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Annals of Vascular Surgery May 2024Nutcracker syndrome is a rare condition that occurs as a result of the entrapment of the left renal vein (LRV) between the aorta and the superior mesenteric artery. It...
BACKGROUND
Nutcracker syndrome is a rare condition that occurs as a result of the entrapment of the left renal vein (LRV) between the aorta and the superior mesenteric artery. It is typically associated with symptoms such as left flank pain, hematuria, proteinuria, and pelvic congestion. The current treatment approach may be conservative in the presence of tolerable symptoms, and surgical or hybrid and stenting procedures in the order of priority in the presence of intolerable symptoms. The aim of this study is to review our experiences to evaluate the results of both methods in this series in which we have a greater tendency toward surgery instead of stenting.
METHODS
The clinical data of consecutive patients with nutcracker syndrome who underwent LRV transposition and LRV stenting between July 2019 and October 2023 were retrospectively reviewed. The patients were divided into 2 groups based on the methods of treatment: surgical and stenting. For procedure selection, LRV transposition was primarily recommended, with stenting offered to those who declined. Primary end points were morbidity and mortality. Secondary end points included late complications, patency, freedom from reintervention, and resolution of symptoms. Standard basic statistics and survival analysis methods were employed.
RESULTS
Nineteen patients with nutcracker syndrome (female: 100%) were treated with LRV stentings (n = 5) and LRV transposition (n = 14). The mean age was 24 (20-27, interquartile range [IQR]) years. The mean follow-up was 23 (9-32, IQR) months. There were no major complications and mortality after both procedures. The most frequent sign and symptom associated with LRV entrapment were left flank pain 100% (n = 19), proteinuria 88% (n = 15), and hematuria 47% (n = 9). The mean peak velocity ratio on Doppler ultrasound was 6.13 (6-6.44, IQR). Aortomesenteric angle, beak angle (beak sign), and mean diameter ratio on computed tomography were 26° (22.6-28.5, IQR), 25° (23.9-28, IQR), and 5.3 (5-6, IQR), respectively. Venous pressure measurements were only used to confirm the diagnosis in 5 patients in the stenting group. The measured renocaval gradient was 4 (3.9-4.4, IQR) mm Hg. After both procedures, the classical symptoms, including left flank pain, proteinuria, and hematuria, resolved in 89.5% (n = 17), 57.8% (n = 11), and 82.3% (n = 15) of the cases, respectively. A total of 4 patients required reintervention, 3 patients after LRV transposition (occlusion, n = 2; stenosis, n = 1), and 1 patient after stenting (occlusion, n = 1). The 1-year and 3-year primary patency for the 19 patients was 87% and 80%, respectively. Three-year primary-assisted patency was 100%. Similarly, the 1-year and 3-year freedom from reintervention rate was 83% and 72%, respectively. Additionally, the 1-year and 3-year primary patency for the surgical group was 91% and 81%, respectively, and the 1-year and 3-year primary patency for the stenting group was 75%.
CONCLUSIONS
Nutcracker syndrome should be kept in mind in cases where flank pain and hematuria cannot be associated with kidney diseases. Radiographic evidence must be accompanied by serious symptoms to initiate the treatment of nutcracker syndrome with LRV transposition and endovascular stenting procedures. Both procedures, along with their respective advantages and disadvantages, can be preferred as primary treatments for nutcracker syndrome. Our study demonstrates that both procedures can be safely and effectively performed, yielding good outcomes.
Topics: Humans; Female; Renal Veins; Flank Pain; Hematuria; Retrospective Studies; Treatment Outcome; Renal Nutcracker Syndrome; Vascular Diseases; Proteinuria
PubMed: 38296038
DOI: 10.1016/j.avsg.2023.11.036 -
Diseases of the Colon and Rectum May 2024
Topics: Humans; Colon, Transverse; Mesenteric Veins; Rectal Neoplasms; Colectomy; Gastrointestinal Neoplasms; Laparoscopy
PubMed: 38294830
DOI: 10.1097/DCR.0000000000002973 -
JGH Open : An Open Access Journal of... Jan 2024Idiopathic mesenteric phlebosclerosis (IMP) is characterized by mesenteric vein calcification and ischemic bowel disease. We describe a unique clinical case of IMP in a...
