Adjacent Small Bowel Research Articles

Ossified Tumor of the Meckel Diverticulum - Rare Cause of Bowel Obstruction by Ileal Volvulus: A Case Report

Volvulus represents a particular form of mechanical bowel obstruction, produced by the abnormal rotation of a segment of the digestive tract around its vascular axis. We present a rare case of a patient diagnosed with bowel obstruction and who was operated on as an emergency, the established mechanism being a tumor of the Meckel diverticulum that determined the volvulus of the adjacent small bowel. Macroscopically, there was a gray tumoral mass with a spherical-oval shape and a “stone-like” consistency. From a microscopic point of view, the tumoral mass was largely composed of an amorphous, calcified material, alternating with compact, bone areas and small regions of mature adipose tissue, the aspect being suggestive of an ossified lipoma. Postoperatively, the patient presented a favorable surgical evolution.

Ossified Tumor of the Meckel Diverticulum - Rare Cause of Bowel Obstruction by Ileal Volvulus: A Case Report

Volvulus represents a particular form of mechanical bowel obstruction, produced by the abnormal rotation of a segment of the digestive tract around its vascular axis. We present a rare case of a patient diagnosed with bowel obstruction and who was operated on as an emergency, the established mechanism being a tumor of the Meckel diverticulum that determined the volvulus of the adjacent small bowel. Macroscopically, there was a gray tumoral mass with a spherical-oval shape and a “stone-like” consistency. From a microscopic point of view, the tumoral mass was largely composed of an amorphous, calcified material, alternating with compact, bone areas and small regions of mature adipose tissue, the aspect being suggestive of an ossified lipoma. Postoperatively, the patient presented a favorable surgical evolution.

Retained surgical item (Gossypiboma): a case report and literature review.

Here, the authors present a case of a 30-year-old woman who had undergone a cesarean section 2 months ago and presented with the cardinal symptoms of small bowel obstruction. A computerized abdominal tomography (CT) scan showed a well-defined tubular hyperdense structure adherent to the anterior abdominal wall that exerts a mass effect on the adjacent small bowel loops. Following the computerized abdominal tomography results, an exploratory laparotomy resection and anastomosis of a small segment of the ileum were performed. The postoperative period was uneventful, and the patient has remained disease-free to date. Because it is not anticipated, and its clinical manifestations are variable, it is frequently misdiagnosed, and often unnecessary radical surgical procedures are performed. It should be considered in the differential diagnosis of any postoperative case with an unresolved or unusual presentation.

Littre’s hernia: A Surgical dilemma. (Case Report)

Meckel’s diverticulum in a hernia sac is designated as a Littre’s hernia. It is an uncommon type of hernia. The diagnosis is invariably made at the time of surgery. Resection anastomosis of the adjacent segment of the small bowel with the diverticulum is a contentious issue. A case of Littre’s hernia is reported. A case of Littre’s hernia in a17 year old boy is reported to highlight the diagnostic and therapeutic issues confronting the attending surgeon. A short segment resection anastomosis of the small bowel along with the Meckel’s diverticulum was done. A herniorrhaphy was done with no complications. The diagnostic challenges and the dilemma of selecting the best option for removing the Meckel’s diverticulum and choice of hernia repair are discussed. Littre’s hernia is invariably diagnosed intraoperatively. A short segment resection anastomosis of the adjacent small bowel along with the Meckel’s diverticulum prevents complications arising due to the diverticulum. A herniorrhaphy for a young patient and the use of an absorbable mesh for other age groups is advisable.

Surgical Technique for Weight Regain after Roux-en-Y Gastric Bypass: Pouch-resizing and the MiniMIZER® Gastric Ring.

