• Journal of Digestive Cancer Research
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• v.4 no.2
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• pp.77-82
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• 2016

The 26^th World Congress of the International Association of Surgeons, Gastroenterologists and Oncologists (IASGO) was held in Seoul, Korea from September 8 to 10, 2016. In this congress, I gave a State-of-the-Art Lecture II entitled "Mesenteric Approach in Pancreatoduodenectomy." The ideal surgery for pancreatic head cancer is isolated pancreatoduodenectomy, which involves en bloc resection using a non-touch isolation technique. My team has been developing isolated pancreatoduodenectomy for pancreatic cancer since 1981, when we developed an antithrombogenic bypass catheter for the portal vein. In this operation, the first and most important step is the use of a mesenteric approach instead of Kocher's maneuver. The mesenteric approach allows dissection from the non-cancer infiltrating side and determination of cancer-free margins and resectability, followed by systematic lymphadenectomy around the superior mesenteric artery. This approach enables early ligation of the inferior pancreatoduodenal artery and total mesopancreas excision. It is the ideal surgery for pancreatic head cancer from both oncological and surgical viewpoints. The precise surgical techniques of the mesenteric approach are herein described.

• Journal of Trauma and Injury
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• v.26 no.3
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• pp.248-251
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• 2013

Introduction: A post-traumatic mesenteric arteriovenous fistula (AVF) is extremely rare. Case Report: A previously healthy 26-year-old male was injured with an abdominal stab wound. Computed tomography (CT) showed liver injury, pancreas injury and a retropancreatic hematoma. We performed the hemostasis of the bleeding due to the liver injury, a distal pancreatectomy with splenectomy and evacuation of the retropancreatic hematoma. On the 5th postoperative day, an abdominal bruit and thrill was detected. CT and angiography showed an AVF between the superior mesenteric artery (SMA) and the inferior mesenteric vein with early enhancement of the portal vein (PV). The point of the AVF was about 4 cm from the SMA's orifice. After an emergent laparotomy and inframesocolic approach, the isolation of the SMA was performed by dissection and ligation of adjacent mesenteric tissues which was about 6 cm length from the nearby SMA orifice, preserving the major side branches of the SMA, because the exact point of the AVF could not be identified despite the shunt flow in the PV being audible during an intraoperative hand-held Doppler-shift measurement. After that, the shunt flow could not be detected by using an intraoperative hand-held Doppler-shift measuring device. CT two and a half months later showed no AVF. There were no major complications during a 19-month follow-up period. Conclusion: Early management of a post-traumatic mesenteric AVF is essential to avoid complications such as hemorrhage, congestive heart failure and portal hypertension.

• Archives of Plastic Surgery
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• v.51 no.1
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• pp.130-134
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• 2024

Refractory chylous ascites can cause significant nutritional and immunologic morbidity, but no clear treatment has been established. This article introduces a case of a 22-year-old female patient with an underlying lymphatic anomaly who presented with refractory chylous ascites after laparoscopic adnexectomy for ovarian teratoma which aggravated after thoracic duct embolization. Ascites (>3,000 mL/d) had to be drained via a percutaneous catheter to relieve abdominal distention and consequent dyspnea, leading to significant cachexia and weight loss. Two sessions of hybrid lymphovenous anastomosis (LVA) surgery with intraoperative mesenteric lymphangiography guidance were performed to decompress the lymphatics. The first LVA was done between inferior mesenteric vein and left para-aortic enlarged lymphatics in a side-to-side manner. The daily drainage of chylous ascites significantly decreased to 130 mL/day immediately following surgery but increased 6 days later. An additional LVA was performed between right ovarian vein and enlarged lymphatics in aortocaval area in side-to-side and end-to-side manner. The chylous ascites resolved subsequently without any complications, and the patient was discharged after 2 weeks. The patient regained weight without ascites recurrence after 22 months of follow-up. This case shares a successful experience of treating refractory chylous ascites with lymphatic anomaly through LVA, reversing the patient's life-threatening weight loss. LVA was applied with a multidisciplinary approach using intraoperative mesenteric lipiodol, and results showed the possibility of expanding its use to challenging problems in the intraperitoneal cavity.

