Colosigmoid Junction Research Articles

Epiploic appendagitis : a case report

Epiploic appendagitis is a condition characterized by the ischemia and inflammation of the epiploic appendices of the colon that, can cause severe abdominal pain. It’s relatively rare. In the present article, we describe the clinical case of a 45- year-old man who was admitted with localized pain in the left iliac fossa. Physical examination revealed rebound tenderness. CT scan showed fat infiltration at the colosigmoid junction in the form of an ovoid fat imag surrounded by peripheral hyperdensity, suggestive of epiploic appendagitis. The evolution was favorable under medical treatment combining nonsteroidal anti-inflammatory drugs and antibiotics.

Subcutaneous emphysema, pneumomediastinum, pneumoretroperitoneum, and pneumoperitoneum secondary to colonic perforation during colonoscopy

Subcutaneous emphysema, pneumomediastinum, pneumoretroperitoneum, and pneumoperitoneum secondary to colonic perforation during colonoscopy

Lengthening of the colon for low rectal anastomosis in a cadaveric study: how much can we gain?

Lengthening of the colon for tension-free low rectal anastomosis comprises ligation of the inferior mesenteric vessels and splenic flexure mobilization. The aim of our study was to evaluate the length gained after each level of mesenteric vessel ligation with or without splenic flexure mobilization. The length of the colon after each mobilization technique, that is, low ligation of the inferior mesenteric artery (IMA), high ligation of IMA, high ligation of the inferior mesenteric vein (IMV), and mobilization of splenic flexure, was measured in 13 cadaveric specimens. After each step, the colon and vessels were placed back in their original position. The distance from the colosigmoid junction (CSJ) to the pubic symphysis (PS) was measured after each mobilization technique. The average elongation of the colon from original CSJ-PS distance to the CSJ-PS distance after low ligation of IMA, high ligation of IMA, high ligation of IMA plus splenic flexure mobilization, and high ligation of IMV was 2.08 ± 4.39 cm, 5.02 ± 5.51 cm, 8.20 ± 5.95 cm, and 17.98 ± 6.80 cm, respectively. The length of colon gained after IMV ligation was greater than the length obtained after low ligation of IMA, high ligation of IMA, and high ligation of IMA plus splenic flexure mobilization (p < 0.0001). This study shows the objective length gained following each standard surgical technique in colonic mobilization for low rectal anastomosis. The maximum length gained is after high ligation of IMV.

Three-dimensional determination of variability in colon anatomy: Applications for numerical modeling of the intestine

BackgroundPrecise knowledge of variability in colonic anatomy is of great importance for numerical modeling studies of the abdomen. This knowledge would allow the creation of personalized models for the gastrointestinal tract used for surgical simulations or in studies of virtual trauma. Materials and methodsTo determine the colonic configuration in the general population and define its variability by gender, age, and corpulence, the layout of the colon was determined via the following reference points: ileocecal junction, left and right colonic flexures, and colosigmoid junction (CSJ). Three-dimensional coordinates for each point were recorded on scanned sections of 100 healthy adults to examine the colonic layout under physiological conditions. Coordinates were repositioned in a new anatomical reference for comparison. The average points' coordinates, standard deviations, and distances between them were compared for each group. ResultsThe right colonic flexure was the most variable point. The CSJ was the least variable. Gender affected mainly the height of the colonic flexures and the length of its segments. Age affected the length of the transverse mesocolon root. Corpulence affected both the position of the ileocecal and CSJs and the length of the right colon. Differences in size and perivisceral fat distribution between groups explained these differences. Three-dimensional anatomical models of the colon were defined for each group by statistical equations. ConclusionThese equations, combined with data concerning the actual lengths of the colonic segments, enable reconstruction of different anatomical models of the colon that are representative according to gender, age, and corpulence.

