < 0.001), and a positive correlation was found between CtL and Ct-SMA (p = 0.002). CtL was measured as 25 mm for the all group. Origin levels of Ct and SMA were evaluated in comparison to vertebral levels. Ct-SMA distance was relatively shorter (9.19 mm) compared to the literature. SMAA findings were consistent with normal population values. CONCLUSION: This study provided valuable insights into the anatomical parameters of the Ct ans SMA in MALS patients. Despite some differences compared to normal population parameters, no evidence supported the hypothesis of a superiorly placed Ct contributing to MALS.

A SICE (Società Italiana di Chirurgia Endoscopica e Nuove Tecnologie) observational prospective multicenter study on anatomical variants of the superior mesenteric artery: intraoperative analysis during laparoscopic right hemicolectomy-CoDIG 2 database (ColonDx Italian Group).

Colorectal cancer, the third most common cancer worldwide, affects 40-45% of patients on the right side. Surgery, especially minimally invasive methods such as laparoscopic and robotic procedures, is the preferred treatment. However, these techniques present technical complications. The anatomical complexity and variations in vessel branching patterns pose challenges, particularly for less experienced surgeons. The CoDIG 2 is a nationwide observational study involving 76 specialized Italian general surgery departments focused on colorectal surgery. The centres were directed to maintain their standard surgical and clinical practices. The aim of this study was to analyse the intraoperative vascular anatomy of Italian patients who underwent laparoscopic right colectomy and explore the ligature techniques used by Italian surgeons. Surgeons reported information about vascularization of the right colon for 616 patients and about surgical anatomy of RCA for 368 patients. Fifty-three patients (10.8%) showed no RCA intraoperatively. The right colic artery (RCA) was categorized according to the Yada classification (types 1-4) during evaluation, and intraoperative assessments revealed that Yada type 1 was the most common type (55.2%), while radiologic evaluations revealed a higher prevalence of type 2. Furthermore, compared with the superior mesenteric vein (SMV), the RCA is more often located anteriorly according to intraoperative and contrast-enhanced CT examination; 59.9% were found in the anterior position during intraoperative examination, while 40.1% were found in the same position on preoperative contrast-enhanced CT. Vascularization of the right colon, including missing branches, additional branches, shared trunks, and retro-superior courses of the mesenteric vein, exhibited notable variations. To understand vascular variations, a preoperative radiological study is necessary; although there was no concordance between the intraoperative and radiological evaluations, this is a limitation of preinterventional radiological evaluation (PII) because it is always needed for oncological staging. This approach is especially critical for inexperienced surgeons to avoid potential complications, such as problematic bleeding.

Multimodal Study of the Superior Mesenteric Artery Wall.

BACKGROUND: To quantitatively analyze histological and fiber structure of the superior mesenteric artery (SMA) wall and to further explore the possible relationship between the architecture and histology changes of vessel wall and the occurrence of related diseases. METHODS: Histological and fiber structure analysis were performed on SMA specimens obtained from 22 cadavers. The SMA specimens were divided into initial, curved, and distal segments, and each segment was separated into the anterior and posterior walls. RESULTS: From the initial to the curved to the distal segment, the ratio of elastin decreased (31.4% ± 6.0%, 21.1% ± 5.8%, 18.6% ± 4.7%, respectively; P < 0.001), whereas the ratio of smooth muscle actin (24.5% ± 8.7%, 30.5% ± 6.8%, 36.1% ± 7.3%, respectively; P < 0.001) increased. Elastic fiber longitudinal amplitude of angular undulation was highest in the initial segment [7° (3.25°, 15°)] and lowest in the curved segment [2° (1°, 5°)]. In SMA curved segment, the anterior wall, when compared with the posterior wall, demonstrated a lower ratio of elastin (19.0% ± 5.8% vs. 23.3% ± 5.0%; P = 0.010) and collagen (41.4% ± 12.3% vs. 49.0% ± 10.2%; P = 0.032), a lower elastic fiber longitudinal amplitude of angular undulation [1° (1°, 5°) vs. 3° (2°, 5.25°); P = 0.013], a lower average fiber diameter (8.06 ± 0.36 pixels vs. 8.45 ± 0.50 pixels; P = 0.005), and a lower average segment length (17.96 ± 1.59 pixels vs. 20.05 ± 2.33 pixels; P = 0.001). CONCLUSIONS: SMA wall structure varies along the circumferential and axial directions, the presence of dense undulated elastic fiber protects the SMA initial segment of from dissection and aneurysm, but highly cross-linked collagen fiber here increases the likelihood of plaque formation. In the anterior wall of the curved segment, lower elastin and collagen content, lower elastic fiber undulation, and higher degree of collagen fiber cross-linking leads to the occurrence of SMA dissection and aneurysm. In the distal segment, high levels of vascular smooth muscle cells and bundles of long collagen fiber offer protection against the development of SMA-related diseases.

