Deep Pouch Research Articles

Morphology and ontogenesis of two new Hemiholosticha species (Ciliophora, Hypotrichia, Hemiholostichidae nov. fam.)

The morphology and ontogenesis of two new hypotrich ciliates, Hemiholosticha solitaria and Hemiholosticha germanica, were studied using live observation, protargol impregnation, and scanning electron microscopy. Both species share a medium-sized, almost globular body with a short anterior projection; two macronuclear nodules with a single micronucleus in between; a central contractile vacuole; three or four ventral, one postoral, one right and one left marginal cirral row; and three dorsal kineties extending along ribs. However, H. germanica is distinguished from congeners by a higher number of cirri in ventral rows R1 and R2 (3–6 vs. 2 cirri in each row). Hemiholosticha solitaria differs from congeners by having four (vs. three) ventral cirral rows and by the lack (vs. presence) of intracellular green algae. The ontogenesis of H. solitaria follows the H. pantanalensis mode in that (i) the oral primordium develops in a deep pouch and generates the first two cirral streaks in addition to adoral membranelles and undulating membranes, (ii) the undulating membrane anlage does not produce any cirri, and (iii) the longitudinal ventral cirral row R3 originates from two anlagen. The ontogenetic peculiarities along with the 18S rRNA gene phylogenies suggest classification of Hemiholosticha, Psilotrichides, and Urospinula into a new family, Hemiholostichidae.

Ultrasound evaluation of pouch of Douglas obliteration and rectal deep endometriosis in women who have had previous combined colorectal and gynaecological laparoscopic surgery for rectal endometriosis: A pilot study.

Ultrasound has been demonstrated to accurately diagnose rectal deep endometriosis (DE) and pouch of Douglas (POD) obliteration. The role of ultrasound in the assessment of patients who have undergone surgery for rectal DE and POD obliteration has not been evaluated. To describe the transvaginal ultrasound (TVS) findings of patients who have undergone rectal surgery for DE. An observational cross-sectional study at a tertiary care centre in Sydney, Australia between January and April 2017. Patients previously treated for rectal DE (low anterior resection vs rectal shaving/disc excision) were recruited and asked to complete a questionnaire on their current symptoms. On TVS, POD state and rectal DE were assessed. Correlating recurrence of POD obliteration and/or rectal DE to surgery type and symptoms was done. Fifty-six patients were contacted; 22/56 (39.3%) attended for the study visit. Average interval of surgery to study visit was 52.8±24.6months. Surgery type breakdown was as follows: low anterior resection (56%) and rectal shaving/disc excision (44%). The prevalence of POD obliteration was 16/22 (72.7%) intraoperatively and 8/22 (36.4%) at study visit, as per the sliding sign. Nine patients (39.1%) had evidence on TVS of recurrent rectal DE. Recurrence of POD obliteration and rectal DE was not associated with surgery type or symptomatology. Despite surgery for rectal DE, many patients have a negative sliding sign on TVS, representing POD obliteration, and rectal DE. Our numbers are too small to correlate with the surgery type or their current symptoms.

OC20.06: Comparison of diagnostic accuracy of transvaginal ultrasound for deep endometriosis and pouch of Douglas obliteration in the presence and absence of ovarian endometriomas

OC20.06: Comparison of diagnostic accuracy of transvaginal ultrasound for deep endometriosis and pouch of Douglas obliteration in the presence and absence of ovarian endometriomas

Laparoscopic Posterolateral Suture Rectopexy for Recurrent Rectal Prolapse in Children.

