Blind Loop Research Articles

Small bowel torsion due to adhesive band, causing blind loop in pregnancy and the prompt salvage: A case report

Small bowel torsion due to adhesive band, causing blind loop in pregnancy and the prompt salvage: A case report

Interobserver agreement of current and new proposed endoscopic scores for postoperative recurrence in Crohn’s disease

Background and AimsThe modified Rutgeerts’ score (mRS) is widely used for the assessment of endoscopic postoperative recurrence (ePOR) in Crohn’s disease (CD) after ileocolic resection to guide therapeutic decisions. To improve the validity and prognostic value of this endoscopic assessment, two new scores have been proposed. This study assessed the interobserver agreement of the current (mRS) and new endoscopic scores for ePOR in CD. MethodsSixteen Dutch academic and non-academic IBD specialists assessed endoscopic videos (n=71) of postoperative CD patients (n=66) retrieved from nine Dutch centers. Each video was assessed for the degree of inflammation by four gastroenterologists using the mRS and the new proposed endoscopic score: REMIND score (separate score of anastomosis and neoterminal ileum) and updated Rutgeerts score (assessment of lesions at the anastomotic line, ileal inlet, ileal body and neoterminal ileum). In addition, lesions at the ileal body, ileal inlet, neoterminal ileum, colonic and/or ileal blind loop were separately assessed. Interobserver agreement was assessed using Fleiss’ weighted kappa. ResultsFleiss’ weighted kappa for the mRS was 0.67 (95% confidence interval [CI] 0.59–0.74). The weighted kappa for the REMIND score was 0.73 (95% CI 0.65–0.80) for lesions in the neoterminal ileum and 0.46 (95% CI 0.35–0.58) for anastomotic lesions. The weighted kappa for the updated Rutgeerts’ score was 0.69 (95% CI 0.62–0.77). The weighted kappa for lesions in the ileal body, ileal inlet, neoterminal ileum, colonic and ileal blind loop was 0.61 (95% CI 0.49–0.73), 0.63 (95% CI 0.54–0.72), 0.61 (95% CI 0.49–0.74), 0.83 (95% CI 0.62–1.00) and 0.68 (95% CI 0.46–0.89). ConclusionThe interobserver agreement of the mRS is substantial. Similarly, the interobserver agreement is substantial for the updated Rutgeerts’ score. According to the REMIND score, the interobserver agreement was substantial for lesions in the neoterminal ileum, whereas only moderate for anastomotic lesions. Since therapeutic decisions in clinical practice are based on these assessments and these scores are used as outcome measure in clinical studies, further improvement of the interobserver agreement is essential.

P277 Interobserver agreement of current and new proposed endoscopic scores for postoperative recurrence in Crohn’s disease

Abstract Background The modified Rutgeerts’ score (mRS) is widely used for the assessment of endoscopic postoperative recurrence (ePOR) in Crohn’s disease (CD) after ileocolic resection to guide therapeutic decisions. To improve the validity and prognostic value of this endoscopic assessment, two new scores have been proposed. This study assessed the interobserver agreement of the current (mRS) and new endoscopic scores for ePOR in CD. Methods Sixteen academic and non-academic IBD specialists assessed endoscopic videos (n=71) of postoperative CD patients (n=66) retrieved from nine Dutch centers. Each video was assessed for the degree of inflammation by four gastroenterologists using the mRS, REMIND score (separate score of anastomosis and neoterminal ileum) and anatomic score (separate score of lesions at the anastomotic line, ileal body, ileal inlet, neoterminal ileum, colonic and/or ileal blind loop). Interobserver agreement was assessed using Fleiss’ weighted kappa. Results Fleiss’ weighted kappa for the mRS was 0.67 (95% confidence interval [CI] 0.59–0.74). The weighted kappa for the REMIND score was 0.73 (95% CI 0.65–0.80) for lesions in the neoterminal ileum and 0.46 (95% CI 0.35–0.58) for anastomotic lesions. In the anatomic score, the weighted kappa for lesions in the ileal body, ileal inlet, neoterminal ileum, colonic and ileal blind loop was 0.61 (95% CI 0.49–0.73), 0.63 (95% CI 0.54–0.72), 0.61 (95% CI 0.49–0.74), 0.83 (95% CI 0.62–1.00) and 0.68 (95% CI 0.46–0.89), and 0.44 (95% CI 0.32–0.55) for lesions at the anastomotic line. Conclusion The interobserver agreement of the mRS is substantial. Similarly, the interobserver agreement is substantial for lesions in the neoterminal ileum according to both the REMIND and anatomic score, whereas only moderate for anastomotic lesions. Since therapeutic decisions in clinical practice are based on these assessments and these scores are used as outcome measure in clinical studies, further improvement of agreement is essential.

