Ligament Of Treitz Research Articles

Clinical Image-Superior Mesenteric Vein Syndrome

The patient was taken to the operating room and underwent diagnostic laparoscopy with laparoscopic mobilization of the right colon and the entire duodenum to the ligament of treitz. Intra-operatively, the patient was found to have extrinsic compression of the duodenum between the inferior vena cava (IVC) and the superior mesenteric vein (SMV).

Magnified endoscopic imaging of a Peutz-Jeghers-type polyp in the jejunum

A 69-year-old female was diagnosed with anemia. She underwent esophagogastroduodenoscopy (EGDs) and colonoscopy because of a positive fecal occult blood test; however, no abnormalities were observed. Capsule endoscopy (CE) showed a protruding lesion in the upper jejunum, and small bowel fluoroscopy showed that the lesion was located at the anal side of the Treitz ligament (Fig. 1a). We considered the tumor as the cause of anemia. Because regular EGD was unable to reach the lesion, endoscopic examination was performed using a magnifying colonoscope (PCF-Q260AZI; Olympus, Tokyo, Japan) and a 30 mm, reddish, protruding, lobular-like tumor was observed (Fig.

Guidelines for Non-variceal Upper Gastrointestinal Bleeding

Non-variceal upper gastrointestinal bleeding (NVUGIB) refers to bleeding that develops in the gastrointestinal tract proximal to the ligament of Treitz. NVUGIB is an important cause for visiting the hospital and is associated with significant morbidity and mortality. Although European and Asian-Pacific guidelines have been published, there has been no previous guidelines regarding management of NVUGIB in Korea. Korea is a country with a high prevalence of Helicobacter pylori infection and patients have easy accessibility to receive endoscopy. Therefore, we believe that guidelines regarding management of NVUGIB are mandatory. The Korean Society of Gastroenterology reviewed recent evidence and recommends practical management guidelines on NVUGIB in Korea.

Types and site distributions of intestinal injuries in seat belt syndrome

Objective Intestinal injuries in seat belt syndrome are relatively uncommon but can be potentially lethal due to accompanying peritonitis and hemorrhaging. It can be difficult to identify the exact injury sites of the intestine as multiple areas are often damaged and massive intraperitoneal hemorrhaging may make it challenging to determine causal bleeding points of mesenteric injuries. This study aimed to clarify the incidence and distribution of intestinal injuries in seat belt syndrome. Methods We retrospectively reviewed the clinical records of 25 patients who underwent laparotomy for suspected intestinal injuries due to seat belt syndrome during a frontal impact. The incidence and distribution of the sites of intestinal injuries, as well as associated injuries, were investigated. Intestinal injuries were divided into bowel and mesenteric injuries. Additionally, bowel injuries were classified into two types: perforation and non-perforation (seromuscular tears/intramural hematomas). Regarding the injured sites, the small intestine was divided into the following three parts: (1) the ligament of Treitz (100-cm distal from the ligament [proximal jejunum]), (2) the ileocecal valve (100-cm proximal from the valve [distal ileum]), and (3) the intermediate area between those two regions (jejunoileal junction). Results In total, there were 64 major injuries among 25 patients requiring surgical intervention: 34 bowel injuries (20 perforations and 14 non-perforations) and 30 mesenteric injuries. Significantly more bowel perforations occurred in the small intestine (1 [interquartile range (IQR), 0–1]) than in the large intestine (0 [IQR, 0–0]) (p = 0.003). Similarly, significantly more mesenteric injuries occurred in the small intestine (1 [IQR, 0–1.25]) than in the large intestine (0 [IQR, 0–0]) (p < 0.001). Specific sites of the mesenteric injuries in the small intestine included the jejunoileal junction (0 [IQR, 0–1]) and distal ileum (0 [IQR, 0–1]); the jejunoileal junction was significantly more vulnerable than the proximal jejunum (0 [IQR, 0–0]) (p = 0.015). Conclusions In patients with seat belt syndrome, the small intestine was more vulnerable to perforation and mesenteric injury than the large intestine. Additionally, for mesenteric injuries, the jejunoileal junction was more likely to be damaged than the proximal jejunum.