Introduction: Laparoscopic rectopexy for recurrent rectal prolapse (RP) is more widely used nowadays. Strict indications are needed to get proper outcomes. The advantages rely on the careful dissection of peritoneal sac and fixation of rectum. One of the theories of recurrent RP is hernia-like physiology in front of the rectum. Purpose: The aim of this study is to present our experience of posterolateral laparoscopic suture rectopexy (LSR) in indicated children of recurrent RP. Patients and Methods: Sixteen patients were included with recurrent RP wherein all were subjected to LSR procedure after exclusion of other probable causes. Dissection of peritoneal sac anterior to the rectum was carried out followed by closure of the deep pouch by nonabsorbable sutures then fixation of the right side of rectum and sigmoid to the lateral wall of areolar tissue. Fixation to sacral promontory is done by Ethibond or Prolene sutures when redundancy is obvious. Results: The study included 11 girls and 5 boys with age ranging between 3 and 12 years in the past 5 years. Ten cases were treated earlier with injection therapy and 6 following Thiersh procedure after failure of conservative treatment for 6 months. Operative time ranged between 40 and 100 minutes. Follow-up period ranged between 6 and 36 months with mean of 19.5 months. Postoperative mucosal prolapse reported in 1 case 6 months postsurgery with no full thickness recurrence. Conclusions: LSR is an efficient technique in well-selected children of recurrent RP and could reverse this underlying pathology. Longer follow-up and evidence are needed to standardize the technique.

Abdominal Approaches to Rectal Prolapse.

Rectal prolapse is a debilitating condition with a complex etiology. Symptoms are most commonly prolapse of the rectum and pain with bowel movements or straining, with worsening fecal incontinence over time due to progressive stretching of the anal sphincters. Physical findings are fairly consistent from patient to patient-most notably diastasis of the levator ani muscles, deep pouch of Douglas, redundant sigmoid colon, a mobile mesorectum, and occasionally a solitary rectal ulcer. Evaluation includes a physical exam or imaging demonstrating the prolapse, and evaluating for other causes of pelvic floor dysfunction. Multiple surgical repairs are available, but treatment must be individualized based on patient symptoms and the presence or absence of constipation or other pelvic floor disorders. Mesh repairs have shown promising results, but carry the added risks of mesh erosion, infection, and mesh migration. The optimal repair has not been clearly demonstrated at this time.

Single-Center Experience on the Use of Vedolizumab for the Treatment of Inflammatory Conditions of the Ileal Pouch: 2016 ACG Presidential Poster Award

Restorative proctocolectomy with ileal-pouch anal anastomosis (IPAA) is the surgical treatment of choice in patients with ulcerative colitis. Pouchitis is the most common complication after IPAA and its treatment has not been standardized. Vedolizumab has been used in the treatment of ulcerative colitis but its use in inflammatory conditions of the pouch has not been evaluated. Retrospective chart review was performed on patients with IPAA and pouchitis in our institution who had been exposed to vedolizumab. Pouchitis was confirmed by evaluation of clinical, endoscopic, and laboratory parameters. We identified 4 patients with ulcerative colitis who underwent restorative proctocolectomy with IPAA and were exposed to vedolizumab after IPAA. A Caucasian male with IPAA and pouch repair/reconstruction and a history of chronic untreated pouchitis developed moderate pouchitis mainly affecting the proximal pouch, refractory to antibiotics, adalimumab and infliximab. He achieved complete mucosal healing one month after four vedolizumab infusions (See Figures). A Caucasian male with recurrent pouchitis refractory to steroids, antibiotics, adalimumab and certolizumab pegol developed prepouch ileitis and pouch inflammation suggestive of Crohn's disease (CD) that responded to three vedolizumab infusions along with antibiotics with mucosal healing after one month. A Caucasian female intolerant to infliximab and adalimumab developed CD of the pouch requiring diverting loop ileostomy due to anal pain. Seven months later she developed pouchitis that responded to three vedolizumab infusions and steroids with repeat pouchoscopy after two weeks revealing scant/rare pouch ulcerations and anal-IPAA stricture. A Hispanic female developed proximal pouch and pouch inlet inflammation and cuffitis refractory to antibiotics and adalimumab. She received five vedolizumab infusions, and methotrexate was initiated four weeks after the first vedolizumab infusion. She did not respond to vedolizumab and repeat pouchoscopy one week after the last infusion revealed deep pouch ulcerations and cuffitis. ESR and CRP decreased after treatment in 3 out of 4 patients (See Table). Vedolizumab was successful in the treatment of inflammatory conditions of the pouch in three out of four IPAA patients. Inflammatory markers improved in three out of four patients. Further studies are needed to examine its potential role for treating refractory pouchitis.Table 1: Endoscopic and inflammatory marker response to vedolizumab treatment. Repeat endoscopic findings and laboratory values obtained 3-6 months after medication induction phase.Figure 1Figure 2

Morphology and ontogenesis of Psilotrichides hawaiiensis nov. gen., nov. spec. and molecular phylogeny of the Psilotrichidae (Ciliophora, Hypotrichia).

