Mesenteric Research Articles

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.

The sigmoid take-off: An anatomical imaging definition of the rectum validated on specimen analysis

BackgroundA pre-operative imaging landmark to define the rectum would optimise clinical care of rectal cancer patients and research efforts to improve outcomes. The sigmoid take-off has been suggested as an imaging landmark for the rectosigmoid junction (RSJ). This study aimed to investigate whether this imaging definition of the rectum was validated by surgical specimen analysis. MethodsThis prospective study recruited 20 patients undergoing surgery and undertook radiological and pathological analysis of their rectal specimens. The radiological landmark of the sigmoid take-off was identified on pre-operative magnetic resonance imaging (MRI), and the distance to the anterior peritoneal reflection was measured by two readers. After surgery, the distance from the beginning of the sigmoid mesocolon to the anterior peritoneal reflection to the beginning of the sigmoid mesocolon on the specimen was measured, and compared to the distance on MRI using Pearson's Correlation Coefficient and Bland-Altman plots. ResultsIn 17 patients, the mean distance from the anterior peritoneal reflection to the RSJ on MRI was 20.3 mm and 23.1 mm for two readers, and on pathology was 20.6 mm. The mean differences between MRI and specimen measurements were −0.31 mm (−2.83 to 2.20 mm), and 2.51 mm (95% confidence interval −0.31 to 5.33 mm) for each reader, with correlation coefficients of 0.77 and 0.81. ConclusionThe sigmoid take-off has been validated on specimen analysis to be an imaging landmark that defines the termination of the rectum. This anatomical landmark can be used to classify tumours and guide treatment and research of sigmoid colon and rectal cancer.

Plicated Sleeve Gastrectomy with Combined Mesocolon and Greater Omentum Fixation After T-Shaped Omentoplasty: How to Do it?

This technique aims to evaluate fixation of the sleeved distal part of the stomach to the root of the transverse mesocolon and greater omentum after its shortening in a T-shaped design. Sleeve gastrectomy is done in a standard five-port technique. Then, we fix the distal end of the staple line using an inverting interrupted 2/0 Ticron suture. We plicate the anterior and posterior walls to invert the staple line and then fix it to the mesocolic fat below the pancreas and to the edge of the disconnected distal omentum close to the antrum. Proceeding caudally, we shorten the greater omentum in the form of a T-shaped suture that forms an omental window between the two edges of the omentum. Plication and fixation are continued upwards until the lower border of the pancreas. Then, we plicate the sleeved stomach using a 2/0 Ticron suture starting cranially near the angle of His. All patients are discharged from the hospital the next day and followed-up at the clinic after the end of first and second weeks, then after 3, 6, and 12 months postoperatively. Plicated sleeve gastrectomy combined with mesocolon and greater omentum fixation after T-Shaped omentoplasty is safe and feasible. Long-term follow-up study is required to validate our results.

Analysis of clinical features of 14 infants with Takayasu arteritis

Objective To improve the understanding and diagnosis and treatment level of infant with Takayasu arteritis (TA) by analyzing the clinical features of 14 pediatric patients and reviewing related articles. Methods The clinical and follow-up data of infants with TA who were admitted to the Children′s Hospital Affiliated to Capital Institute of Pediatrics between July 2016 and May 2019 were retrospectively analyzed.By reviewing related articles, the clinical features of this disease were summarized. Results The age of 14 patients (including 6 males and 8 females) were between 1 month and 23 days and 28 months.The most common clinical manifestations were fever in 10 cases (71.4%), hypertension in 9 cases (64.3%), weak or no pulse in 5 cases (35.7%). According to the clinical type of lesion vessels, 11 cases (78.5%) were generalized type, 3 cases (21.4%) were brachiocephalic artery type, and there was no thoracic abdominal aorta or single pulmonary artery type in this group.Among 14 infants with TA, 12 cases had common carotid artery, carotid artery, subclavian artery, coronary artery and its branches (anterior descending branch, circumflex branch) involved (85.7%); 11 cases had renal artery involved (78.6%); 9 cases had radial artery involved (64.2%); 8 cases had abdominal aorta involved (57.1%); 6 cases had descending aorta involved (42.9%); 6 cases had thoracic aorta involved (42.9%); 6 cases had superior mesenteric artery involved (42.9%); 5 cases had femoral artery involved (35.7%); 5 cases had pulmonary artery involved (35.7%); and 4 cases had brachial artery involved (28.6%). In those 14 patients, 11 cases were misdiagnosed, and 3 cases had unclear diagnosis, with misdiagnosis duration of 18 days to 2 months.In misdiagnosed cases, 8 cases were misdiagnosed as atypical Kawasaki disease.Among those 14 cases, the ranges of most lesions were gradually decreased, and the slightly involved vessels even completely returned to normal state after treatment in 7 cases.The vascular imaging showed no significant exacerbation or improvement in 4 cases.Nine cases developed hypertension, the blood pressure of whom could be controlled within normal range with hypotensive drugs which could not be interrupted.Physical examination found weak or no pulse in 5 cases who were not improved.Among 14 patients, 7 cases showed normal development, while the height and body mass of another 7 cases were the 25th percentile below those of normal children of the same age.All 14 patients were followed up for 2-22 months and received regular treatment without recurrence. Conclusions TA patients aged less than 3 years tend to have more blood vessels involved, be in serious condition and have higher rate of misdiagnosis.The disease can be controlled quickly after treatment, but vascular diseases may be developed easily.Some patients have a poor prognosis. Key words: Infant; Takayasu arteritis; Clinical features

