Proximal Bowel Research Articles

Use of Self-expandable Stents for Obstructive Distal and Proximal Large Bowel Cancer: A Retrospective Study in a Single Centre

The aim of our retrospective study was to determine the effectiveness and safety of self-expandable metal stents in patients presenting with large bowel obstruction secondary to colorectal cancer (regardless of the tumour site), in a district general hospital setting. All patients who had endoscopic colonic stents insertion for obstructive colorectal cancer between 2001 and 2005 at our centre were identified retrospectively from patients' discharge database and the unit database. The patients were divided into the 'palliation group' where the stents were inserted to relief symptoms only and the 'bridge group' where patients with resectable cancer underwent colonic stenting as a bridge to improve patient's general condition before definite surgery. Thirty-eight patients were included in the final analysis. Thirty-three tumours were in the distal colon and five were in more proximal lesions. Stent insertion was successful in 35 patients (92%). Overall clinical success was 71%. All five proximal colonic tumours (13%) had successful stent insertion. Mortality related to procedure was 2%, and the average survival in all patients was 141 days from time of stent insertion. Colonic stent is a safe and effective method for relief of immediate symptoms of malignant distal and proximal large bowel obstruction.

Side-to-Side-to-End Strictureplasty for Crohn’s Disease

Side-to-side strictureplasty is a useful procedure for preserving the bowel in patients with Crohn's disease. However, bowel resection is required in some patients, and diseased proximal bowel and disease-free distal bowel exist after resection. We performed a modified new technique called side-to-side-to-end strictureplasty. Four patients with Crohn's disease underwent this procedure. After resection of the diseased bowel that was not suitable for strictureplasty, side-to-side strictureplasty was performed with use of the proximal diseased loop. Thereafter, the distal end of the side-to-side stricture was anastomosed to the distal disease-free bowel in a side-to-side-to-end manner. The length of the small intestine requiring surgical intervention was 69.8 +/- 26.4 (mean +/- standard deviation) cm, and the length of the small intestine necessitating resection was 31.8 +/- 12.6 cm. Side-to-side stricture was performed by use of 48.8 +/- 20.2 cm of the diseased proximal bowel, which was anastomosed to the disease-free distal bowel. Intra-abdominal abscess, which was not associated with this procedure, was observed in one patient, but was treated by drainage. The recoveries of all four patients were uneventful, without recurrence, after a follow-up of 21.5 +/- 16.2 months. Side-to-side-to-end strictureplasty may be a useful procedure when diseased proximal bowel and disease-free distal bowel are present after bowel resection in patients with Crohn's disease.

Comparison of two schemes of small bowel preparation for capsule endoscopy with polyethylene glycol: a prospective, randomized single-blind study

Small bowel preparation for capsule endoscopy remains controversial. This study was conducted to compare the efficacy of 2 and 4 l of polyethylene glycol. One hundred and one patients (group A) received 2 l and 100 (group B) received 4 l in a prospective, randomized single-blind trial. To objectively evaluate enteric preparation, a cleansing coefficient was calculated for each patient. The two groups were found comparable regarding age, sex, body mass index, and reason for referral. In 82 patients of group A and in 76 of group B, examination of small bowel was completed (P =0.40). Gastric emptying time and small bowel transit time were found comparable in both groups. Cleansing coefficients, for small bowel as a whole or for proximal or distal separately, were similar among the two groups. However, the cleansing coefficient of the proximal bowel was significantly higher than that of the distal, independently of preparation (group A: P < 0.001, group B: P< 0.001). Small bowel preparation was related only with the age of the patients and gastric emptying time; the younger the patient or the shorter the gastric emptying time, the higher the cleansing coefficient. Pathological findings were found in 43 (42.6%) patients of group A and in 37 (37.0%) patients of group B (P =0.42). A final positive diagnosis was established in 33 (32.7%) patients of group A and in 29 (29.0%) of group B (P = 0.57). The two schemes were equal regarding enteric cleansing and completion of the procedure. Therefore, 2 l seems to be an adequate preparation for capsule endoscopy.

