Mesenteric Research Articles

Supramesocolic Approach to Roux-en-Y Gastric Bypass when Standard Inframesocolic Approach Is Not Feasible

The traditional approach to a Roux-en-Y gastric bypass is to construct the biliopancreatic and Roux limbs within the inframesocolic space. This requires reflecting the greater omentum, transverse colon, and mesocolon superiorly. This maneuver can be challenging in patients with a robust omentum, hepatomegaly, or significant omental adhesions. The inability to fully reflect the omentum superiorly prevents an appropriate view of the posterior transverse mesocolon and the inframesocolic space from being obtained. This can make it difficult to construct the biliopancreatic and Roux limbs. In order to circumvent the difficult situations described above, a supramesocolic approach to constructing the biliopancreatic and Roux limbs can be performed. This approach avoids the need to reflect the omentum and transverse colon. Key steps include entering the lesser sac by transecting the gastrocolic ligament and, next, an aperture in the transverse mesocolon made exposing the ligament of Treitz. The small bowel is then eviscerated into the supramesocolic space. The biliopancreatic and Roux limbs are then created in the usual fashion. All of the small bowel except the Roux limb is then returned through the mesocolon to the inframesocolic space. Peterson's space and the mesocolic defect are then closed using permanent suture. The remainder of the procedure is then performed in the usual fashion. No complications were reported immediately postoperatively or at a 12-month follow-up in all 3 cases. The supramesocolic approach to a Roux-en-Y Gastric Bypass is a safe and effective technique when an inframesocolic approach proves difficult.

AUTOPSY FEATURES AT THE ACUTE DESTRUCTIVE PANCREATITIS

In all variants of the destructive form of pancreatitis, the involvement of adipose tissue of both para-pancreatic and distant localization was noted. In this case, it is necessary to improve the pathological diagnosis of acute destructive pancreatitis. The aim of the study was to develop new techniques for postmortem examination of those who died from complications of acute pancreatitis. Pathological studies were supplemented by the methods proposed by the authors, which made it possible to clarify the spread of the infectious agent through the retroperitoneal tissue. The scheme proposed by the authors for recording changes in the tissue of the pancreas and surrounding tissues after a contrast study made it possible to clarify the main ways of propagation of the purulent-necrotic process along the retroperitoneal tissue. The results of postmortem examination of 67 deaths from complications of acute pancreatitis are presented. Based on the study, 5 types of acute destructive pancreatitis were identified. In type I, the pathological process involves the right half of the retroperitoneal tissue, including the mesentery root of the small intestine, the para-pancreatic region, the right para-kidney and sub-hepatic space. The second type is characterized by the presence of inflammatory and destructive changes in the fiber of the right lateral canal, the actual retroperitoneal space on the right and the mesentery root of the transverse colon. Purulent-necrotic changes in para-pancreatic, left perineal tissue, mesentery of the transverse colon, also in peritoneum were typical for type III acute destructive pancreatitis. For type IV disease, in addition to areas of involvement as in type III, involvement of the pelvic tissue and the left sections of the retroperitoneal space itself were noted. The spread of the infectious agent to both the right and left parts of the retroperitoneal tissue was defined as type V acute destructive pancreatitis.

Celiac Disease Presenting as Celiac Artery Stenosis and Intra Abdominal Venous Thrombosis - An Unheard Entity

Extra intestinal manifestations of celiac disease are seen in about 20% of patients including venous thrombosis but arterial stenosis is not described in the literature. We describe a first-ever case of celiac disease in 26-year-old lady presenting as severe celiac artery stenosis, managed successfully with arterial stenting. She also had portal and superior mesenteric vein thrombosis. Excellent improvement was seen during follow up after treatment with a gluten-free diet, oral anticoagulation, antiplatelet and celiac arterial stenting. Hypercoagulability and thromboembolic manifestation in celiac disease should be kept in mind especially during active disease or acute exacerbation of celiac disease.