Laceration of the transverse mesocolon in an old man with a habit of abdominal massage for constipation: a case report

BackgroundAbdominal massage for the resolution of constipation has been reported to be safe and recommended in some studies. It is conventionally performed for the elderly suffering from intractable constipation. Meantime, isolated mesenteric injury after blunt abdominal trauma is uncommon. Here, we report a case of isolated mesenteric injury following self-abdominal massage for constipation.Case presentationA 68-year-old man consulted a local hospital due to a sudden abdominal pain. He had a history of prostate cancer treated with radiation therapy 3 years ago, and he had been suffering from chronic constipation for many years. A plain computed tomography (CT) revealed a fist-sized homogeneous mass-like lesion located in the left upper abdomen and a moderate amount of ascites. With the initial diagnosis of a malignant tumor accompanied by peritonitis carcinomatosa, he was hospitalized for further examinations. On the next day, his hemoglobin concentration dropped from 11.6 to 6.6 g/dl, and diagnostic paracentesis showed bloody ascites. He was urgently transferred to our tertiary emergency center. An enhanced CT demonstrated a non-enhanced, homogeneous, 8.5 cm in diameter, mass lesion located to the posterior of the stomach with massive bloody ascites. He underwent an emergency exploratory laparotomy, and it showed a 5 cm of laceration in the transverse mesocolon adjacent to Treitz’s ligament and approximately 1.5 l of intraabdominal hemorrhage. Hemostasis of the bleeding from the laceration was achieved by suture ligations, but the gap of the laceration could not be closed by suturing because the tissue was too fragile. Blood transfusion with 4 units of packed red blood cells and 10 units of fresh frozen plasma was performed during operation. He was discharged without any significant complications except for postoperative paralytic ileus. Later on, it turned out that he had a habit of massaging his abdomen for the resolution of intractable constipation and did it hard 1 day before the onset.ConclusionsThis is the first report of life-threatening mesenteric injury caused by self-abdominal massage to resolve constipation, though other etiologies such as rupture of small aneurysms could not perfectly be excluded. Abdominal massage is reported to be effective and safe for the resolution of constipation; however, this case demonstrated it could be detrimental.

Massive Chylous Ascites and Chylothorax Secondary to Chronic Pancreatitis: A Novel Surgical Option

Abstract Background Chylous ascites is a debilitating condition characterized by milky, triglyceride-rich fluid accumulating in the peritoneum due to disruption of the intraabdominal lymphatic system. Medical management includes low-fat diets, somatostatin analogues, and therapeutic paracentesis, but is unsuccessful in one-third of patients. Methods We present a 59-year-old man with massive chylous ascites and chylothorax secondary to chronic pancreatitis, who failed medical therapies for nearly two years, before being successfully treated with a novel surgical technique. Demographic and clinical data were obtained from the electronic medical record at Massachusetts General Hospital from 2015 to 2019. Patient information was kept anonymous and informed consent was obtained for publication of this report. Results Based on a previously published small case series, we created a vascularized lymphatic cable flap based on the superior epigastric vessels, which we anastomosed to mesenteric vessels, permitting chylous drainage superiorly through the thoracic duct. With two years of follow-up, our patient has no evidence of recurrent ascites or chylothorax, and robust nutritional and functional status. Conclusion We present this novel surgical technique as a promising intervention for patients with chylous ascites and/or chylothorax who have failed medical management.