Endocrine cells in atresic chick embryo intestine: histochemical and immunohistochemical study

Intestinal motility disorders are an important problem in the postoperative management of patients with intestinal atresia. Intestinal motility could be initiated by luminal factors that activate intrinsic and extrinsic primary afferent nerves involved in the peristaltic reflex. Endocrine cells act as a key point, because they transfer information regarding the intestinal contents and intraluminal pressure to nerve fibers lying in close proximity to the basolateral surface of the epithelium. In chick embryo, experimental intestinal atresia is associated with disorders in the development of the enteric nervous system, related to the severity of intestinal dilation. Our aim was to investigate the distribution pattern of endocrine cells in the developing endocrine system of chick embryo small intestine with experimentally-induced atresia on day 12 and on day 16. Changes in enteroendocrine population were examined in gut specimens (excised proximal and distal to the atresia) from experimental embryos 19 days old and in control sham-operated chick embryos at the same age. Sections from proximal and distal bowel and control bowel were stained with Grimelius silver stain, a valuable histochemical method for detecting the argyrophil and argentophilic cells, and with an immunohistochemical procedure for detecting serotonin and neurotensin immunoreactive cells. In chick embryo proximal bowel, intestinal dilation differed in the various embryos. We found significantly higher enteroendocrine cell counts in proximal bowel than in distal and control bowel. The differences depended on the precociousness of surgery and the severity of dilation. Considering the major contribution of enteroendocrine cells to the peristaltic reflex, our data may help to explain the pathogenesis of motility disorders related to intestinal atresia.

Endocrine cells in atresic chick embryo intestine: histochemical and immunohistochemical study

Intestinal motility disorders are an important problem in the postoperative management of patients with intestinal atresia. Intestinal motility could be initiated by luminal factors that activate intrinsic and extrinsic primary afferent nerves involved in the peristaltic reflex. Endocrine cells act as a key point, because they transfer information regarding the intestinal contents and intraluminal pressure to nerve fibers lying in close proximity to the basolateral surface of the epithelium. In chick embryo, experimental intestinal atresia is associated with disorders in the development of the enteric nervous system, related to the severity of intestinal dilation. Our aim was to investigate the distribution pattern of endocrine cells in the developing endocrine system of chick embryo small intestine with experimentally-induced atresia on day 12 and on day 16. Changes in enteroendocrine population were examined in gut specimens (excised proximal and distal to the atresia) from experimental embryos 19 days old and in control sham-operated chick embryos at the same age. Sections from proximal and distal bowel and control bowel were stained with Grimelius silver stain, a valuable histochemical method for detecting the argyrophil and argentophilic cells, and with an immunohistochemical procedure for detecting serotonin and neurotensin immunoreactive cells. In chick embryo proximal bowel, intestinal dilation differed in the various embryos. We found significantly higher enteroendocrine cell counts in proximal bowel than in distal and control bowel. The differences depended on the precociousness of surgery and the severity of dilation. Considering the major contribution of enteroendocrine cells to the peristaltic reflex, our data may help to explain the pathogenesis of motility disorders related to intestinal atresia.

Quality assurance in flexible sigmoidoscopy: medical and nonmedical endoscopists

The clinical assessment of position in colon and hence completion during flexible sigmoidoscopy (FS) is believed to be inaccurate. The technique of applying endomucosal clips with follow-up X-ray has previously been used for establishing completion in colonoscopy. Furthermore, we have now trained non-healthcare professionals (non-medical endoscopists, NME) to perform FS, but there is no data on assessment of their performance of FS. We performed this study with the aims of determining accuracy of endoscopists' clinical impression regarding actual position of endoscope in colon during FS, comparing medical (ME) and NME in terms of clinical accuracy, and to determine role of endomucosal clips with follow-up X-rays in documenting completion and hence quality assurance. All patients undergoing elective FS, except those with surgical resection, were included, after ethics approval. During FS, endoscopist applied an endomucosal clip at most proximal bowel reached and endoscopists recorded their independent opinion about position of clip. Post procedure, all patients underwent an abdominal X-ray, reported by consultant radiologist, blinded to outcome of FS. X-ray results were compared with endoscopist findings. Complete FS was defined as one where descending colon was reached. Fifty-one patients, with median age of 55 years, participated in study. The endoscopists were accurate in their assessment of position in colon in 38 patients (75%). The attending nurse was accurate in only 31% of cases. The crude and corrected completion rates were 73% and 84%, respectively. There was no correlation between length of endoscope and its position in colon. There were no differences between NME and ME in terms of clinical accuracy. This study has shown that clinical impression of endoscopist during FS regarding position is not very accurate, implying need for regular quality assurance. The technique of applying endomucosal clips with follow-on abdominal X-ray is an excellent objective measure of quality assurance in FS. NME can perform FS with comparable completion rates and accuracy.

