Paracolic Gutter Research Articles

7682 Triglyceride Tango: when Triglycerides take legs for a spin

Abstract Disclosure: D. Misra: None. M.R. Brennan: None. L. Misra: None. M. Kiryakoza: None. A 33-year-old male with no significant medical history presented with acute abdominal pain and n/v. The patient stated his RLQ pain extended down his R. leg resulting in weakness. He was on no medications at home. Vitals signs were stable, and the physical exam revealed diffuse abdominal tenderness in the RLQ and R. flank area with guarding, but no rebound and Neuro exam showed 4/5 strength in the RLE, the rest of the neuro exam was non-focal. Labs revealed an elevated lipase > than 3 times the upper limit and an elevation in transaminases. Other labs including blood glucose and white blood cell count were normal. CT was also performed and revealed significant inflammatory stranding of the pancreatic head and neck along the duodenum. The working diagnosis was pancreatitis. IV fluids were started, and the patient received IV Dilaudid for pain. There was no improvement in his symptoms overnight, so an abdominal CT was repeated. Imaging showed an interval development of a phlegmon and free fluid along the right paracolic gutter extending to the porta hepatis. The patient’s lipid panel revealed a triglyceride level of >1420 mg/dl. Endocrine was consulted and recommended initiation of a fenofibrate and atorvastatin. Although the patient was not a diabetic, endocrinology gave 20 units of basal insulin to the patient (Lantus). Within 24 hours of initiating basal insulin, the triglycerides fell to 680 mg/dl and the patient’s symptoms resolved. The patient was discharged home on day #3 on fenofibrate 160 mg/day and atorvastatin 40 mg/day. The patient was told to follow up with PCP for dyslipidemia and additional work up for transient right sided weakness. The two commonest causes of pancreatitis are alcohol and gallbladder disease, but it is important to entertain other causes. A lipid panel was drawn due to both pancreatitis and the right sided weakness, both of which resolved with the lowering of triglycerides. It is uncertain if hypertriglyceridemia is directly attributed to the right sided weakness, although neurologic findings due to hyperviscosity syndrome in hypertriglyceridemia have been described. If a causal relationship can be established, additional therapy such as anti-platelet therapy should be considered. This case also demonstrates that severe hypertriglyceridemia can be controlled with oral medications and subcutaneous insulin, even in non-diabetics, as opposed to IV insulin which could shorten hospital stays and decrease medical costs. Presentation: 6/3/2024

Atraumatic Hepatic Laceration with Hemoperitoneum.

Introduction: A rare case of atraumatic liver laceration associated with hemoperitoneum is presented in a patient with amyloidosis who came to the hospital for abdominal pain. Case Presentation: The imaging findings reveal significant hepatomegaly with finely heterogeneous hepatic density and subcapsular hypo-dense streaks in segments VI and VII, likely representing lesions. Post-contrast enhancement shows a punctiform contrast medium extravasation within the subhepatic fluid collection, visible from the arterial phase and intensifying in subsequent study phases. Discussion: These imaging findings suggest an atraumatic hepatic laceration, a diagnosis confirmed by the presence of hemoperitoneum distributed bilaterally under the diaphragm, in the paracolic gutters, along the mesentery root, and predominantly in the peri-hepatic region. Conclusion: The detailed imaging analysis provided critical insights into the diagnosis and management of this rare clinical presentation.

Unsuspected Isolated Peritoneal Metastasis of Prostate Cancer Detected with Digital F-18 PSMA PET/CT Scan.

We report the case of a prostate cancer (PC) patient referred to our center to perform F-18 prostate-specific membrane antigen (PSMA) digital positron emission tomography / computed tomography (PET/CT) scan for biochemical recurrence. PET/CT was unremarkable except for a tiny PSMA-expressing nodule on the right paracolic gutter, which increased in size and PSMA-expression on repeat imaging. Excision of the lesion was consistent with PC peritoneal metastasis. The isolated location of the lesion was atypical for PC metastasis. In the era of highly sensitive digital PET/CT detectors, it is always important to investigate abnormal uptake of F-18 PSMA regardless of the location.