The Psilotrichidae are a family of middle-sized hypotrichs with unique morphological and ontogenetic features (e.g. the oral primordium develops in a deep pouch) that, however, did not provide a definite phylogenetic signal. Thus, we studied the 18S rRNA gene of Urospinula succisa (Müller 1786) Esteban et al., 2001 as well as the morphology and ontogenesis of Psilotrichides hawaiiensis, a new genus and species from an ephemeral swamp on Oahu Island, Hawaii. The molecular data classify the psilotrichids into the oxytrichids but without clear branching position. A brief revision, using the structure of the oral apparatus, the location of the contractile vacuole, and three ontogenetic features, showed four distinct genera: Psilotricha Stein, 1859; Urospinula Corliss, 1960; Hemiholosticha Gelei, 1954; and Psilotrichides nov. gen., which differs from the confamilials mainly by the obliquely oriented buccal cavity and the shape of the undulating membranes as well as by a distinct ridge along the right buccal margin. The pyriform species, P. hawaiiensis, is about 65 × 45 μm in size and is easily recognized by the table tennis racket-shaped appearance due to the elongated last cirrus of the left marginal row. Refined diagnoses are provided for the family Psilotrichidae Bütschli, 1889 and the genera contained.

A First Look at the Structure of the Wave Pouch during the 2009 PREDICT–GRIP Dry Runs over the Atlantic

In support of the National Science Foundation Pre-Depression Investigation of Cloud-systems in the tropics (NSF PREDICT) and National Aeronautics and Space Administration Genesis and Rapid Intensification Processes (NASA GRIP) dry run exercises and National Oceanic and Atmospheric Administration Hurricane Intensity Forecast Experiment (NOAA IFEX) during the 2009 hurricane season, a real-time wave-tracking algorithm and corresponding diagnostic analyses based on a recently proposed tropical cyclogenesis model were applied to tropical easterly waves over the Atlantic. The model emphasizes the importance of a Lagrangian recirculation region within a tropical-wave critical layer (the so-called pouch), where persistent deep convection and vorticity aggregation as well as column moistening are favored for tropical cyclogenesis. Distinct scenarios of hybrid wave–vortex evolution are highlighted. It was found that easterly waves without a pouch or with a shallow pouch did not develop. Although not all waves with a deep pouch developed into a tropical storm, a deep wave pouch had formed prior to genesis for all 16 named storms originating from monochromatic easterly waves during the 2008 and 2009 seasons. On the other hand, the diagnosis of two nondeveloping waves with a deep pouch suggests that strong vertical shear or dry air intrusion at the middle–upper levels (where a wave pouch was absent) can disrupt deep convection and suppress storm development. To sum up, this study suggests that a deep wave pouch extending from the midtroposphere (~600–700 hPa) down to the boundary layer is a necessary condition for tropical cyclone formation within an easterly wave. It is hypothesized also that a deep wave pouch together with other large-scale favorable conditions provides a sufficient condition for sustained convection and tropical cyclone formation. This hypothesized sufficient condition requires further testing and will be pursued in future work.

Genital Segments of Sexual Mosaic Offspring fromWolbachia-Infected FemaleZizina emelina(Lepidoptera: Lycaenidae)

ABSTRACT: Eight sexual mosaic offspring of Zizina emelina (Lepidoptera: Lycaenidae) were obtained from females infected with male-killing Wolbachia (wEmeTn2), though they were mostly dead at the stage of pharate adult. Uninfected females or females infected with another strain of Wolbachia (wEmeTn1) produced no mosaics. Therefore, the occurrence of these sexual mosaics was associated with wEmeTn2 infection. In sexual mosaics, the ventral and dorsal parts of genitalia differentiated independently into male-specific and female-specific formations, respectively, i.e., the ventral part of abdominal segment IX may have tendencies to retain male structures, while the dorsal parts of abdominal segments IX and X possess female structures. More than two pairs of ill-developed valvae were observed in several individuals in a deep pouch. The presence of additional valvae would mean that the segment IX or the ventral phallic lobe is at least partly duplicated.

