Mesenteric Root Research Articles

What Lies Beneath: A Case of Mesenteric Panniculitis Masquerading as Recurrent Acute Pancreatitis

Introduction: Mesenteric panniculitis is a rare inflammatory condition characterized by chronic and nonspecific inflammation of the adipose tissue of the intestinal mesentery. Here, we describe a case of mesenteric panniculitis in a patient with recurrent pancreatitis presenting with abdominal pain. To our knowledge, there is scant available literature regarding the association of mesenteric panniculitis and recurrent acute pancreatitis. Case Presentation: A 27-year-old female with past medical history of familial hypertriglyceridemia and recurrent acute pancreatitis presented with a 3-day history of severe epigastric abdominal pain radiating to her upper back with intermittent bilious vomiting. On admission her lipase level was within normal limits and triglyceride level was 1,500 mg/dL. A right upper quadrant ultrasound revealed mild gallbladder wall thickening. Computed tomography scan of the abdomen with IV contrast showed no clear signs of pancreatitis. However, it demonstrated mild stranding of the mesenteric root with several prominent lymph nodes consistent with mesenteric panniculitis (figure 1). During hospitalization her autoimmune workup was negative with IgG subclasses within normal limits. An EGD was performed and only notable for mild duodenitis. The patient had resolution of her symptoms with IV fluid hydration and PPI therapy, and she was discharged on optimal hypertriglyceride therapy.Figure 1Discussion: Mesenteric panniculitis is a rare condition. There is currently a paucity of data regarding this condition. The etiology of this disease remains unknown but has been associated with abdominal trauma, abdominal surgery, infection, autoimmune diseases, paraneoplastic syndromes, or ischemic processes. This case highlights the critical importance of early recognition in order mitigate the possibility of poor outcomes. It is crucial for gastroenterologists to be aware of such etiologies of abdominal pain when evaluating patient who present with otherwise typical symptoms presumptive of pancreatitis.

Whole-body diffusion-weighted magnetic resonance imaging in the diagnosis of recurrent ovarian cancer: a clinical feasibility study.

To assess the clinical feasibility of whole-body diffusion-weighted MRI (WB-DWI/MRI) for diagnosis and prediction of complete tumour resection in patients with suspected recurrent ovarian cancer. 51 females clinically suspected for ovarian cancer recurrence underwent 3-T WB-DWI/MRI in addition to contrast-enhanced CT. WB-DWI/MRI was assessed for detection of tumour recurrence, prediction of tumour extent and complete resection compared with CT. Tumour presence was confirmed by pathology obtained by surgery or biopsy, or by imaging follow-up. WB-DWI/MRI showed 94% accuracy for detecting ovarian cancer recurrence, compared with 78% for CT (p = 0.008). WB-DWI/MRI showed better sensitivity [% (95% confidence interval)] than CT for detecting involvement of surgically critical tumour sites including mesenteric root infiltration [92 (62-100) vs 31 (10-61)], small bowel [93 (64-100) vs 21 (6-51)], colon carcinomatosis [91 (57-100) vs 27 (7-61)] and unresectable distant metastases [90 (54-99) vs 20 (4-56)]. WB-DWI/MRI correctly predicted complete resection in 33 of 35 (94%) patients eligible for salvage surgery compared with 17 of 35 (49%) for CT (p < 0.001). WB-DWI/MRI allowed better detection of ovarian cancer recurrence and better prediction of complete resection than CT. Advances in knowledge: WB-DWI/MRI could assist in optimizing treatment planning for recurrent ovarian cancer, particularly by improving patient selection for salvage surgery, thus giving eligible patients the highest chance on prolonged survival and refraining patients who would not benefit from extensive surgery reducing related morbidity and mortality.

Characteristics and risk factors of lymph node metastasis in colorectal neuroendocrine neoplasm

Objective To investigate the features and risk factors associated with lymph node metastasis in colorectal neuroendocrine neoplasm. Methods Clinical and pathological data of 99 patients with colorectal neuroendocrine neoplasm treated between January 2009 to January 2015 were analyzed retrospectively. Comparisons of categorical data and univariate analysis of risk factors of lymph node metastasis were conducted. Results Of the 99 patients, the rate of regional lymph node metastasis was 30.3% (30/99) with 56.7% limited to para-intestinal lymph nodes in 17 cases, 26.7% limited to mesenteric lymph nodes in 8 cases, and 16.7% limited to mesenteric root central lymph nodes in 5 cases. No metastasis exceeding central lymph nodes was observed. Multivariate regression analysis revealed that tumor size, invasion of lymphatic vessel and pathological grading were independent risk factors for lymph node metastasis in colorectal neuroendocrine neoplasm (P<0.05). Conclusions Colorectal neuroendocrine neoplasm with larger tumor size, invasion of lymphatic vessel or higher grade (G2, G3) has high risk of regional lymph node metastasis. Key words: Colorectal neoplasms; Carcinoma, neuroendocrine; Lymphatic metastasis