Do Patients Benefit from Micronutrient Supplementation following Pancreatico-Duodenectomy?

Pancreatico-duodenectomy (PD) includes resection of the duodenum and use of the proximal jejunum in a blind loop, thus reducing the absorptive capacity for vitamins and minerals. Several studies have analysed the frequency of micronutrient deficiencies, but there is a paucity of data on those taking routine supplements. A retrospective review of medical notes was undertaken on 548 patients under long-term follow-up following PD in a tertiary hepato-pancreatico-biliary centre. Data were available on 205 patients from 1-14 years following PD, and deficiencies were identified as follows: vitamin A (3%), vitamin D (46%), vitamin E (2%), iron (42%), iron-deficiency anaemia (21%), selenium (3%), magnesium (6%), copper (1%), and zinc (44%). Elevated parathyroid hormone was present in 11% of cases. There was no significant difference over time (p > 0.05). Routine supplementation with a vitamin and mineral supplement did appear to reduce the incidence of biochemical deficiency in vitamin A, vitamin E, and selenium compared to published data. However, iron, vitamin D, and zinc deficiencies were prevalent despite supplementation and require surveillance.

Averting an Unnecessary Revision of a Roux-en-Y Hepaticojejunostomy by Surgically Creating an Access Point for the Endoscopic Assessment of the Anastomosis: A Report of a Case

Introduction: Primary sclerosing cholangitis sets the scene for several pathologies of both the intrahepatic and the extrahepatic biliary tree. Surgical treatment, when needed, is almost unanimously summarized in the creation of a Roux-en-Y hepaticojejunostomy, a procedure with a relatively high associated failure rate. Presentation of case: A 70-year-old male, diagnosed with primary sclerosing cholangitis, was submitted to a Roux-en-Y hepaticojejunostomy due to a dominant stricture of the extrahepatic biliary tree. Recurrent episodes of acute cholangitis dictated a workup in the direction of a possible stenosis at the level of the anastomosis. The imaging studies were inconclusive while both the endoscopic and the transhepatic approach failed to assess the status of the anastomosis. A laparotomy, with the intent to revise a high suspicion for stenosis hepaticojejunostomy, was decided. Intraoperatively, a decision to assess the hepaticojejunostomy prior to the scheduled surgical revision, via endoscopy, was made. In this direction, an enterotomy was made on the short jejunal blind loop in order to gain luminal access and an endoscope was propelled through the enterotomy towards the biliary enteric anastomosis. Results: The inspection of the anastomosis under direct endoscopic vision showed no evidences of stenosis and averted an unnecessary, under these circumstances, revision of the anastomosis. Conclusions: The surgical revision of a Roux-en-Y hepaticojejunostomy is a highly demanding operation with an increased associated morbidity, and it should be reserved as the final resort in the treatment algorithm. An approach of utilizing surgery to facilitate the endoscopic assessment prior to proceeding to the surgical revision of the anastomosis appears justified.

CO2 enterography in endoscopic retrograde cholangiography using double-balloon endoscopy: A randomized clinical trial.

Double-balloon endoscopic retrograde cholangiography (DBERC) is a valuable procedure for patients with altered gastrointestinal anatomy. Nonetheless, it is time-consuming and burdensome for both patients and endoscopists, partly because route selection in the reconstructed bowel with complicating loop is challenging. Carbon dioxide insufflation enterography is reportedly useful for route selection in the blind loop. This prospective randomized clinical trial investigated the usefulness of carbon dioxide insufflation enterography for route selection by comparing it with conventional observation. Patients scheduled to undergo DBERC were consecutively registered. They were divided into carbon dioxide insufflation enterography and conventional groups via randomization according to stratification factors, type of reconstruction methods, and experience with DBERC. The primary endpoint was the correct rate of initial route selection. The secondary endpoints were the insertion time, examination time, amount of anesthesia drugs, and complications. The correct rate of route selection was significantly higher in the carbon dioxide insufflation enterography group (23/25, 92%) than in the visual method (15/25, 60%) (P=0.018). The insertion time was significantly shorter in the carbon dioxide insufflation enterography group than in the visual group (10.8±11.1min vs 29.8±15.7min; P<0.001). No significant differences in complications were noted between the two groups. The amounts of sedatives and analgesics used were significantly lower in the carbon dioxide insufflation enterography group (P<0.001 and P<0.001, respectively). Carbon dioxide insufflation enterography can reduce the burden of DBERC on patients and endoscopists by shortening the examination time and reducing the amount of medication.