• Annals of Hepato-Biliary-Pancreatic Surgery
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• v.26 no.3
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• pp.229-234
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• 2022

When planning pancreaticoduodenectomy for pancreatic head cancer, the prevalence of anatomical variation of the proximal jejunal vein (PJV), the associated short-term surgical outcomes, and the level of PJV convergence to the superior mesenteric vein must be carefully analyzed from both technical and oncological points of view. The prevalence of the first jejunal trunk (FJT) and PJV located ventral to the superior mesenteric artery is 58%-88% and 13%-37%, respectively. Patients with the FJT had a larger amount of intraoperative bleeding and a higher proportion of patients requiring transfusions compared to those without a common trunk. The risk of transfusion was higher in patients with ventral PJV compared to those with dorsal PJV. Although less frequent, sacrificing the FJT can result in fatal venous congestion of the jejunum. Therefore, a well-planned approach for pancreaticoduodenectomy, based on preoperative evaluation of anatomical variation in the PJV, may help reduce intraoperative bleeding and postoperative morbidity. Additionally, the importance of invasion into the PJVs should be revisited in terms of resectability and oncological clearance.

• Annals of Hepato-Biliary-Pancreatic Surgery
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• v.28 no.1
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• pp.59-69
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• 2024

Backgrounds/Aims: Pancreaticoduodenectomy (PD) is the only radical treatment for periampullary malignancies. Superior mesenteric artery (SMA) first approach combined with total meso-pancreas (MP) excision was conducted to improve the oncological results. There has not been any previous research of a technique that combines the SMA first approach and total MP excision with a detailed description of the MP macroscopical shape. Methods: We prospectively assessed 77 patients with periampullary malignancies between October 2020 and March 2022 (18 months). All patients had undergone PD with SMA first approach combined total MP excision. The perioperative indications, clinical data, intra-operative index, R0 resection rate of postoperative pathological specimens (especially mesopancreatic margin), postoperative complications, and follow-up results were evaluated. Results: The median operative time was 289.6 min (178-540 min), the median intraoperative blood loss was 209 mL (30-1,600 mL). Microscopically, there were 19 (24.7%) cases with metastatic MP, and five cases (6.5%) with R1-resection of the MP. The number of lymph nodes (LNs) harvested and metastatic LNs were 27.2 (maximum was 74) and 1.8 (maximum was 16), respectively. Some (46.8%) patients had pancreatic fistula, but mostly in grade A, with 7 patients (9.1%) who required re-operations. Some 18.2% of cases developed postoperative refractory diarrhea. The rate of in-hospital mortality was 1.3%. Conclusions: The PD with SMA first approach combined TMpE for periampullary malignancies was effective in achieving superior oncological statistics (rate of MP R0-resection and number of total resected LNs) with non-inferior short-term outcomes. It is necessary to evaluate survival outcomes with long-term follow-up.

• Journal of Trauma and Injury
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• v.35 no.4
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• pp.291-296
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• 2022

The therapeutic approach for colon injury has changed continuously with the evolution of management strategies for trauma patients. In general, immediate laparotomy can be considered in hemodynamically unstable patients with positive findings on extended focused assessment with sonography for trauma. However, in the case of hemodynamically stable patients, an additional evaluation like computed tomography (CT) is required. Surgical treatment is often required if prominent mesenteric extravasation, free fluid, bowel infarction, and/or colon wall perforation are observed. However, immediate intervention in hemodynamically stable patients without indications for surgical treatment remains questionable. Three patients with colon and mesocolon injuries caused by blunt trauma were treated by nonoperative management. At the time of admission, they were alert and their vital signs were stable. Colon and mesocolon injuries, large hematoma, colon wall edema, and/or ischemia were revealed on CT. However, no prominent mesenteric extravasation, free fluid, bowel infarction, and/or colon wall perforation were observed. In two cases, conservative treatment was performed without worsening abdominal pain or laboratory tests. Follow-up CT showed improvement without additional treatment. In the third case, follow-up CT and percutaneous drainage were performed in considering the persistent left abdominal discomfort, fever, and elevated inflammatory markers of the patient. After that, outpatient CT showed improvement of the hematoma. In conclusion, nonoperative management can be considered as a therapeutic option for mesocolon and colon injuries caused by blunt trauma of selected cases, despite the presence of large hematoma and ischemia, if there are no clear indications for immediate intervention.