Helminth parasites from Red Sea fishes: Neowardula brayi gen. nov., sp. nov. (Trematoda: Mesometridae Poche, 1926) and Sclerocollum saudii sp. nov. (Acanthocephala: Cavisomidae Meyer, 1932)

Specimens of the fishes Acanthopagrus bifasciatus Forsskål (Sparidae) and Siganus rivulatus Forsskål (Siganidae) were caught in the Red Sea off the coast of Rabigh, Saudi Arabia. Four (25%) and 24 (80%) of these fishes, respectively, were found to harbour intestinal helminths. Acanthopagrus bifasciatus was parasitised by Neowardula brayi gen. nov., sp. nov. (Trematoda: Mesometridae) and S. rivulatus by Sclerocollum saudii sp. nov. (Acanthocephala: Cavisomidae). Neowardula brayi gen. nov. is similar to Wardula Poche, 1926, but clearly differs from it and from the other four genera of the family Mesometridae Poche, 1926 in having a ventral surface anterior to the intestinal bifurcation greatly modified into a well-developed, relatively deep pouch encircling the genital pore and constantly diagonal testes. Sclerocollum saudii sp. nov. is similar to S. rubrimaris Schmidt et Paprena, 1978 (type species), but clearly differs in having a proboscis only armed with 10 rows of hooks, smaller proboscis hooks, lemnisci much longer than proboscis receptacle and much smaller egg size. The developmental stages of this acanthocephalan (cystacanths, juveniles and immature worms) are also described and figured.

Rectal prolapse associated with extensive anorectal condyloma acuminata

Sir, Complete rectal prolapse (full-thickness and circumferential intussusception of the entire rectal wall through the anal canal) is not a common condition.[1] Furthermore, the presence of anorectal giant condyloma acuminata (Con A; a sexually transmitted disease caused by human papilloma viruses [HPV]) has been rarely reported in association with or as the probable cause of rectal prolapse.[2] We report a patient with extensive longstanding anorectal Con A with recurrent rectal prolapse that became irreducible and required urgent surgery for reduction and perianal and abdominal rectopexy. A 51-year-old woman, mother of six children, presented with longstanding history of extensive perineal and vaginal Con A for 15 years, which has been proved by microbiology, immunology, and histological examination to be due to human papilloma virus (HPV) with occasional concomitant candidal infection. She received different regimens of local and systemic medical treatment for the Con A and candida, but the perianal Con A persisted. She had a history of recurrent mild rectal bleeding that became heavier in the last year and also reported tensemus and occasional reducible anal mass on straining. She developed complete rectal prolapse on straining [Figure 1]. Under general anesthesia, the edematous rectum could only be reduced through lower abdominal laparotomy. The grossly patulous anus was repaired by using Thiersch's procedure, and then rectosigmoidopexy was done. The perianal condyloma was fulgurated by diathermy. The tissue histology was consistent with Con A with no malignancy. Figure 1 Rectal prolapse with inflammation, thickening, edematous, ulcerating, and anal condyloma acuminata The precise cause of rectal prolapse is not fully defined. However, a number of associated abnormalities and conditions have been described. Nearly 50% of rectal prolapse is caused by longstanding constipation with chronic straining. Other causes include increased intraabdominal pressure, a deep pouch of Douglas, weakness of the pelvic floor, decreased resting anal sphincter pressure, neurological disorders, and some parasitic infections (amebiasis and schistosomiasis).[1] On the other hand, Con A (warts) is generally a sexually transmitted disease of adults caused by HPV usually type 6 and 11 double-stranded DNA viruses that replicate in squamous epithelial cells. It occurs mainly in genital and perianal areas (moist area) but rarely in the rectum. The lesion may progress into large papillomatous proliferations called condylomata gigantean or Buschke-Lowenstein tumor that penetrates deep into the underlying tissue, usually without metastatic potential.[3,4] This case report demonstrates some of the challenges in caring for patients with Con A and the consequences. The importance of aggressive extirpation therapy was not appreciated until very late in her course. The presence of anorectal giant Con A and the association with rectal prolapse is rarely recognized in the literature.