Colosigmoid junction: Morphohistologic, morphometric, and endoscopic study with identification of colosigmoid canal with sphincter

To study the anatomical structure of the colosigmoid junction, 15 cadaveric specimens were studied morphologically, another 15 histologically, and a morphometric study was done in 10 specimens. Specimens consisted of the descending colon, sigmoid colon, and the colosigmoid junction. Histologic specimens were stained with hematoxylin and eosin and Masson's trichrome stain. Morphometric studies used an image analysis system. The colosigmoid junction was investigated endoscopically in 18 healthy volunteers. A narrow segment having a mean length of 5.2 +/- 1.1 cm was identified both externally and internally between the descending and sigmoid colon. We called this segment the colosigmoid canal. Mucosal folds were found crowded in the colosigmoid canal, the lower end of which formed a nipple and was surrounded by a fornix. Histologically, the colosigmoid canal mucosa showed multiple folds. Its circular muscle was thicker than that of the descending or the sigmoid colon and confirmed morphometrically. The longitudinal muscle was thicker in only 4 of 10 specimens. Both the narrowing and the mucosal crowding were verified endoscopically. The colosigmoid junction is the narrow segment between the descending and the sigmoid colon. Histologic, morphometric and endoscopic studies indicated the presence of a sphincter in the colosigmoid canal. A colosigmoid sphincter is suggested to control the passage of colonic contents from the descending colon to the colosigmoid canal as well as to prevent reflux of sigmoid contents into the descending colon.

Identification of the location of the colonic pacemakers: a histologic study

A recent electrophysiologic study has suggested the existence of 4 pacemakers in the colon which generate the electric waves that are responsible for the colonic motor activity. These pacemakers are located at the cecal pole, the cecocolonic junction, the mid third of the transverse colon and at the colosigmoid junction. We investigated the hypothesis that these pacemaker sites contain ICCs in great numbers and that the electric waves generated from these sites are transmitted by a chain of ICCs to the remaining colon. Specimens were taken from the 4 electrophysiologically defined pacemaker sites and the remaining colon of 24 cadavers. They were subjected to c-kit immunohistochemistry tests. Controls for antisera specificity consisted of tissue incubation with normal rabbit serum substituted for the primary antiserum. The morphometric study was performed by submitting the immunohistochemically-stained sections to image analysis in order to determine the area percent of immuno-reactivity in comparison to the total area of fields examined in the sections. Data obtained from the image analyzer were statistically analyzed. Immunohistochemical and morphometric studies have shown that the 4 electrophysiologically defined pacemaker sites contained a significantly higher proportion of ICCs than the remaining colon, the ICCs at these sites being multipolar and forming a network surrounded by a fibrous tissue wall. In the remaining colon, the ICCs were bipolar and arranged in a linear fashion. The study revealed the existence of a network of ICCs at the 4 pacemaker sites forming the 'pacemaker nodes' (PMNs). In the rest of the colon, a chain of ICCs extended in the colonic wall in a linear fashion forming the 'pacemaker bundles' (PMBs). We postulate that the colonic electric waves start at the PMNs and spread in the colon along the PMBs.

Electrophysiologic Identification of the Location of the Colonic Pacemakers in Humans: Further Study

We recently defined the sites of four colonic pacemakers that appear to generate the electric waves assumed to be responsible for the colonic motility. We hypothesized that a dysfunction of one or more of these pacemakers might interfere with the generation of electric waves and the colonic motility. This hypothesis was investigated in the current communication. The tests were performed during the repair of huge incisional hernia of 8 subjects (5 F, 3 M; mean age 42.8 +/- 3.3 SD years). Two electrodes were applied to each of the terminal ileum (TI), cecum (C), and ascending (AC), transverse (TC), descending (DC), and sigmoid (SC) colon. The electric activity of the TI and the various colonic segments was recorded using surface silver-silver chloride electrodes applied to the colon. The site of change of the wave variables between the TI and the C and between the different other colonic segments was determined by changing the position of the electrodes placed over the segments to be examined. Presumably, the sites where the wave variables changed represent the potential location of the pacemakers. We anesthetized these sites individually by injection of 2% Xylocaine, and then recorded the electric activity after 20 min in all the subjects and after 2 h in only 5 subjects. Electric waves in the form of pacesetter and action potentials were recorded from the TI and the colon. The sites of potential pacemakers could be defined at the ileocecal and cecocolonic junctions, at the mid third of the TC, and at the colosigmoid junction. Anesthetization of the cecal pole resulted in disappearance of the cecal electric waves, with persistence of the waves from the other colon segments. Anesthetization of the cecocolonic junction eliminated the electric waves of the AC and the right half of the TC, while the waves in the rest of the colon persisted. The remaining two pacemaker sites produced similar results when anesthetized. The electric waves reappeared after the anesthetic effect had waned. Thus, the colon possesses at least four pacemakers that appear to mediate the colonic motor activity. Individual pacemaker block by anesthetization effected disappearance of electric waves in the relative colonic segment, which reappeared after waning of the anesthetic effect. The disappearance of these waves upon pacemaker anesthetization supports a relationship between the pacemakers at the anesthetized site and the electric waves. The electric waves seem to be generated by these pacemakers. We suggest that colonic inertia, segmental or total, results from the dysfunction of one or more pacemakers, and that an artificial pacemaker could be applied for the treatment of such conditions. These suggestions need to be further studied.