Idiopathic mesenteric phlebosclerosis (IMP) is characterized by mesenteric vein calcification and ischemic bowel disease. We describe a unique clinical case of IMP in a patient with a history of oral administration of various drugs, including traditional Chinese medicines (mainly selfheal), vitamin D, and calcium supplements. The disease was not diagnosed in its early stages and was later detected because of the initial symptoms of chest tightness and difficulties in swallowing. During medical examination, esophageal venous sinuses were found through gastroscopy, and CT revealed thickening and widespread calcification of the colonic wall (esophageal wall calcification). Moreover, typical purple-brown changes in the colonic mucosa were found during colonoscopy. Microscopic examination showed more foam phagocyte, focal lymphocyte aggregation, small-vessel proliferation, and surrounding collagen-like deposition which is a typical finding of IMP. More specifically, the patient's mesenteric veins and colon veins were calcified, and the calcification extended to the esophageal veins. These findings were related to long-term use of traditional Chinese medicines (mainly selfheal). It is possible that excessive intake vitamin D and calcium supplementation may have played a role in the occurrence of vascular calcification, which might have exacerbated the progression of IMP disease.
PubMed: 38268963
DOI: 10.1002/jgh3.13027 -
Diseases of the Colon and Rectum May 2024D3 is unaffected by anatomic factors even when the ileocolic artery runs along the dorsal side of the superior mesenteric vein. Complete "true D3" lymph node dissection...
BACKGROUND
D3 is unaffected by anatomic factors even when the ileocolic artery runs along the dorsal side of the superior mesenteric vein. Complete "true D3" lymph node dissection in minimally invasive surgery for right-sided colon cancer could be beneficial for certain patients with lymph node metastases.
IMPACT OF INNOVATION
The study aimed to determine the safety and feasibility of robotic true D3 lymph node dissection for right-sided colon cancer using a superior mesenteric vein-taping technique.
TECHNOLOGY, MATERIALS, AND METHODS
The superior mesenteric vein was slowly and gently separated from the surrounding tissues and taped. Lifting the tape with the robotic third arm and fixing it in place using rock-stable tractions provides a good surgical view, which cannot otherwise be obtained. As a result, the ileocolic artery that branches from the superior mesenteric artery can be accurately exposed. Handling of the taping then enables expansion to a different surgical view. As the lymph nodes are originally concealed on the dorsal side of the superior mesenteric vein, this technique provides a good view for lymph node dissection. The root of the ileocolic artery was clipped and separated, and true D3 was thus completed.
PRELIMINARY RESULTS
Fourteen patients underwent robotic true D3 lymph node dissection for right-sided colon cancer. No Clavien-Dindo classification grade II or higher intraoperative or postoperative complications were observed. The 30-day mortality rate was 0%.
CONCLUSIONS
Our robotic true D3 lymph node dissection with superior mesenteric vein-taping technique is considered safe and feasible; it might be a promising surgical procedure for treating advanced right-sided colon cancer.
FUTURE DIRECTIONS
Even when the ileocolic artery runs along the dorsal aspect of the superior mesenteric vein, the technique seems promising for facilitating robotic D3 lymph node dissection.
Topics: Humans; Colonic Neoplasms; Mesenteric Veins; Robotic Surgical Procedures; Colectomy; Laparoscopy; Lymph Node Excision; Lymph Nodes
PubMed: 38266042
DOI: 10.1097/DCR.0000000000003185 -
Advances in Radiation Oncology Jan 2024In our experience treating locally advanced pancreatic cancer with magnetic resonance-guided radiation therapy (MRgRT), the true-fast imaging with steady-state free...
Initial Observation of Contrast Profiles for 2-Dimensional and 3-Dimensional Magnetic Resonance Imaging Sequences in Magnetic Resonance-Guided Radiation Therapy for Locally Advanced Pancreatic Cancer.
PURPOSE
In our experience treating locally advanced pancreatic cancer with magnetic resonance-guided radiation therapy (MRgRT), the true-fast imaging with steady-state free precession sequences used to generate both the real-time 2-dimensional (2D) magnetic resonance images (MRI; 2D cine) and the pretreatment high-resolution 3-dimensional (3D) MRI impart differing intensities for relevant structures between the 2 scans. Since these variations can confound target tracking selection, we propose that an understanding of the differing contrast profiles could improve selection of tracking structures.
METHODS AND MATERIALS
We retrospectively reviewed both 2D cine and 3D MRI images for 20 patients with pancreatic cancer treated with MRgRT. At simulation, an appropriate tracking target was identified and contoured on a single 3-mm sagittal slice of the 3D MRI. This sagittal slice was directly compared with the coregistered 7-mm 2D cine to identify structures with notable discrepancies in signal intensity. The 3D MRI was then explored in additional planes to confirm structure identities. For quantitative verification of the clinically observed differences, the pixel intensity distributions of 2D cine and 3D MRI digital imaging and communications in medicine data sets were statistically compared.
RESULTS
In all patients reviewed, arteries (aorta, celiac, superior mesenteric artery, hepatic artery) appeared mildly hyperintense on both scans. However, veins (portal vein, superior mesenteric vein) appeared hyperintense on 2D cine but isointense on 3D MRI. Biliary structures appeared mildly hyperintense on 2D cine but starkly hyperintense on 3D MRI. The pixel intensity distributions extracted from 2D cine and 3D MRI images were confirmed to differ significantly (2 sample Kolmogorov-Smirnov test; test statistic, 0.40; < .001).
