Ischemic Colon Research Articles

The Pivotal Role of Negative Pressure Wound Therapy in the Management of Enteroatmospheric Fistula: A Year-Long "Obstacle Marathon"

Background. Enteroatmospheric fistula (EAF) is an abnormal communication between the gastrointestinal tract and the atmosphere. This phenomenon is still considered one of the most significant challenges faced by general surgeons after abdominal surgery. Primary goals of managing EAF include controlling and diverting intestinal contents outside the abdominal cavity, protecting surrounding tissues from retraction, and promoting wound healing. Achieving these goals is not easy. EAF has a 40% mortality rate. Several techniques have been proposed for managing this problem, including negative pressure wound therapy. The use of bladder catheters, nipples, endoscopic stents, vascular grafts, and fistula funnel, among other options, in the management of EAF has also been described. Case Report. The patient in the current report underwent Hartmann reversal surgery. On postoperative day (POD) 5, he had an anastomotic leak with ischemia of the descending colon and the transverse colon. Resection of the ischemic colon was performed, followed by creation of a terminal ileostomy on the last ileal loop on the right side. The first small orifice of EAF appeared on POD 23, the second on POD 28, and the third on POD 45. On POD 253, the patient underwent resection of the fistulated loop, extensive vitreolysis of the entire small intestine, and mechanical jejunojejunal laterolateral anastomosis to reestablish the canalization toward the previous terminal ileostomy on the right side. Complete closure of the skin was evident on POD 358. Conclusion. There is no ideal treatment approach that is valid for all cases of EAF. Spontaneous closure of an EAF is unlikely but feasible in the setting of a single, deep lesion with limited output and when intestinal continuity is preserved.

Indocyanin Green Fluorescence Evaluation of Colonic Perfusion During Elective Open Abdominal Aortic Aneurysm Repair.

Colonic ischaemia is a rare but devastating complication of open aortic aneurysm repair and is associated with high morbidity and a mortality of up to 50%. The aim of this study was to determine the safety and effectiveness of using indocyanin green florescence (ICG) to interrogate colonic perfusion intra-operatively. Prospective observational study. All elective open abdominal aneurysm repairs over a 6month period underwent colonic perfusion interrogation with ICG according to a pre-defined protocol. Patient demographics and imaging findings were recorded prior to surgery. ICG was given just prior to laparotomy closure. Time to florescence was measured from the start of IV administration to surgeon defined maximal florescence of the sigmoid colon. Ten patients fulfilled the inclusion criteria. All patients were male with an average age of 69.7years. Inferior mesenteric artery reimplantation was performed in 5 patients. Median colonic fluorescence time was 58s. No complications related to ICG were identified. A single patient had clinical concern of colonic ischaemia and delayed perfusion (>3min) on ICG; colorectal opinion advised not for immediate resection. At relook laparotomy, ischaemic colon at the area of demarcation was noted and a Hartmann's procedure was performed. No other patients had delayed perfusion and no further episodes of colonic ischaemia were noted. IMA reimplantation did not show statistical difference in colonic ICG time (P = .81, 95% CI -1.98 to 2.45). There was no statistical difference between operating times between the cohort and all repairs performed 6 months before the data collection (P = .59, 95% CI -.73 to 1.24). In this pilot study ICG appears to be a safe and useful adjunct in objective assessment of colonic perfusion during open AAA repair. Further research is required to fully determine its role in this cohort of patients.

Microbiota Phenotype Promotes Anastomotic Leakage in a Model of Rats with Ischemic Colon Resection.

Anastomotic leakage (AL) is a major cause of morbidity and mortality after colorectal surgery, but the mechanism behind this complication is still not fully understood. Despite the advances in surgical techniques and perioperative care, the complication rates have remained steady. Recently, it has been suggested that colon microbiota may be involved in the development of complications after colorectal surgery. The aim of this study was to evaluate the association of gut microbiota in the development of colorectal AL and their possible virulence strategies to better understand the phenomenon. Using 16S rRNA sequencing of samples collected on the day of surgery and the sixth day following surgery, we analyzed the changes in tissue-associated microbiota at anastomotic sites created in a model of rats with ischemic colon resection. We discovered a trend for lower microbial diversity in the AL group compared to non-leak anastomosis (NLA). There were no differences in relative abundance in the different types of microbial respiration between these groups and the high abundance of the facultative anaerobic Gemella palaticanis is a marker species that stands out as a distinctive feature.