A new sight to acute pancreatitis through paracolic gutter exudation, a multicenter retrospective study

ObjectivesParacolic gutter exudation (PGE) may influence the severity of acute pancreatitis, but no study has explored it extensively. The objective of this study was to evaluate PGE for assessing the severity of disease. MethodsWe performed a retrospective analysis of 488 patients from three tertiary hospitals in Guangxi, China. General clinical information, severity, and clinical courses were recorded. The PGE score were classified as follows: 0 for no exudation, 1 for unilateral exudation, and 2 for bilateral exudation. We used ROC curves to assess the predictive value of the PGE score, and logistic regression analysis to determine risk factors associated with death, ICU admission, and the occurrence of MODS. ResultsThis study included 352 patients with moderately severe acute pancreatitis (MSAP) and 136 patients with severe acute pancreatitis (SAP). Patients who had PGE experienced higher total hospitalization costs, longer hospital stays, a higher incidence of SAP, higher mortality rates, higher ICU admission rates, a higher incidence of MODS, and higher incidence of infections than those without (P < 0.05). Diagnostic efficacy in predicting severity in patients with MSAP and SAP increased after BISAP, MCTSI, modified Marshall, and SOFA scores combined with PGE score respectively. The PGE score of >1 is an independent risk factor for ICU admission and MODS occurrence. (P < 0.05). ConclusionThe PGE provides reliable and objective information for assessing severity and clinical course of patients with MSAP and SAP.

A New Step-Up Dual Endoscopic Approach for Large-Size Infected Pancreatic Necrosis: Percutaneous Endoscopic Necrosectomy Followed by Transluminal Endoscopic Drainage/Necrosectomy.

Acute pancreatitis in 10% to 20% of cases can be associated with necrosis of the pancreatic gland, peripancreatic tissue, or both. We report a case series of a new endoscopic approach to treat infected pancreatic necrosis (IPN). Consecutive patients with IPN, extending from the perigastric area up to the paracolic gutters or into the pelvis, were prospectively studied from January 2017 to June 2022. The treatment protocol was radiologic percutaneous drainage as the first step, followed by fully covered metal stent placement (FC-SEMS) in the track of the catheter. Percutaneous endoscopic necrosectomy (PEN) was performed 2 to 4 days later using a flexible endoscope through the percutaneous tract. About 2 to 4 weeks later, when a matured sac was visible, EUS-guided endoscopic transluminal drainage (ETD) with lumen-apposing metal stents (LAMS) was performed. Control of sepsis with resolution of collection(s) was the primary outcome measure. We included 18 patients, males in 50% of cases with age 60±12 years old. Most frequent cause of pancreatitis was biliary (7 cases) followed by alcoholic in 6 cases; in 3 cases pancreatitis was caused by hyperlipemia and in 2 cases was idiopathic. Mean size of WON was 18±2cm. For PEN, SEMSs used were esophageal FC-SEMS. LAMS used for ETD were Hot Axios, Hot Spaxus and Nagistent. Mean time of endoscopic intervention for PEN and ETD was 18±3 and 37±4 days, respectively. In 5 cases adverse events occurred: 3 cases of overinflations resolved with introduction of Verres needles in abdomen. In 2 cases postprocedural GI bleeding required endoscopic intervention. In all cases control of sepsis was reached together with resolution of collections. No cases of deaths were observed. Step-up percutaneous and transluminal endoscopic necrosectomy therapy is an effective strategy for large-size IPN with combined central and peripheral necrosis.

A Novel Peritoneal Packing Method for Management of Hyperkalemia During Acute Kidney Injury in Trauma.