Detection of intestinal bifidobacteria and lactobacilli in patients with Hirschsprung’s disease associated enterocolitis

The etiology of Hirschsprung's disease associated enterocolitis (HAEC) is unknown. Previous investigations have suggested that several factors such as dilation of proximal bowel, changes in colonic mucosal defence, and overgrowth of toxigenic bacteria may be related with it. This study was to quantify bifidobacteria and lactobacilli in the feces of Hirschsprung's disease (HD) patients with or without enterocolitis and those of normal children. Fresh stool specimens were collected at the first three days of the admission from 30 HD patients (aged 2 weeks to 2 years) and 15 healthy age-matched non-HD patients in the morning once a day for at least three days. All of them have not been given probiotics or antibiotics at least 7 days before stool collection. Hematoxylin-eosin and acetylcholinesterase histochemical staining on rectal biopsies of patients with HD confirmed the diagnosis of HD in all 30 patients. The 30 HD patients were divided into two groups based on the clinical history of enterocolitis: the HAEC group (n=10) and HD group (n=20). Fecal bifidobacteria and lactobacilli were consecutively quantified by SYBR Green I-based real-time PCR assay. Data were analyzed using SAS v. 12.6 for Windows. All tests were two-tailed, and P values <0.05 were considered statistically significant. The mean levels of bifidobacteria were 7.35+/-0.59, 8.16+/-1.17, and 8.35+/-0.74 in the HAEC, HD and control groups, respectively. The bifidobacteria colonization levels were lower in the HAEC group than in the HD and control groups (P<0.05, P<0.001 respectively). The mean level of lactobacilli in the HAEC (5.51+/-0.65) and HD groups (5.87+/-0.78) was significantly lower than that in the control group (6.39+/-0.56) (P<0.05). But there was no difference in log numbers of lactobacilli between HAEC and HD groups (P>0.05). The scarcity of bifidobacteria and lactobacilli in HAEC patients may result in a decrease in epithelial barrier function and be a predisposing factor in the development of HAEC. This decline suggests that treatment with probiotics or prebiotics may be beneficial in these individuals. Further research will focus on whether probiotics can decrease the incidence of HAEC.

Laparoscopic right hemicolectomy for intestinal intussuception

Adult intussusception is rare and usually associated with carcinoma in 50% of the cases. These have traditionally been managed using an open technique. We herein describe a laparoscopic extended right hemicolectomy in a 62-year-old lady with an intussuception secondary to a transverse colonic tumor. The patient presented with 6 weeks of crampy, colicky, abdominal pain. Her CT scan reported intussuception of the proximal large bowel. She underwent an extended laparoscopic right hemicolectomy with primary anastomosis. Her post-operative recovery was uneventful and the histology reported a large bowel adenocarcinoma (pT4, N0, M0) with none out of 25 nodes involved. When operative intervention is required, intussuception may be managed using a minimally invasive technique. However, large bowel intussuception in adults may have a malignant cause thus laparoscopic resection should only be performed by surgeons experienced in laparoscopic resections for colorectal malignancies as oncological safety must be the primary concern. This laparoscopic approach facilitates rapid recovery and earlier time to adjuvant therapy if required.

M1541 Hybrid Laparoscopic-Open Resection for Rectal Carcinoma Is Oncologically Safe: A Long-Term Follow Up Study

PURPOSE: The hybrid laparoscopic-open procedure was devised as a means of providing benefits of minimally invasive methods to rectal cancer patients in whom a fully laparoscopic operation may not be feasible. Hybrid methods use a small infra-umbilical incision to perform open TME and cancer resection after closed splenic flexure mobilization, proximal devascularization, and division of the proximal bowel. Currently, we perform laparoscopic, hand-assisted and hybrid procedures. The purpose of this study is to assess the pathologic and long-term oncologic results of hybrid resection for rectal carcinoma. METHODS: We retrospectively reviewed pathologic and oncologic data from 75 patients who underwent hybrid rectal cancer resection at Columbia University from 1995 to 2004. Mean follow up was 3.3yrs. Half of our population had follow up for mean of 5.3yrs. RESULTS: Procedures included rectosigmoidectomy=10, LAR=49 and APR=15. Tumors were located in the proximal=28, middle=29 and distal=18 rectum. Anastomoses included EEA=57 and hand-sewn coloanal=3. Diverting stomas were used in 19 patients. Mean results of clinical and pathologic outcome data are: incision length 10cm (SD 4.5); days to flatus 3.8 (SD 2), length of stay 7.4days (SD 4), distal margin 3.2cm (SD 1.5), proximal margin 19.7cm (SD 7.2), lymph node harvest 14 (SD 7.5). 5-year disease-free survival for hybrid rectal resections was 80%; 28 patients (37%) had preop XRT (figure). CONCLUSIONS: Hybrid rectal resections do not compromise LN harvest or margins and are feasible even in the context of neoadjuvant radiation therapy. Our 5-year disease-free survival of 80% is comparable to rates achieved by open surgery (64%, SEER data).