A Case of Blind Loop Syndrome Manifesting 54 Years after Surgery

A Case of Blind Loop Syndrome Manifesting 54 Years after Surgery

Value of ileo-ascending colic end to side anastomosis after ileocaecal resection.

Objective: To assess the outcome of end to side Ileo-Ascending Colic anastomosis in patients undergoing emergency and elective Ileo-Caecal resection in non-malignant cases. Study Design: Cross Sectional Descriptive study. Setting: Department of Surgery at Fauji Foundation Hospital Rawalpindi. Period: January, 2018 to December, 2020. Material &amp; Methods: A Total of 40 patients with ileo-caecal benign pathology presenting with generalized peritonitis and intestinal obstruction were studied. All patients underwent laparotomy either in emergency or as planned procedure. After dealing with the primary pathology an end to side ileo-ascending colic anastomosis was performed in all cases. Cases of ileo-caecal disease that required an ileostomy or underwent ileo-transverse colic anastomosis were excluded from the study. Anastomosis was performed in conventional two layers with vicryl 3/0. Variables studied were; indication for surgery, per-operative findings and post-operative complications like anastomotic leakage, surgical site infection, burst abdomen and systemic sepsis. Data was analyzed on SPSS (v 26). Results: There were 30 females (75%) and 10 male patients (25%). Age range was 18-72 years with mean age 43.62 years. Common clinical indication of surgery was intestinal obstruction 11 cases (27.5%) followed by generalized peritonitis 10 cases (25%) and trauma 9 cases (22.5%). Post-operative diagnosis in most patients was ileo-caecal tuberculosis 14 cases (35%) followed by trauma to ileo-caecal region 9 cases (22.5%). Anastomotic leakage occurred in 1 patient (2.5%) who underwent second look laparotomy and re-anastomosis. Surgical site infection occurred in 3 cases (7.5%). There was one fatality (2.5%) due to uncontrolled systemic sepsis. Conclusion: An end to side ileo- ascending colic anastomosis in conventional two layers is a safe and reliable procedure after emergency or planned ileo-caecal resection. It saves the patient from ileostomy, preserves colonic length and avoids formation of blind loop.

S2290 Complete Esophageal Obstruction: A Rare Complication of Zollinger-Ellison Syndrome (ZES)

Introduction: Patients diagnosed with ZES typically have minimal esophageal morbidity given advancements in anti-secretory medications. This case presents a rarely documented sequala of modern-day patients with ZES. Case Description/Methods: A 73-year-old man with history of HIV on HAART and ZES presented with worsening dysphagia to both solids and liquids. In the 2 year interval since his original presentation, his medical therapy was quickly maximized to omeprazole 180 mg/day and famotidine 80 mg/day. He also underwent tumor resection with distal gastrectomy, resection of D1, roux-en-Y hepaticojejunostomy, and truncal vagotomy. During that time his gastrin levels normalized from 1941 to 87. Despite these measures, he had undergone 21 EGDs and 7 esophageal stents for dysphagia secondary to refractory esophageal strictures. He lost 48 lbs over 2 years despite extensive attempts at both enteral and total parental nutrition. In January 2022, he presented with inability to swallow his own secretions and profound weakness from malnutrition. An esophagram was performed (figure 1a) revealing complete esophageal obstruction. An EGD with esophageal lumen restoration was attempted using combined retrograde and anterograde recanalization with 2 operators, 2 EGD scopes, and an EUS needle (figure 1c). Unfortunately, the 2 blind loops appeared to be approximately 6 cm apart in different alignments making lumen restoration unfeasible. The patient was most recently evaluated for esophageal reconstruction by jejunal interposition but was not a candidate due to poor nutritional status. Discussion: ZES is characterized by severe ulcerative disease due to gastric acid hypersecretion via neuroendocrine tumors. Our case is unique because this patient developed complete esophageal obstruction (CEO) despite management with maximal acid suppressive therapy, surgical resection, multiple EGDs with dilations, and numerous esophageal stents. CEO is a rare occurrence characterized by lumen obliteration leading to the inability to tolerate own secretions and most recorded cases are due to radiation-therapy for treatment of head and neck cancers. Given the low incidence, there is no single established method for endoscopic lumen restoration. However recombined retrograde and anterograde recanalization and dilation (CARD) has been shown to be successful for strictures less than 3 cm.Figure 1.: (A) Barium swallow study revealing a high-grade stricture in mid thoracic esophagus followed by another high-grade stricture with complete lumen obstruction. (B) EGD showing blind pouch approximately 35 cm from incisors. (C) Fluoroscopic imaging displaying attempt at combined anterograde and retrograde decannulation and dilation.