Tetanus Presented as Acute Abdomen

Tetanus is commonly seen in the emergency department with a puncture wound. This is an unusual presentation of tetanus without an open wound. A 59 year old male with a past history of hypertension, hepatitis C, prior injection drug use, and homeless presented to the emergency department with altered mental status and hyperthermia with fever of 105 F on a hot July afternoon. Patient was found in his car sleeping. Initially, the patient declined medical care, but was later found unresponsive with a methadone bottle next to him. Given Narcan on field with improvement of mental status. Patient developed acute ridged abdominal pain. A CT scan raised concern for acute abdomen, with portal venous gas, and intestinal pneumatosis. Surgery consulted and was concerned for ischemic colon with perforation. Vancomycin, ceftriaxone and metronidazole were given. Emergency exploratory laparotomy was performed with a small serosal injury on colon repaired with suture. Blood culture came back positive for Clostridium tetani and Mobiluncus curtisii. Infectious disease consulted. Felt tetanus cannot be ruled out. Patient was given tetanus immune globulin (TIG), metronidazole and later tetanus vaccine. Patient has fully recovered, tolerates oral diets, and has been discharged to a nursing facility without any neurological deficit. Tetanus is a neurological disorder caused by the tetanus toxins produced by clostridium tetani, which is a gram positive obligate anaerobes commonly found in soil. It is relevant to note that this bacterium can also be found inside the gut of animals and humans. The disease is well characterized by ancient Greeks, and common symptoms include trismus (“lockjaw”), opisthotonos, and a board-like rigid abdomen. Incubation is usually 7-21 days and this disease is usually prevented by vaccination. This case is unusual because there is no open wound and PE is limited due to patient’s overdose on opiates (methadone). Possible cause for this particular case may be that since there was no open wound, the blood could have been seeded by the perforated bowel because they may also be found in the gut. The patient was given metronidazole as part of Tx for acute abdomen, which happens to also be a treatment for tetanus. Diseases can be presented atypically. This case illustrates the importance of differential diagnosis when considering treatments in any pathology.

559 One Mesenteric Defect, Two Segments of Colon, A Number of Surgical Strategies! A Rare Case of An Internal Hernia Causing Bowel Ischemia

Abstract Internal hernias due to mesenteric defects are a rare cause of bowel obstruction, but once present their complications are associated with a high morbidity and mortality. We present the case of a 24-year-old patient who presented to the emergency department with signs and symptoms of an acute abdomen. Following surgical review, taking into consideration the patient’s clinical, biochemical, and radiological findings, the patient was taken for immediate emergency surgical exploration. A laparoscopic approach was initially taken, which revealed dilated and ischemic colon, and therefore an open approach was then adopted. Operative findings included a very mobile caecum and proximal ascending colon which had herniated through a defect in the small bowel mesentery, the sigmoid colon had subsequently become incarcerated by the caecum and small bowel too. Both the ascending and sigmoid colon had become ischemic. A number of surgical strategies were considered, and given the patients age it was decided to preserve as much normal bowel as possible. Thus, a right hemi- and sigmoid colectomy were performed with an ileo-transverse anastomosis and formation of an end colostomy. In this case, radiological diagnosis pointed to a suspicion of an internal hernia, and operative diagnosis highlighted a rare mesenteric defect causing herniation and subsequent ischemia. Relying on the patient’s clinical condition and an early decision for surgical intervention resulted in a positive outcome for outpatient. The patient made a good recovery following the bowel preserving surgery.