CONCLUSIONS
There are significant variations in image intensity between the immediate pretreatment 2D cine compared with the initial planning 3D MRI. Understanding variations of image intensity between the different MRI sequences used in MRgRT is valuable to radiation oncologists and may lead to improved target tracking and optimized treatment delivery.
PubMed: 38260228
DOI: 10.1016/j.adro.2023.101314 -
Mesenteric Vein Thrombosis following Sleeve Gastrectomy: A Case Report and Review of the Literature.Obesity Facts 2024Acute mesenteric ischemia (AMI) is a rare but lethal disease. Mesenteric vein thrombosis (VAMI) is a subtype of AMI. Morbid obesity is usually accompanied by... (Review)
Review
INTRODUCTION
Acute mesenteric ischemia (AMI) is a rare but lethal disease. Mesenteric vein thrombosis (VAMI) is a subtype of AMI. Morbid obesity is usually accompanied by hypertension, hyperlipidemia, or diabetes mellitus, which are risk factors associated with AMI.
CASE PRESENTATION
We present a 28-year-old man with VAMI post-laparoscopic sleeve gastrectomy. He was first misdiagnosed with intestinal obstruction. Superior VAMI was confirmed after computed tomography angiography. Laparotomy, resection of the necrotic small bowel, and ostomy were performed immediately.
CONCLUSION
Patients with morbid obesity accompanied by hypertension, hyperlipidemia, or diabetes mellitus have a high risk of AMI. Abdominal pain with sudden onset should be considered AMI. Anticoagulation therapy post-sleeve gastrectomy might help reduce the incidence of AMI.
Topics: Adult; Humans; Male; Diabetes Mellitus; Gastrectomy; Hyperlipidemias; Hypertension; Laparoscopy; Mesenteric Ischemia; Mesenteric Veins; Obesity, Morbid; Postoperative Complications; Venous Thrombosis
PubMed: 38246162
DOI: 10.1159/000536359 -
Revista Espanola de Enfermedades... Jan 2024Idiopathic mesenteric phlebosclerosis (IMP) is a rare ischemic colitis characterized by calcification of mesenteric veins and submucosal veins of the colon. Melanosis...
Idiopathic mesenteric phlebosclerosis (IMP) is a rare ischemic colitis characterized by calcification of mesenteric veins and submucosal veins of the colon. Melanosis coli (MC) is a pigmented mucosal lesion comprising macrophages in the lamina propria of the colorectal mucosa that contain lipofuscin. This study reports a case of IMP combined with MC.Clinicians should consider medication history, bowel preparation, and thorough observation to prevent missed IMP diagnosis when coexisting with MC.
PubMed: 38235670
DOI: 10.17235/reed.2024.10179/2023 -
Asian Journal of Surgery Apr 2024
Topics: Humans; Superior Mesenteric Artery Syndrome; Mesenteric Artery, Superior; Renal Veins; Renal Nutcracker Syndrome
PubMed: 38233274
DOI: 10.1016/j.asjsur.2024.01.004 -
The American Journal of Gastroenterology Apr 2024
Topics: Humans; Mesenteric Veins; Hyperplasia; Ischemia; Colon; Proctitis
PubMed: 38231406
DOI: 10.14309/ajg.0000000000002660 -
Cureus Dec 2023The growth of several porto-portal collateral veins encircling an existing stenosed or obstructed entry vein is an uncommon condition known as portal cavernoma. It is...
The growth of several porto-portal collateral veins encircling an existing stenosed or obstructed entry vein is an uncommon condition known as portal cavernoma. It is traditionally shown as the entry vein thrombosis (portal vein thrombosis - PVT) outcome. A male of 25 years with stomach discomfort for three days that was acute, nonprogressive, and was not accompanied by fever, loose stools, or vomiting. After he had undergone abdominal ultrasonography, portal vein thrombosis was discovered, and based on no involvement of suprahepatic veins according to ultrasonography, Budd-Chiari syndrome was ruled out. It was accompanied by dilated periportal tortuous veins and visible mesenteric and peri-splenic collaterals. Moderate splenomegaly was also present. All these features on ultrasound were suggestive of the "portal cavernoma" formation. The patient is not an alcoholic and does not have any chronic, hereditary, or metabolic liver disease. Thrombophilia and cancer screening through tumor markers were also negative. We, with this, present a rare case of non-cirrhotic idiopathic portal cavernoma. This rare case contributes to advancing medical and scientific knowledge that will encourage further dialogue on the topic.
PubMed: 38229806
DOI: 10.7759/cureus.50570