Small bowel stenosis after blunt abdominal trauma: a case report

BackgroundSmall bowel stenosis after blunt abdominal trauma is relatively rare, and progression from trauma to bowel stenosis might sometimes be delayed. Herein, we report the case of a patient who was diagnosed with small bowel stenosis relatively early and received laparoscopic surgery.Case presentationAn 18-year-old Japanese male was in a traffic accident and was urgently transported to our hospital. On arrival, he was admitted with right kidney and right adrenal injury and abdominal aortic aneurysm. On hospital day 13, he vomited during conservative treatment without surgery, and computed tomography revealed small bowel stenosis and dilatation of the oral-side small bowel. No improvement with the ileus tube occurred, and he received laparoscopic surgery on hospital day 21. Briefly, the abdominal cavity was observed with a laparoscope. The mesentery was congested, scarring around the stenotic small bowel regions was present, and three stenotic regions were observed 40–50 cm from the Treitz ligament. The patient received partial resection and anastomosis of the small bowel. The postoperative course was stable, and he was discharged on postoperative day eight.ConclusionsMost cases of bowel stenosis after abdominal trauma are irreversible and usually require surgical treatment. Therefore, small bowel stenosis should be considered in patients with abdominal symptoms after blunt abdominal trauma.

Ligament of Treitz Release With Duodenal Lowering for Pediatric Superior Mesenteric Artery Syndrome

BackgroundOperative approaches for superior mesenteric artery syndrome (SMAS) vary from Roux-en-Y duodenojejunostomy to the more conservative division of the ligament of Treitz with inferior duodenal derotation known as the Strong procedure. We sought to examine outcomes following a modified version of Strong procedure where the duodenum is lowered as opposed to derotated for the management of SMAS. Materials and methodsWe conducted a retrospective chart review of children who underwent surgical management of SMAS between January 2008 and December 2017. An online survey regarding symptom resolution, feeding practices, and the need for additional procedures was distributed. Data are reported as medians with interquartile range (IQR) and proportions as percentages. ResultsSeven patients with a median age of 15 y (IQR 8, 16) and median body mass index of 16.9 (IQR, 12.6, 22.1) were included. Presenting symptoms included pain (71%), nausea (57%), and vomiting (43%). Six patients initially underwent duodenal lowering, whereas one patient underwent duodenoduodenostomy. One patient underwent adhesiolysis for bowel obstruction in the early postoperative period. All patients had symptom resolution at a postoperative follow-up of 22 d (IQR, 15, 45). Two patients had symptom recurrence, and one patient required reoperation. Six patients completed the survey at a median of 2.3 y (IQR, 1.7, 3.2) postoperatively, of which four underwent duodenal lowering. Of these, 75% (n = 3) were asymptomatic. One patient with recurrence reported occasional nausea and emesis but has not required additional surgery. ConclusionsRelease of the ligament of Treitz with duodenal lowering results in resolution of symptoms in 75% of patients. This operative approach may be considered before performing more complex operations for SMAS.

Motorised spiral enteroscopy: first prospective clinical feasibility study

ObjectiveCurrently available methods for small bowel endoscopy are often time consuming; motorised PowerSpiral Enteroscopy (PSE) is a further development of spiral enteroscopy to facilitate the approach to the small bowel....

Obstruction After Laparoscopic Roux-en-Y Gastric Bypass: Roux Obstruction and Biliopancreatic Gangrene up to Ligament of Treitz.

Obstruction after laparoscopic Roux-en-Y gastric bypass (LRYGB) is a known complication. We present a video of a patient who suffered both early Roux limb obstruction, and late Petersen's hernia with proximal biliopancreatic limb volvulus and gangrene up to the ligament of Treitz, and how both were managed.

Случай дистальной резекции поджелудочной железы совместно со спленэктомией при оперативном вмешательстве по поводу прорастающей в поджелудочную железу опухоли поперечной ободочной кишки

The article presents a case of successful distal resection of the pancreas together with splenectomy during surgery for a tumor of the transverse colon growing into the pancreas in an elderly patient. The main complications after pancreatic surgery are postoperative pancreatic fistulas, in which there is a risk of septic complications, arrosive bleeding, increased length of stay of patients in hospital and increased mortality [1, 12]. The novelty of the proposed invention, lies in the fact that: pancreatojejunoanastomosis is formed at a distance of 30 cm from the Treitz ligament, then enteroenteroanastomosis is formed between the adducting and diverting loops of the small intestine in the type of side – to-side two rows of sutures, the length of the anastomosis is 4 cm, at a distance of 50 cm from the Treitz ligament, to improve the passage of intestinal chime [2]. This method can be implemented in the practice of surgical hospitals.