The effect of carbon monoxide releasing molecule-2 (CORM-2) on healing of ischemic colon anastomosis in rats

Background/aimIschemia on the colon wall negatively affects healing of anastomosis. We were aimed to evaluate the effects of carbon monoxide releasing molecule-2 (CORM-2) on the healing of anastomosis in a rat model of the ischemic colon. Materials and methodsIn this prospective study a total of 60 rats were randomly divided into three groups as colon transection and end-to-end anastomosis (Group I), colon transection, and end-to-end anastomosis following the induction of ischemia (Group II), and colon transection and end-to-end anastomosis following the induction of ischemia and treated with daily intraperitoneal administration of CORM-2 (Group III). Each group was also divided into two equal subgroups as postoperative 3rd and 7th day. Postoperative healing of anastomoses was evaluated by anastomosis burst pressure (ABP), tissue biomarkers including hydroxyproline (HP), malondialdehyde (MDA), glutathione (GSH), and histopathological findings.ResultsIn the ischemic group treated with CORM-2, lower MDA and higher HP levels were observed in comparison to the untreated ischemic group on the 3rdday. GSH and HP levels were higher and MDA levels was lower in the ischemic rats treated with CORM-2 than in the ischemic untreated rats on the 7th day. In the ischemic group treated with CORM-2, the mucosal epithelial score decreased and the neoangiogenesis score increased compared to the untreated rats on the 7th day.ConclusionIn ischemic colon anastomosis, reduces cell destruction by suppressing the oxidative reaction, and strengthening the antioxidative mechanisms of the cells. It also increases collagen formation, epithelial development, and neoangiogenesis.

Gastrointestinal Pathology in Samples From Coronavirus Disease 2019 (COVID-19)-Positive Patients.

Although primarily considered a respiratory illness, coronavirus disease 2019 (COVID-19) can cause gastrointestinal manifestations. To evaluate histopathology and in situ hybridization for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in gastrointestinal samples from patients with recent and remote COVID-19. Patients with positive SARS-CoV-2 nasopharyngeal tests and a gastrointestinal tissue specimen were included. SARS-CoV-2 in situ hybridization (ISH) was performed on each sample. A subset had SARS-CoV-2 next-generation sequencing (NGS) performed. Twenty-five patients met inclusion criteria. Five had positive SARS-CoV-2 nasopharyngeal tests within 7 days of their gastrointestinal procedure. Two were ulcerative colitis patients on steroid therapy who lacked typical COVID-19 symptoms. Their colectomies showed severe ulcerative colitis; one demonstrated SARS-CoV-2 by NGS but a negative ISH. Another had an ischemic colon resected as a complication of the COVID-19 course; however, both ISH and NGS were negative. A fourth had a normal-appearing terminal ileum but positive ISH and NGS. The fifth patient had ileal ulcers with SARS-CoV-2 negativity by both modalities. The remaining 20 patients had positive nasopharyngeal tests an average of 53 days prior to procedure. None of their samples demonstrated SARS-CoV-2 ISH positivity, but one was positive on NGS despite a negative nasopharyngeal test. Gastrointestinal findings from SARS-CoV-2-infected patients ranged from normal with virus detected by ISH and NGS to bowel ischemia secondary to systemic viral effects without evidence of virus in the tissue. No distinct histologic finding was identified in those with gastrointestinal tissue specimens demonstrating SARS-CoV-2 positivity in this cohort.

940 Mesenteric Haematoma Complicated by A Perforated Sigmoid Diverticulum Following Extracorporeal Shockwave Lithotripsy

Abstract A 78 year old female presented with sudden onset lower abdominal pain, vomiting and fresh rectal bleeding. She had undergone extracorporeal shockwave lithotripsy (ECSL) for a left renal stone two weeks earlier and was taking Rivaroxaban for atrial fibrillation. A CT Abdomen & Pelvis revealed a large mesenteric haematoma and a contained sigmoid perforation secondary to compressive forces of the haematoma on the sigmoid artery, resulting in ischaemia. While mesenteric angiogram-guided embolisation initially controlled the active sigmoid artery bleed, the patient clinically deteriorated the following day warranting a laparotomy. This revealed an ischaemic sigmoid colon with contained faeculent material within the mesentery. An extended left hemi-colectomy with end-colostomy was performed. Despite optimal critical care input, the patient developed multi-organ failure and passed away one week later. Mesenteric haematoma should be considered as a rare complication in patients with sudden onset abdominal pain following ECSL; especially with concurrent anti-coagulation use.