Fluorescence perfusion assessment of vascular ligation during ileal pouch-anal anastomosis

BackgroundIntraoperative fluorescence angiography (FA) is of potential added value during ileal pouch-anal anastomosis (IPAA), especially after vascular ligation as part of lengthening measures. In this study, time to fluorescent enhancement during FA was evaluated in patients with or without vascular ligation during IPAA.MethodsThis is a retrospective cohort study of all consecutive patients that underwent FA-guided IPAA between August 2018 and December 2019 in our tertiary referral centre. Vascular ligation was defined as disruption of the ileocolic arcade or ligation of interconnecting terminal ileal branches. FA was performed before and after ileoanal anastomotic reconstruction. During FA, time to fluorescent enhancement was recorded at different sites of the pouch.ResultsThirty-eight patients [55.3% male, median age 45 years (IQR 24–51 years)] were included, of whom the majority (89.5%) underwent a modified-2-stage restorative proctocolectomy. Vascular ligation was performed in 15 patients (39.5%), and concerned central ligation of the ileocolic arcade in 3 cases, interconnecting branches in 10, and a combination in 2. For the entire cohort, time between indocyanine green (ICG) injection and first fluorescent signal in the pouch was 20 s (IQR 15–31 s) before and 25 s (IQR 20–36 s) after anal anastomotic reconstruction. Time from ICG injection to the first fluorescent signal at the inlet, anvil and blind loop of the pouch were non-significantly prolonged in patients that received vascular ligation.ConclusionsResults from this study indicate that time to fluorescence enhancement during FA might be prolonged due to arterial rerouting through the arcade or venous outflow obstruction in case of vascular ligation.

International expert opinion on optimal treatment of anastomotic leakage after rectal cancer resection: a case-vignette study

PurposeLittle is known about the optimal treatment of anastomotic leakage after low anterior resection (LAR) for rectal cancer and whether treatment strategy depends on leakage features and patient characteristics. The objective of this study was to determine which treatment principles are used by expert colorectal surgeons worldwide.MethodsIn this international case-vignette study, participants completed a survey on their preferred treatment for 11 clinical cases with varying leakage features and two patient scenarios depending on surgical risk (a total of 22 cases).ResultsIn total, 42 of 64 invited surgeons completed the survey from 18 countries worldwide. The majority worked at a university training hospital (62%) and had more than 15 years of experience performing LAR for rectal cancer (52%). Early leaks in septic patients were preferably treated by major salvage surgery, to some extent depending on the patient scenario. In early leaks in non-septic patients, drainage and faecal diversion were the cornerstones of the proposed treatment. Endoscopic vacuum therapy was more often proposed than percutaneous drainage. A minority proposed anastomotic reconstruction, more often for larger defects. Treatment of late leaks ranged from watchful waiting, drainage, or transanal repair to major (non-)restorative salvage surgery, with minimal influence of the degree of symptoms on the proposed strategy. Leaks of the blind loop and rectovaginal fistulae showed high variability in the proposed treatment strategy.ConclusionThis TENTACLE-Rectum case-vignette study demonstrates tailored treatment strategies depending on the clinical type of leak and patient characteristics, with variable degrees of consensus and knowledge gaps which should be addressed in future studies.