Prevention of Reflux Disease After Operations On Gastric And Intestinal Tract

Creating anastomoses between the hollow organs of the abdominal cavity, abdominal formations of the retroperitoneal space and the jejunum always raises the question of preventing reflux from the jejunum into the drained cavity of the esophagus, stomach, gallbladder, external hepatic ducts, cysts of the liver and pancreas. After surgery, any reflux becomes pathological. Reflux is an obligate precancer. Thus, the reflux of bile and pancreatic juices in the stomach, the stump of the stomach and esophagus contributes to the occurrence of reflux esophagitis, reflux gastritis, ulcers and gastric cancer or its stump. After internal drainage of the cavity formation in the jejunum, postoperative reflux disease develops, which is caused by the actions of the surgeon who tried to help the patient sincerely. This allowed such states to be defined as “iatrogenic postoperative reflux disease”. The purpose of this work was to develop and introduce into practice the “plug” on the resulting loop of the jejunum, which does not migrate into the lumen of the intestine, with internal drainage of the hollow organs of the abdominal cavity and abdominal formations of the retroperitoneal space and evaluate the clinical results. As a result, the authors have developed a method for creating a “plug” on the jejunum loop, which is used for drainage, studies are being conducted on its safety, adequacy of functioning, general accessibility, and clinical situations are analyzed. For drainage of the abdominal formation impose a fistula between it and the jejunum loop 40–50 cm from the ligament of Treitz. We form an inter-intestinal fistula according to Brown, above which the length leading to a drained formation of the area of ​​the jejunum is about 10 cm, in the middle of which we impose a “plug”. The length of the small intestine section which diverts from the drained formation to the inter-intestinal brown anastomosis is about 30 cm. To form a “plug”, we use the free area of ​​the greater omentum, through which we perform a ligature of non-absorbable polypropylene material by vcol-vykola. The developed method of forming a "plug" does not cause abrupt ischemic changes in the area of ​​operation, followed by necrosis of the intestinal wall and migration of the "plug" into the intestinal lumen, and its effectiveness has been proven using clinical observations, microcirculation studies, water test results and X-ray examination. The method of creating a "stub" is promising for the internal drainage of abdominal cavity formations and retroperitoneal space, for the formation of areflux nutrient eunostoma.

In Vivo Small Bowel Length is Longer than in Formalin-Fixed Cadavers

SBL was measured prospectively in 167 formalin-fixed cadavers; and studied in 118 without intestinal surgery. A standardized and reproducible method of small bowel measurement was utilized in both <em>in vivo</em> and cadaveric subjects. Small bowel was measured in situ from the Ligament of Treitz to the ileocecal valve. These measurements were compared to previously published cadaveric and <em>in vivo</em> human SBL data. The number of cadavers examined was larger than in other published studies; the number of <em>in vivo</em> subjects was also the highest yet reported.

Endoscopic advances in the management of non-variceal upper gastrointestinal bleeding: A review.

Upper gastrointestinal bleeding is defined as the bleeding originating from the esophagus to the ligament of Treitz and further classified into variceal and non-variceal gastrointestinal bleeding. Non-variceal upper gastrointestinal bleeding remains a common clinical problem globally. It is associated with high mortality, morbidity, and cost of the health care system. Despite the continuous improvement of therapeutic endoscopy, the 30-d readmission rate secondary to rebleeding and associated mortality is an ongoing issue. Available Food and Drug Administration approved traditional or conventional therapeutic endoscopic modalities includes epinephrine injection, argon plasma coagulation, heater probe, and placement of through the scope clip, which can be used alone or in combination to decrease the risk of rebleeding. Recently, more attention has been paid to the novel advanced endoscopic devices for primary treatment of the bleeding lesion and as a secondary measure when conventional therapies fail to achieve hemostasis. This review highlights emerging endoscopic modalities used in the management of non-variceal upper gastrointestinal related bleeding such as over-the-scope clip, Coagrasper, hemostatic sprays, radiofrequency ablation, cryotherapy, endoscopic suturing devices, and endoscopic ultrasound-guided angiotherapy. In this review article, we will also discuss the technical aspects of the common procedures, outcomes in terms of safety and efficacy, and their advantages and limitations in the setting of non-variceal upper gastrointestinal bleeding.