Laparoscopic Roux-en-Y Gastric Bypass (RYGB) is a commonly used method in bariatric surgery that leads to sufficient long-term weight loss and consequently to improvement or resolution of obesity-associated diseases. The nadir weight is commonly reached between six months and two years after surgery. Despite this initially good weight loss, weight regain is observed in up to 20% of the patients. Besides intensive dietological evaluation, bariatric re-operation can be an option in these cases. Before the surgical reintervention, an intensive evaluation of the esophagus, pouch, anastomosis, and adjacent small bowel using upper GI-endoscopy and radiological examinations (X-ray and/or 3D-CT volumetry) is mandatory. In patients with a dilated pouch, pouch-resizing with a MiniMIZER® Gastric Ring (Bariatric Solutions GmbH, Stein am Rhein, Switzerland) could be an option to reestablish restriction in the long term. Currently, there is no gold standard for the choice of the weight regain procedure or for the technique used in the procedure itself. This article focuses on the standardized procedure of pouch resizing with implantation of a MiniMIZER® Gastric Ring for the surgical therapy of weight regain due to pouch dilatation and/or dilatation of the gastrojejunostomy and the adjacent small bowel (usually approximately the first 20cm), resulting in a huge neo-stomach after RYGB, as performed at the Medical University of Vienna. Further, indications for revisional surgery for weight regain, mandatory examinations, and recommended conservative therapy options prior to surgery will be described. Next, the fast-track concept and its advantages are explained. Lastly, the surgical procedure, including positioning of the patient, placement of trocars, the intraoperative process, and special advice, is presented. Exact planning of the procedure and postoperative follow-up are indispensable for a further long-term success after weight regain surgery. In conclusion, pouch-resizing and implantation of the MiniMIZER® Gastric Ring represent a practical and effective solution in patients with dilated pouch/anastomosis/adjacent small bowel with weight regain after RYGB, if conservative therapy, including dietitian counseling and new drugs (e.g., Semaglutide), has failed.

Radiological manifestations of benign mesenteric lipoma that presented with acute intestinal obstruction: A case report

BackgroundIntestinal obstruction is a common surgical emergency that is presented to the hospital with various aetiologies. Among all, mesenteric lipoma is one of the uncommon extraluminal causes of intestinal obstruction. In such conditions, bowel volvulus, compression or even adhesion are the underlying pathologies.Case presentationWe report a 69-year-old gentleman who presented with a triad of intestinal obstruction which required exploratory laparotomy. Preoperative computed tomography revealed multiple coalescing lobulated hypoattenuating lesions encircling part of a small bowel forming transitional zone. These lesions are comparatively more hypoattenuating in comparison with the surrounding mesenteric fat. Intraoperatively, a giant ileal mesenteric lipoma was identified causing compression and folding to the adjacent small bowel, leading to proximal bowel dilatation. Excision of the lipoma with a few mesenteric lymphadenectomy was done, revealing a benign mesenteric lipoma and reactive lymph nodes. Despite ileus, he made a good postoperative recovery and was discharged well.ConclusionsPatients with recurrent abdominal pain must have a thorough endoscopic and imaging assessment. Besides common or malignant aetiology, rarities should be considered and actively sought. Mesenteric lipoma is a relatively indolent tumour for which early detection can alter clinical presentation.

Benign Duodenal Stenosis Caused by Huge Mesenteric Hematoma Conservatively Improved with Long-term Use of Double Elementary Diet Tube.

Mesenteric hematoma is an uncommon condition caused by focal bleeding in the mesenteric vessels. Hematomas are related to trauma, pancreatitis, arteriopathy, and the use of antithrombotic agents. Although hematomas cause intestinal stenosis by compressing the adjacent small bowel, duodenal stenosis due to hematoma is rare. Therefore, the treatment indications for cases of hematoma with stenosis have not been established. We herein report a case with a large mesenteric hematoma that caused duodenal stenosis by compressing the third portion of the duodenum. Stenosis was successfully ameliorated after long-term use of a double elementary diet tube.

The magnetic resonance enterography imaging features of symptomatic Meckel's diverticulum in pediatric patients: a retrospective observational study of 31 cases.