Enteric nervous system with chronic mesenteric ischemia: experimental study

Introduction. The pathology of the enteric ganglia can lead to different diseases (Hirschsprungs, neuronal intestinal dysplasia, ganglioneuromatosis, and Chagasse). Causes of acquired dysganglionosis remained unclear. Some authors hypothesized that pathology of the enteral nervous system may be secondary to intestinal ischemia.
 Aim. To investigate the intestinal function and histological changes of the colon in rats with chronic ischemia.
 Materials and methods. A total of 20 Sprague Dawley rats underwent surgery (ligation of the terminal mesenteric vessels next to the descending colon). The appetite of animals were checked, and stool were collected after the procedure. Reoperation was performed after 7 (n = 1), 9 (n = 2), 12 (n = 2), 14 (n = 1), 21 (n = 1), 42 (n = 1), 53 (n = 1), and 62 (n = 1) days. The diameter of the colon and changes of the serosa were visualized. In the experimental group, two samples biopsy was performed (ischemic and normal colon).
 Results. Functional changes were observed in 90% of rats after the ligation of mesenteric vessels (constipation/impact, softening stool/diarrhea, and hemocolitis). Colonic stenosis of the ischemic area in 30% was detected. 70% animals have the intestinal dilatation above the ischemic segment (partial bowel obstruction). Necrosis of the ischemic colon was observed in 20%. Spontaneous fixation of the omentum to the ischemic segment was found in 40% animals. A microscopically inflamed infiltration of the mucosa in the ischemic zone (70%) and in normal colon (50%) was revealed in the ligation group. The number of the enteric ganglia decreased in the ischemic segment.
 Conclusion. Functional disorders (colitis and obstruction) and morphological changes (inflammation and ganglion cells pathology) were found in rats with chronic mesenteric ischemia.

Effects of Duraseal® and Fibrin Glue on healing of normal and ischemic colon anastomosis

Background and Aims: Anastomotic leaks represent a major complication of colorectal surgery. This study, involving a rat model of normal and ischemic colon anastomosis, aims to compare the effects of Duraseal® with those of Fibrin Glue (FG). Methods: Fifty adult male Wistar Albino rats were divided into six groups; normal colon anastomosis, ischemic colon anastomosis, FG on normal colon anastomosis, Duraseal® on normal colon anastomosis, FG on ischemic colon anastomosis, Duraseal® on ischemic colon anastomosis. After scarification, bursting pressure were measured and samples were collected for histopathological examination and hydroxyproline assays. Results: While the mean bursting pressure was statistically higher in groups treated with Duraseal® when compared to controls (p<0.05), no significant differences between Duraseal® and FG were detected (p>0.05). The mean hydroxyproline level was significantly lower in the Duraseal® groups than in the FG groups (p<0.05). However, significant differences between Duraseal® and control groups were found only in ischemic colon anastomosis (p<0.05). Histopathological examinations did not show any differences in wound healing. Conclusion: Considering the advantages associated with the use of Duraseal®, we may assume that it may play role in gastrointestinal surgery with respect to prevention of anastomotic leaks. However, data is limited, and further studies are warranted to better define its place in surgery.

P186 Efficacy and safety of rituximab in the treatment of systemic vasculitis: experience at a single centre

Abstract Background Rituximab is a monoclonal chimeric antibody targeting the mature B cell molecule CD20, expressed on the cell surface. It is licenced and widely used in the treatment of autoimmune diseases, including the ANCA associated vasculitides and rheumatoid arthritis. The efficacy and safety of rituximab in rare diseases requires ongoing appraisal. Methods We interrogated the records of 62 consecutive patients treated with rituximab for small vessel systemic vasculitis at our unit over the last 3 years, using a contemporaneously maintained central database, as well as individual electronic patient records. Results The patient demographic data, and main results are presented in Table 1. 31 (50%) of the patients treated with rituximab were female, and the indication for treatment in most cases was ANCA associated vasculitis (77.4%). After a mean follow up period of 2.04 years, the mean reduction in BVAS was 1.64 (3.83). 5 severe adverse events were recorded, defined as death or hospitalisation potentially related to treatment with rituximab. 3 patients died of respiratory sepsis, 1 experienced a wound infection, and 1 experienced an ischaemic colon. Four patients were noted to have low immunoglobulins. Conclusion Rituximab is an effective treatment for many patients with systemic, small vessel vasculitis. Understanding the safety profile of this drug in the context of our cohort is challenging, given the significant morbidity associated with the underlying disease, as well as the age profile and concomitant immunosuppressive medications. Continued surveillance regarding efficacy and safety of rituximab in the small vessel systemic vasculitides remains invaluable. Disclosures C. Orr None. A. Verdiyeva None. N. Ahmad None. H. Ariff None. R. Luqmani None.