United States Military operations in resource limited areas are increasing. Furthermore, future peer or near-peer conflicts will require caring for larger numbers of casualties with limited resources. In this setting, traditional renal replacement therapy is not feasible and novel methods are required to address severe acute kidney injury in austere environments lacking definitive therapies. Here, we describe experiments designed to determine the efficacy of a novel peritoneal packing material (Potassium Binding Pack-PBP, CytoSorbents INC) for the acute management of severe hyperkalemia. Male swine (52 ±1 kg) were nephrectomized via midline laparotomy under a plane of anesthesia and randomized into one of two experimental groups (PBP & CON). Exogenous potassium was infused to achieve a serum potassium level of 7.5 mEq/L. Novel potassium absorbing packs (PBP) or sham packs (CON) were placed in the right and left upper quadrants, and the right and left paracolic gutters of the abdomen to simulate four-quadrant packing (n = 6, n = 5, respectively). Two liters of peritoneal dialysis fluid was instilled into the abdomen and temporary closure performed. Animals were observed for 12 hours. Serum and peritoneal fluid (dialysate) potassium levels were sampled at T = 15, 30, 60 min, and Q60min thereafter. Animals were humanely euthanized at the end of the observation period. Baseline characteristics were similar between groups. Pairwise analysis showed that serum potassium concentrations were significantly lower in the PBP group compared to CON at T = 540 and T = 720 (P = 0.006 and P = 0.015, respectively). Potassium concentrations were significantly lower in dialysate of the PBP group compared to CON at all time points after T = 15 (T = 30, P = 0.017; T = 60 through T = 720, P < 0.001). This is the first demonstration of an effective technology for the management of hyperkalemia in trauma in the absence of standard of care; renal replacement therapy. We identified that PBP was able to consistently maintain a concentration gradient between dialysate in the peritoneum and system potassium concentration throughout the experiment. Furthermore, systemic potassium concentrations were reduced in a clinically relevant manner in the PBP group compared to CON. This suggests that peritoneal packing technology for the management of metabolic disturbances in trauma has potential for clinical application. These results are preliminary and should be interpreted with caution.

Intestinal Obstruction due to an Internal Hernia in the Paracolic Gutter of the Descending Colon—A Case Report—

Intestinal Obstruction due to an Internal Hernia in the Paracolic Gutter of the Descending Colon—A Case Report—

Risk factors for adverse outcomes at various phases of endoscopic ultrasound-guided treatment of pancreatic fluid collections: Data from a multi-institutional consortium.

No comprehensive study has examined short- and long-term adverse outcomes of endoscopic ultrasound (EUS)-guided treatment of pancreatic fluid collections (PFCs) including walled-off necrosis (WON) and pseudocysts. In a multi-institutional cohort of 357 patients receiving EUS-guided treatment of PFCs (228 with WON and 129 with pseudocysts), we examined PFC type-specific risk factors for procedure-related adverse events (AEs), clinical failure, and recurrence. Odds ratios (ORs) and hazard ratios (HRs) with 95% confidence intervals (CIs) were computed using the logistic and Cox regression models, respectively, adjusting for potential confounders. Adverse events were observed predominantly in WON, and risk factors were WON extension to the pelvis (OR 2.49; 95% CI 1.00-6.19) and endoscopic necrosectomy (OR 5.15; 95% CI 1.61-16.5). Risk factors for clinical failure in WON treatment included higher Charlson Comorbidity Index (OR for ≥3 vs. ≤2, 2.58; 95% CI 1.05-6.35), extension to the pelvis (OR 3.63; 95% CI 1.57-8.43), nonuse of a lumen-apposing metal stent (OR 2.88; 95% CI 1.10-7.54), and percutaneous drainage (OR 3.73; 95% CI 1.27-10.9). Patients with pseudocysts extending to the paracolic gutter and the need for more than two endoscopic/percutaneous procedures had ORs for clinical failure of 5.28 (95% CI 1.10-25.3) and 5.52 (95% CI 1.61-18.9), respectively. Pseudocysts requiring the multigateway approach were associated with a high risk of recurrence (HR 4.00; 95% CI 1.11-11.6). The adverse outcomes at various phases of EUS-guided PFC treatment may be predictable based on clinical parameters. Further research is warranted to optimize treatment strategies for high-risk patients.

