Jejunal Resection Research Articles

Deferred anastomosis in severe secondary peritonitis using a temporary intestinal shunt – case report

Introduction: As part of the damage control surgery concept applied to the treatment of sepsis due to severe secondary peritonitis following intestinal perforation and/or in high-risk patients we describe the novel "temporary intestinal shunt" (TIS) technique with delayed intestinal anastomosis, as an alternative to primary anastomosis or enterostomy.
 Material and Methods: We present three patients in whom urgent laparotomy was performed due to intestinal perforation, with intestinal resection and TIS.
 Case reports:Case 1: A 39-year-old male presented with acute myeloid leukemia M3 and generalized peritonitis, sigmoid colon perforation and secondary jejunal loop involvement. In view of these findings, we performed 10 cm jejunal resection with TIS placement, sigmoid colon resection, and negative pressure therapy (NPT). Reoperation after 48 hours showed no evidence of peritonitis, so a manual jejuno-jejunal anastomosis and terminal colostomy were performed. Case 2: A 65-year-old woman treated with corticosteroids presented with a pneumoperitoneum secondary to a road traffic accident. Urgent laparotomy revealed a 2 cm jejunal perforation. Resection of the jejunal segment and TIS with NPT was performed. Exploration of the peritoneal cavity 96 hours later showed clinical improvement and a jejuno-ileal anastomosis was performed. Case 3: A 73-year-old male was admitted due to intestinal subocclusion. Clinical deterioration occurred rapidly and we performed an urgent laparotomy diagnosing jejunal perforation secondary to torsion and ischemia of the affected loop, and generalized peritonitis. Intestinal resection and TIS with NPT placement were thus decided. Anastomosis and closure of the abdominal appendage were deferred until 96 hours after the first surgery. 
 Conclusion: Although the evidence we present is limited, we believe TIS to be an additional tool in damage control surgery. This staged management strategy allows definitive reconstruction with the patient in a more favorable physiological condition.

P084 DEEP REMISSION WITH DOUBLE BIOLOGIC THERAPY: A SUCCESSFUL CASE OF COMBINATION USTEKINUMAB AND VEDOLIZUMAB FOR SEVERE REFRACTORY CROHN’S DISEASE

Abstract Background Stricturing Crohn’s disease (CD) constitutes a severe phenotype often associated with a high degree of morbidity (3). Surgical resection is first-line therapy for symptomatic strictures, but most patients relapse without subsequent medical therapy (4–5). Biologics are the mainstay for inducing and maintaining remission, but some cases are refractory despite maximum dosage of therapy. Reports of dual biological therapy (DBT) in refractory, stricturing CD are sparse, and prior case reports document only clinical remission (1). To contribute further knowledge regarding the use of DBT in stricturing CD, we present the case of a refractory CD patient who achieved deep remission with ustekinumab and vedolizumab. Case Presentation A 35 year old non-smoking, Caucasian male was referred to our clinic in 2014 for refractory CD complicated by multiple strictures. Prior to establishing care with us, he received two jejunal resections and a sigmoid resection. Previously failed therapies included azathioprine with infliximab, adalimumab, and certolizumab. He continued to progress under our care despite combination methotrexate/certolizumab, as well as methotrexate/golimumab. He underwent proctocolectomy with end ileostomy in 2015 and initiated vedolizumab q8weeks post-operatively. He reoccurred in 2018, when he presented with an ulcerated ileal stricture. He was switched from vedolizumab to ustekinumab q8weeks and placed on prednisone, but continued to progress, developing significant hematochezia requiring hospitalization and blood transfusions. Ileoscopy performed during hospital admission confirmed severe, ulcerating disease in the ileum with stricture. Ustekinumab dosing was increased to q4weeks, azathioprine was initiated, and he underwent stricturoplasty. Follow-up ileoscopy three months later revealed two ulcers in the neo- TI (Figure 1). Vedolizumab q8weeks was initiated in addition to ustekinumab q4weeks and azathioprine 125mg. After four months on this regimen the patient felt better, but follow-up ileoscopy showed two persistent ulcers in the neo-TI. Vedolizumab dosing interval was increased to q4weeks. After four months, subsequent ileoscopy demonstrated normal neo-TI (Figure 2). Histologic evaluation of biopsies confirmed deep remission of crohn’s disease. No adverse side effects have occurred with maximum doses of both ustekinumab and vedolizumab combination therapy. Discussion This case supports both the safety and efficacy of ustekinumab and vedolizumab dual biologic therapy for treatment of severe, refractory Crohn’s disease. While there are reports of DBT inducing clinical remission, this case supports efficacy for vedolizumab and ustekinumab combination therapy to induce deep histologic remission. Large practical clinical trials are needed to better investigate the safety and efficacy of DBT with vedolizumab and ustekinumab, but our case suggests this combination may be a safe and efficacious therapy for refractory CD patients.

Effects of bradykinin preconditioning in an experimental intestinal ischemia reperfusion model on rats.