Manual Lymph Drainage and Fascial Release for the Treatment of Chylous Ascites Following Radical Nephrectomy: A Case Report

Background: Chylous ascites is “a rare complication of retroperitoneal and mediastinal surgery caused by the unrecognized interruption of major retroperitoneal lymphatic channels and establishment of a lymphoperitoneal fistula.” Chylous ascites occurs 1% to 2% of the time and typically only after surgical injury to the retroperitoneal lymph glands, vessels, or cysterna chyle. Risk factors include manipulation of the para-aortic and superior mesenteric artery root areas, retroperitoneal invasion, focal chronic pancreatitis, having more than 32 lymph nodes removed, several positive lymph nodes, and early enteral feeding. Case Description: Six weeks postradical nephrectomy with complete lymphadenectomy of the periaortic nodes, a 60-year-old otherwise healthy, independent woman was found to have a high-volume chylous ascites. The leakage was attempted to be controlled by a low-fat diet, but she still required 4 paracentesis procedures to remove chylous fluid from her abdomen. Total parenteral nutrition was advised, and the patient declined and referred herself to physical therapy. Other than diet restrictions, she was active and had no functional deficits. Clinical Impression: It had been 6 months since her nephrectomy with lymphadenectomy, it was probable that there was fascial restriction that was preventing closure of the lymphatic vessel wound and allowing chyle to continually leak into the abdomen. Intervention: The chylous ascites was addressed by physical therapy with manual lymph drainage to facilitate the evacuation of fluid out of the abdomen plus fascial releases to mobilize adhesions that may have been impacting the healing of the deep abdominal lymphatic vessels. Measurements and Results: Upon initial examination, her abdomen measured 102 cm at the umbilicus and had multiple large pockets of fluid on the ultrasound scan. On her fourth visit 16 days later, her abdomen measured 81 cm with no appreciable pockets of fluid noted. An 8-week follow-up visit revealed no return of fluid in the abdomen. She was able to return to a normal diet. Discussion: Further research is warranted to determine if fascial release and manual lymph drainage is a viable treatment of chylous ascites.

Harvest tissue source does not alter the protective power of stromal cell therapy after intestinal ischemia and reperfusion injury

BackgroundTransplantation of mesenchymal stromal cells (MSCs) may be a novel treatment for intestinal ischemia. The optimal stromal cell source that could yield maximal protection after injury, however, has not been identified. We hypothesized that (1) MSCs would increase survival and mesenteric perfusion, preserve intestinal histologic architecture, and limit inflammation after intestinal ischemia and reperfusion (I/R) injury, and (2) MSCs harvested from different sources of tissue would have equivalent protective properties to the intestine after I/R inury. MethodsAdult male mice were anesthetized, and a midline laparotomy was performed. The intestines were eviscerated, the small bowel mesenteric root was identified, and baseline intestinal perfusion was determined using laser Doppler imaging. Intestinal ischemia was established by temporarily occluding the superior mesenteric artery for 60 min with a noncrushing clamp. After ischemia, the clamp was removed and the intestines were allowed to recover. Before abdominal closure, 2 × 106 human umbilical cord–derived MSCs, bone marrow–derived MSCs, or keratinocytes in 250 μL of phosphate-buffered saline vehicle were injected into the peritoneum. Animals were allowed to recover for 12 or 24 h (perfusion, histology, and inflammatory studies) or 7 d (survival studies). Survival data was analyzed using the log-rank test. Perfusion was expressed as a percentage of the baseline, and 12- and 24-h data was analyzed using one-way analysis of variance and the Student t-test. Nonparametric data was compared using the Mann–Whitney U-test. A P value of <0.05 was considered statistically significant. ResultsAll MSCs increased 7-d survival after I/R injury and were superior to vehicle and keratinocytes (P < 0.05). All MSCs increased mesenteric perfusion more than vehicle at 12 and 24 h after injury (P < 0.05). All MSCs provided superior perfusion compared with keratinocytes at 24 h after injury (P < 0.05). Administration of each MSC line improved intestinal histology after I/R injury (P < 0.05). Multiple proinflammatory chemokines were downregulated after the application of MSCs, suggesting a decreased inflammatory response after MSC therapy. ConclusionsTransplantation of MSCs after intestinal I/R injury, irrespective of a tissue source, significantly increases survival and mesenteric perfusion and at the same time limits intestinal damage and inflammation. Further studies are needed to identify the mechanism that these cells use to promote improved outcomes after injury.