EP-593 Blind loop mucocele of a side-to-end colorectal anastomosis as a rare cause of large bowel obstruction

Abstract Background Large bowel obstruction (LBO) after colorectal surgery draws wide differentials. Very few reports of LBO secondary to closed loop mucocele have been published. To our knowledge, LBO due to mucocele of the blind colonic limb of a side-to-end colorectal anastomosis has not been described. Case Details A 57-year-old man presented with pain, gradual abdominal distension and one week history of constipation. He had extensive surgical history – colo-vesical fistula takedown, sigmoid resection and Hartmann type end colostomy followed by reversal, and mesh repair of incisional ventral hernia among others. Notably, a side-to-end configuration was fashioned as a descending colo-rectal anastomosis. CT, followed by MRI scans, of the abdomen and pelvis respectively suggested a mucus-filled short blind colonic bowel segment compressing the anastomotic site as the cause of large bowel obstruction proximal to the site. On flexible sigmoidoscopy under general anaesthesia, external compression of the rectum with narrowing of the lumen was noted. Transrectal needle aspiration of the blind colonic segment yielded 145 mL of mucoid fluid and allowed proximal examination. Anastomotic site was of normal calibre. The patient's symptoms improved and he was discharged with scheduled outpatient follow-up. Gastrografin enema post-discharge demonstrated an end-to-side rectosigmoid anastomosis with local rectal stenosis and showed the blind loop had emptied. Conclusion This case highlights that blind colonic loop mucoceles in colorectal anastomosis can rarely cause obstruction and endoscopic management is feasible when accurate diagnosis is confirmed on imaging.

Endoscopic marsupialization for severe candy cane syndrome: long-term follow-up.

Candy cane syndrome (CCS) is a clinical condition that may occur after gastrectomy or gastric bypass, when an excessively long or mispositioned blind jejunal loop proximal to the anastomosis is left in place. Preferential food passage in this loop results in symptoms such as fullness, pain, reflux, regurgitation, and postprandial vomiting. Surgical resection of the dilated loop is technically complex, and morbidity limits its use in fragile patients. An endoscopic approach, using dedicated active magnets, has recently been shown to be effective in the medium-term. We present here the case of a 71-year-old female patient who underwent endoscopic treatment for the first time. She presented with intractable vomiting, food intolerance, and cachexia due to CCS after total gastrectomy for gastric cancer. Surgical treatment was not an option in such a high-risk patient, and she accepted treatment with a novel endoscopic approach using a double-magnet device followed by septotomy to marsupialize the blind loop. Her symptoms were completely resolved, and she regained weight. We report here her clinical outcomes at 3 years, suggesting that endoscopic marsupialization for CCS is not only effective in the short term but also provides long-term clinical benefit.

Megaduodenum in children in the outcom of correction of duadenal atreesia: literature review and own experience

Introduction. Despite the good long-term results of duodenal atresia correction in the long term, about 10% of patients have severe upper gastrointestinal motility disorders: GERD, gastroduodenitis, and megaduodenum, which requires re-reconstruction of the duodenal anastomosis. Materials and methods. For the period from 2010 to 2021 in the clinic of the FGBUZ DGKB them. N. F. Filatov DZM Moscow 7 patients was treated with megaduodenum, operated on for duodenal atresia. The average age of the patients was 5.4 ± 3.9, boys predominated (6/7). All children underwent a standardized examination: ultrasound, barium fluoroscopy, FGEDS and laboratory research methods. MRCP and abdominal CT were performed as indicated (3/7). All patients were operated on, depending on the cause of obstruction and the degree of its compensation. Reconstruction of the previously applied anastomosis (4/7) or resection of the duodenum (3/7) was performed. Results. Main patient complaints: abdominal pain 7/7 (100%), vomiting 7/7 (100%), abdominal distention 4/7 (57.1%), poor weight loss 3/7 (42.8%), constipation 3/7 (42.8%). 5 out of 7 had multiple congenital malformations (MCDs). Mechanical causes of chronic renal failure were detected in 4 out of 7 children: stenosis of the duodeno-duodenoanastomosis (2), “blind loop” syndrome (infringement of the Roux loop in the form of a “double-barrel” in the window of the mesentery of the transverse colon) (1), stenosis of the duodeno-duodenoanastomosis in in combination with fibrosis of the head of the pancreas (1). In the remaining 3 cases a secondary megaduodenum was detected with good obstruction of the previously imposed anastomosis. Hiowever, it was noted that the diameter of the anastomosis was definitely less than the diameter of the duodenum above its level. In 6 out of 7 patients chronic renal failure was complicated by secondary gastroesophageal reflux disease (GERD), which required surgical correction in only one patient after 6 months. In other cases, the dynamics of reflux spontaneously decreased to 1 degree and was intermittent, the patients had no complaints. All children were examined in follow-up after 1, 3, 6 and 12 months. All of them showed positive dynamics in the form of weight gain, absence of complaints and signs of protein-energy insufficiency. Conclusion. Children operated on for duodenal atresia need long-term careful dispensary observation. Since in the presence of pronounced motor-evacuation disorders of the duodenum, repeated interventions are necessary. Surgical tactics should be strictly differentiated. Resection of the duodenum improves passage through the upper gastrointestinal tract and is well tolerated by patients.