BackgroundThe aim of this study was to explore the magnetic resonance enterography (MRE) imaging manifestations of a symptomatic Meckel’s diverticulum (MD) in pediatric patients in order to provide a reference for the diagnosis of the condition.MethodsThe medical records of 31 pediatric patients with MD from May 2014 to October 2020 were retrospectively analyzed. The inclusion criteria were patients with MD accompanied by unexplained gastrointestinal bleeding, anemia (except hematological diseases), chronic persistent abdominal pain, repeated intussusception, or intussusception in older pediatric patients during surgery. The clinical variables (age, sex, and hemoglobin) and imaging, surgical, and pathological findings were recorded.ResultsMD was definitively identified in 28 patients, with the following characteristics: a blind-ending fluid-filled and/or gas-filled structure (n=23), an elongated shape (n=1), a dumbbell shape (n=1), and a solid mass (n=3). The diverticula were located in the right lower quadrant (n=16), the right abdomen at the level of the umbilicus (n=3), the right upper quadrant (n=2), the left upper quadrant (n=2), and the midline lower abdomen (n=5). Supply arteries were visualized in nine cases. In all cases, mural enhancement was comparable to that of the adjacent small-bowel (SB). Extravasation of the intravascular contrast medium was seen in two cases. Peripheral structural abnormalities included mesenteric fat stranding (n=7), hemorrhage in the adjacent lumen (n=3), free intraperitoneal gas (n=1), abnormal fluid retention (n=2), intestinal obstruction (n=1), and lymph node enlargement (n=7). A normal appendix was identified in 18 cases.ConclusionsMRE is an appropriate method of diagnosing symptomatic MD in pediatric patients and is particularly useful in the assessment of complications.

Abstract PR-006: Pulsed low-dose-rate radiation (PLDR) limits pancreatic pro-tumor stroma aggravation: Pre-clinical basis for an ongoing PLDR trail

Abstract Radiation, combined with radio-sensitizing chemotherapy, is used preoperatively as neoadjuvant therapy (NT) for borderline resectable pancreatic ductal adenocarcinoma (PDAC) with the intent of facilitating a curative surgical intervention. PDAC is uniquely characterized by an extensive fibrous microenvironment, desmoplasia, which can unintendedly be aggravated by NT to foster its pro-tumoral function. Radiation, as part of NT, is aimed at providing a margin adjacent to un-resectable vessels and sterilizing regional lymph nodes. Yet, to avoid the unintended desmoplastic aggravation, and because of a risk of toxicities associated with high doses due to the radio-sensitivity of adjacent small bowel and stomach, the total dose of NT radiation delivered to PDAC patients is classically modest. Therefore, NT radiation in PDAC patients is often lower than optimal for effective tumor cell elimination. Pulsed low-dose-rate (PLDR) radiation improves the safety of radiation treatment as it allows time for DNA damage repair in non-tumorous cells/tissues while simultaneously remaining as effective as continuous dose rate (CDR) radiation in cancer cells. In theory, PLDR could be amendable for increased radiation dosage. Of interest, the use of PLDR in pre-clinical animal studies revealed a systemic lowering of transforming growth factor beta (TGFβ), a known immunosuppressive factor. Hence, we posit that since cancer-associated fibroblasts (CAFs) produce TGFβ and constitute one of the most abundant cells in PDAC desmoplasia, variations in TGFβ levels in response to NT will inform on desmoplastic dynamic changes. Our team has developed means to assess CAF functions and activation statuses. These efforts were guided by generating a desmoplastic biomarker signature obtained from patient-harvested CAFs during the production of extracellular matrix (ECM), using our well-established in vitro 3D system. We employed this in vivo-mimetic system to test the hypothesis that PLDR limits pro-tumoral desmoplastic CAF aggravation. As part of the CAF functional signature, we tested levels of immunosuppressive TGFβ secretion, expression of netrin-G1, palladin, and others; together with the biogenesis of unique extracellular vesicles, and the production of ECMs capable of nurturing PDAC cells under starvation. During a 5-day assay, human PDAC 3D ECM producing CAFs were treated with gemcitabine (Gem; 5nm) plus 4Gy or 8Gy PLDR vs. CDR. Results indicated that Gem alone or with CDR indeed aggravated CAF’s pro-PDAC phenotype and function, while Gem combined with PDLR limited and sometimes reverted this functional pro-tumor CAF signature. Based on these results, we are poised to test this functional CAF/desmoplasia signature, as laboratory correlatives, in an ongoing clinical trial at Fox Chase Cancer Center. The phase I trial is a dose-escalation study of PLDR radiation and chemotherapy at standard and intensified doses in preoperative pancreatic cancer patients with toxicity, histopathologic, and CAF-informing translational endpoints. Citation Format: Janusz Franco-Barraza, Tiffany Luong, Jessica K. Wong, Debora B. Vendramini-Costa, Ralph Francescone, Jaye C. Gardiner, Kristopher S. Raghavan, Joshua E. Meyer, Edna Cukierman. Pulsed low-dose-rate radiation (PLDR) limits pancreatic pro-tumor stroma aggravation: Pre-clinical basis for an ongoing PLDR trail [abstract]. In: Proceedings of the AACR Virtual Special Conference on Radiation Science and Medicine; 2021 Mar 2-3. Philadelphia (PA): AACR; Clin Cancer Res 2021;27(8_Suppl):Abstract nr PR-006.