Rise and mix of membrane anatomy

Membrane anatomy is the anatomy of mesentery in broad sense and its beds, which was merged from clinical results of surgical practice, optic observation and traditional theories contradiction or omission. Membrane anatomy is not only a plane, but also a body or bloc which is surrounded by fascia and serous membrane. It is not only fascia, but also a channel or pathway, in which the life event occurred. It is not only mesentery anatomy, but included mesentery beds, on which the mesentery was lied, even buried in. Following the new version of this anatomy map, surgical hazard during operation and postoperative oncological recurrence will be decreased simultaneously. And, following the definition of the mesentery in broad sense, new mesenteries will be discovered under macro surgery, which will optimize surgical operation and get better surgical and oncological results.

Idiopathic Retractile Calcific Mesenteritis: a Rare Cause of Small Bowel Obstruction

Retractile mesenteritis is an idiopathic rare disorder characterized by fibrosis and calcification of the mesentery. We report a case of a 70-year-old female patient who presented to the surgical emergency with small bowel obstruction. On exploratory laparotomy, small bowel loops were dilated and clumped together in the pelvis with kinking of terminal ileum. Small bowel mesentery was inflamed, fibrosed, and shortened with patterned calcifications. Mesentery of sigmoid colon, transverse mesocolon, and greater omentum also had similar findings. Rest of the peritoneum and solid organs were grossly normal. We present the clinical images of this rare condition where finding the etiology for this condition was a challenging task.

Large Splenic Aneurysm Originating From the Superior Mesenteric Artery

Large Splenic Aneurysm Originating From the Superior Mesenteric Artery

Giant mesenteric teratoma

Abstract Mesenteric teratoma is a rare tumor in children. The present case is huge mesenteric teratoma (20 × 20 × 10 cm) and (1.96 kg) arising near the root of mesentery with ileal segment attached to it. Complete surgical excision of the mass with adherent intestinal segment with primary anastomosis. The histopathological examination showed bengin muture teratoma with no atypia or malignancy.

Ureteric mapping with Indocyanine green: A new tool to prevent ureteral injury in complex gynecological surgery

Introduction: The aim of this video is to show that ureteric injection of Indocyanine green dye in difficult gynecological operations is a useful tool to identify and safeguard ureters. Case description: A 56-year-old lady with a large 10.5 × 14.5 × 13 cm3 multiloculated endometriotic cyst in the right adnexa was scheduled for robotic-assisted hysterectomy with bilateral salphingooophorectomy. She had undergone a laparotomy and three laparoscopic surgeries for endometriosis and fibroid uterus. Before starting surgery, cystoscopy was performed and with 6 Fr ureteral catheter inserted into ureteral orifice, 5 mL of 0.5% Indocyanine green dye (Aurolab, Madurai, India) was injected into both ureters. Intraoperatively bilateral adnexal cysts were seen densely adherent to omentum, sigmoid colon, sigmoid mesocolon, bladder, and lateral pelvic wall. Bladder and rectosigmoid were pulled up both anteriorly and posteriorly, respectively, and densely adherent to uterus and to adnexal cysts. During surgery, the course of ureter was identified by the green fluorescence emitted by the Indocyanine green dye under near-infrared light on da Vinci Xi camera. During this difficult surgery, the real-time visualization of ureteric course helped to identify and safeguard ureter during adhesiolysis and surgery could be completed without any injury to ureter. Patient did not experience any side effects due to the ureteric Indocyanine green injection. Conclusion: Endometriosis can distort the pelvic anatomy making surgery very challenging. Identifying the course of ureter during surgery can help in avoiding injuries and reduce surgical morbidity.