Purpose To investigate the effects of bradykinin on reperfusion injury in an experimental intestinal ischemia reperfusion model.Methods We used 32 Wistar-Albino rats. We composed 4 groups each containing 8 rats. Rats in sham group were sacrified at 100 minutes observation after laparotomy. Thirty minutes reperfusion was performed following 50 minutes ischaemia in control group after observing 20 minutes. Ischaemic preconditioning was performed in one group of the study. We performed the other study group pharmacologic preconditioning by infusional administration of 10 μg/kg/minute bradykinin intravenously. We sacrified all of the rats by taking blood samples to evaluate the lactate and lactate dehydrogenase (LDH) after resection of jejunum for detecting tissue myeloperoxidase (MPO) activity.Results Lactate and LDH levels were significantly higher in control and study groups than the sham group (P<0.001). There is no difference between the study groups statistically. (P>0.05). The results were the same for MPO levels. Although definitive cell damage was determinated in the control group by hystopatological evaluation, the damage in the study groups observed was lower in different levels. However, there was no significant difference between the study groups statistically (P>0.05).Conclusion Either ischeamic preconditioning or pharmacologic preconditioning made by bradykinin reduced the ischemia reperfusion injury at jejunum.

2521 Jejunal Carcinoid in a Patient With Primary Biliary Cholangitis Presenting as Small Bowel Obstruction

INTRODUCTION: Gastrointestinal carcinoid tumors arise from specialized neuroendocrine cells all along the gastro-entero-pancreatic system, which secrete bioactive amines and peptides. These are often asymptomatic and rarely cause obstructive symptoms. We describe a rare case of jejunal carcinoid presenting as small bowel obstruction. CASE DESCRIPTION/METHODS: A 60-year-old female with primary biliary cholangitis and scleroderma presented with three-months of abdominal pain, vomiting, and constipation with worsening three days prior to presentation. Patient was hemodynamically stable with unremarkable physical examination findings. Computed Tomography (CT) of abdomen and pelvis and follow up magnetic resonance enterography (MRE) showed a focal small bowel ileus with enlarged mesenteric lymph nodes (Figure 1). Chromogranin-A level was elevated to 11 nmol/L. The patient underwent exploratory laparotomy for small bowel obstruction; mesenteric mass and jejunal resection with jejunojejunal anastomosis was performed. The final histopathology report of both the lymph node and mesenteric mass revealed well-differentiated neuroendocrine tumor (NET), also termed carcinoid tumor (Figure 2). A follow-up Gallium PET/CT three weeks later showed residual disease in the small bowel mesentery near the site of resection for which the patient was started on Lanreotide. DISCUSSION: Carcinoid tumors are most common in the small bowel (30.8%) typically within 60 cm of ileocecal valve and are mostly asymptomatic. While midgut carcinoid may present with abdominal pain due to intermittent obstruction, mesenteric ischemia, or intraluminal tumor, it is rare. Although the initial modality of choice for small bowel obstruction is CT abdomen, it has low sensitivity in detecting small primary intestinal masses. MRE is more sensitive in detecting the dominant finding of a mesenteric mass. Octreotide scan and gallium-68 PET/CT can detect extent of disease or preoperatively diagnose patients with suspected NET that could not be detected using other modalities. Surgical resection with lymphadenectomy remains the standard treatment with a favorable prognosis of 83% five-year survival rate. Somatostatin analogs are the first line of treatment for any residual disease. With a favorable prognosis in mind, our case highlights the need for high clinical suspicion for carcinoid as part of the differential, especially in a patient presenting with small bowel obstruction and mesenteric mass in the setting of autoimmune disease.

2091 Orofacial Granulomatosis: The Proof Is in the (Cinnamon) Pudding

INTRODUCTION: Orofacial granulomatosis (OFG) can present in isolation or in conjunction with other systemic disease including Crohn’s disease (CD). Data suggests that CD presenting with OFG may represent a distinct sub-phenotype of CD with more extensive inflammation and perianal disease [1]. Treatment of the oral manifestations of CD is typically challenging with numerous strategies proposed including topical and intralesional agents, immunomodulators, biological agents and dietary interventions. CASE DESCRIPTION/METHODS: A 24-year-old female with CD affecting the upper gastrointestinal tract, small and large bowel and perianal disease was referred to our unit for further management. She was diagnosed at the age of 19 when she had an emergency admission with jejunal obstruction. A jejunal resection with primary anastomosis was performed. She was managed with Infliximab and Azathioprine. She developed thickening of her buccal mucosa (Figure 1). A biopsy confirmed chronic inflammation with several non-necrotic granulomas in keeping with OFG. The patient was commenced on prednisolone with some improvement of the oral swelling however it later recurred requiring further oral steroids. Despite pro-active optimisation of Infliximab and Azathioprine levels, her oral manifestations of Crohn’s disease worsen (Figure 2). A cinnamon- and benzoate-free diet was recommended in liaison with specialist IBD dietitians with a dramatic improvement of her oral swelling within 4 weeks and near resolution in 8 weeks (Figure 3). Following 12 months of the diet the patient was advised to start re-introducing cinnamon and benzoates gradually into her diet and since this there has been no recurrence of oral symptoms. She has been maintained on an anti-TNF and Azathioprine for treatment of her ileo-colonic and perianal disease. DISCUSSION: There is good evidence for the efficacy of a cinnamon- and benzoate-free diet in patients with OFG raising the possibility of a dietary antigen and subsequent hypersensitivity in its aetiology. In our case the excellent response of the OFG to this diet, following failure to respond to conventional treatment for CD, is of interest. The debate regarding whether OFG is a distinct disease entity from oral CD continues. More studies are required to guide treatment options in this group of patients.