Treatment of Duodenal Atresia with Kimura’s Diamond-Shaped-Duodeno-Duodenostomy (DSD)

Background: Kimura’s diamond shaped duodeno-duodenostomy (DSD) is a well-recognized treatment for the management of duodenal atresia. Purpose: The aim of this study is to determine and share the experience of diamond shaped duodeno-duodenostomy and an overview of the benefits of this procedure. Place and Duration: In the Pediatric Surgery department of Govt. Sardar Begum Teaching Hospital Sialkot and Bacha Khan Medical Complex Swabi for five and half years from January 2016 to November 2021. METHODS: 42 neonates were surgically treated for duodenal atresia by Kimura’s technique. The transverse incision was given in the proximal dilated duodenum and longitudinal incision was given in the distal part of duodenum. Results: On 5th to 8 th day post-operatively, oral feeding was started (mean 6.2 days), full oral feeds were commenced between 7th to10th day (mean 9.2), peripheral intravenous fluids were discontinued 7th day to 10th day (mean 9.2), and hospital stay varies from 7th to 21st day (mean 10.8). The complications such as anastomosis leakage 1(2.4), infection 1(2.4), abnormal duodenal morphology 6(14.2) and Gastroesophageal reflux in 2(4.8) of patients. In prenatal ultrasonography of the fetus, obstruction of the duodenum was diagnosed in 31/42 (73.9%) and polyhydramnios in 19/42 (45.2%) cases. Conclusion: DSD offers a valuable technique to guard the ampulla of Vater from injury and blind loop can be avoided by this technique. The outcomes exhibited that patients of DSD attain complete per-oral nutrition in a very brief duration after surgery and subsequently the extent of hospital stay is reduced significantly.

Growth of Intestinal Neomucosa on Pedicled Gastric Wall Flap, a Novel Technique in an Animal Model

Background: Short bowel syndrome (SBS) remains an unsolved issue in modern medicine. Numerous experimental surgical techniques have been proposed in the attempt to increase the intestinal absorptive capacity. Materials and Methods: Ten female Landrace pigs, divided in two groups of 5 (A and B), were explored through a midline incision. A spindle-shaped vascularized full-thickness gastric wall flap (GWF) consisting of part of the major curvature with the gastroepiploic arch preserved was de-epithelialized and then placed as a “patch” to cover an antimesenteric border defect of either a nonfunctional blind intestinal loop (group A) or a functional intestinal loop of the gastrointestinal tract (group B). A spindle-shaped curved, rigid, low density polyethylene (LDPE) splint was sutured on the external surface of the patch in order to prevent shrinkage of GWF and collapse of the intestinal wall in group A. Results: There was a decrease of both dimensions of the patch. Microscopically a thin layer of columnar epithelial cells covered the center of the patch, evolving in shorter, blunt, poorly developed villi with increasing maturation laterally. The patch surface was covered by nearly 90%. In the three animals that died prematurely the coverage of GWF was negligent or suboptimal directly dependent on the length of survival. Conclusions: The hereby-described patching technique demonstrated the growth of intestinal neomucosa on the GWF. The capability of the stomach to provide large flaps and the advantages of the use of native tissues render this animal model valuable for the future research in the field.

A Clinicopathological Study of Developmental and Acquired Causes of Intestinal Obstruction in Paediatric Population- A Retrospective Study