Evaluation of comparative intradermal tuberculin and interferon gamma release tests for prediction of tuberculous lesion development in slaughtered cattle

Bovine tuberculosis (BTB) is a chronic contagious disease of cattle which has economical, public health and veterinary importance worldwide. So far, test and slaughter is the most feasible method to control the disease but identification of lesions from slaughtered animals does not always coincide with ante-mortem test results. Fifty four animals which were found positive by comparative intradermal tuberculin test (CIDT) or INF-γ release assay or both were slaughtered and post mortem examination (PME) was conducted to identify tuberculous (TB) lesions. The animals were composed of four age groups (≤ 3; 4-6; 7-9 and ≥ 10 years) the two sexes and two breeds (Boran, Boran-Friesian cross). Out of all the slaughtered animals, lesions were detected from 70.3% (38/54) of them. No significant difference was observed among the four age groups and two sexes of both breeds of animals on the level of TB lesion detection. Higher proportion of the lesion was observed by mediastinal (40.4%) followed by bronchial (34.8%), retropharyngeal (17.9%) and lastly miliary form and mesenteric lymph nodes in equal proportion (3.3%). Among the CIDT positive animals, 59.2% of them had lesions. Similarly, 46.2% of INF-γ release assay positive animals had lesions during postmortem examination. Of the total CIDT (+) and INF-γ (-) animals, postmortem lesions were detected from 22.2% of them, and in the vice-versa, of the CIDT (-) and INF-γ (+) animals, 9.2% of them contain TB lesions. Using the PME as reference test, sensitivity of CIDT was 84.2% and the specificity was 6.2%. Similarly, the sensitivity and specificity of the INF-γ release assay was 65.7 and 37.5% respectively. It is concluded that, both tests predict the development of TB lesions. However, in our condition, CIDT was found more predictable for detection of TB lesions as compared to INF-γ release assay. Key words: Bovine tuberculosis (BTB), comparative intradermal tuberculin test (CIDT), interferon gamma (INF-γ) release, post mortem examination (PME), tuberculous (TB) lesion

1946-P: Dapagliflozin Suppresses Adipose Fatty Acid Accumulation in Rats Fed on High-Fat Diet but Not on Normal Chow

SGLT2 inhibitor (SGLT2i) exerts not only on enhancement of glucose excretion but also on improvement of serum lipid profile via increase in lipid utilization as an energy source instead of glucose. That is, SGLT2i might affect the lipid storage. In the present study, we evaluated the effects of dapagliflozin (DAPA) on weight and fatty acid contents of adipose tissues. At 8 weeks of age, male rats were divided into four groups: (a) NC (n=6) fed on a standard laboratory chow (LC); (b) NC+DAPA (n=6) on the LC with 1 mg/kg/day DAPA administration; (c) HFD (n=6) on a high-fat diet (HF); (d) HFD+DAPA (n=6) on the HF with 1 mg/kg/day DAPA administration. After 7 weeks, we weighed epididymal (EPI), mesenteric (MES), retroperitoneal (RET), and inguinal subcutaneous (SUB) adipose tissues, and measured 21 adipose fatty-acid contents (μmol/g BW). As a result, adipose tissue weight in the examined four sites in HFD rats were significantly higher (P<0.01) than those, respectively, in NC rats. No significant differences were observed in weights of any adipose tissues or in their contents of fatty acids between the NC and NC+DAPA rats. In contrast, MES weight in HFD+DAPA rats was significantly lower (P<0.05) than that in the HFD rats. Contents of 1, 3, 2 and 1 saturated fatty acids (SFAs) in EPI, MES, RET and SUB, respectively, in the HFD+DAPA rats were significantly lower (P<0.05) than those, respectively, in the HFD rats. Contents of 3 and 2 monounsaturated fatty acids in MES and SUB, respectively, and contents of 2 and 1 polyunsaturated fatty acids in MES and RET, respectively, in the HFD+DAPA rats were significantly lower (P<0.05) than those, respectively, in the HFD rats. These results suggest that DAPA could reduce some SFAs in any adipose tissues in HF-fed rats, but not in LC-fed rats. The reduction might sometimes arise without concomitant decrease in tissue weight. In addition, DAPA might suppress accumulation of a wide range of fatty acids in MES of HF-fed rats in particular, probably due to their consumption. Disclosure D. Sato: None. J. Amarume: None. M. Yano: None. Y. Umehara: None. M. Kusunoki: Other Relationship; Self; Kaken Pharmaceutical Co., Ltd., Ono Pharmaceutical Co., Ltd., Taisho Pharmaceutical Co., Ltd. Z. Feng: None. T. Nakamura: Research Support; Self; AstraZeneca K.K., Ono Pharmaceutical Co., Ltd. Funding Ono Pharmaceutical Co., Ltd.; AstraZeneca K.K.