Wilkie's syndrome - An unusual presentation in an elderly female

Wilkie's syndrome, also called as superior mesenteric artery syndrome (SMAS), is an extremely uncommon condition, which is evident in only 0.1%–0.3% of the population. This is a case of a 55-year-old female who presented to our hospital complaining of abdominal discomfort for 20 days, vomiting of two episodes per day for 20 days, constipation for 20 days, decreased appetite for 20 days, and significant weight loss. After further examination and investigations, it was diagnosed as SMAS and managed surgically through duodeno-jejunostomy followed by duodeno-jejunal and jejuno-jejunal anastomosis. She was later followed through conservative management and discharged from the hospital in a stable condition.

Bilioptysis due to a single transcavitary thoracoabdominal gunshot wound

A 27-year-old man was transported to our trauma center after sustaining a single gunshot wound. On arrival, he was hemodynamically stable and neurologically intact, with a non-tender abdomen and negative...

Extrauterine Adenomyoma Invading the Sigmoid Mesocolon in the Pelvic Cavity

Adenomyomas are benign tumors typically located in the uterus, and extrauterine adenomyomas are rare, especially those in the sigmoid mesocolon. Extrauterine adenomyomas resemble the uterine structure and can occur anywhere in the pelvic cavity or abdomen. Here, we present 2 cases of extrauterine adenomyomas invading the sigmoid mesocolon.

Petersen's space hernia - An expanding diagnosis after bariatric surgery: A case report and review of literature

Petersen's hernia refers to an internal herniation of small bowel through the potential space between the transverse mesocolon and the Roux limb of gastrojejunal anastomosis. The incidence of this is increasing with the widespread practice of bariatric surgery in the last decade. In this report, we present the case of a 44-year-old male who had undergone a laparoscopic Roux-en-Y gastric bypass for morbid obesity and presented after 14 months with a history of nonspecific abdominal pain. The examination of his abdomen was unremarkable. The computed tomography scan revealed the suspicious features of internal herniation of the small bowel and a twist in the mesentery. On diagnostic laparoscopy, he was found to have Petersen's space hernia. His clinical presentation, investigations, and treatment have been highlighted in this case report with a review of the literature. Although rare, Petersen's hernia could lead to a disastrous complication of small bowel strangulation if not intervened early. Hence, if suspected, the threshold to perform a diagnostic laparoscopy should be low.

Spectrum of Acute Non Traumatic Diffuse Secondary Peritonitis in the Tropics

Background: Peritonitis is one of the most common surgical emergency in tropical countries. It is still a significant cause of mortality and morbidity. This study aimed to describe the aetiology of acute non traumatic diffuse secondary peritonitis (ANDSP) and to report the outcome after treatment. Material and Methods: A retrospective survey of patients with ANDSP was carried out from January 2007 to December 2016 in the Digestive and General Surgery Service of Bouaké Teaching Hospital in the central part of Côte d’Ivoire. The hospital is a tertiary referral centre and serves urban and rural population from Bouaké’s agglomeration but also from the whole central and northern parts of the country. During the study period, all patients found to have at laparotomy ANDSP were included. The analysed variables include epidemiologic charts, clinical presentation, cause of peritonitis, surgical treatment, postoperative outcome and prognostic factors. Results: Over the studied period 626 cases of ANDSP were operated on. The main aetiologies were gastroduodenal peptic ulcer perforation (n = 252, 41.1%), typhoid ileal perforation (n = 207, 33%) and appendicular peritonitis (n = 123, 19.6%). The mean duration of hospital stay was 13.8 ± 9.6 days (range 8 - 87 days). The length of hospital stay was significantly influenced by postoperative complications (23.5 ± 5.4 days versus 10.8 ± 2.7 days P = 0.000000). Two hundred and sixty one postoperative complications were recorded in 242 patients (38.6%) with wound infection being the commonest postoperative complication. A repeat laparotomy was indicated in 73 patients. Eigthy (n = 80) patients died (mortality 11.2%). Risk factors for death were hemodynamic shock, ASA > II, Age ≥ 60 years, M PI > 29 and digestive sutures performed in septic environment below the transverse mesocolon. Conclusion: The spectrum of aetiology of ANDSP in this tropical area is different from the one observed in the Western countries. Proper treatment of typhoid fever and amoebiasis can reduce the incidence of peritonitis. Early consultation together with adequate resuscitation and surgical management can improve the prognostic which still remains poor.

