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Objective This study was performed to assess the changes in diameter of the superior mesenteric artery (SMA) in patients with spontaneous isolated SMA dissection (SISMAD) on nonenhanced multidetector computed tomography (MDCT) and determine the clinical value of follow-up MDCT after endovascular stent placement (ESP). Methods The diameters of the SMA and superior mesenteric vein (SMV) as measured on nonenhanced MDCT were compared between 20 patients with SISMAD and 20 control subjects. ESP was performed in 14 patients with SISMAD, and follow-up MDCT was performed after ESP. Results The mean diameter of the SMA in the SISMAD group and control group was 11.69 ± 1.26 and 7.10 ± 0.97 mm, respectively, with a statistically significant difference. The SMA diameters were even larger than the SMV diameters. Follow-up MDCT showed stent patency in 13 patients and occlusion in 1 patient. Conclusions An enlarged diameter of the SMA on nonenhanced MDCT is an important finding for diagnosis of SISMAD, and MDCT is a valuable follow-up method after ESP for SISMAD.

Background The superior mesenteric artery (SMA)-first approach for pancreatic cancer (PC) is common surgical technique in pancreaticoduodenectomy. To date, few studies have reported SMA-first approach in robot-assisted pancreaticoduodenectomy (RPD). Herein, we present the anterior SMA-first approach for PC during RPD. Patient and Method A 75-year-old man with resectable PC underwent RPD after neoadjuvant chemotherapy. As pancreatic head tumor contacted with the superior mesenteric vein (SMV), the anterior SMA approach was applied. After the mesenteric Kocher maneuver, the jejunum was divided and the left side of the SMA was dissected. Subsequently, the anterior plane of the SMA was dissected. Following the division of branches from the mesenteric vessels, the SMA was taped, and the circumferential dissection around the SMA was performed to detach the pancreatic neck from the SMA completely. Finally, the dissection between the SMV and the tumor was performed under vascular control to remove the specimen. Conclusions The anterior SMA-first approach can be optional in patients with PC undergoing RPD. This unique approach allows for the circumferential dissection around the SMA during RPD.

Background Locally advanced cancers of the pancreatic body can abut or involve the celiac axis, hepatic artery, or superior mesenteric artery. Recent evidence suggests that these tumors are amenable to surgery after neoadjuvant chemotherapy (Hackert et al., Locally advanced pancreatic cancer: neoadjuvant therapy with FOLFIRINOX results in resectability in 60 % of the patients. Ann Surg 264:457–463, 2016; Rangelova et al., Surgery improves survival after neoadjuvant therapy for borderline and locally advanced pancreatic cancer: a single-institution experience. Ann Surg 273:579–86, 2021). An arterial divestment technique can be used for these cancers to get an R0 clearance, thereby avoiding morbid arterial resections (Miao et al., Arterial divestment instead of resection for locally advanced pancreatic cancer (LAPC). Pancreatology 16:S59, 2016; Habib et al., Periadventitial dissection of the superior mesenteric artery for locally advanced pancreatic cancer: surgical planning with the “halo sign” and “string sign.” Surgery 169(5):1026–1031, 2021; Diener et al., Periarterial divestment in pancreatic cancer surgery. Surgery 169(5):1026–31, 2020). Two techniques are described for arterial divestment. In the periarterial divestment technique, the plane of the dissection is between the tumor and the adventitia (Habib et al., Periadventitial dissection of the superior mesenteric artery for locally advanced pancreatic cancer: surgical planning with the “halo sign” and “string sign.” Surgery 169(5):1026–1031, 2021; Diener et al., Periarterial divestment in pancreatic cancer surgery. Surgery 169(5):1026–31, 2020). In sub-adventitial dissection, the plane of dissection is between the tunica adventitia and the external elastic lamina (Gao et al., Sub-adventitial divestment technique for resecting artery-involved pancreatic cancer: a retrospective cohort study. Langenbecks Arch Surg 406:691–701, 2021). The TRIANGLE operation also is one of the surgical techniques to achieve R0 resection in locally advanced pancreatic cancer (Hackert et al., The TRIANGLE operation: radical surgery after neoadjuvant treatment for advanced pancreatic cancer: a single-arm observational study. HPB Oxford 19:1001–1007, 2017). This multimedia article aims to demonstrate peri-arterial and sub-adventitial divestment techniques as well as the TRIANGLE operation for a locally advanced cancer of the body of the pancreas. The video also highlights the technique of posterior radical antegrade modular pancreato-splenectomy (RAMPS) together with lymph node clearance. Patient and Methods A 57-year-old women was detected to have pancreatic body adenocarcinoma with tumor contact of the artery and superior mesenteric artery. After neoadjuvant chemotherapy, she was planned to undergo surgical resection. Results The surgical technique consisted of peri-arterial and sub-adventitial divestment, the TRIANGLE operation and RAMPS (Fig. 1). The procedure was performed within 240 min and involved blood loss of 250 mL. After the procedure, pancreatic leak (POPF-B), chyle leak and diarrhea developed, which were managed conservatively. The final histopathology showed residual, viable, moderately differentiated adenocarcinoma (ypT2N1M0) with all resection margins free. Conclusion The surgical technique consisting of peri-arterial and sub-adventitial divestment, the TRIANGLE operation and RAMPS helps in R0 resection of locally advanced pancreatic body cancer without any compromise in oncologic outcomes and offers an alternative surgical approach to morbid arterial resection.