Colosigmoid Junction: A Study of Its Functional Activity With Identification of a Physiologic Sphincter and Involvement in Reflex Actions

The colosigmoid junction (CSJ) marks the termination of the descending colon (DC) and the beginning of the sigmoid colon (SC); it is a fixed area in the retroperitoneum. At this site where two functionally different areas meet, we hypothesized the presence at the CSJ of a physiologic sphincter that regulates the passage of gut contents from the DC to the SC. This hypothesis was investigated for this communication. Eight subjects (mean age 36.6 - 4.7 SD years, 6 women) were studied during surgical repair of incisional hernia or laparotomy. The pressure responses of the CSJ to individual distension of the DC and SC were recorded. A balloon-ended tube was introduced per anum to lie in the DC or SC, and the pressure in the DC, CSJ, and SC was measured by saline-perfused catheters. To study whether the CSJ response to individual DC or SC distension was a direct or reflex action, the test was repeated in six of eight patients after separate anesthetization of the DC, CSJ, and SC. The CSJ had a higher pressure than that of the DC or SC; the high-pressure zone measured a mean of 2.1 - 0.9 cm. High-volume DC distension effected a significant DC pressure rise ( p < .001) and a CSJ pressure decline ( p < .05), which lasted a mean of 7.2 - 1.2 s. In contrast, the CSJ responded to big volume SC distension by significant pressure elevation ( p < .001) which was also momentary. Small volume distension of the DC or SC effected no significant CSJ pressure response ( p > .05). The CSJ pressure did not respond to distension of the anesthetized DC or SC. Likewise, the anesthetized CSJ did not react to DC or SC distension. When the test was repeated using saline instead of xylocaine, the CSJ pressure response was similar to that without saline injection. The CSJ is a high pressure zone with a measurable length. It reacts to DC or SC balloon distension by dilatation or narrowing, respectively. These findings presumably denote the existence of a "physiologic sphincter" at the CSJ, which appears to regulate the passage of colonic contents to the SC. We postulate that the CSJ pressure response to DC or SC distension is reflex and mediated through the "colosigmoid reflexes." The role of the colosigmoid sphincter and reflexes in colonic motility disorders remains to be investigated.

Colosigmoid Junction: A Study of Its Functional Activity With Identification of a Physiologic Sphincter and Involvement in Reflex Actions

The colosigmoid junction (CSJ) marks the termination of the descending colon (DC) and the beginning of the sigmoid colon (SC); it is a fixed area in the retroperitoneum. At this site where two functionally different areas meet, we hypothesized the presence at the CSJ of a physiologic sphincter that regulates the passage of gut contents from the DC to the SC. This hypothesis was investigated for this communication. Eight subjects (mean age 36.6 &#45 4.7 SD years, 6 women) were studied during surgical repair of incisional hernia or laparotomy. The pressure responses of the CSJ to individual distension of the DC and SC were recorded. A balloon-ended tube was introduced per anum to lie in the DC or SC, and the pressure in the DC, CSJ, and SC was measured by saline-perfused catheters. To study whether the CSJ response to individual DC or SC distension was a direct or reflex action, the test was repeated in six of eight patients after separate anesthetization of the DC, CSJ, and SC. The CSJ had a higher pressure than that of the DC or SC; the high-pressure zone measured a mean of 2.1 &#45 0.9 cm. High-volume DC distension effected a significant DC pressure rise ( p < .001) and a CSJ pressure decline ( p < .05), which lasted a mean of 7.2 &#45 1.2 s. In contrast, the CSJ responded to big volume SC distension by significant pressure elevation ( p < .001) which was also momentary. Small volume distension of the DC or SC effected no significant CSJ pressure response ( p > .05). The CSJ pressure did not respond to distension of the anesthetized DC or SC. Likewise, the anesthetized CSJ did not react to DC or SC distension. When the test was repeated using saline instead of xylocaine, the CSJ pressure response was similar to that without saline injection. The CSJ is a high pressure zone with a measurable length. It reacts to DC or SC balloon distension by dilatation or narrowing, respectively. These findings presumably denote the existence of a "physiologic sphincter" at the CSJ, which appears to regulate the passage of colonic contents to the SC. We postulate that the CSJ pressure response to DC or SC distension is reflex and mediated through the "colosigmoid reflexes." The role of the colosigmoid sphincter and reflexes in colonic motility disorders remains to be investigated.