3022 Metastatic Colon Adenocarcinoma Presenting as a Hilar Obstructing Lesion Diagnosed With EUS-FNB

INTRODUCTION: Bile duct obstruction from periportal masses has a broad differential diagnosis.1 Cross-sectional abdominal imaging can help to detect periportal masses, but have low sensitivity in the diagnosis of proximal biliary and hilar lesions.2 Endoscopic ultrasound (EUS) allows for evaluation of periportal and biliary lesions and enables tissue diagnosis via fine needle biopsy (FNB). We present a case of a young patient who was presumed to have primary metastatic ovarian cancer; with EUS and ERCP guided sampling we arrived at a specific diagnosis of metastatic adenocarcinoma of colonic origin. CASE DESCRIPTION/METHODS: A 41-year-old female with a history of ovarian cancer s/p TAH and BSO and jejunal resection presented with painless jaundice, hematochezia, and high fever. Abdominopelvic CT scan showed a 2 cm mass in the region of the porta hepatis invading the portal vein and diffuse thickening of the rectosigmoid colon (Figure 1). Colonoscopy from a year prior was unremarkable, and subsequent colonoscopy was significant for hemorrhoids and hyperplastic polyps. Due to clinical suspicion for cholangitis, an ERCP was performed primarily for biliary drainage; a common hepatic duct (CHD) stricture and right hepatic duct dilation were found (Figure 2). Two 7 French 12 cm plastic stents were deployed across the common bile duct (CBD) stricture with their proximal end within the dilated right main hepatic duct. EUS showed a 2 cm lesion adjacent to the hilum that was invading the CHD and biliary bifurcation extending 1-2 cm distal and proximal to the bifurcation, portal, and hepatic artery. EUS-FNB demonstrated adenocarcinoma of jejunal origin based on cytokeratin markers (Figure 3). DISCUSSION: Specific diagnosis of periportal lesions involving the hilum of the liver is a limitation of cross-sectional imaging. EUS offers better visualization of the periportal region and enables tissue sampling for cytological or histological diagnosis. EUS-FNB has high sensitivity for diagnosis of lesions involving the common hepatic duct. It also enables assessment of vascular invasion and loco-regional staging, which is essential prior to therapy. Our case highlights, how EUS-FNB of a periportal lesion offered a specific diagnosis of metastatic colonic adenocarcinoma to the common hepatic duct. ERCP at the same session enabled biliary drainage that was essential prior to appropriate chemotherapy. The EUS FNB and ERCP with stent placement made a significant impact on the management of our patient.

1966 Jejunal Submucosal Hemangioma as a Cause of Massive Gastrointestinal Bleeding: A Case Report

INTRODUCTION: Small intestinal hemangiomas are uncommon tumors that usually present with gastrointestinal bleeding (GIB). Hemangiomas account for only 0.05% of all intestinal tumors. The most common location in the small intestine is the mid-jejunum. Diagnosis, detection, and treatment can be challenging and may require surgery. CASE DESCRIPTION/METHODS: An 81-year-old female presented to the emergency department with a one-week history of melena, associated with fatigue and palpitations. She denied hematemesis, hematochezia, NSAIDs use, or the use of anticoagulants or antiplatelet agents. Her vital signs were stable, and her physical examination was unremarkable except for lower limb edema. Hemoglobin was 4.7 g/dl, which was lower than her baseline of 8 g/dl. The patient was transfused to maintain her hemoglobin above 7 g/dl, and a proton pump inhibitor infusion was initiated. Esophagogastroduodenoscopy was performed, and benign-appearing and non-bleeding polyps were detected in the gastric fundus and body. Colonoscopy did not detect significant abnormalities other than moderate diverticulosis, internal hemorrhoids and old melenic liquid throughout the colon but no active bleeding. Due to continued blood transfusion requirements, a video capsule endoscopy was performed, and active bleeding was detected. Push enteroscopy was performed, and a polypoid nodule with central umbilication and red spot was detected in the proximal jejunum [Figure 1]. The lesion was biopsied, and post-biopsy bleeding developed. Hemostasis was achieved by injection of epinephrine (1:10000 concentration) and application of three hemoclips. Subsequently, the patient underwent a laparoscopic segmental jejunal resection. Histologic examination of the resected specimen demonstrated a jejunal submucosal hemangioma with surrounding hemorrhage, an organizing hematoma, and no evidence of dysplasia or malignancy. DISCUSSION: Submucosal hemangiomas are a rare cause of GIB. They can present with melena and severe anemia. As the most common site is mid-jejunum, it is difficult to detect submucosal hemangiomas. In this case, the lesion was detected by video capsule endoscopy and was reached by push enteroscopy. Surgery is usually required for a definitive diagnosis and definitive treatment.