Simultaneous computer-assisted assessment of mucosal and serosal perfusion in a model of segmental colonic ischemia.

Fluorescence-based enhanced reality (FLER) enables the quantification of fluorescence signal dynamics, which can be superimposed onto real-time laparoscopic images by using a virtual perfusion cartogram. The current practice of perfusion assessment relies on visualizing the bowel serosa. The aim of this experimental study was to quantify potential differences in mucosal and serosal perfusion levels in an ischemic colon segment. An ischemic colon segment was created in 12 pigs. Simultaneous quantitative mucosal and serosal fluorescence imaging was obtained via intravenous indocyanine green injection (0.2mg/kg), using two near-infrared camera systems, and computer-assisted FLER analysis. Lactate levels were measured in capillary blood of the colonic wall at seven regions of interest (ROIs) as determined with FLER perfusion cartography: the ischemic zone (I), the proximal and distal vascularized areas (PV, DV), and the 50% perfusion threshold proximally and distally at the mucosal and serosal side (P50M, P50S, D50M, D50S). The mean ischemic zone as measured (mm) for the mucosal side was significantly larger than the serosal one (56.3 ± 21.3 vs. 40.8 ± 14.9, p = 0.001) with significantly lower lactate values at the mucosal ROIs. There was a significant weak inverse correlation between lactate and slope values for the defined ROIs (r = -0.2452, p = 0.0246). Mucosal ischemic zones were larger than serosal zones. These results suggest that an assessment of bowel perfusion from the serosal side only can underestimate the extent of ischemia. Further studies are required to predict the optimal resection margin and anastomotic site.

Effect of the wrapping of experimentally induced ischemic colonic anastomoses with the amniotic membrane on anastomosis safety in rats.

Objective: Colonic anastomotic leakage represents a complication with high mortality and morbidity. In the present study, it was aimed to examine the effect of the amniotic membrane on the healing of ischemic colonic anastomosis. Methods: 25 pregnant Wistar albino rats aged 19-21 days were randomly divided into 5 groups. With midline laparotomy, pregnancies were terminated, and fresh amniotic membranes were obtained. In Group 1 Sham (S), no procedure except for laparotomy was performed. In Group 2 of colonic anastomosis (A), the descending colon was completely transected and anastomosed. In Group 3 of amniotic anastomosis (AA), the anastomosis line was fixed by being wrapped with the fresh amniotic membrane. In Group 4 of colonic ischemic anastomosis (IA), the marginal arteries were ligated after descending colon transection. Ischemia was induced, and anastomosis was performed. In Group 5 of colonic ischemic anastomosis wrapped with the amniotic membrane (AIA), after ischemic colonic anastomosis was performed, the anastomosis line was fixed by being wrapped with the amniotic membrane. On the postoperative 7th day, rats were sacrificed, and their anastomotic bursting pressures were measured. For histological examination, the colon segment containing the anastomosis line was removed. Hematoxylin-eosin and Van Gieson trichrome stained specimens were histologically evaluated and scored according to the Ehrlich-Hunt model. Results: Anastomotic bursting pressures were measured in group S as the highest, in AA, AIA, A in a decreasing order and in group IA as the lowest. The difference between groups S and AA was statistically insignificant in the paired comparison of groups according to their bursting pressure values (p=0.222). When the other pairs were compared, the difference between the groups was calculated as significant (p< 0.05). According to the Ehrlich-Hunt model, the total score was the highest in AIA group, decreased in AA, IA, A groups in a decreasing order, and was the lowest in group S. A paired comparison for total scores between the groups was statistically insignificant between groups S and A (p=0.222). Other paired comparisons were statistically significant (p< 0.05). Conclusion: Wrapping the colon anastomosis line with the amniotic membrane gave positive results both in the ischemic colon as well as in the non-ischemic colon in terms of bursting pressure and histological anastomosis safety.

Healing of Ischemic Colon Anastomosis in Rats Could Be Provided by Administering Dexpanthenol or Coenzyme Q10.