Quality assurance in colonoscopy: role of endomucosal clips

Quality assurance in colonoscopy is important, and subjective assessment of completion based on endoscopic signs can be inaccurate leading to missed lesions. We aimed to determine the technique of endomucosal clips with follow-up X-rays in objectively documenting completion and correlation with pathology miss rates. A total of 82 patients undergoing colonoscopy by trained colonoscopists had an endomucosal clip applied to the most proximal bowel reached. A plain abdominal X-ray was performed while there was still a pneumocolon, and the clip position was assessed by a blinded radiologist to determine objective completion rates. Repeat colonoscopies were performed in patients with incomplete procedures. Pathology and endoscopy database were also reviewed to identify missed lesions at a median follow-up of 6 years. These were correlated with colonoscopy completions. The clip was found in caecum of 76 (93%), ascending-colon in three (3.6%), hepatic flexure in one (1.2%) and splenic flexure in two (2.4%) patients. The endoscopist opinion was incorrect in six incomplete colonoscopies. A total of 33 patients underwent repeat colonoscopies over the median 6-year follow-up. Three adenomas and one carcinoma were missed in the incomplete group and were subsequently picked up in repeat endoscopies. Only one adenoma was truly missed in complete colonoscopies, providing an overall miss rate of 1.3%. Use of endomucosal clips with follow-on abdominal X-ray is a safe and effective method of determining completion of colonoscopy. This technique is also an excellent objective measure of quality assurance of completion and miss rates in colonoscopy, especially when combined with an audit to determine the missed lesions at two years postprocedure.

Management of intestinal atresia: Challenges and outcomes in a resource‐scarce region

Aim: Intestinal atresia is a common cause of intestinal obstruction in the newborn, associated with poor outcomes in many developing countries due to clinical sequelae of the lesion. Although outcomes have improved in many centers, the management requires facilities that are in short supply in developing countries. Here we report on five‐year outcomes, challenges, and experiences gained with the management of intestinal atresia in a resource‐scarce region and compare results with the preceding five years.Methods: A prospective study based on children diagnosed with intestinal atresia between July 2003 and June 2008 at the University of Benin Teaching Hospital, Benin City, Nigeria. Results were documented on a structured form and analyzed. The outcomes were compared between group A, comprising the preceding five years (July 1999–June 2003), and group B, comprising the present study group (July 2003–June 2008).Results: Forty‐three babies aged between 2 and 32 days (mean 11 ± 1.8 days), comprising 26 males and 17 females (ratio 1.5 : 1), were managed with intestinal atresia. Delayed presentation of these babies, which allowed fluid/electrolyte derangement, inanition, and established overwhelming resistant sepsis, as well as a lack of facilities, were major challenges resulting in poor outcomes (P &lt; 0.0001). Aggressive resuscitation, resection of dilated proximal bowel segment allowing early commencement of oral feeds, enteroplasty, long use of broad spectrum antibiotics, improvised facilities to supply heat, and dedicated staff led to improved results. The number of survivors increased from 25% in group A to 75% in group B.Conclusion: This 75% survival rate could be increased further if there was provision of adequate facilities, especially total parenteral nutrition, and health awareness programs that result in early presentation.

Synchronous Intussusceptions Following Roux-en-Y Gastric Bypass: Case Report and Review of the Literature

Intussusception is an atypical cause of small bowel obstruction following Roux-en-Y gastric bypass and, as such, is not often considered in the differential diagnosis. In this setting, the pathophysiology appears to differ in that a pathologic lead point is rarely identified and the intussusceptum most often progresses retrograde into the proximal bowel. Involvement of the jejunojejunostomy is nearly universal in reported cases and, if untreated, can lead to devastating consequences. Despite this potential, the clinical presentation often lacks remarkable features yet timely surgical intervention is generally required. This phenomenon is being reported with greater frequency and altered motility in the Roux limb is the prevailing hypothesis regarding pathogenesis. Awareness of the potential for this process and prompt consultation with a bariatric surgeon are keys to optimal outcomes.