Safety of Laparoscopic Appendectomy in Complicated Appendicitis in children

ABSTRACT&#x0D; INTRODUCTION: Acute appendicitis is one of the most common surgical emergency in pediatric age group. Laparoscopic Appendectomy (LA) is no more a new procedure in pediatric surgery. The idea behind laparoscopy is short hospital stay, minimal complications and better cosmesis especially in overweight and obese patients. Laparoscopy offers detailed and magnified visualization and better access into the whole abdominal cavity. In many pediatric surgery centers, laparoscopic management of acute appendicitis is practiced but we have observed that most of them performed laparoscopic appendectomy for simple straight forward appendicitis. It is generally considered that complicated appendicitis is better managed by open procedure. We have performed laparoscopy in 42 patients of Complicated Appendicitis (CA) and observed that the rate of complication is comparable to the known reported studies.&#x0D; OBJECTIVE: The objective of this study was to establish safety of laparoscopic appendectomy in complicated appendicitis in children&#x0D; STUDY DESIGN: It was a retrospective study.&#x0D; SETTING: Research was conducted at Department of Pediatric Surgery, Shifa International Hospital Islamabad.&#x0D; DURATION: Duration of study was 3 years after due approval from ethical and research review board.&#x0D; MATERIAL AND METHODS: The present study is a retrospective analytical review of 42 patients who were operated for complicated appendicitis laparoscopically at Shifa International Hospital, Islamabad from January 2018 to December 2020.&#x0D; All patients were enrolled from emergency department. Clinical assessment of the patients were done in the routine way by history and physical examination. Investigations included complete blood count, C reactive protein and ultrasound abdomen and pelvis. Those patients were excluded from the study who had simple non-complicated appendicitis, open appendectomy, those who had laparotomy for other reasons and interval appendectomy. Similarly those patients who were COVID positive were excluded from the study.&#x0D; All those patients who had complicated appendix like perforation, abscess, mass or gangrene were included in the study.&#x0D; Variables observed in this study were age, sex, operative findings, operative time, hospital stay and post op complications.&#x0D; RESULTS: From January 2018 to December 2020, total 42 patients were included in this study who underwent laparoscopic appendectomy for complicated appendicitis. Complicated appendicitis includes perforated appendicitis, abscess, mass or gangrene. Mean age of the patients was 9.95 with standard deviation of 3.22. Of 42 patients in total, 32 (76%) patients were male and 10 (24%) were female. Mean operative time was 42.5min with standard deviation of 20.03. Mean hospital stay time was 2.23 days with standard deviation of 1.55 (table 1).&#x0D; Out of total 42 patients, 20 (48%) had perforated appendicitis, 9 (21%) patients had appendicular mass, 12 (29%) patients had appendicular abscess and 1 (2%) patient had gangrenous appendicitis. Postoperatively, one patient of perforated appendicitis had trocar site infection. One patient had mass formation with partial obstruction and post-operatively developed urinary retention with peri-orbital puffiness. Two patients of appendicular mass had transaction of appendicular base due to perforated and sloughed appendicular base. One patient of appendicular abscess had large collection in right paracolic gutter. One patient of appendicular abscess developed peritonitis with abscess formation secondary to cecal perforation.&#x0D; CONCLUSION: Our experience with laparoscopy in appendicitis revealed that for complicated appendix laparoscopy is very safe in children with only fewer complications. Although our sample size is small but in our 3 last year experience we learned that laparoscopy may safely be done as a first choice in all patients with appendicitis, whether simple or complicated. Our experience indicates that the apprehension amongst the treating surgeons is not very justified as we routinely do laparoscopy in all appendicitis.&#x0D; KEY WORDS: Laparoscopic appendectomy, complicated appendicitis.

Paracolic Gutter Routing: A Novel Retroperitoneal Extra-Anatomical Repair for Infected Aorto-Iliac Axis.

We describe and analyze outcomes of a novel extra-anatomical paracolic gutter routing technique for surgical repair of aorto-iliac infections. A double-center, observational, cohort study of all consecutive patients with aorto-iliac infections treated using extra-anatomical paracolic gutter technique. Between May 2015 and December 2022, six patients with aorto-iliac infections were treated with the paracolic gutter routing technique. Cases were identified retrospectively in an institutional database, and data were retrieved from surgical records, imaging studies, and follow-up records. Aorto-bifemoral vascular reconstructions were performed using this technique in six patients. During mean follow-up of 52 ± 44 months, there was one case of graft thrombosis (17%) with subsequent successful thrombectomy. Primary and secondary graft patency rates were 83% and 100%, respectively. There was one mortality (17%) due to candida sepsis. All graft prostheses were patent at last follow-up. The paracolic gutter technique is a useful technique in patients with extensive aorto-iliac infections, arteriovenous and iliac-ureteric fistulas, or at a high risk of vascular graft infection and is associated with favorable reinfection and patency rates.