Introduction: Intestinal Obstruction (IO) in the paediatric age group can be due to a variety of developmental and acquired causes which depend on the age at presentation. Histopathological examination of the resected intestine can provide definite evidence of underlying aetiology. Aim: To analyse the spectrum of lesions causing IO and it’s relation with clinicopathological features. Materials and Methods: This was a retrospective study conducted in the Department of Pathology at Seth G.S Medical College and Dr. R. N. Cooper Hospital, Mumbai, Maharashtra, India. Gross and microscopy of 70 surgically resected specimens of patients with IO, received over a period of five years, from January 2009 to December 2013, were studied after getting ethical clearance. Clinical details were retrieved from the records. Lesions were classified as developmental and acquired which were further categorised into infective, neoplastic and miscellaneous categories. Data was analysed using Microsoft excel 2010 and was expressed as frequency and percentage. Results: Out of the 70 cases studied there were 40 males and 30 females. There were 37 cases less than 1 month old, 13 cases between one month to 1 year age and 20 cases between 1 year to 12 years of age. The developmental category comprised of 52/70 cases (74.29%) with 17 cases of Meckel’s diverticulum,16 cases of intestinal atresia, three cases each of mesenteric cysts and duplication cysts, five cases of duodenal webs, four cases of congenital bands, one case each of lymphangiectatic cyst, malrotation, blind ileal loop and meconium ileus. In the acquired category there were three cases of tuberculosis and one case each of fungus and Ascaris infection. In the neoplastic category there were five cases of polyps and one case each of cystic teratoma and Burkitt lymphoma. There were three cases of volvulus, two of perforation and one case of intussusception. Conclusion: The present study highlights the various causes of IO in children from neonatal period up to 12 years of age. With proper gross and microscopic examination it was possible to give confirmed diagnosis which is necessary for further management of the patient.

GASTROESOPHAGEAL SYMPTOMS AFTER LAPAROSCOPIC GASTRIC BYPASS: MISTAKES IN PERFORMING THE PROCEDURE?

ABSTRACT - BACKGROUND:Laparoscopic Roux-en-Y gastric bypass (LGB) is the recommended procedure for morbidly obese patients with gastroesophageal reflux disease (GERD). However, there have been reported gastroesophageal reflux symptoms or esophagitis after LGB. Few functional esophageal studies have been reported to date.AIM: To evaluate the anatomic and physiologic factors contributing to the appearance of these problems in patients who underwent LGB.METHODS: This prospective study included 38 patients with postoperative gastroesophageal reflux symptoms submitted to LGB. They were subjected to clinical, endoscopic, radiologic, manometric, and 24-h pH-monitoring evaluations.RESULTS: Eighteen (47.4%) of 38 patients presented with heartburn or regurgitation, 7 presented with pain, and 4 presented with dysphagia. Erosive esophagitis was observed in 11 (28.9%) patients, and Barrett’s esophagus (5.7%) and jejunitis (10.5%) were also observed. Hiatal hernia was the most frequent finding observed in 15 (39.5%) patients, and most (10.5%) of these patients appeared with concomitant anastomotic strictures. A long blind jejunal loop was detected in one (2.6%) patient. Nearly 75% of the patients had hypotensive lower esophageal sphincter (9.61±4.05 mmHg), 17.4% had hypomotility of the esophageal body, and 64.7% had pathologic acid reflux (% time pH <4=6.98±5.5; DeMeester’s score=32.4±21.15).CONCLUSION: Although rare, it is possible to observe gastroesophageal reflux and other important postoperative symptoms after LGB, which are associated with anatomic and physiologic abnormalities at the esophagogastric junction and proximal gastric pouch.

Magnet and wire remodeling for the treatment of candy cane syndrome: first case series of a new approach (with video)

Candy cane syndrome (CCS) is an adverse event (AE) from gastrectomy or gastric bypass and end-to-side anastomosis to a jejunal loop. Preferential passage of food to the blind loop induces early satiety, pain, and regurgitation. An endoscopic device that combines 2 magnets and a self-retractable wire was designed to perform progressive septotomy with marsupialization. We evaluated the clinical safety and efficacy of this treatment in CCS. Consecutive patients presenting with symptoms associated with CCS after gastrectomy or Roux-en-Y gastric bypass were treated with the MAGUS (Magnetic Gastrointestinal Universal Septotome) system. Weight, dysphagia, pain scores, 12-item Short Form Survey quality of life physical and mental scores, GERD Health-Related Quality of Life, and Eckardt score were measured at baseline and 1 and 3 months postprocedure. Satisfaction with therapy and AEs were monitored during follow-up. Fourteen consecutive patients with CCS were enrolled in the study. Thirteen MAGUS systems migrated within 28 days after achieving uneventful complete septotomy. In 1 patient the magnet had to be collected from the right-sided colon after 1 month. Treatment was completed in a single endoscopy session. Dysphagia score (2 [1-3] vs 1 [1-1], P= .02), pain score (7 [6-8] vs 1 [0-1], P= .002), Eckardt score (5 [3-8] vs 1 [0-2], P= .002), GERD Health-Related Quality of Life score (37 [29-45] vs 8 [6-23], P= .002), and quality of life physical and mental scores were all significantly improved at 3 months. No device or procedure-related serious AEs were observed. One patient died during follow-up from evolution of oncologic disease. Endoluminal septotomy using a retractable wire and magnet system in CCS is feasible and safe, with rapid improvement of symptoms. (Clinical trial registration number: NCT04480216.).