• Journal of Digestive Cancer Research
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• v.5 no.1
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• pp.23-27
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• 2017

Although laparoscopic pancreaticoduodenectomy (LPD) is considered as minimally invasive surgery, an advanced level of laparoscopic skill is still required. LPD comprises various procedures including reconstruction. Therefore, establishment of a safe approach at each step is needed. Prevention of intraoperative bleeding is the most important factor in safe completion of LPD. The establishment of effective retraction methods is also important at each site to prevent vascular injury. I also recommend the "uncinate process first" approach during initial cases of LPD, in which the branches of the inferior pancreaticoduodenal artery are dissected first, at points where they enter the uncinate process. This approach is performed at the left side of the superior mesenteric artery (SMA) before isolating the pancreatic head from the right aspect of the SMA, which allows safe dissection without bleeding. Safe and reliable reconstruction is also important to prevent postoperative complications. Laparoscopic pancreatojejunostomy requires highly skilled suturing technique. Pancreatojejunostomy through a small abdominal incision, as in hybrid-LPD, facilitates reconstruction. In LPD, the surgical view is limited. Therefore, we must carefully verify the position of the pancreaticobiliary limb. A twisted mesentery may cause severe congestion of the pancreaticobiliary limb following reconstruction, resulting in severe complications. We must secure the appropriate position of the pancreaticobiliary limb before starting reconstruction. We describe the incidence of intraoperative and postoperative complications and appropriate technique for safe performance of LPD.

• Annals of Hepato-Biliary-Pancreatic Surgery
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• v.28 no.2
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• pp.262-265
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• 2024

The pancreatoduodenectomy (PD) technique is yet to be standardized. One of the most difficult passages in PD is the mobilization of the second, third, and fourth parts of the duodenum. This maneuver is classically performed from the supramesocolic space after the division of the gastrocolic ligament, but traction on the transverse mesocolon and the superior mesenteric pedicle can cause bleeding from the venous and arterial branches of the pancreatic head and uncinate process. We hereby describe a technique to access and mobilize the distal duodenum and proximal jejunum (D2 to J1) through the duodenal window and the Treitz's foramen, performing an almost complete Kocher's maneuver before opening the gastrocolic ligament and mobilizing the hepatic flexure. The anatomical basis and the surgical technique of the duodenal-window-first PD are discussed. The duodenal-window-first approach is a standardizable step of PD that allows an easy and safe mobilization of D2 to J1. This technique has been applied to 15 cases of PD, both open and robotic, with no specific morbidity. Therefore, we propose the adoption of the duodenal-window-first technique as a routine standardized step of PD.

• Journal of Chest Surgery
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• v.52 no.5
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• pp.372-375
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• 2019

A 55-year-old man was admitted to the trauma center after a car accident. Cardiac tamponade, traumatic aortic injury, and hemoperitoneum were diagnosed by ultrasonography. The trauma surgeon, cardiac surgeon, and interventional radiologist discussed the prioritization of interventions. Multi-detector computed tomography was carried out first to determine the severity and extent of the injuries, followed by exploratory sternotomy to repair a left auricle rupture. A damage control laparotomy was then performed to control mesenteric bleeding. Lastly, a descending thoracic aorta injury was treated by endovascular stenting. These procedures were performed in the hybrid-angio room. The patient was discharged on postoperative day 135, without complications.

• The Korean Journal of Pain
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• v.12 no.1
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• pp.87-94
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• 1999

Backgroud: We have performed the CT-guided celiac plexus block (CPB) using anterior approach to evaluate the safety and efficacy of the procedure and to determine the role of CT. Methods: CPB were done in 10 patients (5 men and 5 women: mean age, 58.1 years) with intractable upper abdominal pain due to terminal malignancy of the stomach (n=3), pancreas (n=4), gallbladder (n=2), and liver (n=1). To permit an anterior approach, patients lay supine on the CT scan table during the procedure. One 21-guage Chiba needle was placed just anterior to the diaphragmatic crus between the celiac and superior mesenteric arteries and 10~12 ml of dehydrated alcohol was injected. Degree of pain relief following the procedure was assessed and pain was graded on a numeric rating scale (NRS) from 0 to 10. Results: The results suggest a direct relation between the degree of celiac invasion and the response to the CPB. With CT guidance, it is possible for us to direct the needle into more accurate region, allowing alcohol to be deposited in specific ganglion area. Conclusions: CT-guided CPB using an anterior approach was an easy and effective way of reducing intractable upper abdominal pain due to terminal malignancies. CT-guidance allowed precise needle placement and safe procedure. Careful classification of cases is important to predict the degree of pain relief using the grading system based on the degree of involvement of the celiac plexus.