From Paris to Montreal: disease regression is common during long term follow-up of paediatric Crohn’s disease

Introduction: Paediatric Crohn’s disease (PCD) often presents with extensive and a frequent pan-enteric phenotype at onset. However, its long term evolution into adulthood, especially since the widespread use of biological agents, is not well characterised. We conducted a single centre cohort study of all PCD patients transitioned to adult care to assess the long term disease evolution in the era of biologic therapy.Methods: We conducted a retrospective observational, study of all PCD patients who were subsequently transferred to the care of an adult gastroenterology unit and had a minimum follow up of 2 years. We examined the case notes for evolution of disease location and behaviour. Disease location and behaviour was characterised using Paris classification at diagnosis and Montreal classification at last follow-up. In addition, we examined variables associated with complicated disease behaviour and the need for CD related intestinal resection.Results: In total, 132 patients were included with a median age at diagnosis of 13 (IQR 11–14) and a median follow up of 11 years (range 4–14). At diagnosis, 23 (17.4%), 39 (29.6%) and 70 (53%) patients had ileal, colonic and ileocolonic disease respectively. In addition, 31 (23.5%) patients had L4a or L4b disease at diagnosis (proximal or distal to the ligament of treitz respectively) and 13 patients (9.8%) had both whilst 27 (20.4%) patients had perianal disease. At diagnosis, 27 (20.4%) patients had complicated disease behaviour but 83 (62.9)% of patients had an extensive ‘pan-enteric’ phenotype. Of these patients only 55 (66.3%) retained the pan-enteric phenotype at last follow-up (p = .0002). Disease extension was noted in 25 (18.9%) of patients and regression was noted in 47 (35.6%) of patients, whereas upper GI disease was noted in significantly fewer patients at last follow-up (21, 15.9%) (p = .0001). More patients had complicated disease behaviour (46 patients, 34.9%, p = .0018) at last follow-up. There was a high exposure to both thiopurines 121 (91.7%) and biologics 84 (63.6%). The cumulative probability (95% CI) of surgery was 0.05 (0.02, 0.11) at 1 year, 0.17 (0.11, 0.24) at 3 years and 0.22 (0.15, 0.30) at 5 years. Neither disease location nor behaviour were associated with the need for intestinal resectional surgery.Conclusions: Over the course of an extended follow-up period, there appeared to be changes in both disease location and behaviour in PCD. Interestingly, a significant proportion of patients had disease involution which may be related to a high rate of exposure to thiopurines and biologics. We were unable to identify any variables associated with complicated disease course or the need for intestinal surgery.

Ileal Transposition Increases Pancreatic β Cell Mass and Decreases β Cell Senescence in Diet-Induced Obese Rats.

Ileal transposition (IT) is a surgical procedure to investigate the role of the distal small intestine in metabolic improvements induced by bariatric/metabolic surgery, which has been applied to some human cases. We performed IT in diet-induced obese rats to investigate the effect of IT on glucose metabolism and β cell senescence. Sprague-Dawley rats were fed high-fat diet (60% of total calories from fat) for 12weeks and randomized into either IT or sham surgery. In the IT group, the distal ileal segment located between 5 and 15cm proximal to the ileocecal valve was transposed 10cm distal to the Treitz ligament isoperistaltically. In the sham surgery group, 3 corresponding transections of the intestine were made at the same locations as in IT and reattached in situ. β cell senescence was examined by the expression of two markers in vivo, p53BP1 and p16. IT did not have a significant effect on body weight and insulin sensitivity, but postprandial insulin secretion was significantly increased. Glucagon-like peptide-1 (GLP-1) and peptide YY secretion were also increased after IT. The histology of the transposed ileum showed distinct hypertrophy with increased GLP-1 positive enteroendocrine cells. Pancreatic β cell area was significantly increased in the IT group. The percentage of p16 or p53BP1 positive senescent β cells was significantly lower in the IT group versus the sham group. IT improved glucose tolerance in diet-induced obese rats mainly through augmented insulin secretion. This improvement was associated with attenuated β cell senescence.