Propofol improves intestinal ischemia-reperfusion injury in rats through NF-κB pathway.

The aim of this study was to investigate the effects of propofol on intestinal ischemia-reperfusion injury in rats through the nuclear factor-kappa B (NF-κB) pathway. A total of 24 Sprague-Dawley rats were selected and randomly divided into three groups, including sham operation group, ischemia group and propofol group. Rats in sham operation group were only treated with isolation of superior mesenteric artery, which was clipped for 1 h and reperfused for 2 h in ischemia group. Meanwhile, propofol (60 mg/kg) was injected into the femoral vein 1 h before ischemia in propofol group. TUNEL assay was performed to detect cell apoptosis of intestinal tissues. Real-time quantitative polymerase chain reaction (RT-qPCR) was conducted to measure the expression levels of malondialdehyde (MDA), superoxide dismutase (SOD), myeloperoxidase (MPO), caspase-3 and B-cell lymphoma-2 (Bcl-2) in rats of each group. Western blotting was utilized to detect the protein expression levels of NF-κB pathway related molecules, such as myeloid differential protein-88 (MyD88), v-rel avian reticuloendotheliosis viral oncogene homolog A (RelA) and NF-κB. Furthermore, changes in plasma cytokine levels were determined via enzyme-linked immunosorbent assay (ELISA). The number of apoptotic cells in ischemia group was remarkably higher than that in sham operation group (p<0.05). However, it decreased notably in propofol group compared with ischemia group (p<0.05). In comparison with sham operation group, significantly up-regulated expression of caspase-3 and down-regulated expression of Bcl-2 were observed in the intestinal tissues of rats in ischemia group (p<0.05). Caspase-3 was lowly expressed, while Bcl-2 was highly expressed in the intestinal tissues of rats in propofol group compared with ischemia group (p<0.05). In addition, no statistically significant differences were observed in the expression level of SOD among sham operation group, ischemia group and propofol group (p>0.05). The expression levels of MDA and MPO were overtly higher in the intestinal tissues of rats in ischemia group than those in sham operation group and propofol group (p<0.05). Besides, the protein expression levels of MyD88, RelA and NF-κB in the intestinal tissues of rats in ischemia group were remarkably higher than those in sham operation group and propofol group (p<0.05). The activity of the NF-κB pathway in the intestinal tissues of rats in propofol group significantly declined compared with ischemia group (p<0.05). Moreover, compared with sham operation group, plasma levels of TNF-α, interleukin (IL)-2, IL-6 and IL-4 increased significantly in rats of ischemia group (p<0.05). However, they were markedly lower in propofol group than those in ischemia group (p<0.05). Propofol protects rats from intestinal ischemia-reperfusion injury through the NF-κB pathway.

Acute Pancreatitis Complicating Liver Transplantation in a Case of Fulminant Hepatic Failure Due to Yellow Phosphorus Poisoning

Yellow phosphorus (YP) is a general protoplasmic poison causing hepatic, cardiac, renal, and multiorgan failure. We report an unusual case of fulminant liver failure due to ratol (YP) poisoning complicated by acute pancreatitis postoperatively after liver transplantation. A 25-yr-old man presented with alleged consumption of approximately 7gm of Ratol paste. Serum amylase and lipase levels were 880 and 2423, respectively, and CT imaging of pancreas was normal. He developed fulminant liver failure, fulfilling King's college criteria and an living donor liver transplantation was performed. Intraoperatively fat saponification was seen at the root of mesentery. On postoperative day (POD) 13, he developed incisional wound dehiscence and he underwent laparotomy with extensive slough removal from the lateral aspect of wound. On POD 21, wound showed evidence of burst abdomen. CT abdomen revealed inflamed tail of pancreas with peripancreatic fat stranding and an exploratory laparotomy was performed again. Intraoperatively, walled-off necrotic collection was seen in the tail of the pancreas and necrosectomy was carried out. All the aforementioned re-explorations were carried out under steroid immunosuppression. He was restarted on tacrolimus on POD27. Graft function and cholestatic biochemistry improved progressively, and he was discharged and is on regular follow-up. YP is very toxic with rapid absorption and gets accumulated in liver causing acute liver failure. Acute pancreatitis in a patient after liver transplantation for fulminant liver failure owing to Ratol poisoning has not been reported in published English literature. Although clinically relevant pancreatitis is rare in ratol poisoning, despite elevated pancreatic enzymes, it is prudent to meticulously image pancreas before embarking on liver transplantation. In those with pretransplant elevation of pancreatic enzymes, it is desirable to follow up the enzyme values postoperatively.