Solitary Fibrous Tumor in Pelvis Extended to Transverse Mesocolon and Peritoneum

Solitary fibrous tumor (SFT) is a rare, spindle-cell neoplasm, which is classified as mesenchymal neoplasm emanating from ubiquitous dendritic interstitial cells. SFTs are benign tumor with a low rate of malignancy developed in intrathoracic areas and its growth is rarely observed in extrapleural locations. Based on to the rarity of malignant SFT, there is no certain treatment to the inoperable malignant. This case study is a report of a man with SFT of the pelvis, transverse mesocolon, and peritoneum. So far, more than 58 patients with SFT of the pelvic have been reported in the literature, out of which 26% of them were malignant either clinically or histologically. The female/male ratio was equal within the age range of 27–83 years. The size of reported tumors were ranged 1–33 cm. Malignancy were reported in 26% of cases.

Comparison of Intracorporeal or extracorporeal placement of stapler anvil in colorectal NOSE surgery

Aim: The aim of this study is to compare the results of the patients for whom intracorporeal or extracorporeal anvil insertions were performed. Natural orifice specimen extraction (NOSE) surgery has been started from the 21st century onwards in order to reduce wound-related complications of laparoscopy. Two types of anvil placements, including intracorporeal or extracorporeal placements, are used in the application of NOSE, which is combined with distal colorectal surgery. Material and Methods: We retrospectively collected the data from 77 patients who underwent laparoscopic distal colorectal surgery combined with NOSE in our clinic between 2013 and 2019. Patients were evaluated in two groups as intra-corporeal and extracorporeal. Selection of the technique was based on the length of sigmoid colon and mesocolon. Demographic data, operative findings, pathological results and follow-up information were evaluated.Results: Of 77 patients who underwent distal colorectal surgery and circular stapler anastomosis; 44 were in the intracorporeal group and 33 were in the extracorporeal group. There was no difference between the two groups in terms of gender, age, BMI, comorbidity, and abdominal operation history of patients. The number of patients undergoing low anterior resection was higher in the extracorporeal group, and also the number of patients undergoing anterior resection was higher in the intracorporeal group. Peroperative findings, intraoperative and postoperative complications of patients were similar in both groups. The postoperative first-day pain scale was lower in the intracorporeal group (3.3±2.1 vs. 4.4±2.3, p=0.03). No significant difference was found between the two groups in other pain scales and cosmetic scores. The oncologic results were similar during the mean follow-up of 35.5±24.1 months.Conclusion: Although anvil placement techniques are not interchangeable, it is seen that neither method predominates the other in cases where both are suitable.

Right sided sigmoid colon and oblique descending colon with its embryological basis and clinical significance

Embryological development of the colon is complex and often unpredictable, leading to variations in the length and position. During routine dissection for undergraduate students in the Department of Anatomy, BLDE DU) Shri B. M. Patil Medical College and Research centre we found rare variations in the disposition of large intestine and inferior mesenteric artery in two male elderly cadavers. Case 1: The caecum and appendix were present in the right lumbar region, ascending colon is short, descending colon crossed the great vessels of the abdomen from left to right obliquely and sigmoid colon was present in the right iliac fossa below caecum and appendix. Inferior mesenteric artery arose from the right side of the ventral surface of the abdominal aorta to supply the left one-third of transverse colon, splenic flexure, descending colon, sigmoid colon. Case 2: same variations as in the first case with Sigmoid mesocolon adhered to mesentery near the ileocaecal junction. These variations may be helpful for the radiologists and Surgeons while undertaking an investigative or surgical procedure.

A Difficult-to-diagnose Case of Sigmoid Mesocolon Endometriosis

A Difficult-to-diagnose Case of Sigmoid Mesocolon Endometriosis

INTESTINAL MALROTATION IN 35 YEAR OLD WOMEN FROM PESHAWAR, PAKISTAN

Thirty five years old women presented to the Accident and Emergency Department with acute onset right upper quadrant abdominal pain with normal vitals. CT images revealed a malrotation causing midgut volvulus and intestinal obstruction. On emergency exploratory laparotomy, the gut loops showed partial ischemia due to a double twist at the root of mesentery and malrotation of the gut along with the caecum which was mobile coming from left iliac fossa and lying in the right iliac fossa. Duodeno-jejunal junction was identified. The coils of the intestine were untwisted and rotation was corrected. The gut color changed back to normal. She was discharged painless after routine post-operative care.