Electrophysiologic Identification of the Location of the Colonic Pacemakers in Humans: Further Study

We recently defined the sites of four colonic pacemakers that appear to generate the electric waves assumed to be responsible for the colonic motility. We hypothesized that a dysfunction of one or more of these pacemakers might interfere with the generation of electric waves and the colonic motility. This hypothesis was investigated in the current communication. The tests were performed during the repair of huge incisional hernia of 8 subjects (5 F, 3 M; mean age 42.8 - 3.3 SD years). Two electrodes were applied to each of the terminal ileum (TI), cecum (C), and ascending (AC), transverse (TC), descending (DC), and sigmoid (SC) colon. The electric activity of the TI and the various colonic segments was recorded using surface silver-silver chloride electrodes applied to the colon. The site of change of the wave variables between the TI and the C and between the different other colonic segments was determined by changing the position of the electrodes placed over the segments to be examined. Presumably, the sites where the wave variables changed represent the potential location of the pacemakers. We anesthetized these sites individually by injection of 2% Xylocaine, and then recorded the electric activity after 20 min in all the subjects and after 2 h in only 5 subjects. Electric waves in the form of pacesetter and action potentials were recorded from the TI and the colon. The sites of potential pacemakers could be defined at the ileocecal and cecocolonic junctions, at the mid third of the TC, and at the colosigmoid junction. Anesthetization of the cecal pole resulted in disappearance of the cecal electric waves, with persistence of the waves from the other colon segments. Anesthetization of the cecocolonic junction eliminated the electric waves of the AC and the right half of the TC, while the waves in the rest of the colon persisted. The remaining two pacemaker sites produced similar results when anesthetized. The electric waves reappeared after the anesthetic effect had waned. Thus, the colon possesses at least four pacemakers that appear to mediate the colonic motor activity. Individual pacemaker block by anesthetization effected disappearance of electric waves in the relative colonic segment, which reappeared after waning of the anesthetic effect. The disappearance of these waves upon pacemaker anesthetization supports a relationship between the pacemakers at the anesthetized site and the electric waves. The electric waves seem to be generated by these pacemakers. We suggest that colonic inertia, segmental or total, results from the dysfunction of one or more pacemakers, and that an artificial pacemaker could be applied for the treatment of such conditions. These suggestions need to be further studied.

Colonic pacing in the treatment of patients with irritable bowel syndrome: technique and results.