The Pig as an Experimental Model for Colonic Healing Study of Leakage and Ischemia in Colonic Anastomosis

Background: The object of this experimental study was to develop a model of anastomotic failure due to primary leakage and ischemia in porcine large bowel anastomosis. Methods: End-to-end anastomosis was constructed at descending colon in 12 pigs. The pigs were randomly divided into three groups. In Group A, the anastomosis was applied with a leak of 18 mm. In Group B, in addition to primary leakage, an artificial ischemia of the proximal anastomotic bowel segment was created by ligation of supplying vessels over 5 cm. In Group C, an artificial ischemia was created in the same manner at the proximal and distal anastomotic segment and the anastomosis was applied with an intentional leakage as in Groups A and B. The animals were sacrificed immediately in case of clinical signs of anastomotic dehiscence, sepsis, peritonitis, or ileus. The animals were sacrificed on day 28. The peritoneal cavity was examined for peritonitis, anastomotic wound dehiscence, and pericolic abscess formation. Results: Distinct fibrinous coverings and adhesions at the anastomotic area were found in all animals. In cases of primary leakage without ischemia, only one of the four animals developed abscess at anastomotic side with clinical sepsis. In cases of primary leakage with ischemia of the proximal anastomotic bowel segment, one of the four animals presented generalized peritonitis with sepsis. In Group C, there were no signs of leakage or peritonitis, although three of the four animals developed colonic ileus due to obturation of the colonic lumen by a clot of necrotic bowel wall. Conclusion: Large anastomotic dehiscence and local ischemia of the bowel wall are not reliable factors for the development of intra-abdominal abscess, peritonitis, or sepsis in the pig model.

Preservation of intestinal motility after the serial transverse enteroplasty procedure in a large animal model of short bowel syndrome

Introduction Serial transverse enteroplasty (STEP) has been shown to improve bowel function in short bowel syndrome. The effect of the STEP procedure on intestinal motility is not known, but some have hypothesized that it could disrupt bowel innervation and thus impair intestinal motility. Methods Growing Yorkshire pigs (n = 7) underwent 3 operations at 6-week intervals: (1) reversal of 50 cm of jejunum, (2) 90% bowel resection ± STEP to the proximal dilated bowel (4 STEP, 3 control), and (3) implantation of serosal strain gauges. At each operation, baseline and post-octreotide small intestinal motility was studied with continuously perfused manometry catheters using non-anticholinergic anesthesia. In addition, awake monitoring was performed using strain gauge analysis 1 week after the third operation. Characteristics of phase III of the migrating motor complex (MMC) were compared between and within groups using t test, χ 2, and analysis of variance, with significance set at P < .05. Results Manometry data from the third surgery revealed no differences between groups or compared with baseline within groups for the presence and characteristics of phase III of the MMC. Specifically, the mean amplitude and frequency of phase III after octreotide, and both the mean baseline and mean octreotide-stimulated motility indices were equivalent. The duration of phase III after octreotide stimulation was significantly increased in the STEP animals, suggesting a potential benefit of the STEP procedure. Strain gauge analysis, performed in awake animals, confirmed no differences between the groups for basal and octreotide-stimulated characteristics of phase III of the MMC. Conclusions These preliminary data suggest that the STEP procedure in a porcine model of short bowel syndrome does not interfere with baseline or hormonally stimulated motility within the small bowel. These findings further support the STEP procedure as a safe option for the surgical management of short bowel syndrome.

Short-Term Adaptation of Rat Intestine to Ileostomy: Implication for Pediatric Practice