FEMORAL HERNIA: UNCOMMON, BUT ASSOCIATED WITH POTENTIALLY SEVERE COMPLICATIONS.

ABSTRACT Background: Although the laparoscopic access is becoming the preferable treatment for femoral hernia, there are only few studies on this important subject. Aim: To assess the outcomes of the totally extraperitoneal laparoscopic (TEP) access in the treatment of femoral hernia. Methods: Data of 62 patients with femoral hernia who underwent herniorrhaphy were retrospectively reviewed. The diagnosis of femoral hernia was established by clinical and/or imaging exams in 55 patients and by laparoscopic findings in seven. Results: There were 55 (88.7%) females and 7 (11.3%) males, with female to male ratio of 8:1. The mean age was of 58.9±15.9 years, ranging from 22 to 92 years. Most patients (n=53; 85.5%) had single hernia and the remaining (n=9; 14.5%) bilateral, making a total of 71 hernias operated. Prior lower abdominal operations were recorded in 21 (33.9%) patients. Conversion to laparoscopic transabdominal preperitoneal procedure was performed in four (6.5%). Open herniorrhaphy was needed in two (3.2%), one with spontaneous enterocutaneous fistula in the groin region (Richter’s hernia) and the another with incidental perforation of the adjacent small bowel that occurred during dissection of hernia sac. There was no mortality. Conclusion:Femoral hernia is uncommon, and it may be associated with potentially severe complications. Most femoral hernias may be successfully treated with totally extraperitoneal laparoscopic access, with low conversion and complication rates.

“Meckel’s Diverticulum” – A diagnostic bizarre of abdominal pain in adults

A 30-year-old male presented to the emergency room with complaints of periumbilical abdominal pain and vomiting. A contrast-enhanced computed tomography scan of the abdomen revealed subacute intestinal obstruction with dilated small bowel loops and associated bowel wall thickening of mid and distal ileal bowel loops. There was a fairly large small bowel diverticulum arising from the antimesenteric border of distal ileum. Findings were suggestive of small bowel diverticulitis or possibly focal enteritis. The patient was then immediately taken to the operating room for emergency laparotomy and was intra-operatively found to have a thickened Meckel’s diverticulitis with adjacent small bowel obstruction. Meckel’s diverticulectomy was performed in continuity with the adjacent inflamed small bowel. The patient had a stable post-operative course without any complications and was discharged within a week.

Dislodged Nephrostomy Catheter: An Unusual Case of Idiopathic Transposition of Nephrostomy Catheter From Transplanted Kidney to Adjacent Small Bowel Loop: A Case Report

A 72-year-old man with a past medical history notable for deceased renal transplant presented to the interventional radiology department for routine right lower quadrant renal transplant nephroureteral catheter exchange. The nephroureteral catheter was placed in 2016 because of the presence of a hematoma causing partial page kidney and hydronephrosis.An antegrade nephrostogram was notable for opacification of the small bowel instead of the renal collecting system. The patient then subsequently developed urinary retention and intractable abdominal pain. Because of the combination of events, it was deemed necessary for laparotomy and surgical repair of the small bowel. Intraoperative findings were notable for small bowel adhesion to the abdominal wall but otherwise no evidence of acute inflammatory changes. In this case report, we describe the first case of an idiopathically dislodged nephrostomy catheter to the small bowel from a transplanted kidney and its successful management.

