Anatomical study of the pre-segmental and segmental arteries of the kidney and their impact in the nephronsparing surgery

Clamping of the main renal artery (RA) is still regarded as a commonly used technique to decrease haemorrhage in partial nephrectomy, but it causes warm ischaemic injury. The aim of this study was to describe the pattern of pre-segmental and segmental branches of the RA. To obtain vascular corrosions casts, twenty kidneys were injected with acrylic resins and underwent to computed tomography examination. Analysis of images and of casts showed that the pattern of vascularisation of posterior renal segment was constant (except that in one case), presenting one segmental artery. The vascularisation of the anterior parenchyma (apical, superior, middle and inferior segments) originated directly from an anterior branch of the RA (70%) or thorough pre-segmental arteries (PSA) (30%). In 20% two middle segmental artery originated from two different PSAs. A series of vascular renal patterns have been identified, that the surgeon must know before to conduct the selective clamping, i.e. the selective clamping of segmental artery originating from a PSA could more difficult, because the surgeon can wrongly close the PSA with subsequent ischemia of the more parenchymal segments. Moreover, in case of multiple segmental arteries, originating from two PSA, the surgeon can wrongly clamp only one of them with subsequent intraoperative hemorrhage

An anatomo-radiological study of the renal segments

An increasing number of observations call the general scheme of five renal segments into question, with anatomists, radiologists and surgeons that have reported discrepancies between Graves’s scheme and morphological observations. The aims of the present study was to analyse the arterial vascular anatomy with reference to the renal segments. 15 kidneys were injected with acrylic resins to obtain vascular corrosions casts that were analyzed also with computed tomography. A mean number of 6,1 (range 4-8) avascular fissures were found, determining the presence of a mean number of 7,1 segments (range 5-9). The apical and posterior segments were in all the cases single. In the superior and middle territory there was a single segment in 6 cases (40%) and two segments in 9 cases (60%). In the inferior territory there was a single segment in 1 case (6,7%), two segments in 12 cases (80%), and three segments in 2 cases (13,3%). The renal arterial vasculature cannot be schematized according to the classical Graves classification because the majority of the evaluated cases showed a different number of segments. The presence of the fissures in the virtual vascular casts is a useful tool to identify the boundary between the vascular territories

Brödel’s line: an anatomo-radiological study of the avascular kidney’s plane

The division in anterior and posterior branches of the renal artery implies the existence of an avascular plane, the so call Brödel’s line (1). This longitudinal zone is described along the convex renal border (2) or just posterior to the lateral aspect of the kidney (3). The aim of this study was to describe the extension of Brödel’s line with reference to the renal segments. 12 kidneys were injected with acrylic resins to obtain vascular corrosions casts that were analyzed also with computed tomography. We observed the presence of a relative avascular plane in all vascular casts, located on the posterior surface, ascribable to the Brodel’s line. In 33% of cases the line extended from the apical to the inferior segments, in the 33% of cases it extended from the superior to the inferior segments, in 33% of cases it is limited to the superior and middle segments. Since the Brödel’s line corresponds with the plane of the anterior surface of the posterior hilar calyces, the knowledge of its extension is relevant from the surgical point of view: this area permits a relatively safe access route to the pelvicalyceal system for nephrostomy insertion and incision within this plane results in significantly less blood loss than outside this plane

Anatomical and Radiologic study about the vascular supply of the pancreas interrelated with resective surgery

Postoperative pancreatic fistula is still regarded as a major complication. Its incidence varies greatly in different reports. The aim of the present study was to evaluate possible correlation between the incidence of postoperative complications and the vascular architecture of the pancreas. Ten specimens of pancreas, duodenum and spleen were injected to obtain vascular casts of the hepatic, splenic and superior mesenteric artery (SMA). Computed tomography angiographs of the upper abdomen of 30 patients, that undergone to pancreatoduodenectomy, and of 50 subject controls (25 female, 25 men) with a mean age of 70.2 years were analysed to investigate the depiction rate and branching of the vascular supply of the pancreas main vessels. The anterior superior pancreaticoduodenal artery (ASPD) and the posterior superior pancreaticoduodenal artery (PSPD) were visible in 95% and 98.2%. The ASPD contributes to create one or two anterior arcade in 90% and 10% respectively, the PSPD contributes to create one posterior arcade in 100%. The inferior pancreaticoduodenal stem was visible in 100% with its two branches. The inferior origin of the posterior arcade i.e. inferior anterior pancreaticoduodenal artery (IAPA) emerges from SMA in 40%, from the first jejunal artery in 60%.The dorsal pancreatic artery (DPA) was visible in 45%, coming from the splenic artery in 60%, from the celiac trunk in 30%, from the common hepatic artery on 10%. The transverse artery was visible in 80% coming from the SMA in 60%, from the dorsal pancreatic artery in 30% and from the anterior arcade in 10%. Preoperative understanding of the vascular anatomy of the pancreatic head is important in order to reduce frequency of complication

Clinical anatomy of the caudal pancreatic arteries and their relevance in the surgery of the splenic trauma

Splenectomy is the treatment of splenic trauma but is not exempt from intra-operative and post-operative complications. Conservative approach is preferred for paediatric population and for minor trauma. The aim of the present study was to evaluate the vascularisation of the tail of the pancreas, with particular reference to the presence of anastomosis between the pancreatic and splenic vessels, through an anatomoradiologic study performed on 9 unembalmed cadavers (age range 44-77 years). To obtain vascular corrosion casts, the splenic, the gastroduodenal and the superior mesenteric arteries were injected with acrylic and radioopaque resins and computed tomography (CT) of the specimens were acquired. The caudal pancreatic arteries (mean number ± standard deviation: 3.2 ± 2.4) were observable in all the casts, originating from the splenic artery at its distal third (70%) and from its inferior branch (30%). At CT scans analysis the mean calibre of caudal pancreatic arteries was 2.1 ± 1.1 mm. Anastomosis were found with great pancreatic artery in 20%, and with hilar splenic artery in 80%. The pattern of anastomosis between the pancreas tail and the spleen could allow the surgeon to close the splenic artery at the origin and also the short gastric and the left gastroepiploic arteries, in cases of splenic trauma, favouring the hemostasis and allowing splenic preservation at a same time

Endoscopic diode laser therapy for chronic radiation proctitis

The purpose of this study is to determine the effectiveness of endoscopic diode laser therapy in patients presenting rectal bleeding due to chronic radiation proctitis (CRP). A retrospective analysis of CRP patients who underwent diode laser therapy in a single institution between 2010 and 2016 was carried out. The patients were treated by non-contact fibers without sedation in an outpatient setting. Fourteen patients (median age 77, range 73-87 years) diagnosed with CRP who had undergone high-dose radiotherapy for prostatic cancer and who presented with rectal bleeding were included. Six required blood transfusions. Antiplatelet (three patients) and anticoagulant (two patients) therapy was not suspended during the treatments. The patients underwent a median of two sessions; overall, a mean of 1684 J of laser energy per session was used. Bleeding was resolved in 10/14 (71%) patients, and other two patients showed improvement (93%). Only one patient, who did not complete the treatment, required blood transfusions after laser therapy; no complications were noted during or after the procedures. Study findings demonstrated that endoscopic non-contact diode laser treatment is safe and effective in CRP patients, even in those receiving antiplatelet and/or anticoagulant therap