Possible Therapeutics for Pseudomyxoma Peritonei: A Rare, Lethal, and the Least Investigated Disease

AbstractPseudomyxoma peritonei (PMP) refers to a growth disorder characterized by glycoprotein neoplasm in the peritoneum, where mucin oversecretion occurs. The tumors of the appendix region are well associated with PMP; however, ovarian, colon, stomach, pancreas, and urachus tumors have also been linked to PMP. Other mucinous tumors in the pelvis, paracolic gutters, greater omentum, retrohepatic space, and Treitz ligament can be the reason for PMP. Despite being rare and having a slow growth rate, PMP can be lethal without treatment. It is treated with neoadjuvant chemotherapy with the option of cytoreductive surgery and intraperitoneal chemotherapy. In the current study, we hypothesize that there may be novel gentle ways to inhibit or eliminate the mucin. Dr. David Morris has used mucolytics—such as bromelain and N-acetyl cysteine to solubilize mucin. In the present review, we aimed to study the regulation of mucin expression by promoter methylation, and drugs that can inhibit mucin, such as boldine, amiloride, naltrexone, dexamethasone, and retinoid acid receptors antagonist. This review also explored some possible pathways, such as inhibition of Na + , Ca2+ channels and induction of DNA methyltransferase along with inhibition of ten-eleven translocation enzymes, which can be good targets to control mucin. Mucins are strong adhesive molecules that play great roles in clinging to cells or cell to cell. Besides, they have been greatly involved in metastasis and also act as disease markers for cancers. Diagnostic markers may have exclusive roles in disease initiation and progression. Therefore, the present review explores various drugs to control and target mucin in various diseases, specifically cancers.

Diagnosis and treatment of peritoneal carcinomatosis - a comprehensive overview.

Peritoneal carcinomatosis, which is the most common malignant process of the peritoneal cavity, originates mostly from colorectal, gastric, and gynaecological malignancies. The differential diagnosis is broad and covers primary peritoneal malignancies, as well as many benign disorders such as endometriosis, and inflammatory and infectious diseases. Peritoneal implants tend to locate in the areas of the physiological stasis of the peritoneal fluid: pelvic peritoneal reflections, right and left paracolic gutters, superior part of the sigmoid mesocolon, ileocolic area, and the right subdiaphragmatic space. The 3 most common imaging findings are ascites, nodular implants, and infiltration of the peritoneal fatty tissue. Several imaging modalities may be applied in patients with peritoneal carcinomatosis. Ultrasound has low sensitivity and specificity, and therefore plays only a marginal role. Computed tomography is the method of choice, due to its availability, cost-effectiveness, and relatively high sensitivity. The sensitivity of magnetic resonance imaging depends on the size of peritoneal implants - in cases of implants larger than 10 mm is comparable to CT. Some studies suggest that PET/CT may be the most sensitive method, yet its usefulness in everyday practice is controversial. The Peritoneal Carcinomatosis Index (PCI) is a scale used to assess the tumour burden in the peritoneum and may serve as a communication tool between clinicians and radiologists. The imaging findings may influence the surgeon's decision on performing cytoreductive surgery, which may be followed by intraperitoneal chemotherapy (HIPEC or EPIC procedures). The introduction of these therapeutic methods has significantly improved the life expectancy of patients with peritoneal carcinomatosis.