Surgical treatment of patients with duodenal fistulas and duodenal injuries

The aim — to improve the treatment results of patients with external fistulas of duodenum (EFD) and retroperitoneal duodenal lesions of the by selecting the optimal surgical procedure and determining the most effective treatment for duodenal fistulas of different etiology.Materials and methods. The results of treatment of 29 patients (19 men and 10 women) aged from 24 to 72 years; from 2002 to 2016 with external unformed high flow complete duodenal fistulas were analyzed. In 6 patients with external unformed high flow complete duodenal fistulas, emergency surgery was performed according to urgent indications (group I). In 9 patients with damage to the II‑B part of the duodenum was formed behind the transversal colon Roux‑en‑Y anastomosis with the exception of duodenum (group II). Multi‑staged surgery was performed in 8 patients with iatrogenic lesions of the retroperitoneal descended (II‑A and II‑B) parts of the duodenum and retroperitoneal phlegmon (group III). A resection of the lower horizontal part of the duodenum was performed in 2 patients with damage of the III (lower horizontal) duodenal part, with the duodenal — jejunal anastomosis formation on the small intestine loop with stoma. In 2 patients with aortal‑duodenal fistulas after the end of the vascular stage of the operation performed resection of the duodeno‑jejunal anastomosis in front of the root of the mesentery (group IV).Results and discussion. Early surgical intervention with the gastroenteroanastomosis behind the colon transverse with duodenum disabling is consider to be the optimal treatment method for high duodenal EF, which helps to reduce the fistula elimination time and to early rehabilitation of patients. External drainage of common bile duct is considered to be a mandatory stage of surgical treatment of duodenal EF, which is developed as a result of pancreatic necrosis or iatrogenic damage during endoscopic retrograde cholangiopancreatography and endoscopic papillosphincterotomy. Early enteral probe nutrition is essential condition for adequate management of patients in the postoperative period.Conclusions. Active surgical tactics with early surgery prevent the development of purulent‑septic complications and electrolyte disorders, especially in the case of lesions of the retroperitoneal part of the duodenum. An individual approach to the choice of the method of exclusion from the passage of the duodenum in a short mono‑ or long loop allows to reduce the flow of the damaged intestine and to reduce the possibility of fatal postoperative complications.

Application value of CT/MRI examination in clinical diagnosis and treatment of Crohn′s disease

Accurate evaluation of Crohn′s disease is critical for determination of a therapeutic plan. Computed tomography (CT)/magnetic resonance imaging (MRI) can not only display the intraluminal and intraperitoneal inflammation objectively, but also reveal accurately the affected mesentery and related complications comprehensively, which attracted more and more attention in recent years. This review discussed the choice of CT/MRI examination methods, their roles in determining the severity of intestinal and mesenteric inflammation, the nature of intestinal stenosis, the extent of fistula, abscess and cellulitis, and the value in diagnosing postoperative complications, in order to investigate the application value of CT/MRI examination in clinical diagnosis and treatment of Crohn′s disease. Key words: Crohn′s disease; Computed tomography; Magnetic resonance imaging; Clinical diagnosis; Clinical treatment

Variations and subtypes of gastrocolic trunk and its significance in colon cancer surgery

With the increasing standardization of right colon cancer radical resection, more emphasis is put on keeping the mesentery intact along with vascular root ligation and extensive lymph nodes dissection which inevitably demands higher level of surveillance on the possible complications especially around gastrocolic trunk with large variation of tributary and complex vascular course, to achieve a successful surgical and oncological outcome. This article discusses the complex anatomy of the gastrocolic trunk and its implication in the choice of surgical approaches. Key words: Colonic neoplasms; Surgical procedures, operative; Review; Henle′s trunk

Therapeutic effects of an azaphenothiazine derivative in mouse experimental colitis.

Phenothiazines represent a class of compounds of potential therapeutic utility. In this report we evaluated therapeutic value of an azaphenothiazine derivative, 6-acetylaminobutyl-9-chloroquino[3,2-b]benzo[1,4]thiazine (QBT), given intragastrically, in the model of dextran sodium sulfate-induced colitis in C57BL/6 mice using 5-aminosalicylic acid (5-ASA) as a reference drug. Colitis symptoms such as body weight loss, diarrhea and hematochezia (blood in stool) were observed and registered and disease activity index (DAI) was calculated. In addition, weight and cell numbers in the lymphatic organs and histological parameters of the colon wall were analyzed. The effects of QBT on viability of colon epithelial cell lines were also determined. We showed that weight and cell number of draining mesenteric lymph nodes were lower in mice treated with QBT in comparison to their control counterparts. The number of thymocytes, drastically reduced in control mice, was elevated in mice treated with the compounds with a significant effect of 5-ASA. In addition, an abnormal composition of blood cell types was partially corrected in these groups. Histological analysis of the colon revealed that the pathological changes were partially normalized by QBT and even to a higher degree by 5-ASA. In conclusion we demonstrated a therapeutic efficacy of the compound in amelioration of local and systemic pathological changes associated with chemically-induced colitis in mice. A possible mechanism of action of the compound is discussed.