Is the transverse mesocolon a trap to avoid during endoscopic gastrojejunal anastomosis? Stent misdeployment into the peritoneum

Is the transverse mesocolon a trap to avoid during endoscopic gastrojejunal anastomosis? Stent misdeployment into the peritoneum

Resectional surgery for malignant disease of abdominal digestive organs is not surgery of the organ itself, but also that of the mesenteric organ

Despite large strides in molecular oncology, surgery remains the bedrock in the management of visceral cancer. The primacy of surgery cannot be understated and a mesenteric (i.e. ontogenetic) approach is particularly beneficial to patients. Heald greatly advanced the management of rectal cancer with his description of the anatomical foundation of total mesorectal excision (TME), dramatically improving outcomes worldwide with this mesenteric-based approach. Moreover, complete mesocolic excision (CME) based on similar principles is becoming popular. Introduced by Hohenberger, CME resembles TME insofar as it emphasises strictly anatomical dissection along embryological planes to detach an intact (i.e. “complete”) mesentery with peritoneal envelope. CME also incorporates “central” vascular ligation (CVL) which broadly correlates with the “D3 lymphadenectomy” of Eastern literature. As many surgeons already practise anatomical and mesenteric-based surgery, it is unclear how the putative benefits of CME (including CVL) arise. Herein, we argue that these may relate to a more extensive resection of the mesentery, and thus mesenteric tumour deposits within the connective tissue lattice of the mesentery, and not necessarily the lymphadenectomy alone. We believe the connective tissue interface between the bowel wall and mesentery provides an alternative mode of spread of pathogenic elements. Whilst this remains a suggestion only, it would explain the histological independence of tumour deposits and why a greater mesenterectomy could be associated with benefits in survival. If this argument holds, it follows that resectional surgery for digestive organ malignancy is not surgery of the organ itself (or lymphatics only), but also that of the contiguous mesentery.

Pathological complete response after intraperitoneal paclitaxel and systemic combined chemotherapy in a patient with peritoneal metastases from gastric cancer: a case report

BackgroundDespite recent progress in systemic chemotherapy, the prognosis of patients with peritoneal metastases from gastric cancer is still poor. Efficacious intraperitoneal and systemic combination chemotherapy regimens to treat patients with peritoneal metastases have recently been developed.Case presentationA 74-year-old man with gastric cancer T4b (transverse mesocolon) N3 M1 (peritoneum) received combination chemotherapy with intraperitoneal administration of paclitaxel, intravenous oxaliplatin, and oral S-1. Eight courses of combined chemotherapy had remarkable anti-tumor effects on the primary lesion, lymph node metastases, and peritoneal metastases. Total gastrectomy with regional lymph node dissection was performed. Pathological examination revealed no viable tumor cells in the resected specimens. After gastrectomy, the patient received 25 courses of the same chemotherapy without oxaliplatin and has no evidence of recurrence 24 months later.DiscussionTherapeutic approaches including systemic chemotherapy, extended resection, and heated intraperitoneal chemotherapy have been used to treat patients with peritoneal metastases. Repeat therapy with intraperitoneal paclitaxel has been used recently. Intraperitoneal administration of paclitaxel results in prolonged retention in the peritoneal cavity with effects against peritoneal metastases. Repeated administration of paclitaxel does not cause adhesions in the peritoneal cavity. When combination chemotherapy is effective, salvage gastrectomy is a promising option with minimal morbidity and mortality.ConclusionCombined chemotherapy with intraperitoneal paclitaxel and systemic chemotherapy followed by gastrectomy is a promising strategy for patients with advanced gastric cancer and peritoneal metastases.

