The Vascularization Pattern of the Colon and Surgical Decision in Esophageal Reconstruction with Colon. A Selective SMA and IMA Arteriographic Study

Rezumat Pattern-ul de vascularizaåie al colonului aei decizia chirurgicalã în reconstrucåia esofagianã cu colon -studiu arteriografic selectiv al AMS aei AMI Introducere: Indiferent de tehnica reconstructivã, conceptele de fundamentare din reconstrucåia visceralã au ca baza principalã suportul vascular necesar pentru grefonul de substituåie. Particularitãåile vasculare individuale pot înclina sau chiar obliga chirurgul la o anumitã opåiune cãtre unul sau altul dintre procedee. De aceea, vascularizaåia este, fãrã îndoialã, factorul care dominã mobilizarea colonului pentru reconstrucåia esofagianã. Material aei metodã: Studiul nostru arteriografic aei-a propus o investigaåie asupra tiparului vascular al celor douã surse principale ce participã prin vasele emergente la irigarea arterialã a colonului: a. mezentericã superioarã (AMS) respectiv a. mezentericã inferioarã (AMI). Nu am avut în vedere selectarea pacienåilor dupã un anumit criteriu dupã cum nu am realizat nici o excludere dintr-un anumit considerent. Lotul de studiu a constat din 49 de pacienåi care s-au prezentat în clinicã pentru o tehnicã reconstructivã, toåi aparåinând perioadei 2000-2010. În intervalul 1981-2012, au fost efectuate 187 de tehnici reconstructive pentru o indicaåie postcausticã. Din totalul de 49 de pacienåi, 11 bolnavi suferiserã intervenåii chirurgicale abdominale majore iar dintre aceaetia, 5 cu tentative nereuaeite de reconstrucåie. Rezultate: Din cei 49 de pacienåi la care s-a efectuat explorarea, arteriografia a evidenåiat o situaåie favorabilã reconstrucåiei la 31 dintre aceştia. La ceilalåi 18 pacienåi au fost identificate anomalii ori distribuåii atipice, 5 ale AMS respectiv 13 ale AMI. Decizia operatorie a fost ajustatã la 22 de bolnavi. Un lucru important de semnalat dpdv predictiv asupra viscerul de mobilizat: nu am avut necroze de grefon la pacienåii cu examinare arteriograficã preoperatorie. Concluzii: Dictate de necesitatea unei bune mobilizãri, ligaturile arteriale trebuie adaptate şi modificate în funcåie de particularitãåile de distribuåie vascularã, astfel încât sã se menåinã un flux sangvin suficient în arcada marginalã pânã la nivelul secåiunilor colice şi, implicit, în arterele drepte din vecinãtatea acestora. main grounds the mandatory vascular support for the graft replacement. Individual vascular particularities can influence or even oblige the surgeon to choose a certain procedure. This is why the vascularization is beyond doubt the dominant factor in mobilizing the colon for reconstruction. Material and method: Our arteriographic study entails an investigation upon the vascularization pattern of the two main sources that participate in the arterial irrigation of the colon via the emerging vessels: superior mesenteric artery (SMA) and inferior mesenteric artery (IMA). We did not consider certain patients upon a specific criterion; also, we did not exclude any patients due to various reasons. We took into account 49 patients as study group, all of them having registered into the clinic for a reconstructive technique, throughout the years from 2000 to 2010. From 1981 to 2012 there have been 187 reconstructive techniques performed due to post caustic pathology. From a total of 49 patients, 11 had suffered major abdominal surgeries, 5 of which had had unsuccessful reconstructive attempts. Results: Out of the 49 patients on whom we have performed the exploration, arteriography showed a favorable situation for reconstruction in 31 of them. In the other 18 patients anomalies or atypical distributions were identified, in 5 of the SMA and in 13 of the IMA, respectively. Operative decision was modified in 22 patients. One important thing to note from the point of view of the segment to be moved: we had no graft necrosis in patients with preoperative arteriographic examination. Conclusions: Due to the need for good mobilization, arterial ligations should be adjusted and modified depending on the particular vascular distribution, to maintain a sufficient blood flow in the marginal artery, in order to reach the colic sections and the straight arteries near them. Abbreviations: SMA -superior mesenteric artery; IMAinferior mesenteric artery; ICa -ileocolic artery; RCa -right colic artery; MCa -middle colic artery; LCa -left colic artery; LC acc.a -left accessory colic artery (or middle left colic artery); ILCa -inferior left colic artery; S trunk -sigmoidian trunk; Sa -sigmoidian artery; SRa -superior rectal arter