Peritonite meconial relacionada à doença hepática materna: relato de caso

Meconium peritonitis has been associated with cystic fibrosis, congenital infections, and bowel disease. A growing number of reports have also associated it with maternal liver disease. This report describes the case of a preterm newborn with meconium peritonitis born from a woman with liver disease and presents a review of the literature on the subject. A male preterm newborn weighing 2595g was admitted to the Neonatal Intermediate Care Unit due to an obstetric ultrasound scan performed at 31 weeks and 3 days of gestation showing calcifications of various sizes throughout his abdomen. His mother had autoimmune hepatitis and sclerosing cholangitis. Postnatal abdominal x-ray images showed calcifications in the liver and right paracolic gutter and abdomen ultrasound scans showed large peritoneal calcifications in the hepatic and splenic capsules and in the pouch of Morrison, in addition to calcifications in the right scrotum.

Spontaneous uterine artery rupture in a non-pregnant woman: A case report

Objective: Spontaneous uterine artery rupture in a non-pregnant woman is an extremely uncommon event. To date, there have only been a few cases. Patients often present with acute abdomen and are hemodynamically unstable. Case Presentation: A 42-year-old female presented with multiple episodes of syncopal attack associated with vomiting and generalized abdominal pain. Upon arrival, she was hypotensive which required aggressive fluid resuscitation with crystalloids and blood products. Urine pregnancy test was negative. In addition, ultrasound scan showed free fluid in the abdomen mainly at the splenorenal area and organized clots around the uterus. Computed tomography of the Abdomen revealed a moderate amount of hemoperitoneum with hypodense clots at the left para-colic gutter and pelvis. She underwent an exploratory laparotomy and intraoperatively noted bleeding from left uterine artery with 1.2 L of hemoperitoneum with no other abnormalities detected. Intraoperatively, there was an estimated 5 L blood loss which required packed cell and disseminated intravascular coagulation transfusion. Subsequently, the patient was sent to intensive care unit where she recovered well and was discharged home 5 days later. Conclusion: Spontaneous uterine artery rupture is an extremely rare occurrence with high mortality if there is failure to detect and intervene early.

Disseminated Intravascular Coagulation from Intraperitoneal Oxaliplatin for Appendiceal Carcinoma: A Case Report

This is a case of a 65-year-old female diagnosed with appendiceal carcinoma, who underwent cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Profuse bleeding through the peritoneal drains, with hemodynamic instability, warranted a re-exploration on the fourth postoperative day. Intraoperatively, there was 500 mL of blood clots mostly on the right upper quadrant, diffuse muscle oozing along the previously-stripped right hemidiaphragm and right paracolic gutter, and a non-expanding hematoma on the right anterior abdominal wall. Bleeding parameters were checked postoperatively, and derangements pointing to a disseminated intravascular coagulation were noted. The patient was managed with multiple blood transfusions of packed red blood cells, fresh frozen plasma, platelet concentrates, and cryoprecipitate. Dexamethasone and tranexamic acid were given intravenously. The patient was discharged well on postoperative day 14 after clinical resolution of the bleeding. Eight days after discharge, however, patient succumbed to myocardial infarction. Key words: disseminated intravascular coagulation, oxaliplatin, hyperthermic intraperitoneal chemotherapy

Percutaneous Endoscopic Necrosectomy of Walled-Off Necrosis in Post-ERCP Pancreatitis

Introduction: Acute pancreatitis is the most frequent complication in patients who undergo endoscopic retrograde cholangiopancreatography (ERCP), with an incidence rate of 3.5-9.7% [1]. 5-10% of these develop acute necrotizing pancreatitis, which may have a pancreatic or peripancreatic localization in 75-80% [2]. We describe a case report of post-ERCP acute necrotizing pancreatitis with walled-off necrosis (WON) treated with percutaneous endoscopic necrosectomy (PEN) [3]. Case Report: A 60-year-old man with obstructive jaundice and common bile duct stones at abdominal CT scan underwent ERCP to clear the biliary tract. In the following days, due to the onset of severe acute pancreatitis and sepsis, he repeated the abdominal CT scan where multiple necrotic collections were found around the pancreas with extension to the pelvic paracolic gutters. Following a step-up approach, targeted antibiotic therapy was started. After four weeks, it was not possible to perform Endoscopic Ultrasound-Guided drainage because of the distance from the stomach or the duodenum to the WON. Then percutaneous drainage was radiologically inserted into the collections through the left side of the abdomen of the patient to flush with hydrogen peroxide every day. Due to the persistent infection and necrosis in the collections, an esophageal fully covered self-expanding metal stent was temporarily inserted through the percutaneous fistula in order to increase the caliber of the fistula and to perform PEN. Discussion: The step-up approach suggests endoscopic or percutaneous drainage of infected WON as the first interventional method, depending on the location of the WON and the local expertise [1]. PEN is a safe and effective alternative to surgical treatment with a technical success rate of 47-93% and a complication rate of no more than 20% [4]. Conclusion: PEN is an advanced endoscopic technique that is showing promising results but still needs randomized controlled trials to establish safety and efficacy.