Background: In this study, the effectiveness of dexpanthenol and coenzyme Q10 (CoQ10) on the healing of ischemic colon anastomosis was investigated. Methods: Forty eight male Wistar Albino rats were divided into four equal groups (Sham-S, Sham-I, DXP, Q10). Following full layer colon resection, single layer colon anastomosis, without creating ischemia, was performed on the Sham-S group. The same experimental model was performed on remaining groups after ischemia was created. Intraperitoneal dexpanthenol and CoQ10 was administered to the DXP and Q10 groups once a day for three days. Ten days later, all colon anastomoses were investigated histopathologically and biochemically, as well as their burst pressure values, in all sacrificed rats. Results: The highest burst pressure value was observed in the Sham-S group, decreasing from high to low in the DXP, Q10, and Sham-I groups, respectively (p = 0.008). Furthermore, tissue hydroxyproline (p = 0.001) level values were significantly different among the groups. Additionally, histopathological analysis revealed a significant difference among groups regarding reepithelization (p = 0.027) and polymorphonuclear leukocyte density (p = 0.022). Conclusions: This preliminary study has shown that ischemia-reperfusion injury may impair the healing of colon anastomosis and it has been concluded that dexpanthenol and CoQ10 may have positive effects on the healing of ischemic colon anastomosis in rat, although re-epithelization may be adversely affected using CoQ10.

Clinical efficacy of the laparoscope-assisted transanal total mesorectal excision for middle-low rectal cancer

Objective To explore the clinical efficacy of laparoscope-assisted transanal total mesorectal excision (La-TaTME) for middle-low rectal cancer. Methods The retrospective cross-sectional study was conducted. The clinical data of 16 patients with middle-low rectal cancer who underwent La-TaTME in the Peking University Third Hospital from August 2015 to August 2016 were collected. Sequential surgery of La-TaTME was applied to patients in the same team, with laparoscopic surgery first and then transanal surgery. Observation indicators: (1) operation and postoperative recovery situations: conversion to open surgery, anastomosis method, operation time, volume of intraoperative blood loss, intraoperative complications, time for out-of-bed activity, time for liquid diet intake, postoperative complications and duration of postoperative hospital stay. (2) postoperative pathological situations: length of surgical specimen, tumor diameter, distance from tumor to resected distant intestinal canal, complete degree of mesorectum, circumferential resection margin, pathological T stage, pathological N stage, number of lymph node detected and tumor cell differentiation. (3) follow-up. Patients in stage Ⅲ-Ⅳ of TNM stage of RC underwent postoperative adjuvant chemotherapy. Follow-up using outpatient examination was performed once every 3 months postoperatively to detect the patients′ survival and tumor recurrence up to December 2016. Measurement data were represented as M (range). Results (1) Operation and postoperative recovery situations: all the 16 patients underwent successful La-TaTME without conversion to open surgery, including 10 with colorectal anastomosis, 3 with colon-canalis analis anastomosis and 3 with permanent colostomy. Operation time and volume of intraoperative blood loss were 290 minutes (range, 215-420 minutes) and 50 mL (range, 30-100 mL), respectively. One patient had intraoperative complication, showing broken ends ischemia of sigmoid colon after dragging out resected rectum from the anus, following free splenic flexure of colon, about 5 cm ischemic sigmoid colon were resected, and descending colon-rectum anastomosis was performed. Time for out-of-bed activity and time for liquid diet intake were 1 days (range, 1-3 days) and 2 days (range, 1-9 days), respectively. Among 3 patients with postoperative complications (Ⅱ stage of Clavien-Dindo), 2 with incomplete intestinal obstruction were improved by gastrointestinal decompression and total parenteral nutrition, and 1 with presacral infection was improved by drainage and antibiotic therapy. Duration of postoperative hospital stay was 7 days (range, 5-21 days). (2) Postoperative pathological situations: length of surgecal specimen, tumor diameter and distance from tumor to resected distant intestinal canal were respectively 18.0 cm (range, 12.0-24.0 cm), 3.5 cm (range, 0.5-6.8 cm) and 2.5 cm (range, 1.0-5.0 cm). Evaluation of mesorectum of surgical specimen: 14 patients had complete mesorectum of surgical specimen and 2 had nearly complete mesorectum. There was no residual tumor at circumferential resection margin, proximal and distal ends. Pathological T stage of 16 patients: T0 (pathological complete response after neoadjuvant therapy), T1, T2 and T3 stages were found in 1, 1, 4 and 10 patients, respectively. Pathological N stage: 12, 2 and 2 patients were detected in N0, N1 and N2 stages, respectively. Number of lymph node detected was 16 (range, 6-32). Tumor cell differentiation: no tumor cell (pathological complete response after neoadjuvant therapy), high-, moderate- and low-differentiated tumors were respectively detected in 1, 2, 7 and 6 patients. (3) Follow-up. All the patients were followed up for 12 months (range, 4-16 months). There were no local tumor recurrence or distant metastasis and death. Conclusion La-TaTME may be a new, safe and effective resection for middle-low rectal cancer. Key words: Rectal neoplasms, middle-low; Total mesorectal excision; Transanal; Laparoscopy