Evaluation of the cavotricuspid isthmus and right atrium by multidetector-row computed tomography in patients with common atrial flutter

The sizes of the right atrium (RA), cavotricuspid isthmus, and Eustachian valve are predictors of success of radiofrequency catheter ablation for atrial flutter (AFL). We examined the relationship between the sizes of cavotricuspid isthmus as measured by multidetector-row computed tomography (MDCT) and fluoroscopy. We used eight-detector MDCT to measure the tricuspid isthmus of 23 patients prior to linear ablation for common AFL. One patient with a deep pouch in the RA was excluded. Parameters measured were (1) the length of the trace of isthmus (Ti), which was equivalent to the blocking line; (2) the size of the tricuspid isthmus (DTi); and (3) the distance from the tricuspid valve and inferior vena cava (IVC) (LDTi). DTi and LDTi indicate the size of the RA, reflecting the appropriately sized steerable ablation catheter, respectively. Of the 22 patients, 21 were ablated successfully without recurrence of AFL, and clinical success was achieved in one additional patient despite failure to obtain a bidirectional block. Ti, DTi, and LDTi were correlated with fluoroscopy time (r = 0.84, r = 0.88, and r = 0.88, respectively; P < 0.0001), total delivered energy (r = 0.81, r = 0.80, and r = 0.83, respectively; P < 0.0001), and application time (r = 0.84, r = 0.80, and r = 0.87, respectively; P < 0.0001). Measurement of the tricuspid isthmus by MDCT may noninvasively provide important information for successful linear ablation.

Role of pelvicography and colpocystodefecography in diagnosis of outlet obstructive constipation

The aim was to research the changes in pelvic floor morphology and corresponding visceras in patients with outlet obstructive constipation (OOC). Thirty-eight patients with OOC and 12 healthy volunteers were enrolled in this study. With simultaneous pelvicography and colpocystodefecography (PCCD), including pelvicography, vaginal opacification, voiding cystography and defecography, pelvic floor morphology was observed and the anorectal angle, the level of the perineum, peritoneum and bladder were measured. Thirty-seven cases of internal rectal prolapse (IRP), 5 cases of rectocele (RC) and 5 cases of spastic pelvic floor syndrome SPFS were diagnosed by PCCD. 12 IRP, 4 RC and 1 SPFS were detected by common physical examination. All of these were confirmed by PCCD. Moreover, PCCD found 9 pelvic floor hernia or peritoneoceles, 6 cystoceles, 3 descending perineum syndromes and 10 uterine prolapses. Compared with controls, OOC patients had a significantly large anorectal angle during defecation, abnormal descending of the perineum at rest and during defecation, and a deep pouch of Douglas during defecation. Some patients with urinary system symptoms may have had an abnormal descent of the bladder during rest and defecation. Simultaneous PCCD has a higher positive ratio than the common physical examination in diagnosing IRP and RC, and provides information for the diagnosis of pelvic floor hernia or peritoneocele, cystocele or uterine prolapse. PCCD is helpful in the selection of a proper surgical procedure.

The depth of the pouch of Douglas in nulliparous and parous women without genital prolapse and in patients with genital prolapse

Objective:This study was undertaken to assess the depth of the pouch of Douglas among nulliparous women and to compare it with those among parous women and patients with genital prolapse. Study Design:The depth of the pouch of Douglas was measured in 22 nulliparous women and 28 parous women without genital prolapse and in 18 patients with prolapse of the posterior vaginal wall. Results:The pouch of Douglas extended from 11 % to 89% of the total vaginal length among nulliparous and parous women, without significant difference between these groups (mean, 49% and 45%, respectively). It was significantly deeper in patients with prolapse, ranging from 25% to 96% (mean, 72%). Conclusions:There is an extensive variation in the depth of the pouch of Douglas. A deep pouch of Douglas is frequently present in young nulliparous women and may increase the risk for development of a posterior vaginal wall prolapse.

Rectoceles: value of videodefaecography in selection of treatment policy

Videodefaecography allows identification of three different types of rectoceles: type I or digitiform rectocele, type II or rectocele with a lax rectovaginal septum, an anterior mucosal prolapse and a deep pouch of Douglas, and a type III in which a rectocele is associated with intussusception or even rectal prolapse. Furthermore, videodefaecography gave information on functional mechanisms resulting in incontinence or constipation. Surgical treatment should be tailored to the radiological and clinical findings: endoanal approach in type I, posterior colpomyorhaphy in type II and double abdomino-vaginal approach in type III. One hundred and fifty cases were prospectively treated according to this policy. Recurrence occurred in one out of 150 cases (1.3%). Incontinence was cured in 93% and constipation in 88%.