OC-073 PATHWAYS OF THE PREPERITONEAL PLANE: FROM THE “FATTY TRIANGLE” IN RIVES TO THE “FATTY TRIDENT” IN EXTENDED RETROMUSCULAR ABDOMINAL WALL RECONSTRUCTION

Abstract Aim Retromuscular dissection performed for abdominal wall reconstruction in complex abdominal wall has progressively exposed the anatomy between the peritoneal layer and abdominal wall muscles. This study aimed to assess the morphology and distribution of preperitoneal fat in a cadaveric model and its influence on retromuscular preperitoneal dissections. Material &amp; Methods Thirty frozen cadaver torsos were dissected by posterior component separation (PCS). The shape of the preperitoneal fat was identified, and the dimensions and distances were calculated. Results Results showed that preperitoneal fat resembles a trident, along the midline under the linea alba, and expands in the epigastrium into a rhomboid shape. The fatty triangle was found to be a part of this rhomboid. Caudally, the midline preperitoneal fat widened under the arcuate line to reach Retzius´s space. Bogros space communicated the root of the trident laterally with the paracolic gutters, Toldt's fascia, and pararenal fats, forming the lateral prong of the trident. The peritoneum uncovered by the preperitoneal trident was easy to break. Three pathways could be tracked following the distribution of this fat that facilitated the dissection of the preperitoneal space to prepare the landing zone of the meshes in hernia repair. Conclusion The concept of preperitoneal fatty trident may be of practical assistance in performing hernia procedures, from the simple ventral hernia repair to more complex preperitoneal ventral repair or PCS techniques. The consistency of this layer allows us to follow three specific pathways to the plane between the peritoneum and muscles to extend the preperitoneal dissection.

P-100 ANATOMICAL STUDY ON THE PREPERITONEAL FAT DISTRIBUTION IN EXTENDED RETROMUSCULAR PREPERITONEAL DISSECTION: FROM THE FATTY TRIANGLE TO THE FATTY TRIDENT

Abstract Aim Extended retromuscular dissection performed for abdominal wall reconstruction in complex abdominal wall repair has progressively exposed the anatomy between the peritoneal layer and abdominal wall muscles. This study aimed to assess the morphology and distribution of preperitoneal fat in a cadaveric model. Material and methods Thirty frozen cadaver torsos were dissected by posterior component separation. The shape of the preperitoneal fat was identified, and the dimensions and more significant distances were calculated. Results The results showed that the preperitoneal fat resembles a trident, exists along the midline under the linea alba, and expands in the epigastric area into a rhomboid shape. The fatty triangle was found to be a part of this rhomboid. The mean rhomboid area was 35 cm2. Caudally, the midline preperitoneal fat widened under the arcuate line to reach the Retzius space. Laterally, the Bogros space communicated the root of the trident with the paracolic gutters, Toldt's fascia, and pararenal fats, forming the lateral prong of the trident. The mean width of the midline prong at the umbilicus was 2.8 cm. It was easier to tear the peritoneum outside the area reinforced by the fatty trident. Conclusions The concept of preperitoneal fatty trident may be of practical assistance to perform various hernia procedures, from the simple ventral hernia repair to the more complex preperitoneal ventral repair or posterior component separation techniques. The consistency of this layer allows us to follow our plane between the peritoneum and muscle layers to extend the preperitoneal dissection.