Transanal completion proctectomy after total colectomy and ileal pouch-anal anastomosis for ulcerative colitis: a modified single stapled technique.

Minimally invasive surgery has proved its efficacy for the surgical treatment of ulcerative colitis (UC). The recent evolution in single port (SP) surgery together with transanal rectal surgery could further facilitate minimally invasive surgery in UC patients. This technical note describes a technical modification for single stapled anastomoses in patients undergoing transanal completion proctectomy and ileal pouch-anal anastomosis (ta-IPAA) for UC. A step-by-step approach of the ta-IPAA in UC is described, including pictures and a video illustration. We describe a ta-IPAA with SP laparoscopy at the ileostomy site. All patients underwent a total colectomy with end-ileostomy for therapy refractory UC in a first step. Colectomy was done by multiport laparoscopy in six patients, while the ileostomy site was used as single port access in five patients. In all 11 patients the stoma site was used for SP mobilization of the mesenteric root and fashioning of the J-pouch. Completion proctectomy was done using a transanal approach. A single stapled anastomosis was performed in all patients. An 18 French catheter was used to approximate the pouch to the rectal cuff. A technical modification of the single stapled anastomosis facilitates the formation of the ta-IPAA, further reducing invasiveness in UC patients.

Human Adipose Stromal Cells Increase Survival and Mesenteric Perfusion Following Intestinal Ischemia and Reperfusion Injury.

Intestinal ischemia can quickly escalate to bowel necrosis and perforation. Transplantation of stem cells presents a novel treatment modality for this problem. We hypothesized that: human adipose-derived stromal cells (hASCs) would increase survival and mesenteric perfusion to a greater degree compared with differentiated cellular controls following ischemic intestinal injury, and improved outcomes with hASC therapy would be associated with preservation of intestinal histological and tight junction architecture, and lower levels of systemic inflammation following intestinal injury. hASCs and keratinocytes (differentiated cellular control) were cultured on polystyrene flasks at 37°C in 5% CO2 in air. Adult male C57Bl6J mice were anesthetized and a midline laparotomy performed. The intestines were eviscerated, the small bowel mesenteric root identified, and intestinal ischemia was established by temporarily occluding the superior mesenteric artery for 60 min with a noncrushing vascular clamp. Following ischemia, the clamp was removed, and the intestines were returned to the abdominal cavity. Before abdominal closure, 2 million hASCs or keratinocytes in 250 μL of phosphate-buffered saline (carrier for cells and control solution) were infused into the peritoneum. Animals were allowed to recover for 12 or 24 h (perfusion, histology, cytokine, and immunofluoresence studies), or 7 days (survival studies). Intestinal perfusion was assessed by laser Doppler imaging. Intestinal tissue segments were stained with hematoxylin and eosin, as well as antibodies for the tight junction protein claudin-1. Separate aliquots of intestine, liver, and lung tissue were homogenized and assessed for inflammatory cytokines via multiplex beaded assay. Animals administered hASCs following intestinal ischemia and reperfusion (I/R) injury had significantly greater 7-day survival and better postischemic recovery of mesenteric perfusion compared with vehicle or keratinocyte therapy. hASCs also abated intestinal mucosal destruction, facilitated preservation of intestinal tight junctions, and decreased the systemic inflammatory response to injury. Human adipose-derived stromal cells improved survival and mesenteric perfusion and attenuated the mucosal damage associated with intestinal I/R injury. hASCs should be considered as a plausible cell source for novel cellular treatment plans following intestinal ischemia.

Resectability of Peritoneal Carcinomatosis: Learnings from a Prospective Cohort of 533 Consecutive Patients Selected for Cytoreductive Surgery.