Fluorescent test accurately predicts leak of ischemic colon anastomosis in rats.

To investigate if fluorescein fluorescent test can predict dehiscence in a model of ischemic colonic anastomosis in rats. This experimental controlled trial randomly assigned 55 rats to four groups. Anastomoses were performed in non-ischemic colon segments (control group) and in ischemic colon segments measuring 1, 2 or 3 cm long (groups 1, 2 and 3, respectively). Fluorescein was injected and the tissues were examined under ultraviolet light. Seven days later, a second-look surgery was performed to check for the presence or absence of anastomosis dehiscence. Twenty-four rats presented anastomotic dehiscence during the second-look surgery. Reticular and nonfluorescent patterns were significantly associated with the occurrence of anastomotic dehiscence. Fluorescein fluorescence had a sensitivity of 95.8%, specificity of 89.2%, positive predictive value of 88.4%, negative predictive value of 96.2%, and accuracy of 92.3% to predict anastomotic dehiscence. Fluorescein fluorescent test can accurately predict leak in a model of ischemic colonic anastomosis in rats.

Radiofrequency Ablation-Associated Delayed Diaphragmatic Hernia Treated with the Thoracolaparotomy Approach: A Case Report

Background: Radiofrequency ablation (RFA) is an effective treatment for hepatocellular carcinoma (HCC). However, rare but serious complications may occur after RFA. We describe a case of diaphragmatic hernia associated with RFA. Case Presentation: A 68-year-old man with a history of hepatitis C-related liver cirrhosis was admitted to our hospital because of lower abdominal pain. Three years earlier, he underwent RFA for HCC in segment 8. Computed tomography revealed that the intestine was intruding into the right thoracic cavity through a diaphragmatic hernia. On the basis of the diagnosis of right diaphragmatic hernia with a strangulated ileus, an emergency operation was performed. Perforation of the strangulated transverse colon into the right thoracic cavity was suspected, and a combined approach of laparotomy and thoracotomy was utilized. The operative findings showed that the diaphragmatic hernia was 3.5 × 2.0 cm in diameter, and it was simply sutured with a nonabsorbable suture material. Resection of the intruded ischemic transverse colon was completed, and a covering ileostomy was performed. The patient was discharged without any complications. Conclusions: RFA is widely used for the treatment of HCC. Reports of early- and late-phase complications indicate that heat damage contributes to the fragility of neighboring organs. The occurrence of diaphragmatic hernia after RFA is one of the delayed complications. Although it rarely occurs, this complication requires emergency surgery. In conclusion, if perforation of the intestine into the thoracic cavity is suspected, thoracolaparotomy should be considered as a treatment option to prevent postoperative massive empyema.

Therapeutic improvement of colonic anastomotic healing under complicated conditions: A systematic review.