2029 Perforated IVC Filter Leading to Duodenocaval Fistula and Massive Gastrointestinal Bleeding

INTRODUCTION: Inferior Vena Cava (IVC) filters are primarily indicated for patients with a history of deep venous thrombosis (DVT) or pulmonary embolism (PE) who have contraindications to anticoagulation. In most patients, the indication for placement of a filter is temporary. Although filter penetration of the IVC wall has been reported to range from 9% to 24% for all IVC filters, symptomatic perforation is rare and is reported to occur in about 0.4%-0.8% of cases. We are presenting a rare case of duodenocaval fistula presenting as massive gastrointestinal bleeding. CASE DESCRIPTION/METHODS: A 39-year-old male with a history of motor vehicle accident 10 years ago resulting in paraplegia and multiple lower extremity DVTs which required the placement of an IVC filter at that time was admitted to the hospital with one day of nausea, vomiting and hematochezia. History was very concerning for high volume bright red bleeding per rectum with associated non-bilious vomiting and dizziness. On arrival, he was hypotensive with a blood pressure of 60/40 mmHg, physical examination significant for actively oozing bright red blood per rectum. Labwork was remarkable for a Hemoglobin of 7.0 mg/dL and a BUN of 35 mg/dL. A CT scan of abdomen/pelvis with contrast revealed an IVC filter strut travelling through the IVC wall and perforating to the adjacent small bowel with active extravasation of the IV contrast to the small bowel, suggestive of a fistulous communication between IVC and a perforated loop of bowel. The patient was emergently taken to the operating room for exploratory laparotomy. IVC filter strut was found to be eroding through the IVC and into the duodenum confirming the CT findings. Transverse venotomy was performed and the filter was removed. An area of small bowel serosal tear was incorporated into the enterectomy segment, and end to end small bowel anastomosis was performed. IVC was repaired, and hemostasis was secured. Post-operatively, patient stayed stable clinically and hemodynamically with cessation of hematochezia. DISCUSSION: Duodenocaval fistula is a very rare complication of IVC filter placement, with around 10 reported cases in the literature. Even though it is rare, our case highlights the importance of a thorough and timely sensitive workup for an unstable patient with gastrointestinal bleeding and history of an IVC filter placement to rule out IVC penetration into surrounding viscera, since this can lead to significant morbidity and mortality if not recognized early during the clinical course.

1537 Colonic Gallstone Obstruction in the Setting of Cholecystocolonic Fistula

INTRODUCTION: Gallstone ileus is a relatively rare complication of cholelithiasis, estimated to account for approximately 1%-4% of all cases of mechanical intestinal obstruction. Cholecystoenteric fistulas form as a result of an inflamed gallbladder adhering to adjacent small bowel or colonic tissue, opening a channel by which gallstones can enter the intestinal tract. Fistula formation is most commonly to the duodenum (32.5-96.5%) but can also infrequently occur in the colon leading to gallstone impaction past the ileocecal valve. CASE DESCRIPTION/METHODS: Our patient is a 63 year old female who presented to the emergency room with one week of nonradiating stabbing left lower quadrant abdominal pain and constipation. She reported associated anorexia, and nausea without emesis. She was afebrile and hemodynamically stable. On exam, she was tender to palpation in the lower quadrants. No stool was present in the rectal vault. She had a negative Murphy's sign. Labs revealed WBC count 18.6 thousand/mcL, normal AST, normal ALT, and alkaline phosphatase 158 unit/L. Computed tomography (CT) scan abdomen/pelvis revealed gallbladder wall thickening with pneumobilia, cholelithiasis, normal common bile duct, and a large curvilinear hyperdensity in the distal colon (A). This was suspected to be a displaced gallstone in the sigmoid colon related to a fistula between the gallbladder and hepatic flexure (B). Removal of the stone was attempted by flexible sigmoidoscopy with snare and basket but was unsuccessful. She was then taken for exploratory laparotomy, transverse colotomy with extraction of 5 × 3.4 cm gallstone, loop transverse colostomy, and ventral hernia repair (C). She received IV antibiotics for 5 days and was discharged home. DISCUSSION: This case highlights a rare etiology of colonic gallstone obstruction in a patient without risk factors including underlying malignancy, colonic stricture, or diverticulum. Optimal surgical management of gallstone ileus with associated fistula is still being defined as few cases have been reported in the literature. One large retrospective survey found enterotomy with stone extraction to be associated with improved survival outcomes and decreased postoperative complications compared to surgery with fistula closure and bowel resection. Our patient had stable gallbladder changes and persistent cholecystoenteric fistula on CT scan over the next three months and expressed several gallstones through her colostomy without requiring further surgery.