The aim of this study was to identify the risk factors and causes of unresectability in a large cohort of patients with peritoneal carcinomatosis (PC) selected for cytoreductive surgery (CRS), and to assess the contribution of the different imaging modalities to the patient-selection process. The pre- and intraoperative data of 533 consecutive patients with PC planned for CRS at a single institution were reviewed. All patients underwent computed tomography (CT) magnetic resonance imaging and/or positron emission tomography/CT within the 2days prior to surgery. Among the 533 patients, 436 (82%) underwent complete CRS, 86 (16%) underwent exploratory laparotomy without CRS because of multiple small-bowel involvement (n=31), invasion of different digestive segments (n=15), an elevated PC index (n=14), invasion of the mesenteric root (n=12), or another cause (n=14), and 11 (2%) did not undergo laparotomy because of disease progression on preoperative imaging findings. On univariate analysis, elevated levels of tumor markers and a short delay between the last cycle of chemotherapy and the scheduled surgery were identified as predictors of unresectability for the colonic PC population, while a younger age was identified in patients with gastric PC. Multivariate analysis disclosed the use of neoadjuvant chemotherapy and a younger age as independent predictors of unresectability in the colonic PC population. The current modalities for the assessment of PC resectability, including functional imaging examinations, have a low impact on patient selection for CRS. New tools are needed to decrease the rate of open-close procedures.

Mesenteric root dissection with individualized ileo-colic vessel ligation versus mesenteric pedicle stapling.

Numerous factors have been associated with the number of lymph nodes retrieved during laparoscopic colectomy. This study compared the impact of vascular pedicle ligation method on the number of retrieved lymph nodes in patients undergoing laparoscopic right hemicolectomy for cancer. Mesenteric root dissection with individualized vessel ligation was compared to en bloc vascular root stapling. Data were retrospectively collected from a database of patients' charts including operative and pathological reports. All patients that underwent laparoscopic colectomy in a single department were identified. Patients that underwent elective laparoscopic right hemicolectomy for cancer were further evaluated. The impact of the method used for ileo-colic vascular transection, age, gender, nodes status, T stage, BMI and the operating surgeon on the number of retrieved lymph nodes was studied. Among 239 laparoscopic colectomies, 75 patients underwent elective laparoscopic right colectomy for cancer. Ileo-colic vascular transection was routinely performed at the level of the inferior border of the pancreas. In total, 34 patients underwent ileo-colic vascular root dissection with individualized vessel ligation and 41 underwent vascular root stapling. No difference was found in the mean number of retrieved lymph nodes between pedicle dissection and vascular root stapling (18.7±5.9 vs. 19.6±7.9, P=0.396), and in the rate of patients who had 12 nodes or more (97.1 vs. 92.7%, P=0.401). BMI above 30 was associated with decreased number of retrieved nodes (P=0.001). No difference was found in the number of retrieved lymph nodes between ileo-colic vascular root dissection with individual vessel ligation and vascular root stapling in patients undergoing laparoscopic right hemicolectomy for cancer. High BMI was associated with decreased number of retrieved nodes in both groups. A standard approach regarding the level of mesenteric root transection, regardless of the ligation approach, leads to adequate lymph node harvesting by different surgeons.

Slow Growing Abdominal Mass Over 10 Years

Gastroenterolo Question: A 79year-old man was admitted for evaluation of jaundice and abdominal pain that began 2 weeks before admission. The patient had received right pneumonectomy for lung cancer 30 years ago and had undergone endoscopic retrograde cholangiopancreatography to remove common bile duct stones 10 years ago. Physical examination at admission revealed icteric sclera and mild right upper quadrant tenderness. Initial laboratory test result showed liver function enzyme elevation in a cholestatic pattern, and computed tomography (CT) scan demonstrated multiple gallbladder stones and common bile duct stones. Therefore, endoscopic retrograde cholangiopancreatography was performed to resolve the biliary obstruction. However, in addition to the bile duct stones noted on CT, there was a 8.3-cm, heterogeneously enhancing mass lesion abutting jejunum and involving many jejunal branches of superior mesenteric artery (Figure A). On retrospective review of the CT scan taken 10 years ago at the time of the initial common bile duct stone removal, a 3 2-cm mass lesion abutting jejunum at the umbilical level of mesenteric root was found to have been present (Figure B). Percutaneous biopsy had been performed 10 years ago and proliferation of spindle cells was reported to have been observed. Although surgical resection had been recommended to remove the mass, the patient was lost to follow-up. A follow-up percutaneous biopsy showed severe cellular atypia. Because the mass increased by nearly 3-fold, albeit over the period of 10 years, surgical resection was performed. What is the diagnosis of this slow growing abdominal mass? Look on page 1696 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Redefining the projectional and clinical anatomy of the duodenojejunal flexure in children.