2568 A Unique Case Presentation of Small Bowel Intussusception

INTRODUCTION: Intussusception is a life-threatening condition and can cause ischemia of the small intestine if not intervened promptly. When present in adults, intussusception typically is caused by a neoplasm, adhesions of the small bowel, or resultant of weight loss surgeries. Below we describe a unique intervention provided to a case presentation of intussesception. CASE DESCRIPTION/METHODS: 21 y.o. year old female with a past medical history of chronic abdominal pain, PTSD, suicide attempts, gender dysphoria, gastroesophageal reflux disease, depression, presented to the emergency department with secondary to abnormally low hemoglobin, abdominal pain, nausea and vomiting. She described pain in the epigastric abdominal region. She had no known family history of colon cancer, colonic polyps or other malignancies. She was noted to have a hemoglobin of 4.4 with no overt bleeding. She was tested negative for celiac serologies. She was evaluated with a CT scan of the abdomen and pelvis with IV contrast which showed long segment of proximal jejunal intussusception with associated inflammatory changes. The surgical team approached the gastroenterology team to attempt to reduce the intussusception prior to surgical resection. As a result of which a push enteroscopy was performed where in a normal esophagus, with erythematous mucosa in the gastric fundus and gastric body were seen. The duodenum was normal. An intussusception was encountered after the C-loop of the duodenum, around the proximal jejunum. This was reduced with the scope. A vascular appearing jejunal mass was seen. Biopsy was not attempted given the vascular appearance. A tattoo was applied. The patient subsequently underwent jejunal resection with small bowel anastomosis. The pathology of the mass resulted as benign hamartomatous polyp with surface erosion and no dysplasia. The patient's symptoms and anemia resolved post operatively. In addition she was evaluated with an upper endoscopy and flexible sigmoidoscopy previously which were within normal limits. DISCUSSION: Hamartomatous polyps of the small intestine can be associated with Cowden syndrome, Bannayan-Riley Ruvalcaba syndrome (BRRS), and juvenile polyposis syndrome (JPS). The above mentioned patient is unique as she does not meet criteria for any of these syndromes. In addition the emergent symptom relief was provided by endoscopic reduction of the intussusception providing the surgeons for a planned elective procedure rather than an emergent procedure.

3089 Orifice to Orifice Evaluation, in a Single Exam

INTRODUCTION: We present a case of a middle age Caucasian male with Peutz-Jeghers syndrome who underwent an antegrade double balloon enteroscopy (DBE) for surveillance of a known small bowel polyps. He has a history of right hemicolectomy for a large polyp and subsequent partial small bowel resection for intussusception of a jejunal polyp. He had a DBE a year ago which revealed several small bowel polyps, the larger ones requiring therapeutic intervention. We show a video demonstrating feasibility of complete entero-colonoscopy dictated by necessity. CASE DESCRIPTION/METHODS: A 55-year-old Caucasian male with Peutz-Jeghers syndrome presented for his surveillance antegrade DBE. He has history of right hemicolectomy &amp; partial jejunal resection due to intussusception deemed secondary to a large hamartomatous polyp. He has been getting EGD, Colonoscopy and antegrade DBE every 2 years given his history of multiple large hamartomatous polyps. His vital signs, physical examination and lab work were unremarkable. DISCUSSION: This patient underwent antegrade DBE with a therapeutic double-balloon enteroscope (Fujinon EN-450 T5) using push and pull maneuver, under general anesthesia and utilizing CO2 for insufflation. A stiffening device (Zutron medical) was used during portions of the procedure to help prevent loop formation. Around the distal jejunum, the stiffening device snapped within the biopsy channel at the boot of the insertion tube of the enteroscope. Given that a significant amount of time has been already invested in the procedure an attempt at reaching the anus was pursued with success. The stiffening device was pushed out of the channel using a biopsy forceps and the procedure was resumed. Multiple polyps (atleast 30) were observed in the small bowel ranging in size from 4-25 mm, some of which were oozing. The oozing polyps and those larger than 10 mm (total 6) were resected. The procedure was completed with no adverse events. The patient's oral cavity was cleaned using hydrogen peroxide swab before he was extubated and sent to recovery. The patient experienced no infection related complication, bleeding, perforation or pancreatitis. CONCLUSION: 1. It is feasible and safe to perform through and through entero-colonoscopy in specific scenarios. 2. Panendoscopy in one encounter may not always be achievable in patients without a history of bowel resection. 3. Advancing the enteroscopy outside the anus may be considered to clear an obstructed biopsy channel as an option to salvage a long procedure. Watch the video: http://bit.ly/2XTDKhY

