Vascular challenges from pancreatoduodenectomy in the setting of coeliac artery stenosis

Coeliac artery stenosis due to median arcuate ligament compression or atherosclerotic disease is a frequently unrecognised challenge to recovery after pancreatoduodenectomy. The described case illustrates management with intraoperative superior mesenteric artery to hepatic artery bypass graft that led to haemorrhagic challenges postoperatively but ultimately a good recovery. Aspects of preoperative diagnosis, preoperative intervention and intraoperative management options are reviewed. Surgeons need to possess these tools to prevent complications from coeliac artery stenosis when pancreatoduodenectomy is required

The celiac axis compression syndrome (CACS): critical review in the laparoscopic era

The celiac axis compression syndrome (CACS) due to median arcuate ligament (MAL) was first described by Harjola in 1963; originating postpandrial abdominal pain, weight loss, epigastric bruit and celiac axis stenosis > 75% in angiographic studies. This clinical condition has been the origin of controversies about its pathogenesis, diagnosis and its long term clinical results. Advances in diagnostic imaging as 64 multidetector–row CT (MDCT), 3-D reconstruction, magnetic resonance (MR) and color duplex ultrasonography, provide better understanding of the syndrome and allow to identify the best candidates for surgical division of MAL fibers. Since the introduction of laparoscopic approach, and also endovascular procedures, in 2000, a new perspective has established in this challenging syndrome. With the occasion of our own experience, a critical review of the syndrome is presented

A case of pancreatic cancer with concomitant median arcuate ligament syndrome treated successfully using an allograft arterial transposition

An association of pancreatic cancer and median arcuate ligament syndrome (MALS) is a rare and challenging situation in terms of treatment. A 60-year-old man diagnosed with pancreatic cancer underwent laparotomy. A pancreaticoduodenectomy was planned, but during the resection part of the operation, a celiac artery stenosis was noticed. The patient was diagnosed with MALS causing almost total celiac artery occlusion, with no radiological solution. The patient was re-operated the next day, and an iliac artery allograft was used for aorta-proper hepatic artery reconstruction, concomitant with the total pancreaticoduodenectomy. Preoperative meticulous evaluation of vascular structures of the celiac trunk and its branches is important, especially in pancreatic surgery. A vascular allograft may be a lifesaving alternative when vascular reconstruction is necessary

Logistics and technique for combined hepatic-intestinal retrieval

During a 13-month period, en bloc liver-small bowel cadaveric grafts were procured for seven children and one adult. All liver grafts functioned immediately, and all but one of the recipient patients recovered. Return of absorptive small bowel function was slow, but the integrity of the bacterial intestinal barrier was not disrupted. The described technique allows the procurement of other abdominothoracic organs, with the exception of the whole pancreas

What is Doppler ultrasound?

The term Doppler should be capitalized because it refers to Christian Johann Doppler, an Austrian physicist (1803–1853). He described a phenomenon whereby the frequency of sound changes when it is reflected off a moving object. If the object is moving towards the observer, reflected sound frequency is increased (blue shift), while if the reflecting object is moving away from the observer, the sound frequency decreases (red shift). This is analogous to a moving ambulance with its siren on; the siren pitch increases as ambulance approaches and decreases as it receeds. The Doppler Effect may be used also in ultrasound. With normal grey scale ultrasound we rely on amplitude of reflected sound waves and the reflectivity of anatomic structures is proportional to the intensity (or amplitude) of the reflected sound and hence brightness on the scanner display. If frequency (rather than amplitude) is analysed, one can detect motion on the basis of Doppler shifts. These frequency shifts can be quantified reasonably accurately according to direction, velocity and also acceleration, all of which provide specific signatures that help identify both normal and diseased blood vessels.peer-reviewe

An intriguing autopsy case of gangrene intestine

Background Hashimoto’s thyroiditis is one of the most common causes of hypothyroidism. Hypothyroidism is a known cause of hyperlipidemia. There is a strong correlation between coronary and mesenteric vessel atherosclerosis. Acute mesenteric ischemia is a cause of intestinal hemorrhagic infarction. Case history We present an autopsy case of 35-year-old male who presented with features of obstruction and edema with previously undetected hypothyroidism. Conclusion Hypothyroidism associated with atherosclerosis can lead to fatal intestinal gangrene as corroborated by this autopsy case. Key words –Hypothyroidism, intestinal gangrene, autopsy, atherosclerosi

Abdominal multivisceral transplantation

Under FK506-based immunosuppression, 13 abdominal multivisceral transplantations were performed in 6 children and 7 adults. Of the 13 recipients, 7 (53.8%) are alive and well with functioning grafts after 9 to 31 months. Six recipients died: Three from PTLD, one from rejection, one from sepsis, and one from respiratory failure. In addition to rejection, postoperative complications occurring in more than isolated cases included PTLD (n=6), abdominal abscess formation (n=5), pancreatitis (n=3), and ampullary dysfunction (n=2). In addition, infection by enteric microorganisms was common during the early postoperative period. Currently, all 7 survivors are on an oral diet and have normal liver function. Two recipients (one insulin-dependent) require antidiabetes treatment, in one case following distal pancreatectomy and in the other after two episodes of pancreatic rejection. Thus, abdominal multivisceral transplantation is a difficult but feasible operation that demands complex and prolonged posttransplantation management. It is not yet ready for application and awaits a better strategy of immune modulation. © 1995 by Williams & Wilkins