To identify therapeutic agents for the prophylaxis of gastrointestinal anastomotic leakage (AL) under complicated conditions. The PubMed and EMBASE databases were searched for English articles published between January 1975 and September 2014. Studies with the primary purpose of improving anastomotic healing in the colon or rectum under complicated preoperative and/or intraoperative conditions were included. We excluded studies investigating the adverse effects or risk assessment of an active intervention. Furthermore, investigations of biophysical materials, sealants, electrical stimulation and nutrients were excluded. The primary study outcome was biomechanical anastomotic strength or AL. The meta-analysis focused on therapeutic agents that were investigated in one animal model using the same outcome by at least three independent research groups. The 65 studies included were divided into 7 different complicated animal models: Bowel ischemia, ischemia/reperfusion, bowel obstruction, obstructive jaundice, peritonitis, chemotherapy and radiotherapy. In total, 48 different therapeutic compounds were examined. The majority of investigated agents (65%) were reported as beneficial for anastomotic healing. Twelve of the agents (25%) were tested more than once in the same model, whereas 13 (27%) of the agents were tested in two or more models of complicated healing. Two therapeutic agents met our inclusion criteria for the meta-analysis. Postoperative hyperbaric oxygen therapy significantly increased anastomotic bursting pressure in ischemic colon anastomoses by a mean of 28 mmHg (95%CI: 17 to 39 mmHg, P < 0.00001). Granulocyte macrophage-colony stimulating factor failed to show a significant increase in anastomotic bursting pressure (95%CI: -20 to 21 mmHg, P = 0.97) vs controls in experimental chemotherapeutic models. This systematic review identified potential therapeutic agents, but more studies are needed before concluding that any of these are useful for AL prophylaxis.

Hidronefroz ile Birlikteliği olan İzole Rüptüre Dev İliak Arter Anevrizması: Olgu Sunumu

We report a 51year-old male patient admitted to our emergency department because of sudden abdominal pain, hypotension, and dyspnea. On physical examination, abdominal tenderness was observed, primarily in the lower abdomen. Hemoglobin was 8.5g/dl and hematocrit was 26%. Renal function was within normal limits. Ruptured giant left IIIAA ( diameter 11 cm ) with massive hematoma on the left side of retroperitoneal space and extensive left kidney ( diameter 26x18x20 cm ) hydronephrosis ( Figure 1a,1b ) was detected with contrast-enhanced computed tomography (CT). The patient been consulted to the urology department at the same time and decided left nephrectomy for left kidney hydronephrosis. The patient was immediately taken to operation room due to hemodynamic instability. Proximal control was obtained by percutaneous endoaortic balloon occlusion catheter. The aneurismal sac was reached after midline laparotomy (figure 2). Ligation was performed to both the proximal and distal neck of aneurismal sac. After this procedure aneursimal sac was opened and drained. Concomitantly nephrectomy was performed. The postoperative follow up was uneventful. Symptoms of ischemic colon and claudicating were not observed and renal function tests were impaired. The patient was discharged on day 7 postoperatively. At 6 months postoperative, the patient remained well.

Efficacy of Pentoxifylline and Tadalafil in Rat Model of Ischemic ColITIS

ABSTRACTObjective: The aim of this study is to investigate the efficacy of tadalafil against pentoxifylline in rat model of ischemic colitis (IC). Material-Methods: Thirty-two Wistar albino rats were subjected to laparotomy and left colon devascularization to create an IC model and then randomly placed into four groups. Group-1 (sham group) was administered 0.9% NaCl following laparotomy, group 2 (control group) was administered 0.9% NaCl following induced IC, group 3 was given pentoxifylline (n = 8), and group 4 was given tadalafil. On the third day; macroscopic findings, Gomella's ischemic area and Wallace scoring, histopathological analysis, and Chiu scoring were performed, and malondialdehyde (MDA) measurement in ischemic colon tissue was carried out through chemical analysis. Results: Significant differences were observed in acidic fluid, bowel dilatation, and serosal change (p < .05). The ischemic area measured 63.3 mm2 in the control group, 2.8 mm2 in the pentoxifylline group (p = .0001), and 2.4 mm2 (p = .0001) in the tadalafil group. A significant difference was seen between the sham group and the control and pentoxifylline groups (p < .01), in terms of Wallace score and Chiu classification. Similarly, a significant difference was determined between the control group and pentoxifylline and tadalafil groups (p < .01), but no significant difference was established between the pentoxifylline group and tadalafil group (p = .33). MDA measurement was found on an average to be 63.7 in the control group, 22.7 in group 3 and 22.8 in group 4 (p = 001). Conclusion: Although tadalafil is superior to pentoxifylline, both drugs are considered to have positive effects.