Diagnosis and Management of Ovarian Cancer, Current Status and Future Potential

Ovarian carcinoma is the fifth common cause of cancer death among women in Malaysia, with five-year survival rates of 30%. It has been associated with delayed diagnosis, advanced stage of presentation and poor prognosis due to vague symptoms and lack of effective screening. The continued high fatality rate has underpinned efforts to develop effective screening tests and newer therapies that could impact on prognosis. New insights into proteomic analysis and genomic tests with a better understanding of the target lesion have leading to discovery of new treatment modalities in ovarian carcinoma. We present a 58-year-old lady with Stage IV ovarian cancer who had lower abdominal pain and mass, constipation and voiding frequency for six months duration. Ultrasound guided biopsy revealed serous adenocarcinoma likely ovarian in origin. CT scan showed gross ascites and right ovarian mass with infiltration to adjacent small bowel. Tumour markers CA 125 and LDH were high. She has received neoadjuvant chemotherapy followed by cytoreductive surgery and currently in remission.

A rare case of locally advanced mucinous adenocarcinoma of the appendix confined in the inguinal canal: Clinical presentation, operative management.

Background: An Amyand’s hernia is a right inguinal hernia that contains the appendix in the hernia sac. Mucinous adenocarcinoma of the vermiform appendix is a rare neoplasm commonly discovered through the histology report of a presumed appendicitis specimen or as the cause of pseudomyxoma peritonei. It is very rare for the two entities to co-exist and present as an incarcerated right inguinal hernia. Case Summary: We report a rare case of a mucinous appendiceal adenocarcinoma that ruptured towards the confided anatomical space of the inguinal canal. Initial presentation of the patient was with small bowel obstruction and clinical examination revealed a co-existing right inguinal hernia. Exploratory laparotomy findings revealed an appendiceal mucinous adenocarcinoma invading the adjacent bowel loops and identified an encapsulated collection of mucinous material extended into the inguinal canal and lateral abdominal wall. He underwent a right hemicolectomy with excision of the adjacent small bowel loops and the affected abdominal wall. Conclusion: As the patient presented with a long-standing history of inconsistent symptoms, he underwent thorough preoperative investigations which revealed the true extend of the underlying disease and led to appropriate surgical intervention. The fact that the tumour extended towards the confided space of the inguinal canal prevented the development of pseudomyxoma peritonei. It remains to be examined if such cases, where the mucinous material is contained bare a favourable prognosis.

Incidental Mesenteric Paraganglioma: A Case Report and Literature Review.

Mesenteric paragangliomas are a rare entity; consequently, only 12 cases have been reported to date. Although considered benign and often found incidentally, they have the potential to metastasize and are an important diagnosis to consider for patients with a mesenteric tumor. We report the case of a 71-year-old woman who was found on magnetic resonance imaging to have an incidental, large, complex, intra-abdominal mass that had initially been misdiagnosed as ovarian in origin. She underwent an open resection of the tumor and adjacent small bowel with no perioperative complications; histology confirmed the mass to be a mesenteric paraganglioma. This case report highlights several important key issues regarding paraganglioma, including diagnosis, imaging, genetic testing, and surgical resection. The results of a literature review are also discussed.

Colonic Thickening and Abdominal Pain: Etiology Unfolded!

Introduction: Cecal volvulus accounts for 2-4% of all gastrointestinal obstructions and 1-2% of all large bowel obstructions. This often occurs when the cecum rotates along its long axis in relation to the terminal ileum and ascending colon. Cecal bascule is a rare type of cecal volvulus that occurs due to anteromedial folding of the cecum. Clinically, all forms of cecal volvuli are indistinguishable and the mortality rate is similarly high. However, abdominal imagining can distinguish cecal bascule from other forms of volvuli. We present a case of abdominal pain and colonic thickening on CT due to cecal bascule Case presentation: A 50 years old female with no significant medical history presented with 3 days of moderately severe cramping lower abdominal pain. She has prior history of hysterectomy. She denies any other complains including nausea, vomiting or constipation. No family history of colon cancer. Her physical exam was normal except for periumbilical tenderness on deep palpation. Labs were normal including urinalysis. CT scan of the abdomen showed thickened ascending colon and collapsed distal colon with hyperenhancing distended distal small bowel without associated whirling. Colonoscopy was done but could not be advanced beyond the ascending colon due to stricture. An air contrast barium enema showed severe ascending colon stricture with distended superior anteromedial cecal displacement suggesting cecal bascule. Laparoscopic ileocectomy was performed and cecal bascule was confirmed intraoperatively. The patient recovered well and was discharged home.Figure: Barium enema with dilated cecum.Figure: Ascending colon thickening and adjacent small bowel dilation.Discussion: Cecal bascule accounts for 0.01% of all large bowel obstructions. This occurs due to anteromedial folding of the cecum. On CT scan, axial torsion of the cecum is associated with the presence of a “whirl” sign that has never been reported in cecal bascule before. In this case, a barium enema is more beneficial in establishing the diagnosis. Colonoscopy is rarely required to diagnose or treat the condition and might in fact result in colonic perforation. Regardless of the type of cecal volvulus, treatment is primarily surgical. Gastroenterologists should be aware of this disorder especially prior to colonoscopy in patients with large bowel obstruction.