Flow patterns and classification within Spontaneous Isolated Superior Mesenteric Artery Dissection (SISMAD) are crucial for selecting subsequent treatment options. This study aims to propose a new classification of SISMAD and to propose two corresponding treatment plans based on this new classification. The 3D models of 70 patients with SISMAD were reconstructed and classified into Li types I-V based on morphology, followed by computational fluid dynamics analysis. The results show significant differences in blood flow patterns among patients with the same Li-type SISMAD, suggesting that the same treatment plan should not be applied universally. Based on the different blood flow conditions, a new classification of SISMAD is proposed (HX classification): Type I (dual-lumen flow type), subdivided into Ia and Ib; and Type II (single-lumen flow type). The simulation reveals that the rupture area of Type I SISMAD is related to the pressure difference between its true and false lumens, while the maximum-to-minimum diameter ratio of Type II SISMAD is associated with insufficient true lumen blood supply and lumen dilation. Furthermore, based on patient follow-up data and hemodynamic simulation results, corresponding treatment plans were proposed for the new classification: Type I was judged based on the ratio of rupture area to entrance area as a risk factor, and intervention treatment was recommended if the value was greater than 0.44; Type II can be judged as a risk factor based on the ratio of minimum diameter to maximum diameter, and if the value is less than 0.38, intervention treatment is recommended.

Background Robotic pancreatoduodenectomy is an increasingly accepted alternative for the treatment of pancreatic ductal adenocarcinoma (PDAC). 1 However, the ability to perform a meticulous robotic-assisted superior mesenteric artery (SMA) dissection to obtain a margin-negative resection remains unknown. 2 PDAC within the head of the pancreas (HOP) that involves the superior mesenteric vein (SMV) and portal vein (PV) requires total venous control (TVC) and a ‘vein-to-the-right’ (or anterior artery-first) approach to SMA dissection to minimize venous congestion and operative blood loss. 3 – 5 Here, we demonstrate a robotic pancreatoduodenectomy with TVC and a ‘vein-to-the-right’ approach. Methods A 70-year-old woman with cT2N0M0 HOP PDAC with lateral SMV involvement and right gastroepiploic vein occlusion underwent robotic pancreatoduodenectomy after neoadjuvant chemotherapy. After transecting the pancreas, we achieved TVC by dividing the small venous tributaries and encircling the SMV, splenic vein, and PV. We then proceeded with a ‘vein-to-the-right’ approach. The inferior pancreatoduodenal arteries were divided to minimize HOP inflow and decrease specimen bleeding. Once the specimen was dissected off the periadventitial plane of the distal SMA, the SMV dissection was carefully performed using a partial side-wall vein resection using a vascular stapler. Results Total operative time was 7.5 h and estimated blood loss was 25 mL. The patient recovered well postoperatively and was discharged on postoperative day 3. Final pathology exhibited a 2.4 cm, moderately to poorly differentiated adenocarcinoma with negative margins (ypT2N1, 2/38 lymph nodes positive). Conclusion For tumors with lateral vein involvement, robotic pancreatoduodenectomy can be safely performed via TVC and a ‘vein-to-the-right’ approach.