Robotic Pancreaticoduodenectomy After Unsuspected Double Perforation (Bile Duct And Portal Vein) During Endoscopic Biliary Stent Placement

Presenter: Fabio Makdissi MD | Hospital Nove de Julho Background: Endoscopic placement of biliary stent (ERCP) is a common procedure used in malignant jaundice patients. However, sometimes the cannulation of the bile duct fails, and an alternative is to perform a choledochoduodenal fistula (infundibulotomy) to access the biliary tract and place a biliary stent. We present a robotic pancreaticoduodenectomy performed after a complicated ERCP that required emergency laparotomy for drainage. The initial diagnosis was duodenal perforation. During the definitive operation, an unsuspected double perforation (bile duct and portal vein) was found and successfully treated. Methods: A 57-year-old woman presented with progressive jaundice. ERCP disclosed a 2-cm tumor in the ampulla but cannulation of the biliary duct through the papilla failed. A choledochoduodenal fistula (infundibulotomy) was performed. A plastic endoprosthesis was inserted. Immediate after this procedure, patient developed diffuse peritonitis, leading to emergency laparotomy. Duodenal perforation was suspected but perforation site was not identified. Drain was placed. Drainage ceased after 3 weeks, drain was removed, and patient was transferred to our care. Multidisciplinary team decided for upfront pancreaticoduodenectomy. Robotic approach was proposed, and consent was obtained. Da Vinci Xi robotic system was used. Operation begins with division of adhesions from previous operation. The Kocher maneuver is performed and the ligament of Treitz is mobilized. The proximal jejunum is passed behind the mesenteric vessels and divided with stapler. The duodenum is divided with stapler 2 centimeters below the pylorus. The gastroduodenal artery is dissected, ligated and divided between hemolocks. The common bile duct is divided with robotic scissors; however, the biliary stent is not found in the common bile duct. We suspected that it has migrated distally. Pancreas is divided with harmonic shears until identification of the pancreatic duct which is divided with scissors. Pancreatic head and uncinate process are carefully dissected from the portal vein and from the superior mesenteric artery. When the surgical specimen was only attached by a large branch from portal vein, this branch was dissected for hemolock insertion. However, hemolock insertion failed due to tissue resistance. We then realize that the missing biliary stent was, in fact, inside this portal branch and extended into the main portal vein. This branch is encircled and opened with identification of the biliary stent. Portal vein branch was clamped for safe removal of the biliary stent with minimum loss of blood. Reconstruction of the alimentary tract was then performed as usual. Surgical specimen is removed through extension of auxiliary port incision. Abdominal cavity is drained, and procedure is completed. Results: Total operative time was 6 hours and 38 minutes. Estimated blood loss was 320 mL, with no need of transfusion. Recovery was uneventful and patient was discharged on the 7th postoperative day. Pathology confirmed ampulla of Vater adenocarcinoma T2N0M0. Patient is well with no signs of disease, 4 months after operation. Conclusion: Robotic pancreaticoduodenectomy is safe and feasible even after ERCP complications that required laparotomy. Absence of endoprosthesis in the common bile duct may arise suspicion of wrongful insertion towards adjacent organs and must be dealt with caution.

One-anastomosis gastric bypass with a short limb

To develop an acceptable method of surgical treatment of patients with obesity grade 1 and 2 in accordance with the following criteria: high safety, no risk or minimal risk of intestinal malabsorption, no limitations for postoperative gastrointestinal examination, no need for organ resection and surgical reversibility in case of necessity. In accordance with the above-mentioned criteria, we have modified OAGB (one-anastomosis gastric bypass). A gastric tube was formed from a lesser curvature using 33Fr stomach catheter with a length of at least 25 cm. Manual retrogastric retrocolic anastomosis in «end-to-side» fashion was performed within 20 cm from the ligament of Treitz. This type of anastomosis made it possible to preserve gastric tube length as much as possible that reduces the risk of jejunogastroesophageal reflux. There were 16 patients (15 females and 1 male) aged 23-48 years for the period from June 2019 till March 2020. Mean weight of patients was 86.12 kg (range 62-124). Mean BMI was 35.15 kg/m2 (ranged 21.96-39.62). In 6 months after surgery, all patients achieved normal BMI. Man BMI dropped to 23.8 kg/m2. Minimal excessive weight loss was 81.8%, maximal excessive weight loss - 125%. Control esophagogastroduodenoscopy was performed in 5 patients after 6 months and later. During retrograde duodenoscopy, we visualized major duodenal papilla in all cases using a flexible endoscope with standard optic system. The proposed modification of one-anastomosis gastric bypass with a short limb is a safe and effective procedure in bariatric surgery. This surgery ensures postoperative diagnostic and therapeutic endoscopic procedures in all parts of stomach and duodenum. This method could be recommended for surgical treatment of patients with obesity grade 1 and 2 after additional clinical trials and analysis of long-term results.