The duodenojejunal flexure (DJF) is an important surgical landmark that enables the pediatric surgeon to establish whether normal intestinal rotation has occurred. The degree of variation in the position of the DJF has not been studied in the pediatric population, and there have been only limited studies on adults. The aim of the present study was to determine the position and relationships of the DJF in infants and children utilizing cross-sectional imaging. Computer tomography scans of 120 children were divided into three age groups and systematically analyzed. The DJF position was measured in relation to the vertebral body level, midline, anterior-posterior distance from the vertebral body, transpyloric plane, and mesenteric vessels. The position of the third part of the duodenum and the length of the mesenteric root were also determined. There was considerable variation in the DJF position with respect to the above landmarks in all three age groups. The vertebral body level of the DJF was centered on L1, but ranged between T11 and L3. In 3% of children with normal rotation the SMA/SMV relationship was abnormal. The third part of the duodenum was consistently found to be retromesenteric. The length of the mesenteric root ranged from 7 to 22 cm, and generally lengthened with increasing age. Owing to its variable position in infants and children, the DJF on its own may not be a reliable landmark for establishing normal intestinal rotation. Assessing for normal rotation is multifaceted and further comparative studies are required to characterize the anatomical features of normal and abnormal rotation.

Humoral Hypercalcemia of Malignancy in a Patient With Gastric Cancer During Chemotherapy

A 61-year-old man visited our hospital because he was checked up by gastric cancer screening using barium radiography. Endoscopy revealed a friable mass in the antrum of the stomach. The mass was diagnosed as poorly differentiated adenocarcinoma by biopsy. Computed tomography (CT) of the abdomen showed enlarged metastatic lymph nodes around the superior mesenteric arterial root. The patient was treated with combination of TS-1 (tegafur, gimeracil, and potassium oxonate) and cisplatin. After 8 months, CT revealed stable disease and laboratory examination showed no adverse effects. Therefore, another course of chemotherapy was started. However, 2 weeks later, he presented with fatigue due to hypercalcemia. After hospitalization, we started intensive care for hypercalcemia, which included intravenous hydration and zoledronic acid and calcitonin administration. However, the patient died of multiple organ failure. He showed hypercalcemia and elevated level of serum parathyroid hormone-related protein (PTHrP) with suppressed intact PTH level. The gastric tumor was positive for PTHrP by immunohistochemistry. Therefore, the diagnosis of humoral hypercalcemia of malignancy (HHM) due to hypersecretion of PTHrP in gastric cancer was made. HHM is most commonly seen in the squamous cell carcinoma, including lung, esophagus, head and neck. Other tumors, which can cause HHM are breast cancer, renal cancer and adult T-cell leukemia. However, HHM is rarely seen in patients with gastric cancer. In April 2015, we searched for reports using PubMed with keywords of “hypercalcemia” “gastric cancer” and “PTHrP”. There were only 9 case reports about hypercalcemia in PTHrP-producing gastric cancer. We surveyed these 9 cases and our case to investigate the characteristics of HHM in patients with gastric cancer associated with HHM. Our case is the first case with gastric cancer who developed hypercalcemia due to PTHrP during chemotherapy. Elevated serum PTHrP level may be associated with poor prognosis.