Surgical management of 86 patients with duodenal injuries

Objective To study the early diagnosis, surgical treatment options, prevention and management of complications in patients with duodenal trauma. Methods All patients with duodenal trauma treated operatively from January 2009 to December 2018 were studied retrospectively. Factors including sex, age, cause of injury, AAST grading, diagnostic method, operative procedure, therapeutic effectiveness, complications, and factors related to death were analyzed. The technique consisting of duodenal decompression and jejunal feeding as recommend by the authors were used in severe cases. Results Blunt trauma occurred in 66 of 86 patients (76.7%). The diagnosis of duodenal trauma was made preoperatively based on abdominal signs, peritoneocentesis, and imaging in 32 patients (37.2%). The remaining 54 patients (62.8%), with duodenal injury was detected during emergency laparotomy. All the 86 patients underwent surgical intervention which included simple suturing, pedicled jejunal flap, segmental resection and anastomosis, Roux-en-Y duodenojejunostomy, diverticularization, and Whipple's procedure using the principle of Damage Control Surgery (DCS). Postoperative morbidity occurred in 15 patients (17.4%). There was a high incidence of duodenal (or pancreatic, biliary) fistulae. The overall mortality rate was 12.8% (in 11 patients). The causes of deaths were mainly massive bleeding and poly-trauma. Conclusions To decrease morbidity and mortality rates, early diagnosis and surgical intervention were critical. The choice of surgical treatment procedures should be based on the duodenal trauma grading and whether there were associated injuries. For patients with a combined pancreaticoduodenal trauma, DCS is a wise procedure to adopt. The double-tube gastrostomy technique as recommended by the authors is beneficial to severe cases in decreasing the incidences of postoperative duodenal and jejunal obstruction. Key words: Duodenum; Wounds and injuries; Digestive system surgical procedures; Decompression, Surgical; Enteral nutrition; Postoperative complications

Anticoagulation Therapy with Warfarin after Jejunal and Ileal Resection - A Case Report

Anticoagulation Therapy with Warfarin after Jejunal and Ileal Resection - A Case Report

Uncertain progress in Swiss perioperative mortality 1998-2014 for 22 operation groups.

The perioperative mortality rate (POMR) is used as a quality indicator to monitor health care system performance at regional and national levels. The Swiss Federal Office of Public Health publishes national in-hospital mortality rates for several indicator conditions and indicator operation types (IORs). We investigated long-term time trends of POMRs from 1998-2014. In view of continual advances in perioperative care, we expected to find decreasing trends. Non-cardiosurgical IORs containing aggregated age- and sex-specific data (number of operations and deaths) for all years of the study period were included to calculate age-standardised POMRs using the 2013 European Standard Population. We assessed calendar time trends of POMRs using multivariable Poisson regression. We categorised IORs according to the type of time trend (decreasing, unchanged, or increasing incident rate ratio) and mean risk levels (age-adjusted POMR). A total of 22 IORs were included, comprising 1,561,012 operations and 22,140 deaths (overall crude POMR 1.42%). POMR trends decreased for 6 IORs representing 26.8% of operations, remained unchanged for 13 IORs (56.9% of operations), and increased for 3 IORs (16.4% of operations). IOR categorisation according to POMR trends and to risk levels yielded four groups. (1) Decreasing POMR trends, low- to intermediate-risk IORs (age-adjusted POMR 0.2-2.2%): cholecystectomy; arterial pelvic/leg aneurysm or dissection operation; femoral neck fracture; trochanteric fractures; gastric, duodenal or jejunal ulcer resection; major pulmonary or bronchial resection. (2) Unchanged POMR trends, low-risk IORs (0.1-0.9%): transurethral resection of the prostate (TUR prostate); hernia repair without intestinal operation; hysterectomy; extracranial vascular operation; nephrectomy; amputation foot, non-traumatic. (3) Unchanged POMR trends, intermediate-risk IORs (1.7-3.8%): hernia repair with intestinal operation; gastric carcinoma resection; non-ruptured abdominal aortic aneurysm (open operation); arterial pelvic/leg thromboembolic operation; colorectal resection, pancreatic resection; complex oesophageal procedure. (4) Increasing POMR trends, low- to high-risk IORs (0.1-5.2%): hip endoprosthesis; cystectomy; amputation lower limb. Impact of sex on POMR: hysterectomy and TUR prostate comprised 19.7% of all operations; among the remaining operations, 68.5% showed significantly lower and 27.1% significantly higher POMRs in females. 4.4% showed no sex difference. In Switzerland, in-hospital POMR trends from 1998-2014 were unchanged or even increasing for the majority of IORs (73% of included operations). Our analysis used age-standardisation but cannot account for changes in coding practices and organisation of healthcare delivery. POMR trends should be systematically monitored at the national level and used to guide priorities in national quality improvement strategies.