Laparoscopic pancreaticoduodenectomy: a report of 102 patients in one single center

Objective To summarize the technical points of laparoscopic pancreaticoduodenectomy (LPD) carried out in a single center. Methods The clinical data of 102 patients who underwent laparoscopic pancreaticoduodenectomy in 2018 at the Department of Hepatobiliary Surgery of the Second Hospital of Hebei Medical University were retrospectively analyzed, and the general conditions, operation time, intraoperative blood loss, and surgical operation were analyzed. Post-operative complications, hospital stay and other indicators were studied. Results Of the 102 patients who were included, there were 57 males and 45 females, aged 15.0 to 79.0 (59.9±11.8) years old, with a body mass index (23.6±3.6) kg/m2. For the 102 patients who underwent LPD, 6 were total pancreatic resection. Three were combined with vascular resection in the form of portal vein-superior mesentery vein segmental resection. The operation time was (376.6±87.2) min, the intraoperative blood loss was 350 (100, 800) ml, and the postoperative hospital stay was (17.0±5.9) days. Postoperative complications occurred in 26 of the 102 patients (25.5%), and more than two complications occurred in 17 patients. B/C grade pancreatic fistula occurred in 9 patients (9.4%), abdominal bleeding in 8 patients (7.8%), gastrointestinal bleeding in 2 patients (2.0%), biliary fistula in 4 patients (3.9%), and gastric emptying disorder in 5 patients (4.9%), 8 patients had pulmonary infection (7.8%). Five patients (4.9%) died during the perioperative period. Conclusion The main technical points of LPD included en bloc resection, pancreaticojejunostomy, and vascular reconstruction. The basis of LPD is en bloc resection. Combined resection and reconstruction of vascular segments is a sign of maturity of LPD technology and a prerequisite for further development as a routine procedure. Key words: Laparoscopy; Pancreaticoduodenectomy; Monolithectomy; Combined vascular resection and reconstruction

Different surgical techniques that influenced internal hernia prevalence rate after laparoscopic roux-en-Y gastric bypass: a retrospective analysis of 331 cases

BackgroundInternal hernia (IH) is a serious complication following laparoscopic Roux-en-Y gastric bypass (LRYGB), and closure of mesenteric defect has been recommended to reduce this complication. But what kind of material about suture and how to close the mesenteric defects were still controversial. The main aim of this study was to compare the incidence rate of internal hernia after LRYGB between patients with different surgical techniques.MethodThree hundred and thirty-one patients underwent LRYGB between June 2004 and December 2017 in one single institute were retrospective analysed. The IH rate was evaluated according to different surgical methods and surgical materials before and 12 months after LRYGB.ResultsAll the cases were subdivided into three groups based on the suturing method, Roux limb position, and Suture material. The mean follow up time was 36 ± 12 months, and the total incident rate of IH was 1.8% (n = 6). In the six IH cases, the duration of IH occurred time ranged from 1 month to 36 months postoperatively, and for the IH sites, one for intestinal defect, three for transverse mesocolon defect and two Peterson defect respectively. There was a significant difference about IH rate between interrupted suture and running suture groups (p = 0.011), and there were no significant differences between the other two groups.ConclusionCompare with interrupted suture, running suture may prevent IH after LRYGB. Patient’s gender, age, body mass index(BMI), glycometabolism condition, and Roux limb position and suture material had no effects on the IH prevalence after LRYGB.