A Case of Wandering Malignant Solitary Fibrous Tumor

Introduction: Solitary fibrous tumor (SFT) is a rare mesenchymal tumor of fibroblastic origin, which may originate from any part of body but most commonly arises from the visceral pleura. We present a rare case of wandering malignant SFT, arising from the lesser omentum. Case: A 60 year old Caucasian male with history of hypertension and diabetes mellitus, admitted initially, for fall in nursing home, developed nausea, vomiting and abdominal distension. A palpable mass was noted on abdominal examination. Non-contrast CT revealed a 17 cm pedunculated bilobed mass with eccentric calcifications in right mid abdomen compressing pylorus with a markedly distended stomach and gastric wall pneumatosis. Repeat CT abdomen with contrast in 12 hours showed interval migration of the mass into the left abdomen with twisting of the mesenteric root and narrowing of the venous structures. The patient underwent emergent exploratory laparotomy with resection of a 1.5 kg mass. Biopsy revealed spindle cell proliferation and abundant collagenous stroma along with large necrotic areas and increased mitotic activity. Immunohistochemical stains were positive for CD34 and STAT6 consistent with malignant SFT. Patient had an uneventful postoperative course and repeat CT imaging after 3 months confirmed complete resolution. Discussion: SFTs are mesenchymal tumors commonly arising from pleura but extrathoracic SFTs have been reported such as intra-abdominal originating from omentum as in our case. Majority of SFTs are benign while 12-22% are malignant. Mean age of onset is 55-65 years. These may be associated with paraneoplastic syndromes, most commonly hypoglycemia or hypertrophic pulmonary osteoarthropathy. Differential diagnoses include gastrointestinal stromal tumor, neurogenic tumors, myogenic tumors or vascular tumors. CD 34 and STAT6 are useful positive biomarkers for SFT as in our case. Molecular hallmark in SFT is recurrent gene fusion of NAB2-STAT6 on chromosome 12q13-15. Imaging modalities including CT or MRI can be suggestive of the diagnosis but definitive diagnosis requires a tissue specimen. The mainstay of treatment is complete surgical resection with clear margins. They can have unpredictable biological behavior and can recur locally or disseminate. Long-term surveillance is recommended post operatively, as disseminated recurrence can occur in tumors with histological features of malignancy, but data to guide further management of such patients is lacking.Figure 1Figure 2

The uncinate process first approach: a novel technique for laparoscopic right hemicolectomy with complete mesocolic excision.

Current evidence suggests that complete mesocolic excision (CME) for right-sided colon cancer could be beneficial in terms of long-term survival. However, CME is a considerably more complex operation than standard right hemicolectomy; this is especially true for the laparoscopic approach. Consequently, we have explored a new laparoscopic approach that provides surgical radicality at the mesenteric root on the one hand and maximum safety on the other hand. The key feature of the uncinate process first approach (UFA) is the commencement of the dissection at the fourth part of the duodenum using a medial to lateral approach, thus mobilizing the whole mesenteric root posteriorly before the central parts of the mesenteric vessels are accessed. Twenty-eight selected patients with right-sided colon cancer underwent surgery using the UFA and were compared with 51 patients who underwent an open CME procedure (CON). In 11/28 and 51/51 patients in the UFA and CON groups, respectively, a planimetric assessment of the specimen was performed. Surgical time was longer (144.8 vs. 202.5min; p<0.000) and postoperative stay shorter (8.0 vs. 10.5days; p<0.01) for the laparoscopic approach. The area of the resected mesentery (UFA, 15,097mm(2); CON, 15,788mm(2); p=0.47) and the lymph node count (UFA, 59.0; CON, 51.0; p=0.09) was not significantly different; additionally, no difference was observed regarding anastomotic leakage (both n=0) and postoperative mortality (UFA, 0/28; CON, 1/51; p=1.0). Laparoscopic right hemicolectomy with CME using the UFA provides adequate radicality according to the CME principles and seems feasible and as safe as an open technique. However, future trails will have to demonstrate whether the theoretical advantages of the UFA, with a higher degree of mobility and accessibility of the mesenteric root, translate into a significant clinical benefit, especially relative to the other laparoscopic techniques.

The patterns of lymph node metastasis in adenocarcinoma of esophagogastric junction : a reference for target volume delineation in radical radiotherapy

Objective To analyze the patterns and distribution of lymph node metastasis in patients with adenocarcinoma of the esophagogastric junction(AEG). Methods The pathological data of 393 patients with AEG from 2006 to 2009 were analyzed. The patterns and distribution of lymph node metastasis were analyzed in patients with different Siewert subtypes, depths of tumor invasion, and maximum diameters of the tumor, and the high-risk lymphatic drainage areas were investigated. Between-group comparison was performed by χ2 test. Results The metastatic rate and ratio of abdominal lymph nodes in AEG were 69. 2% and 31. 31%, respectively. The incidence rates of lymph node metastasis in the cardia, lesser curvature, left gastric artery, splenic artery, splenic hilum, mesenteric root, and abdominal aorta were the highest. The metastatic rate and ratio of mediastinal lymph nodes were 16.4% and 8.3%, respectively. The incidence rates of lymph node metastasis in the lower paraesophageal, esophageal hiatus, and superior diaphragmatic areas were the highest. Compared with Siewert type Ⅱ and type Ⅲ AEG, Siewert type I AEG had a significantly higher mediastinal lymph node metastatic rate(P = 0. 003)and a significantly lower abdominal lymph node metastatic ratio(P=0. 002).The metastatic ratios of lymph nodes in multiple abdominal regions were higher in patients with stage T3+T4 AEG and a maximum tumor diameter of cm than in the control group, while the metastatic ratios of mediastinal lymph nodes in groups with different maximum tumor diameters were similar. The metastatic ratios of lymph nodes in the greater curvature, hepatoduodenal ligament, and inferior diaphragmatic areas were lower than 10% in all groups. Conclusions In radiotherapy for AEG, the abdominal high-risk lymphatic drainage areas involve the cardia, lesser curvature, left gastric artery, splenic artery, splenic hilum, mesenteric root, and abdominal aorta, while the mediastinal high-risk lymphatic drainage areas involve the lower paraesophageal, esophageal hiatus, and superior diaphragmatic areas. In addition, the personalized target volume design should be based on the patterns of lymph node metastasis with different Siewert subtypes and clinical pathological characteristics. Key words: Esophagogastric junction neoplasm/radiotherapy; Target delineation; Lymph node metastasis