GLP-1 mediated improvement of the glucose tolerance in the T2DM GK rat model after massive jejunal resection

ObjectiveThe aim of this study was to clarify the role of the middle gut in the entero-pancreatic axis modification that leads to glucose improvement in the Goto-Kakizaki (GK) rat as a non-obese T2DM model. BackgroundBariatric surgery is considered an assured solution for type 2 Diabetes (T2DM). Enterohormones such as ghrelin, gastric inhibitory polypeptide and mainly glucagon-like peptide-1 (GLP-1) were recognized as key players in the physiophathological mechanisms associated with entero-pancreatic axis regulation and glucose tolerance improvement. However, the influence of anatomical arrangements post-bariatric surgery on this axis is still debatable. MethodTo this purpose, 50% of small intestine resections were performed on GK rats (n = 6), preserving the proximal half of the jejunum and the ileum (IR50). Phenotypic and functional changes, such as performance in oral glucose tolerance tests, ileal release of GLP-1, beta-cell sensitivity to GLP-1, beta-cell mass, and turnover were characterized in IR50 and the surgical control group (Sham). ResultsThe glucose tolerance was improved and ileal release of GLP-1 was enhanced four weeks after IR50 versus the control group rats. Beta-cell mass, beta-cell proliferation, and beta-cell sensitivity to GLP-1 were also increased in the pancreas of IR50 versus the control group rats. Conclusionthe jejunal exclusion increases beta-cell-mass and improves glucose tolerance by increasing in GLP-1 expression and number of receptors via the entero-pancreatic axis.

Effect of length of Proximal Jejunal Resection on the Incidence of Delayed Gastric Emptying Following Pylorus Resecting Pancreaticoduodenectomy (PrPD), a Randomised Controlled Trial

Aim: To determine the role of length of proximal jejunal resection in the occurrence of Delayed Gastric Emptying following Pylorus resecting Pancreaticoduodenectomy (PrPD). Methods: Of the 137 patients enrolled, 97 patients were randomised to long segment (30cm) (n=46) and short segment(15cm)(n=51) proximal jejunal resection. Delayed Gastric Emptying (DGE) was defined as per ISPGS guidelines. Operative time, removal of NG tube, resumption of oral feed, morbidity, mortality and overall hospital stay was compared. Results: Both the groups were comparable in terms of demographic and operative data. The overall incidence of delayed gastric emptying in this study was 58.8% with long segment 47.8% and short segment 68.6% (p=0.010).Incidence of Clinically relevant delayed gastric emptying was lesser in the long segment group (21.7% vs 54.9%, P=0.001). The incidence of Primary delayed gastric emptying was significantly lower in long segment group (26.1% vs. 31.3%, P=0.029) and there was a trend towards fewer incidence of secondary delayed gastric emptying (21.7% vs. 37.2%, P=0.096). Patients in the long segment group had early removal of NG tube (5.13±4.39 vs. 8.28±5.59 days, P=0.046) and early resumption of solid diet (7.6±4.51 vs. 10.4±5.61 days P=0.011). The post-operative hospital stay was comparable in both groups. Other post-operative complications were comparable in both the groups. Conclusion: Resection of 30 cm of proximal jejunum decreases the incidence of delayed gastric emptying both primary and secondary. This translates into early removal of NG tube, and early resumption of oral feed.

Vascular anatomy of the jejunal mesentery and complications associated with division of the first jejunal venous trunk during pancreaticoduodenectomy

BACKGROUND Little is known about the anatomy of the jejunal veins (JVs) flowing into the superior mesenteric vein (SMV), and whether they can be safely divided during pancreaticoduodenectomy. METHODS Computed tomography was used to review the jejunal branches off the superior mesenteric artery (SMA) and into the SMV in 123 consecutive patients. The common trunk of the JVs (jejunal venous trunk, JVT) was classified as ventral or dorsal to the SMA. RESULTS The first JVT involved multiple JVs in 108 (87.8%) cases. The first JVT diameter (≥7 or <7 mm) was significantly associated with the number of JVs (≥4 or <4; P < 0.05). Surgical outcomes were not significantly different between cases in which the first JVT was sacrificed (n = 32) or preserved (n = 91), except for operation time and portal venous resection frequency. One of the 32 cases (3.1%) with first JVT sacrifice showed severe congestion of the jejunal limb requiring emergency jejunal resection. CONCLUSIONS The size and topology of the first JVT are associated with the number of JVs involved. This is important for understanding the resectional area of the mesojejunum and the pathogenesis of jejunal congestion.