Background: Surgical neonates with complex intestinal conditions, such as enterocolitis, midgut volvulus with bowel loss and multiple atresias, often require temporary stomas. Little is known on the postsurgical response of the altered gut segments, although adaptation is an important consideration in neonatal postoperative care, particularly after stoma closure. Materials and Methods: Rats underwent bowel resection at a point 15 cm proximal to the ileocecal valve, and a split ileostomy was performed. On the 6th postoperative day the mucosal thickness was calculated with Soft Imaging System Analysis Pro, the rate of proliferation was measured following Ki67 immunohistochemistry and the apoptotic index was determined on sections stained with ApopTag Plus. The intestinal motor activity was recorded on isolated gut segments. Neuronal nitric oxide synthase (nNOS) expression and distribution was examined with NADPH-diaphorase histochemistry and Western blot analysis. Results: An increased wet weight of the mucosa and a pronounced mucosal thickening were observed in the proximal functional bowel segment. Enterocyte proliferation rate was increased significantly, while the apoptotic index remained unchanged in the epithelial layer. The dilation of the gut lumen resulted in a morphological change in the nitrergic myenteric network with an overexpression of nNOS. As a consequence of the surgical procedure, the functional proximal gut segment showed strong and frequent contraction waves, with an enhanced responsiveness to cholinergic stimuli. Conclusions: The dilated functional bowel segment was characterized by hyperplasic changes in the mucosa and stronger mechanical activity with overproduction of nNOS. Although early restoration of intestinal continuity is recommended, our observations on adaptive changes may partly explain intestinal motility disorders after early stoma closure, suggesting the need for a careful approach to a redo-laparotomy.

Dietary glutamine and oral antibiotics each improve indexes of gut barrier function in rat short bowel syndrome

Short bowel syndrome (SBS) is associated with gut barrier dysfunction. We examined effects of dietary glutamine (GLN) or oral antibiotics (ABX) on indexes of gut barrier function in a rat model of SBS. Adult rats underwent a 60% distal small bowel + proximal colonic resection (RX) or bowel transection (TX; control). Rats were pair fed diets with or without l-GLN for 20 days after operation. Oral ABX (neomycin, metronidazole, and polymyxin B) were given in some RX rats fed control diet. Stool secretory immunoglobulin A (sIgA) was measured serially. On day 21, mesenteric lymph nodes (MLN) were cultured for gram-negative bacteria. IgA-positive plasma cells in jejunum, stool levels of flagellin- and lipopolysaccharide (LPS)-specific sIgA, and serum total, anti-flagellin- and anti-LPS IgG levels were determined. RX caused gram-negative bacterial translocation to MLN, increased serum total and anti-LPS IgG and increased stool total sIgA. After RX, dietary GLN tended to blunt bacterial translocation to MLN (-29%, P = NS) and significantly decreased anti-LPS IgG levels in serum, increased both stool and jejunal mucosal sIgA and increased stool anti-LPS-specific IgA. Oral ABX eliminated RX-induced bacterial translocation, significantly decreased total and anti-LPS IgG levels in serum, significantly decreased stool total IgA and increased stool LPS-specific IgA. Partial small bowel-colonic resection in rats is associated with gram-negative bacterial translocation from the gut and a concomitant adaptive immune response to LPS. These indexes of gut barrier dysfunction are ameliorated or blunted by administration of dietary GLN or oral ABX, respectively. Dietary GLN upregulates small bowel sIgA in this model.

The development of a novel intracolonic occlusion balloon for transcolonic natural orifice transluminal endoscopic surgery: description of the technique and early experience in a porcine model (with videos)

Transgastric and transvaginal approaches in natural orifice transluminal endoscopic surgery (NOTES) are the most commonly used, although the transcolonic approach may have some advantages. To develop a workable technique for transcolonic NOTES. A nonsurvival study followed by a survival study in a porcine model. Transcolonic peritoneoscopy was performed with the use of a novel intracolonic occlusion balloon. The colotomy was closed with endoclips. A necropsy and histologic evaluation were performed 2 weeks after surgery. Academic hospital, health science research center. Fifteen female Yorkshire pigs (5 nonsurvival, 10 survival). A balloon-tipped catheter was placed proximal to the colotomy site. The balloon was inflated to occlude the colonic lumen. An endoscope was inserted through the anus. Colonic incision was created with an endoscopic needle-knife at 15 to 20 cm from the anal verge. Peritoneoscopy was performed. The colotomy was closed with endoclips. Rates of complications, survival, healing, and adhesions. Two initial experiments were complicated by bowel distension and contamination of the incision area by colonic content. In the remaining 13 pigs, the experiments were performed with the use of the intracolonic occlusion balloon. No complications were documented. Necropsies were performed 2 weeks after surgery. Gross and histologic evaluations demonstrated near complete healing. Minimal adhesions were identified in 4 of 10 pigs. Imperfection of the prototype balloon. Excessive bowel distension and fecal contamination because of spillage from the proximal bowel may be barriers to performing transcolonic NOTES. Isolation of the operative area by splitting the bowel and sealing the colonic lumen with the balloon above the colonic incision may overcome these problems and optimize the technique.