Expression of IFITM3 in colorectal carcinoma and its clinical significance

To investigate the expression of IFITM3 in colorectal carcinoma and its clinical significance. 213 patients with colon ademocarcinoma and 214 patients with colon adenoma treated by surgery in our hospital from March 2008 to June 2010 were included in this study. The levels of IFITM3 in normal colon nucosa, adenoma, and adenocarcinoma tissues were detected by real-time PCR and immunochemistry, and its relationship with metastasis and prognosis in 213 colorectal cancer patients was analyzed. The IFITM3 mRNA level in metastatic tumor group was 18.37 ± 0.61, significantly higher than that in the normal 4.49 ± 0.69 and non-metastases groups (7.32 ± 0.76; F = 460.380, P < 0.001). The positive rate of IFITM3 protein expression in metastatic tumor group (69.0%) was significantly higher than that in the normal (3.9%), non-metastasies groups (19.0%) and adenoma groups (11.3%). Our clinical analysis confirmed that the IFITM3 expression was associated with peritumoral invasion, hepatic metastases, metastases of para-colonic lymph nodes, mesocolonic lymph nodes and mesenteric root lymph nodes, omental metastasis and AJCC classification (P < 0.05). Furthermore, the survival curve analysis showed that patients with lower IFITM3 level expression had a higher 5-year survival rate (88.8%) than that in the patients with higher expression (40.2%, P < 0.001). IFITM3 expression has a positive correlation with metastasis and prognosis in patients with colorectal carcinoma.

Modified Liver-free Multivisceral Transplantation for a Metastatic Small Bowel Neuroendocrine Tumor: A Case Report

Neuroendocrine tumors originating from the small bowel frequently metastasize to the lymph nodes and/or liver. Although surgical extirpation of the primary tumor and locoregional metastases epitomizes the management of patients with such tumors, this is not always possible with conventional surgical techniques. Nonresectable, slow-growing tumors involving the mesenteric root represent a generally accepted indication for deceased donor intestinal and multivisceral transplantation. Furthermore, vascularized sentinel forearm flaps offer opportunities for monitoring graft rejection and tailoring immunosuppression regimens. Here, we report the first documented case of modified liver-free multivisceral transplantation preceded by neoadjuvant 177-lutetium peptide receptor radionuclide therapy in a patient with a small bowel neuroendocrine tumor and extensive lymph node metastases in the mesenterium. At a follow-up of 21 months the patient is biochemically and radiologically disease-free.

Fifteen years’ experience of intestinal and multivisceral transplantation in the Nordic countries

Objective. Intestinal and multivisceral transplantation have gained acceptance as treatment modalities for patients with: intestinal failure and life-threatening complications of parenteral nutrition (PN), rare cases of vascular abdominal catastrophes and selected cases of low-grade neoplastic tumors such as neuroendocrine pancreatic tumors and desmoids involving the mesenteric root. The aim was to describe the survival and nutritional outcome in the transplanted Nordic patients and the complications attributed to this procedure. Method. The authors included all Nordic patients transplanted between January 1998 and December 2013. Information on patients transplanted outside the Nordic region was collected through questionnaires. Results. A total of 34 patients received different types of intestinal allografts. Currently, there are two Nordic transplant centers (n = 29) performing these procedures (Gothenburg, Sweden n = 24, Helsinki, Finland n = 5). The remaining five patients were transplanted in the USA (n = 3) and the UK (n = 2). Most patients were transplanted for life-threatening failure of PN (70%) caused primarily by intestinal motility diseases (59%). Allograft rejection was the most common complication and occurred in 79% of the patients followed by post-transplantation lymphoproliferative disorders (21%) and graft-versus-host disease (18%). The 1- and 5-year survival was 79% and 65% respectively for the whole cohort and nutritional autonomy was achieved in 73% of the adults and 57% of the children at 1 year after transplantation. Conclusion. This collective Nordic experience confirms that intestinal transplantation is a complex procedure with many complications, yet with the possibility to provide long-term survival in selected conditions previously considered untreatable.