Superior mesenteric artery revisited using magnetic resonance angiography.

PURPOSE: We aimed to examine the superior mesenteric artery in detail by magnetic resonance angiography to provide an alternative to other imaging methods, to reduce the exposure time of patients and physicians to X-rays and the time spent in catheter angiography, to determine the variations, positions, and locations of the celiac trunk, and to provide detailed information for surgeons and interventional radiologists using this method. METHODS: The procedures were approved by the Kocaeli University Medical School Non-Interventional Clinical Research Ethics Committee (10.04.2023, approval number: 2021/51). MR angiography images of 185 patients with abdominal imaging in PACS (Picture Archiving Communication Systems) were retrospectively registered. The level of origin of the superior mesenteric artery according to the vertebral column, angle of origin, distance between the superior mesenteric artery and branches of the abdominal aorta, and branching pattern of the superior mesenteric artery were evaluated. Parameters were evaluated according to gender and age using SPSS version 25. RESULTS: The distance between superior mesenteric artery-inferior mesenteric artery and superior mesenteric artery-aortic bifurcation in males was higher than in females, and the difference was statistically significant. In females and the whole study group, a low, positive and significant relationship was found between age and superior mesenteric artery-sagittal angle. The most common origin site for the superior mesenteric artery, according to the vertebral column was found to be at L1 middle for males and L1 upper for females. The most common superior mesenteric artery branching pattern was classical type in both genders. CONCLUSION: Individual evaluation of the superior mesenteric artery could reduce the risks during surgical interventions, considering the relationship of the superior mesenteric artery, especially with distally located vessels, and the gender differences for the angle of origin. Furthermore, considering that interventional radiologists choose the catheter according to the angle of origin of the artery during catheter angiography procedures, individual evaluation of patients taking into account gender and age is of utmost importance.

Deep learning algorithm applied to plain CT images to identify superior mesenteric artery abnormalities.

OBJECTIVES: Atypical presentations, lack of biomarkers, and low sensitivity of plain CT can delay the diagnosis of superior mesenteric artery (SMA) abnormalities, resulting in poor clinical outcomes. Our study aims to develop a deep learning (DL) model for detecting SMA abnormalities in plain CT and evaluate its performance in comparison with a clinical model and radiologist assessment. MATERIALS AND METHODS: A total of 1048 patients comprised the internal (474 patients with SMA abnormalities, 474 controls) and external testing (50 patients with SMA abnormalities, 50 controls) cohorts. The internal cohort was divided into the training cohort (n = 776), validation cohort (n = 86), and internal testing cohort (n = 86). A total of 5 You Only Look Once version 8 (YOLOv8)-based DL submodels were developed, and the performance of the optimal submodel was compared with that of a clinical model and of experienced radiologists. RESULTS: Of the submodels, YOLOv8x had the best performance. The area under the curve (AUC) of the YOLOv8x submodel was higher than that of the clinical model (internal test set: 0.990 vs 0.878, P =.002; external test set: 0.967 vs 0.912, P =.140) and that of all radiologists (P <.001). The YOLOv8x submodel, when compared with radiologist assessment, demonstrated higher sensitivity (internal test set: 100.0 % vs 70.7 %, P =.002; external test set: 96.0 % vs 68.8 %, P <.001) and specificity (internal test set: 90.7 % vs 66.0 %, P =.025; external test set: = 88.0 % vs 66.0 %, P <.001). CONCLUSION: Using plain CT images, YOLOv8x was able to efficiently identify cases of SMA abnormalities. This could potentially improve early diagnosis accuracy and thus improve clinical outcomes.

Dynamic ultrasonography for optimizing treatment position in superior mesenteric artery syndrome: Two case reports and review of literature.