Increase of survival and improvement of the prognosis with new therapies for the treatment of cystic fibrosis

Cystic fibrosis (CF) is the most prevalent autosomal recessive disease in Caucasians, resulting from a mutation of the gene located on the long arm of chromosome 7, which encodes the production of cystic fibrosis transmembrane conductance regulator (CFTR) protein, present in epithelia, which functions as a channel for the passage of chlorine and other ions. Clinically it presents multi-organ involvement; being more serious the pulmonary manifestation and prognostic determinant. Despite scientific advances, it remains an incurable disease, only with treatment to prevent and treat symptoms, until the appearance of therapies (genotype-dependent) such as the combined lumacaftor/ivacaftor, indicated in F508del homozygote patients above 12 years; aimed to correct the defect in CFTR, which could improve quality of life, prognosis and survival. Seven-year-old patient with CF diagnosis through positive neonatal screening: genotype F508del/F508del. During the perinatal period, she presented: intestinal perforation, meconium peritonitis, jejunal atresia: Appel-Peel, intervened (resection of jejunum and ileum), as well as malnutrition. At 7 years of age, presented recurrent pulmonary exacerbations despite the symptomatic treatment of inflammation, infection and fluidification of secretions of the respiratory system and pulmonary rehabilitation. In addition, she required nutrition by gastrotomy with a low weight gain due to malabsorption. In view of the poor clinical evolution, treatment with lumacaftor/ivacaftor is introduced, for compassionate use, being less than 12 years old. One year after treatment, it was observed an important decrease in the number of pulmonary exacerbations (from having 3 to 1 exacerbations/year), weight gain (BMI from 12.98 kg/m 2 to 14.52 kg/m 2 ), improvement in FEV 1 (from 54% to 65%) and quality of life. The new physiopathological treatments suppose a great hope in CF; in our patient they have decreased: the number of pulmonary exacerbations, improved lung function and quality of life. Even so, pulmonary rehabilitation remains one of the pillars of treatment for these patients.

Limited distal duodenal resection: Surgical approach and outcomes. A case series.

IntroductionTumours involving the duodenum are usually treated with pancreaticoduodenectomy, which may be associated with considerable morbidity. Limited distal duodenal resection, a relatively smaller procedure, can be done in some of these patients. We describe our experience with this operation for such lesions.MethodsWe retrospectively analyzed, from prospectively collected data 10 consecutive patients who underwent limited duodenal and proximal jejunal resection between March 2011 and Nov 2015.ResultsThere were 8 males and 2 females who had a median age of 47 years. Their common presentations were abdominal pain (50%) and upper gastrointestinal bleeding (40%). Five had malignancy (adenocarcinoma: 2, neuroendocrine tumours: 2, non Hodgkin's lymphoma 1). Three had gastrointestinal stromal tumours (GISTs) and 2 had other benign tumours (lipoma 1, ectopic pancreas 1). The 30-day post-operative morbidity rate was 60% (n = 6) with mostly minor complications (Clavien grade 1 or 2). Median post-operative stay was 9 (range, 6–13) days. All ten patients were alive without recurrence after a median follow up of 26.5 months.ConclusionLimited distal duodenal resection is a feasible surgical alternative to a pancreaticoduodenectomy in carefully selected patients with benign and some malignant tumours of the third and fourth part of the duodenum.

Surgical treatment and prognosis of Borrmann type IIII( gastric cancer involving the whole stomach