Complete Colonic Diaphragm-Like Stricture After Ileostomy and Sigmoidectomy for Sigmoid Colon Perforation With Diverticulitis.

CASE REPORT Anastomotic strictures occur in up to 22% of patients after colorectal resection, and up to 70% of them will eventually require surgical intervention.1,2 Traditionally, the approach taken in such cases has included endoscopic balloon dilation, self-expandable metal stent insertion, or surgical intervention; however, balloon dilation remains the primary modality because of its efficacy and safety profile.1–3 A 61-year-old Japanese woman underwent loop ileostomy creation and then sigmoidectomy for refractory sigmoidovesical fistula because of sigmoid colon perforation with diverticulitis (Figures 1 and 2). We performed a colonoscopy from both the anal and oral stoma sides before ileostomy closure surgery. We identified a complete diaphragm-like stricture in the sigmoid colon that was similar to the end of a blind loop during colonoscopy, and the region of complete construction was whitish and surrounded by a few xanthomas (Figure 3). Therefore, we performed an endoscopic intervention to treat the complete colonic stricture.Figure 1.: Abdominal computed tomography showing (A and B) sigmoidovesical fistula (A; arrow) with an inflammatory fibrous tissue (B; arrowhead) because of sigmoid colon perforation with diverticulitis.Figure 2.: The schema of operation site of this patient. Red circle is loop ileostomy as first operation, and blue slashes are sigmoidectomy as secondary operation.Figure 3.: (A) Colonoscopy from both the anal and oral sides revealing a complete diaphragm-like stricture in the sigmoid colon. (B) An endoscopic injection needle was used to penetrate the contralateral oral side of the colon. (C) An endoscopic catheter was used to investigate the opposite site with a 0.025-inch guidewire. (D and E) A through-the-scope sequential balloon dilator (8 mm) was used to dilate the stricture, and (F) Amidotrizoic acid was advanced into the opposite anal side.First, a 23-G endoscopic injection needle was used to penetrate the center of the blind lumen from the oral side, and then, a pinhole was made in the stricture (Figure 3). The contrast medium was then injected through the needle. After the position of the proximal lumen was confirmed, an endoscopic catheter was inserted into the pinhole that had been made in the stricture, with a 0.025-inch guidewire (Figure 3). Finally, a through-the-scope sequential balloon dilator (8 mm) was used to dilate the stricture, and Amidotrizoic acid was advanced into the opposite site (Figure 3). This intervention led to positive outcomes. Eight days later, the colonic stricture improved. However, the endoscope could not pass through; therefore, we performed balloon dilatation (12.5 mm) again (Figure 4). After 2 sessions, the patient showed improvement and underwent ileostomy closure (Figure 4).Figure 4.: Endoscopy showing (A) the colonic stricture had improved but did the endoscope could not pass through the site of the stricture. (B) A balloon dilator (12.5 mm) is used to dilate the stricture. (C) After 2 sessions, the patient improved.We encountered a colonic diaphragm-like stricture after performing a sigmoidectomy because of perforated colonic diverticulitis. Although anastomotic strictures of the colon are common complications after colorectal surgery, such a complete diagram-like membrane stenosis is rarely seen.4 In this case, we considered that because the loop ileostomy did not allow the passage of stool to the anastomotic site, a complete membrane stenosis had formed. Despite improvements in technology and surgical techniques, the incidence of colorectal anastomotic complications remains stable and substantial, and the detection and treatment of anastomotic complications remain a challenge.5 Our endoscopic intervention was effective in treating a diaphragm-like stricture characterized by complete circular stenosis. DISCLOSURES Author contributions: K. Soga wrote the manuscript and is the article guarantor. H. Mukai and N. Akamatsu edited the manuscript. Financial disclosure: None to report. Informed consent was obtained for this case report.