BACKGROUND: Superior mesenteric artery (SMA) syndrome is a rare cause of duodenal obstruction by extrinsic compression between the SMA and the aorta (SMA-Ao). Although the left lateral recumbent position is considered effective in the treatment of SMA syndrome, individual variations in the optimal patient position have been noted. In this report, we present two elderly cases of SMA syndrome that exhibited rapid recovery due to ultrasonographic dynamic evaluation of the optimal position for each patient. CASE SUMMARY: Case 1: A 90-year-old man with nausea and vomiting. Following diagnosis of SMA syndrome by computed tomography (CT), ultrasonography (US) revealed the SMA-Ao distance in the supine position (4 mm), which slightly improved in the lateral position (5.7-7.0 mm) without the passage of duodenal contents. However, in the sitting position, the SMA-Ao distance was increased to 15 mm accompanied by improved content passage. Additionally, US indicated enhanced passage upon abdominal massage on the right side. By day 2, the patient could eat comfortably with the optimal position and massage. Case 2: An 87-year-old woman with vomiting. After the diagnosis of SMA syndrome and aspiration pneumonia by CT, dynamic US confirmed the optimal position (SMA-Ao distance was improved to 7 mm in forward-bent position, whereas it remained at 5 mm in the supine position). By day 7 when her pneumonia recovered, she could eat with the optimal position. CONCLUSION: The optimal position for SMA syndrome varies among individuals. Dynamic US appears to be a valuable tool in improving patient outcomes.

Acute superior mesenteric artery syndrome complicated by severe gastric, pancreatic and renal ischaemia.

Superior mesenteric artery syndrome (SMAS) is a rare and potentially life-threatening cause of small bowel obstruction in which the superior mesenteric artery impinges on the third portion of the duodenum. SMAS is typically encountered in patients with low body fat and a history of rapid weight loss and is often diagnosed as a chronic or subacute condition. Here, we describe a case of a healthy adolescent boy without typical SMAS prodromal symptoms presenting with a severe, hyperacute proximal small bowel obstruction due to SMAS. Complications arising from massive gastric and duodenal distension, including gastric, pancreatic and renal ischaemia, necessitated emergent surgical intervention consisting of the duodenojejunostomy bypass with partial gastric resection. The patient recovered without significant lasting consequences.

Successful Endovascular Treatment of Calcified Superior Mesenteric Artery Complicated by Intramural Hematoma in Chronic Mesenteric Ischemia.

BACKGROUND Chronic mesenteric ischemia (CMI) is defined as ischemic symptoms caused by insufficient supply of blood to the gastrointestinal tract. Patients diagnosed with advanced symptomatic CMI should be treated subsequently, as the transition from CMI to acute mesenteric ischemia can be unpredictable. However, there is little information regarding the management of potential procedural complications during endovascular therapy (EVT) for CMI. CASE REPORT A 70-year-old man was admitted to our hospital with recurrent abdominal pain just after hemodialysis. The angiogram showed significant stenosis with heavy calcification in the proximal of the superior mesenteric artery (SMA), leading to the diagnosis of CMI. To alleviate the symptom, EVT for the stenotic lesion of the SMA was indicated. During the procedure, a cutting balloon was inflated to facilitate vessel expansion in the target lesion. As a result, intravascular ultrasound (IVUS) imaging revealed dissection into the media with extension into the medial space without reentry and demonstrated a semilunar intramural hematoma. We were able to contain the intramural hematoma by covering the whole dissection in the SMA with implantation of self-expandable stents. CONCLUSIONS This case highlights the potential of EVT for heavy calcification of the SMA complicated by dissection without reentry. Intramural hematoma was observed with IVUS examination. We were able to contain the hematoma by the implantation of self-expandable stents over the whole length of the SMA dissection under IVUS-guided EVT.

Use of selective visceral angiography in surgical strategy planning for celiac artery aneurysm in the celiacomesenteric trunk.

BACKGROUND: The celiacomesenteric trunk (CMT) is a common duct of the celiac artery (CA) and the superior mesenteric artery originating from the aorta, which is an uncommon anatomical variant of visceral artery circulation. Because of the variety of visceral circulation in those with CMT, the visceral circulation associated with each branch should be evaluated prior to surgical treatment of visceral artery aneurysm in the CMT. CASE PRESENTATION: A 64-year-old woman was diagnosed with a CA aneurysm in the CMT. Aneurysmectomy of the aneurysm was performed successfully. On preoperative selective visceral angiography, the CA was seen to bifurcate into the common hepatic and splenic artery. The left gastric artery was directly isolated from the aorta and perfused to the common hepatic and splenic artery through collateral circulation. These findings showed that celiac artery embolization is anatomically feasible, even in cases of celiac artery aneurysm rupture. CONCLUSIONS: Selective visceral angiography can contribute to surgical strategy planning for CA aneurysm with CMT.