The nephrogenic adenoma of the bladder: 8 cases and literature review

Objective To analyze the clinical characteristics of nephrogenic adenoma of the bladder. Methods The clinical and pathological data of 8 patients with bladder nephrogenic adenoma, during the period from July 2016 to June 2019, were retrospectively analyzed. Patients’ age were 33 to 71 years old and the average age was 55, including 5 males and 3 females. The clinical manifestations were hematuria in 7 cases, urinary tract irritation in 6 cases, and no obvious symptoms in 1 case. There were 7 cases with cystitis, 3 cases with urolithiasis, 2 cases with bladder cancer, 1 case with invasive colonic mesentery fibroma, and 1 case without other complications. 5 cases had the history of urological operation. The predilection site was the lateral wall with 5cases; 5 cases were solitary; the average maximum diameter of the tumor was 0.9 cm (range 0.1-1.8 cm). Under cystoscope, papillary mass can be seen, the surface is bright red, the pedicle is not obvious, the papilla is thick and short, easy to bleed when touching; some of them are scattered and lichen like changes. All patients received transurethral resection of bladder mucosa. Results Pathological examination shows that the bladder mucosa showed chronic inflammation, interstitial edema, granulation tissue hyperplasia, eosinophil infiltration and metaplasia of mesonephroid epithelium. All of the 8 patients were followed up by telephone for 2 to 38 months, with an average of 17.1 months. So far, neither recurrence has been detected. Conclusions The diagnosis of nephrogenic adenoma of the bladder depends on pathological examination. It must be totally removed during operation. The recurrence and malignancy should be treated in time after operation. Key words: Urinary bladder neoplasms; Nephrogenic adenoma; Pathology

Resistive Index Value of Superior Mesenteric Artery In Preterm Infants With Necrotizing Enterocolitis

Aims: to find out the comparison of RI values of superior mesenteric artery inpremature infants with NEC and without NEC.Material and methods: This study was an observational analytic study, with acase-control study design, where the sampling method was using consecutive samplingin the NICU Room, Anturium and Radiology Department Dr. Hasan Sadikin GeneralHospital Bandung from September to October 2019. Data processing uses unpairedT-test.Results: The total sample was 22 subjects, consisting of 11 with positive NEC and11 negative NEC, with an average gestational age of 31.36 weeks and an average birthweight of 1490.45 grams. In the positive NEC group, the average RI value was 0.90and in the negative NEC group, the average RI value was 0.70. Statistical test resultswith unpaired T-test showed that there was a statistically significant increase in thevalue of superior mesenteric artery RI in premature infants with NEC compared topremature infants without NEC with a p-value = 0.0001 (p-value < 0.05).Conclusion: There was an increase in the value of superior mesenteric artery RIin premature infants with NEC compared to premature infants without NEC with avalue of p = 0.0001 (p-value <0.05).Key words: Necrotizing Enterocolitis–Superior Mesenteric Artery–Ultrasonography

Primary mesorectal carcinoid tumour, a case report and review of literature

: Carcinoid tumours of unknown origin (CUO) are rare and account for only 10% of carcinoid tumours (1). Utilisation of 68-gallium Dotatate positron emission computerised tomography (PET-CT) offers increased sensitivity and characterization of CUO, compared to traditional Octreotide scans (2). Development of this may allow investigation into the mesentery as a potential primary site. A 55-year-old woman was referred with a 4-month history of proctalgia and obstructive defecation. Digital rectal examination (DRE) revealed a posterior retro-rectal mass. Computerised tomography (CT), biopsy and octreotide scan along with elevated serum chromogranin A levels confirmed a carcinoid mass in the mesorectum, distinct from the bowel wall. Laparoscopic ultra-low anterior resection with ileostomy formation was performed. Eighteen months post-operatively, surveillance CT thorax, abdomen and pelvis (TAP) highlighted an enlarged lymph node in the right external iliac chain, which was positive on gallium PET-CT. Following multidisciplinary (MDT) discussion, a laparoscopic right obturator lymph node resection was undertaken after which post-operative histology confirmed metastatic well-differentiated neuroendocrine tumour. Management of CUO is challenging and as such should be individualized with an MDT-based approach. The mesenteric organ should be considered as a potential primary site in the setting of mesenteric carcinoid when no other primary focus is identifiable. Future guidelines should reflect this.