Jejunal perforation by fishbone

Foreign body ingestion is a common presentation in clinical practice. Although most ingested foreign bodies pass uneventfully across the gastrointestinal tract, sharp elongated objects pose a greater risk of intestinal perforation. We report here a case of jejunal perforation following the ingestion of fishbone. A 78-year-old female presented with acute onset of generalised abdominal pain for few hours. Examination revealed tenderness, guarding and rigidity all over the abdomen. Erect Abdominal X-ray findings were inconclusive. However, contrast-enhanced computed tomography (CT) showed a thin, linear hyperdense foreign body perforating through the jejunum. Exploratory laparotomy was done, and a fishbone piercing the small bowel 50 cm distal to the ligament of Treitz was retrieved. The perforation hole was closed with primary suture. Postoperatively, the patient recovered well. Small bowel perforation is a life-threatening emergency that necessities urgent surgical intervention. Fishbones are commonly associated with perforations and the most common site of perforation is the terminal ileum. The most important risk factor associated with intestinal perforation by fishbones is the use of dentures which impair protective sensory mechanisms. Clinical presentation can be non-specific, and contrast-enhanced CT is required to establish diagnosis. Intestinal perforation associated with foreign body ingestion should be considered when evaluating patients with acute abdomen.

A Case of Primary Jejunal Cancer Located Near the Treitz Ligament Treated by Laparoscopic-Assisted Partial Small Bowel Resection

A Case of Primary Jejunal Cancer Located Near the Treitz Ligament Treated by Laparoscopic-Assisted Partial Small Bowel Resection

Superior mesenteric artery syndrome: a case report and a novel surgical approach

Background: Superior mesenteric artery syndrome (SMAS) is a rare cause of duodenal obstruction that has non-specific and insidious symptoms. An initial treatment is conservative, and surgery is reserved for patients who continuously present with symptoms or complications. The aim of this study is to describe a combination of two surgical techniques: duodenojejunostomy and Strong\&amp;apos;s procedure (the release of the Treitz ligament) through a laparoscopic approach. This combination of both techniques has already been described, however, with a lack of technical detail. Case Presentation: This report presents the case of a 19-year-old male diagnosed with SMAS, confirmed through computed tomography and angiographic magnetic resonance imaging of the abdomen. He underwent a laparoscopic duodenojejunostomy and release of the Treitz\&amp;apos;s ligament. The patient recovered well with no complications and was discharged 5 days postoperatively. Conclusion: Due to the rarity of the disease, there is a lack of literature comparing the benefits of either of these two techniques, and also, there are no established protocols favoring the use of one procedure over the other. In this case, we combined both techniques to reduce the rate of recurrence, increase the anastomotic safety, and reduce long-term complications. However, a larger study would be necessary to establish the combined use of these two techniques.

Heterotopic Gastric Mucosa Presenting as Lower Gastrointestinal Bleeding: An Unusual Case Report

Heterotopic gastric mucosa (HGM) is gastric mucosal tissue outside the stomach. It can be discovered anywhere throughout the gastrointestinal tract and is mostly asymptomatic. HGM, although rare beyond the ligament of Treitz, should be included in the differential diagnosis in a young patient with a polyp causing obstructive symptoms or bleeding. Very few cases are published in literature. We describe a case of young male who presented with an episode of large amount of melena, from a bleeding jejunal lesion, diagnosed by endoscopy. Laparotomy and wedge resection of the jejunal lesion was done, and histopathology showed gastric heterotopia in a small jejunal diverticulum.