S2747 Malignant Peritoneal Mesothelioma Seen on MRI Enterography During IBD Colitis Investigation in a 32-Year-Old Non-Asbestos Exposed Female Healthcare Worker

Introduction: This case describes an unexpected diagnosis of a malignant peritoneal mesothelioma (MPM) in a 32 y/o female physician without any known asbestos exposure. She presented to our department with a prior diagnosis of non-celiac gluten intolerance and intermittent but worsening left-sided abdominal pain for over 20 years. Several CTs suggested findings associated with IBD-related etiology and IBD specialist consultation was advised. After negative EGD/colonoscopy, an MRI Enterography revealed a small enhancing nodule suggestive of peritoneal malignancy. Pathology report after biopsy revealed a biphasic MPM. This case highlights the insidious nature of MPM and adds to the body of literature suggestive of IBD-mimicking symptomatology associated with this disease. Case Description/Methods: A 32 y/o F presented with chronic intermittent left-sided abdominal pain and gluten intolerance. Throughout her life, she reports 2-week periods of abdominal pain that is usually dull and sometimes sharp. The pain is focused LUQ with occasional LLQ pain. This is worsened by acute angle bending and deep palpation to the area. The patient still experiences pain despite a gluten-free diet. EGD is negative for celiac disease. CT imaging showed a left-sided pericolonic abscess and wall thickening of the lower descending and proximal sigmoid colon. An ill-defined soft tissue density in the left paracolic gutter was also seen and classified as a reactive lymph node. Abscess underwent CT aspiration; follow-up CT noted a new focal area of segmental wall thickening in the ascending colon with an inflamed diverticulum. IBD consult was recommended where negative EGD/colonoscopy resulted in MRI Enterography referral and results suggestive of peritoneal malignancy (Figure). Pathologic examination confirmed the presence of MPM, biphasic type (epithelial/spindle) with cytologic atypia and invasive growth being consistent with malignancy. The patient is on nivolumab, ipilimumab, carboplatin, pemetrexed and leuprolide for the next 3 months and considering debulking. Discussion: MPM presenting with decades long history of LUQ/LLQ pain exacerbations is rarely seen. CT results led to consideration of IBD etiology, as wall thickening, inflamed diverticulum, and a timeline suggestive of IBD was described. The lack of asbestos exposure highlighted the unlikely MPM differential. Prompt advanced imaging was key to diagnosis. Due to the insidious nature of MPM and poor outcomes, further exploration of timely advanced imaging is warranted.Figure 1.: MRI enterography reveals no evidence of active or chronic inflammatory bowel disease and no evidence of diverticulitis or diverticular abscess. There is a 10 mm enhancing nodule along the serosal margin of the splenic flexure in the left upper quadrant that is suspicious for a peritoneal malignancy.

Intra-abdominal cystic lymphangioma in adults: A case series of 32 patients and literature review

IntroductionCystic lymphangioma (CL) is a benign tumor originating from the lymph vessels. Lymphangiomas in the abdominal cavity are extremely rare, particularly in adults.This article was designed to study the epidemiological, diagnostic difficulties, and therapeutic principles of intra-abdominal cystic lymphangioma (ACL) in adults. Material and methodsWe conducted a single-center, retrospective study of 32 adult patients with ACL admitted to surgical department “A” in “La Rabta Hospital” in Tunis, from January 1998 through December 2020. The demographic, clinical, biological, radiological characteristics, histopathologic, and therapeutic data were collected, as well as the surgical intervention used and the postoperative immediate and late complications. ResultsThirty-two adult patients with ACL were recruited, including 20 females and 12 males. The median age at treatment was 47 (range 14–80) years. The most prevalent sites were the retroperitoneum (25%), the mesentery (21.9%), and the paracolic gutters (n = 18. 7%). Twenty patients underwent open surgery (62.5%), whereas 12 cases (37.5%) had laparoscopic surgery. Twenty-eight patients received total cystectomy (87%). Three recurrences were observed during follow-up (9.4%). ConclusionThe clinical features of CL in adults remain unclear. The diagnosis is only confirmed by histopathological examination after complete surgical resection. The laparoscopic approach is considered safe and feasible.