Simultaneous defecography and peritoneography in defecation disorders.

A number of physiologic and radiologic investigations are used in investigating defecation disorders. Defecography is one important part of these investigations. However, a correct diagnosis of an enterocele is sometimes difficult despite use of contrast media in the rectum, vagina, and small bowel. This study was undertaken to ascertain if it was technically possible to perform simultaneous defecography and peritoneography in an effort to improve the diagnostic possibilities in patients with defecation disorders. Twelve patients with defecation disorders and an unexplained widening of the rectovaginal space at defecography were investigated. Contrast medium was introduced intraperitoneally, after which conventional defecography was performed. All investigations were carried out without complications and demonstrated the peritoneal outline in all patients. Simultaneous defecography and peritoneography differentiated between an enterocele and a pathologically deep pouch of Douglas--a peritoneocele. Three types of peritoneocele were visualized: vaginal peritoneocele, septal peritoneocele, and rectal peritoneocele with or without enterocele. Combinations of the three types were also found. Eight of the 12 patients had rectal intussusception or rectal prolapse. All of these eight patients had a rectal peritoneocele. Simultaneous defecography and peritoneography can be performed without technical difficulties or complications. Peritoneal outlines and pouches can, therefore, be studied directly during the act of defecation. An unexplained widening of the rectovaginal space at defecography can be clarified as a peritoneocele, with or without an enterocele. Peritoneocele can be of three different types: rectal, septal, or vaginal.

Atypical Chordoid Structures in the Aristotle's Lantern of Regular Echinoids

AbstractRegular sea–urchins, as a rule, prepare and process their food as pellets in their buccal cavity before ingesting them. This is obtained through the synergistic interaction of the five teeth with five fleshy protuberances (paradental tongues) which extend into the oral cavity and work like tongues. Each of these structures consists of two anatomically distinct parts: the outer component is a deep pouch of the terminal tract of the pharynx and shows a histological organization similar to that usually shown by the pharyngeal wall itself. The deeper component (paradental axis) is represented by a supporting rod and shows a peculiar histological structure, which consists of glycogen containing vesiculate cells mixed to slim muscle fibres and held together by a thin fibrillar stroma. The paradental axes are very problematic structures in terms of comparative anatomy and phylogenetic aspects. Their microscopic and submicroscopic organization is unusual for an echinoderm and recalls that of different types of chordoid organs commonly found in other invertebrates (Protostomata and Deuterostomata).

Rectal prolapse: relationship with joint mobility.

Joint mobility was assessed in 25 patients who had undergone surgery for complete rectal prolapse and in 25 age- and sex-matched control subjects. A significant increase in extensibility of the fifth finger was found in the patients with rectal prolapse. It was further found that there was a progressive decrease in joint mobility with age in both groups. The pathophysiology of rectal prolapse is complex. Factors considered to be important include rectal intussusception associated with the commonly observed lack of rectal fixation within the sacral hollow, with a deep Pouch of Douglas and weak pelvic floor musculature. The joint hypermobility demonstrated in these patients suggests an underlying connective tissue abnormality which perhaps contributes to the lack of rectal fixation within the pelvis and to the rectal wall intussusception.

Patterns of parental care and parental investment in marsupials.

Patterns of parental care and parental investment in marsupials.

Transsacral repair of rectal prolapse.

Whatever the basic pathogenesis of rectal prolapse, the structural alterations invariably include a defect in the pelvic floor fascia, a deep pouch anterior to the rectum, a patulous anus, loose fixation of the rectum to the pelvic structures, and a long sigmoid colon. A variety of corrective procedures have been described for rectal prolapse, but all suffer from various disadvantages. The transsacral approach to the rectum has several advantages: (1) it is simple and safe even for the elderly, (2) it avoids an abdominal incision with its concomitant postoperative complications, (3) it will allow complete correction of all abnormalities, and (4) it has been performed with a low recurrence rate.