MicroRNAs associated with small bowel neuroendocrine tumours and their metastases

Novel molecular analytes are needed in small bowel neuroendocrine tumours (SBNETs) to better determine disease aggressiveness and predict treatment response. In this study, we aimed to profile the global miRNome of SBNETs, and identify microRNAs (miRNAs) involved in tumour progression for use as potential biomarkers. Two independent miRNA profiling experiments were performed (n=90), including primary SBNETs (n=28), adjacent normal small bowel (NSB; n=14), matched lymph node (LN) metastases (n=24), normal LNs (n=7), normal liver (n=2) and liver metastases (n=15). We then evaluated potentially targeted genes by performing integrated computational analyses. We discovered 39 miRNAs significantly deregulated in SBNETs compared with adjacent NSB. The most upregulated (miR-204-5p, miR-7-5p and miR-375) were confirmed by qRT-PCR. Two miRNAs (miR-1 and miR-143-3p) were significantly downregulated in LN and liver metastases compared with primary tumours. Furthermore, we identified upregulated gene targets for miR-1 and miR-143-3p in an existing SBNET dataset, which could contribute to disease progression, and show that these miRNAs directly regulate FOSB and NUAK2 oncogenes. Our study represents the largest global miRNA profiling of SBNETs using matched primary tumour and metastatic samples. We revealed novel miRNAs deregulated during SBNET disease progression, and important miRNA-mRNA interactions. These miRNAs have the potential to act as biomarkers for patient stratification and may also be able to guide treatment decisions. Further experiments to define molecular mechanisms and validate these miRNAs in larger tissue cohorts and in biofluids are now warranted.

Giant dedifferentiated liposarcoma of small bowel mesentery: a case report.

BackgroundDedifferentiated liposarcoma is an uncommon variant of liposarcoma, with poor prognosis and higher preponderance to local recurrence. Only nine cases of dedifferentiated liposarcoma of small bowel mesentery have been reported till now. This is a case of giant dedifferentiated liposarcoma of the small bowel mesentery, weighing nearly 9 kg (19.8 lbs), with synchronous lesions in the extraperitoneal space, which is the first such case to be reported.Case presentationWe report a case of a 62-year-old man, who presented with a huge abdominal mass occupying nearly the entire abdomen. A contrast enhanced computed tomography of abdomen and pelvis revealed a large, poorly enhancing, heterogeneous, lobulated mass of size 27 × 16 cm, displacing the bowel loops peripherally. At laparotomy, a large mass arising from the small bowel mesentery was found. In addition, many other smaller synchronous lesions were studded in the entire small bowel mesentery and a couple more in the extraperitoneal space. A palliative excision of the giant mass along with the adjacent small bowel was done. The other smaller swellings were not causing any mass effect and were left behind as they were numerous, virtually ruling out any possibility of a curative excision. The histopathological examination suggested the diagnosis of dedifferentiated liposarcoma. On immunohistochemistry, S-100 was positive in the well-differentiated sarcomatous areas. The CD 117 and SMA were strongly negative ruling out the possibility of a gastrointestinal stromal tumour. The CD 34 however was positive in the tumour cells.ConclusionsDedifferentiated liposarcoma of the small bowel mesentery is rare. Involvement of nearly whole of the small bowel mesentery in the disease process virtually rules out the possibility of a curative resection, the mainstay of management. This report would add to the knowledge of this rare disease and the possible therapeutic problem that may be encountered in case of multifocal disease.