The Role of Video Capsule Endoscopy in Patients with Suspected Small Bowel Crohnʼs Disease Despite a Normal Ileoscopy

Purpose: To evaluate the benefit of performing video capsule endoscopy (VCE) in patients with suspected Crohn's Disease of the small bowel (SB-CD) despite a normal exam of the ileum on colonoscopy. Methods: We prospectively recorded the findings of patients who have undergone both a colonoscopy (CLN) with exam of the terminal ileum and a VCE for the evaluation of suspected SB-CD at our institution between January 2006 and March 2008. Positive findings on ileoscopy and VCE suggestive of CD included the presence of ulcers, erosions, inflammatory polyps, and inflammatory strictures. Isolated erythema was considered a normal finding in this study. NSAIDs use was recorded. Results: A total of 47 patients with suspected SB-CD underwent CLN with ileoscopy and VCE. 30 patients were female and 17 patients were male, with a mean age of 38 years. Patient's symptoms included abdominal pain, blood in the stool, and diarrhea. Ileoscopy was normal in 35 patients (74.5%) and abnormal in 12 patients (25.5%). VCE was normal in 34 patients (72.3%) and abnormal in 13 patients (27.7%). VCE was abnormal in 5 of the 35 patients with normal ileoscopy (14.3%). All 5 patients in this subset had ulcers and/or erosions in the proximal and mid-small bowel. None of these patients had reported NSAID use. The VCE was normal in 4 of the 12 patients with ileal ulcers on CLN, but it detected proximal and mid-SB ulcers in the remaining 8 patients. Conclusion: VCE is a valuable tool for the diagnosis of SB-CD and the evaluation of the extent of SB involvement with CD in a subset of patients whose diagnosis would have been missed if it was solely based on a normal exam of the ileum on colonoscopy.

Acute Colonic Pseudo-Obstruction

Purpose: Acute colonic pseudo-obstruction is characterized by symptoms, signs and radiological appearance of acute large bowel obstruction in the absence of a true mechanical obstruction. The pathophysiology is not well understood. A proposed theory involves transient impairment of the sacral parasympathetic nerves causing atony of the distal large bowel resulting in functional obstruction. Methods: We present a case of a patient with Guillain-Barré syndrome complicated by acute colonic pseudo-obstruction, in whom neostigmine could not be used. Results: A 57 year old man with Guillain-Barré syndrome and progressive ascending muscular weakness was hospitalized for significant autonomic dysfunction and pronounced muscular weakness. He developed diffuse abdominal pain and distension, and was unable to pass gas or feces on hospital day 5. The physical exam was significant for abdominal distension, hyperactive bowel sounds, and diffuse abdominal tenderness. An abdominal CT showed dilated colon and cecum with a maximum diameter of 8.3 cm without associated abnormality of the bowel wall or proximal bowel dilation, consistent with acute colonic pseudo-obstruction. Successful endoscopic colonic decompression was performed the next day and supportive measures continued, including nasogastric (NG) suction and maintaining electrolyte balance. The patient developed recurrent distension within 24 hours. Neostigmine was contraindicated because of autonomic dysfunction and he failed to respond to erythromycin. Tegaserod 6 mg was given every 12 hours per NG tube and within 14 hours the patient started passing gas and had a spontaneous bowel movement. Abdominal pain and distension resolved, confirmed by an abdominal film. The patient continued to receive tegaserod until discharge 7 days later with no recurrence of obstructive symptoms. Conclusion: Treatment options for acute colonic pseudo-obstruction have had variable outcomes and include medications (neostigmine and erythromycin), endoscopic decompression, percutaneous tube cecostomy and colectomy. To our knowledge, this is the first case report of acute colonic pseudo-obstruction with a clinical response to treatment with tegaserod, a partial 5-HT4 receptor agonist. 5-HT4 receptor agonists may be a viable option in the treatment of acute colonic pseudo-obstruction.