Background Pancreatic head cancer with perineural invasion of the superior mesenteric artery (SMA) requires dissection of the nerve plexus around the SMA (PLsma, superior mesenteric nerve plexus) to obtain cancer-free margins. 1 , 2 Technically challenging robot-assisted pancreaticoduodenectomy with PLsma resection is rarely performed owing to the technical limitations of the robot. In this multimedia article, we present our approach to robot-assisted pancreaticoduodenectomy with PLsma dissection. 3 – 5 Methods We performed a robot-assisted pancreaticoduodenectomy with resection of the hemicircle of the PLsma in a 78-year-old woman with resectable pancreatic cancer extending to the root of the inferior pancreaticoduodenal artery. In this video, we show how to obtain an optimal view using the multiple scope transition method, 4 and technical tips to perform a PLsma dissection with a robot to perform this difficult surgery safely. Results The operative time was 568 min and 300 mL of blood was lost. The pathological diagnosis was invasive pancreatic ductal carcinoma with lymph node metastasis, and R0 resection was performed. The distance margin from the SMA was 2 mm. The patient was discharged on the 18th postoperative day without postoperative complications. Conclusions Robot-assisted pancreaticoduodenectomy with dissection of the hemicircle of the PLsma, which is difficult to perform, can be performed safely with an optimal view using the multiple-scope transition method, and delicate dissection using a robot.

The purpose of this study is to investigate the association between the aortomesenteric angle (AMA) and the occurrence and image characteristics of spontaneous isolated superior mesenteric artery dissection (SISMAD). This is a single-centre retrospective case-control study. Between January 1 2013 and December 13 2022, consecutive patients with computed tomography angiography (CTA) confirmed symptomatic SISMAD were included. Controls were selected with 1:1 matches in patients with CTA of the superior mesenteric artery but without SISMAD using propensity score matching for age, sex, and body mass index. Patient demographics, symptoms, and dissection characteristics were recorded. Logistic regression was performed to assess the association between AMA and SISMAD. The study also evaluated the association between AMA and SISMAD using restricted cubic splines (RCS). The associations between AMA and the characteristics of SISMAD were evaluated. One hundred and five SISMAD patients (mean age, 54.8 ± 8.9 years) were included, and most patients were male (87.6%). Univariable analysis revealed hypertension, hyperlipemia, and AMA (all p  < .001) were associated with SISMAD. An increasing AMA (adjusted OR, 1.03 per 1 ° increase in angulation) and hypertension (adjusted OR, 3.52) were identified as risk factors for SISMAD. Compared with small AMA level (< 50°), intermediate (50–71°) (adjusted OR, 2.62; 95% CI, 1.23–5.58; p  = .013) and large angle level (> 71°) (adjusted OR, 4.50; 95% CI, 2.07–9.82; p  < .001) were significantly associated with SISMAD. No obvious associations between AMA and the SISMAD imaging characteristics were found. Greater AMA and hypertension were independent risk factors for SISMAD.

We report the forensic and clinicopathological spectrum of 14 postmortem cases involving the vertebral artery. In all cases, there was either pontocerebellar infarction (n = 8) or subarachnoid hemorrhage (n = 6). The underlying pathology of the vertebral artery was segmental mediolytic arteriopathy (n = 5), traumatic rupture of the arterial wall (n = 3), arterial dissection (n = 2), or atherosclerosis (n = 4). Histopathologic changes were often present in both the intracranial and extracranial segments of the vertebral artery. In our case series, the most frequent disease in the vertebral artery was segmental mediolytic arteriopathy which sometimes simultaneously involved the superior mesenteric artery. Our data show that a heterogeneous combination of acquired and genetic cofactors likely played a role in etiopathogenesis. The two main cofactors included sudden neck movements from applied external force (7/14 case, 50 %), and genetics (3/14 case, 21 %). Mutations in structural or regulatory genes of the arterial wall appear to be key risk factors and may interact with trauma or neck motion to result in fatal outcomes. We recommend that the autopsy of all cases with suspected vertebral artery lesions include histologic examination of both the intracranial and extracranial segments of the vertebral artery, histologic sampling of the intra-abdominal (mesenteric) arteries, and genetic testing. This will help clarify the role of injury, genetics, and disease when determining the cause of death in these complex cases. •Vertebral artery-related deaths often combine trauma, disease, and genetics•Traumatic rupture, dissection, mediolysis, and atheroma can occur•Histology of the vertebral artery can detect subtle diseases•Genetics can reveal inherited diseases