To explore the surgical treatment and prognosis of Borrmann type IIII( gastric cancer involving the whole stomach. Clinicopathological characteristics and survival data of 223 patients with Borrmann type IIII( gastric cancer involving the whole stomach (defined as the tumor infiltrating 3 regions of the stomach) receiving surgical treatment at the Department of Abdominal Surgery of Zhejiang Cancer Hospital between January 2002 and December 2015 were analyzed retrospectively. The survival time of patients with different clinicopathological features and different treatment methods was compared. Cox regression was used to analyze the independent prognostic factors. Two hundred and twenty-three patients with Borrmann type IIII( gastric cancer involving the whole stomach accounted for 24.0% (223/930) of all Borrmann type IIII( gastric cancer cases undergoing surgical resection at the same period. There were 147 males and 76 females with an average age of 57.8 years. All the patients underwent total gastrectomy. Of these patients, radical resection was performed in 149 cases(66.8%) and palliative resection in 74 cases (33.2%). Combined organ resection was performed in 43 patients (19.3%), including 25 splenectomies, 6 pancreatic body and tail plus spleen and transverse colon resections, 2 transverse colon plus spleen resections, 2 right colon resections, 2 transverse colon resections, 2 ovariectomies, 1 partial jejunal resection, 1 pancreatoduodenectomy, 1 pancreatic tail plus transverse colon resection, and 1 partial pancreatectomy. Postoperative complications occurred in 28 patients(12.6%), including 10 patients with combined organ resection. Esophagojejunal fistula was the most frequent complication, accounting for 39.3%(11/28). Perioperative mortality occurred in 3 patients (1.3%). Thirty-nine patients underwent preoperative adjuvant chemotherapy (clinical stage: cT4aN0M0 in 1 patient, cT4bN1-2M0 in 12 patients, cT4aN1-2M0 in 20 patients, and cT4aN3M0 in 6 patients). Among these 39 patients, post-chemotherapeutic degenerative response was detected in 25 postoperative pathological specimens (64.1%), radical resection was performed in 21 patients (53.8%), distant metastasis was observed in 7 patients (17.9%) and peritoneal metastasis was found in 17 patients (43.6%) during operation. The average maximal tumor diameter was 13.2 cm (range from 6 to 22). Histological types included 23 moderate-poorly differentiated adenocarcinomas (10.3%), 146 poorly differentiated adenocarcinomas (65.5%), 41 signet ring cell carcinomas (18.4%), 11 mucinous adenocarcinomas(4.9%), 1 squamous cell carcinoma (0.4%) and 1 undifferentiated carcinoma (0.4%). Tumor-infiltrating duodenum was found in 57 patients (25.6%) and tumor-infiltrating esophagus in 132 patients (59.2%). The positive margin was found in 66 patients (29.6%): upper margin in 35 patients (15.7%), lower margin in 22 patients (9.9%), and both margins in 9 patients(4.0%). Immunohistochemical positive HER2(3+) was detected in 4 patients (1.8%). Tumor infiltrating into serosa(T4a) was found in 197 patients (88.3%) and infiltrating into adjacent organ (T4b) in 26 patients(11.7%). One hundred and forty-three cases (64.1%) had lymphatic or venous invasion, 187 (83.9%) had neural invasion, and 35 (15.7%) had cancer nodules. Of 149 patients undergoing radical resection, 5 patients were stage II(b, 9 patients were III(a, 20 patients were III(b and 115 patients were III(c. Of 145 patients(65.0%) undergoing postoperative chemotherapy, the average cycles of chemotherapy was 3.6 (median 3 cycles) and only 69 patients (47.6%) completed 4 cycles or more. Patients were followed up for 1-102 months (average 17.3 months). The median overall survival time was 13.8 months and the 1-, 3-, and 5-year survival rate was 57.9%, 14.1% and 6.8% respectively. The median survival time of the 149 cases with radical resection was 16.7 months and the 1-, 3- and 5-year survival rate was 67.5%, 16.5% and 8.4% respectively; the median survival time of the 74 cases with palliative resection was 10.3 months and the 1-, 3- and 5-year survival rate was 42.6%, 8.5% and 1.7% respectively, whose differences were statistically significant (all P=0.000). Multivariate analysis showed that tumor staging (P=0.005), radical resection (P=0.009), lymphatic or venous invasion (P=0.017) and postoperative chemotherapy (P=0.001) were independent prognostic factors. Surgical treatment for Borrmann type IIII( gastric cancer involving the whole stomach is safe. Radical resection can improve the prognosis though the overall survival is poor.

Nasojejunal tube in the treatment of enterocutaneous fistula: A blessing in disguise

We present a patient who developed a jejunocutaneous fistula following jejunal resection, in whom a nasojejunal tube was placed with the tip distal to the fistula. Although the primary purpose of placing the tube was for feeding, the output from the fistula that was averaging 600 ml/day, stopped completely on the day after the tube was placed and the wound healed within 10 days. In this report, the role of a nasojejunal tube in functioning as an internal scaffold to facilitate closure of an enterocutaneous fistula is highlighted.

Surgical Management of Intestinal Tuberculosis in Preoperatively Unsuspected Cases at a Tertiary Care Hospital in Dhaka City

Background: Surgical management of intestinal tuberculosis is a crucial task in preoperatively unsuspected cases. Objective: The present study was undertaken to see the different surgical management of intestinal tuberculosis in preoperatively unsuspected cases. Methodology: This clinical trial was conducted in different units of the Department of Surgery at Dhaka Medical College Hospital, Dhaka from March 2002 to March 2004 for a period of two (2) years. Purposive sampling technique was applied to collect the study population. Patients with no suspicion about pulmonary as well as intestinal tuberculosis, history of cough & hemoptysis, no history of antitubercular drug taken, diagnosed as other than tuberculosis, per operative suspicion raised by any one or more of followings, enlarge lymph nodes in mesentery, omental masses, ileocaecal masses, suspicious growth in ileum, omental thickening, perforation suspected by tuberculosis were selected as study population. Biopsy was taken from suspicious lesions. Histopathology was confirmed the granulomatous lesion. Results: A total number of 300 patients were undergone surgical intervention of which 38(12.7%) cases. Maximum affected age group was 21 to 30 years which was 16(42%) cases. Granulomatous inflammation was found in 12(31.6%) cases. Maximum mode of presentation was in the form of emergency which was 36(94.7%) cases. Tissue was taken for biopsy from mesenteric lymph node in 16(42.10%) cases. Procedures done during laparotomy were resection of ileum and ileoileal anastomosis and proximal ileostomy which was performed in 6(23.07%) cases, resection of ileum and ileostomy in 5(19.23%) cases and resection of ileum with ileoileal anastomosis in 3(11.53%) cases. Conclusion: In conclusion surgical management is performed by resection of jejunum with jejunojejunal anastomosis, hemicolectomy with ileotrasverse anastomosis and resection of ileum with ileostomy.