Laparoscopic Ultralow Anterior Resection with Colonic J-pouch-Anal Anastomosis

Optimal treatment of mid to distal rectal cancers includes total mesorectal excision for oncologic clearance and, where reanastomosis is feasible, a colonic J-pouch-anal anastomosis improves bowel function. There is recent interest in performing an ultralow anterior resection laparoscopically. A technique is described that includes specimen extraction through the eventual routine defunctioning colostomy or ileostomy site. Consecutive unselected patients who underwent laparoscopic ultralow anterior resection were recruited. Patients with adenocarcinoma underwent preoperative endorectal ultrasound to individualize for neoadjuvant chemoradiotherapy, based on local extent and lymph nodes seen. The operative procedures were as shown in the video. Posterior dissection along the "total mesorectal excision plane" included incision of Waldeyer's fascia. Bowel continuity was restored by an intracoporeal double-cross stapled colonic J-pouch-anal anastomosis, but where not possible a coloplasty with pull-through handsewn coloanal anastomosis was performed. Laparoscopic ultralow anterior resection was performed on 55 patients (35 men; median age, 63 (range, 33-90) years) from March 2004 to October 2006. The median body mass index was 26.3 (19-38); 14 patients (25 percent) had a body mass index >30. Ten patients (18 percent) had an American Society of Anesthesiologists' classification of III. The indications were adenocarcinoma (n = 51), squamous-cell carcinoma of rectum (n = 1), dermoid tumor of mesorectum (n = 1), large villous adenoma (n = 1), and carcinoid with local lymph node metastases (n = 1). The adenocarcinomas were a median distance of 6 (3-12) cm from the anal verge. Neoadjuvant radiotherapy was given in 12 patients (24 percent) who had preoperative endoanal ultrasound findings of tumor extension beyond the muscularis propria and chemoradiotherapy in 7 (14 percent) of these patients where the tumor was more bulky and fixed. Laparoscopic ultralow anterior resection was completed at a median 180 (90-405) minutes, with 53.5 (2-2250) ml of blood loss, and the specimen was extracted through a 4.5 (3.5-11) cm wound. The latter included three cases (5 percent) that were converted. Significant adhesiolysis was required in 29 patients (52.7 percent) because of previous operations. The histologic grading or the adenocarcinoma patients were: Stage I, n = 14; Stage II, n = 23; Stage III, n = 11; Stage IV, n = 3. Of those who underwent curative resection (Stages I-III), the distal resection margin was 2.9 +/- 0.7 cm (mean +/- standard error) and the radial resection margins were at least 2 mm in all patients. The level of the coloanal anastomosis was a median 3.5 (0-4.5) cm from the anal verge; a coloanal pull-through anastomosis was required in one patient who had a distal cancer. The ileostomies functioned and patients tolerated free fluids at a median of two (1-9) days, and the median postoperative hospital stay was seven (3-22) days. At a median follow-up of 14 (2-33) months, none of the adenocarcinoma patients who had undergone curative resection had recurrences. Four patients (8 percent) had postoperative complications that required operative/invasive intervention (anatomotic leak n = 1, proximal bowel ischemia n = 1, port site hernia n = 1, pelvic collection n = 1). Four other patients had smaller pelvic collections that resolved with antibiotics; pelvic collections were associated with advanced stage of cancer (P = 0.047). Discharge was delayed by acute gastric distension in 11 patients; the latter was associated with poorer American Society of Anesthesiologists' risk classification (P = 0.035). Erectile dysfunction occurred in ten men, and this was associated with adjuvant chemoradiotherapy (P = 0.042). One patient (2 percent) had persistent urinary retention that required catheterization at latest follow-up. The ileostomy had been closed in 50 patients, and at last follow-up, the median stool frequency was two (1-8) bowel movements per day. Laparoscopic ultralow anterior resection could be offered routinely and completed safely in Western populations, where obesity and adhesions from previous abdominal surgery is common. A laparoscopic technique readily allowed visual identification of the autonomic nerves in the abdomen over the aorta, which could then be followed down into the pelvis. If the pelvis was deep, inversion of the 30 degrees laparoscope in the "upside down" position fascilited incision of Waldeyer's fascia. This brought the rectum proximally and anteriorly, aiding with the laparoscopic stapler transection of the distal rectum, especially if the cancer was distal, the patient was obese, and the pelvis was narrow. Extraction of the specimen at the eventual defunctioning stoma site reduced the incisions required. Preoperative chemoradiotherapy may have a role in postoperative male sexual dysfunction. Further randomized, controlled studies that include assessing five-year cancer survival/recurrence, pelvic nerve dysfunction, and bowel function are needed before laparoscopic ultralow anterior resection becomes widely accepted.