The treatment of the irritable bowel syndrome (IBS) is not entirely satisfactory as the exact cause of the condition has not been revealed. We have demonstrated in a recent study that the IBS exhibited a "tachyarrhythmic" electromyographic pattern; the wave rhythm was irregular and wave variables were higher than those of the healthy volunteers. We suggested that a disorder of the colonic pacemaker discharges these abnormal waves thereby causing the motor disorders of IBS. In another study, we determined the colonic pacing parameters needed to modulate the disordered pacemaker. In the current communication we investigated the effect of colonic pacing, using these parameters, on the EMG activity of the sigmoid colon (SC) and on the clinical manifestations of patients with IBS. A pacemaker was implanted in a subcutaneous pocket in the inguinal area and its two leads were hooked to the colosigmoid junction. The effect of colonic pacing on the SC EMG activity was investigated by inserting two recording electrodes into the SC muscle. The patients were then trained for home pacing after removal of the 2 recording electrodes. Nine patients (age 42.7 +/- 4.2 years, 6 women) with IBS were studied. The pre-pacing tachyarrhythmic pattern of EMG was recorded. On colonic pacing, the slow wave rhythm became regular and wave variables were normalized; the symptoms of the IBS improved. The optimal parameters used for pacing comprised an amplitude of 6 mA, a pulse width of 150 ms and a frequency of 25% higher than that of the basal colonic waves. In 7/9 patients the improvement of symptoms continued when pacing was ceased after 6 months of daily pacing; the pacemaker was removed after 3 months of non-pacing. In 2/9 patients, pacing needed to be continued because the symptoms recurred each time the pacing was ceased. In conclusion, colonic pacing succeeded in normalizing the tachyarrhythmic pattern and relieving the symptoms of the IBS. No complications were encountered and the method was well accepted and tolerated. Further studies on a large group of patients are required.

Electrophysiologic identification of the location of the colonic pacemakers. A human study.

Colonic inertia, total or segmental, is a known cause of constipation, yet its etiology is poorly understood and its treatment not satisfactory. Although the colonic electric activity has been studied by many investigators, the colonic pacemakers that are assumed to generate the electric waves, are scarcely addressed and their location, to our knowledge, has not been determined. The current communication investigates the possible sites of the colonic pacemakers, aiming at a better understanding of the mechanism of colonic motility and its disorders, notably colonic inertia. The tests were performed during the repair of huge incisional hernia in 12 subjects (mean age 37.7 +/- 10.2 years, 7 women). Monopolar silver-silver chloride electrodes were applied to the terminal ileum (TI) and cecum (C), and to the ascending (AC), transverse (TC), descending (DC) and sigmoid colon (SC); they were fixed by electrode gel to the ileal and colonic serosa. The electric activity of each of the TI, C, AC, TC, DC and SC was recorded. Electric waves in the form of slow waves or pacesetter potentials and action potentials were recorded from the TI and colon. Differences in the frequency, amplitude and conduction velocity of the waves occurred between the TI and the various segments of the colon. The change in the wave variables between the TI and C occurred at the ileocecal junction, between the C and AC at the cecocolonic junction, the AC and TC at the mid third of the TC and the DC and SC at the colosigmoid junction. The colonic electric waves are suggested to be generated by at least 4 pacemakers, which are presumably located at the ileocecal junction, the cecocolonic junction, the mid third of TC and at the colosigmoid junction. The electric waves appear to be responsible for conducting the colonic motor activity. We postulate that disordered colonic pacemakers may produce segmental or total colonic inertia, a proposition that needs further investigation.

The motor efficacy of the artificial colonic pacemaker in colonic inertia patients.

We have recently demonstrated that the colon possesses at least 4 pacemakers which presumably generate electric waves and that colonic pacing evokes electric activity in colonic inertia. We tested the hypothesis that electric waves produced by artificial colonic pacing in colonic inertia patients may initiate colonic motilitiy and effect evacuation. 17 patients with constipation due to total colonic inertia were divided into 2 groups: 10 (age 45.6 ( 6.3 years, 7 women) in the study group and 7 (age 43.7 ( 5.8 years, 5 women) as controls. 7 healthy volunteers were included in the study. Colonic pacing was tested at 2 sites of pacemakers: mid-transverse colon and colosigmoid junction. A stimulating electrode was hooked to the colonic mucosa at the pacemaker site and 2-3 recording electrodes distally to it. Healthy volunteers showed resting electric waves in the form of pacesetter and action potentials which increased significantly on colonic pacing. Inertia patients exhibited no basal electric activity. Colonic pacing in the study group evoked electric waves and caused expulsion of small volume balloon. Balloon distension at pacemaker site produced mass movement of balloon, while away from pacemaker site step-wise movement. In conclusion, colonic pacing evoked electric waves in colonic inertia patients and effected balloon expulsion. We postulate that the pacemaker generates electric waves which spread along pacemaker branches that are composed of interstitial cells of Cajal and nerve fibers of the enteric nervous plexus and effect colonic mass contraction. Ex-pacemaker stimulation presumably leads to local activation of interstitial cells of Cajal and segmental step-wise contraction.