Introduction Approximately, 20% of patients with pancreatic ductal adenocarcinoma have resectable disease at diagnosis. Given improvements in locoregional and systemic therapies, some patients with borderline resectable pancreatic cancer (BRPC) can now undergo successful resection. The outcomes of patients with BRPC after neoadjuvant therapy remain unclear. Methods A prospectively maintained single-institution database was utilized to identify patients with BRPC who were managed at the Johns Hopkins Pancreas Multidisciplinary Clinic (PMDC) between 2013 and 2016. BRPC was defined as any tumor that presented with radiographic evidence of the involvement of the portal vein (PV) or superior mesenteric vein (SMV) that was deemed to be technically resectable (with or without the need for reconstruction), or the abutment (< 180° involvement) of the common hepatic artery (CHA) or superior mesenteric artery (SMA), in the absence of involvement of the celiac axis (CA). We collected data on treatment, the course of the disease, resection rate, and survival. Results Of the 866 patients evaluated at the PMDC during the study period, 151 (17.5%) were staged as BRPC. Ninety-six patients (63.6%) underwent resection. Neoadjuvant chemotherapy was administered to 142 patients (94.0%), while 78 patients (51.7%) received radiation therapy in the neoadjuvant setting. The median overall survival from the date of diagnosis, of resected BRPC patients, was 28.8 months compared to 14.5 months in those who did not ( p  < 0.001). Factors associated with increased chance of surgical resection included lower ECOG performance status ( p  = 0.011) and neck location of the tumor ( p  = 0.001). Forty-seven patients with BRPC (31.1%) demonstrated progression of disease; surgical resection was attempted and aborted in 12 patients (7.9%). Eight patients (5.3%) were unable to tolerate chemotherapy; six had disease progression and two did not want to pursue surgery. Lastly, four patients (3.3%) were conditionally unresectable due to medical comorbidities at the time of diagnosis due to comorbidities and failed to improve their status and subsequently had progression of the disease. Conclusion After initial management, 31.1% of patients with BRPC have progression of disease, while 63.6% of all patients successfully undergo resection, which was associated with improved survival. Factors associated with increased likelihood of surgical resection include lower ECOG performance status and tumor location in the neck.

PurposeVarious approaches have been reported for the resection of the nervous and lymphatic tissues around the superior mesenteric artery (SMA) during pancreaticoduodenectomy (PD) for pancreatic cancer. We developed a new procedure for circumferential lymph node dissection around the SMA to minimize local recurrence.MethodsWe included 24 patients who underwent PD with circumferential lymph node dissection around the SMA (circumferential dissection) and 94 patients who underwent classical mesopancreatic dissection (classical dissection) between 2019 and 2021. The technical details of this new method are described in the figures and videos, and the clinical characteristics and outcomes of this technique were compared with those of classical dissection.ResultsThe median follow-up durations in the circumferential and classical dissection groups were 39 and 36 months, respectively. The patients’ characteristics, including tumor resectability, preoperative and adjuvant chemotherapy rates, postoperative complication rates, and tumor stage, were similar between the two groups. No differences were observed in recurrence-free survival and overall survival between the two groups; however, the classical dissection group tended to have more local recurrences than the circumferential dissection group (8.3% vs. 33.3%, P = 0.168). Although no case of nodular-type recurrence after circumferential dissection was observed, 61.1% of local recurrences after classical dissection were of the nodular-type, and 36.4% were located on the left side of the SMA.ConclusionsPerforming circumferential lymph node dissection around the SMA during PD can be conducted safely with minimal risks of local recurrence and may enhance the completeness of local resection.