Crohn’s Disease: How Sure is Sure?

Introduction: Endoscopy with biopsy has been the gold standard for diagnosis of Crohn’s disease. A 33-year-old male presented with mid epigastric discomfort and constipation. Miralax and protonix was initiated. Over the ensuing 6 weeks, his symptoms of abdominal pain and bloating worsened. He lost 15 pounds, and had night sweats, early satiety, and abdominal tenderness. A CT scan of the abdomen showed abnormally thickened proximal ileal loops consistent with Crohn’s disease, and prednisone was started. He returned within days with worsening abdominal pain. Urgent colonoscopy with ileal visualization showed no significant abnormalities. Steroids were continued. CT enterography showed a segment of small bowel within the mid abdomen extending right to left with diffuse wall thickening as well as cystic implants within the omentum and adenopathy at the mesenteric root. Eventually, he experienced worse abdominal pain, fever, and vomiting. CT showed intra-peritoneal air consistent with a perforated hollow viscous. Emergent laparotomy with biopsy of peritoneal implants confirmed the diagnosis of intermediate grade follicular center cell lymphoma. Bowel perforation in GI lymphomas is seen in approximately 9% of intestinal lymphoma cases, half of which occur after initiation of chemotherapy. Clinical entities that mimic intestinal lymphoma include Crohn’s disease, carcinomatosis, carcinoid tumors, and ischemic injury. Bowel perforation in GI lymphomas is seen in approximately 9% of intestinal lymphoma cases, half of which occur after initiation of chemotherapy. Clinical entities that mimic intestinal lymphoma include Crohn’s disease, carcinomatosis, carcinoid tumors, and ischemic injury. Clues in this case that Crohn’s disease was not the right diagnosis was the rapid progression of disease, night sweats, weight loss, and absence of diarrhea. CT enterography showed progression of disease uncharacteristic of Crohn’s disease. Radiographs often depict abnormalities in patients with inflammatory bowel disease (IBD). However, a false positive rate of 16-20% with the low positive predictive value of a normal radiograph (62%) make radiography a poor diagnostic test. The empiric use of steroids in this patient may have not only increased the risk of bowel perforation, but was likely the cause for inconclusive histopathology on colonoscopic biopsy. This serves to reinforce that it is still crucial to have a biopsy-proven diagnosis of Crohn’s disease prior to initiation of steroids.Figure 1

Dynamic article: surgical anatomical planes for complete mesocolic excision and applied vascular anatomy of the right colon.

Lower local recurrence rates and better overall survival are associated with complete mesocolic excision with central vascular ligation for treatment of colon cancer. To accomplish this, surgeons need to pay special attention to the surgical anatomical planes and vascular anatomy of the colon. However, surgical education in this area has been neglected. The aim of this study is to define the correct surgical anatomical planes for complete mesocolic excision with central vascular ligation and to demonstrate the correct dissection technique for protecting anatomical structures. Macroscopic and microscopic surgical dissections were performed on 12 cadavers in the anatomy laboratory and on autopsy specimens. The dissections were recorded as video clips. Dissections were performed in accordance with the complete mesocolic excision technique on 10 male and 2 female cadavers. Vascular structures, autonomic nerves, and related fascias were shown. Within each step of the surgical procedure, important anatomical structures were displayed on still images captured from videos by animations. Three crucial steps for complete mesocolic excision with central vascular ligation are demonstrated on the cadavers: 1) full mobilization of the superior mesenteric root following the embryological planes between the visceral and the parietal fascias; 2) mobilization of the mesocolon from the duodenum and the pancreas and identification of vascular structures, especially the veins around the pancreas; and 3) central vascular ligation of the colonic vessels at their origin, taking into account the vascular variations within the mesocolonic vessels and the autonomic nerves around the superior mesenteric artery. The limitation of this study was the number of the cadavers used. Successful complete mesocolic excision with central vascular ligation depends on an accurate knowledge of the surgical anatomical planes and the vascular anatomy of the colon.