Proximal Bowel Research Articles

Intestinal sweet-sensing pathways and metabolic changes after Roux-en-Y gastric bypass surgery.

Studies suggest that improvements in type 2 diabetes (T2D) post- Roux-en-Y gastric bypass (RYGB) surgery are attributable to decreased intestinal glucose absorption capacity mediated by exclusion of sweet taste-sensing pathways in isolated proximal bowel. We probed these pathways in rat models that had undergone RYGB with catheter placement in the biliopancreatic (BP) limb to permit post-RYGB exposure of isolated bowel to sweet taste stimulants. Lean Sprague Dawley (n = 13) and obese Zucker diabetic fatty rats (n = 15) underwent RYGB with BP catheter placement. On postoperative day 11 (POD 11), rats received catheter infusions of saccharin [sweet taste receptor (T1R2/3) agonist] or saline (control). Jejunum was analyzed for changes in glucose transporter/sensor mRNA expression and functional sodium-glucose transporter 1 (SGLT1)-mediated glucose uptake. Saccharin infusion did not alter glucose uptake in the Roux limb of RYGB rats. Intestinal expression of the glucose sensor T1R2 and transporters (SGLT1, glucose transporter 2) was similar in saccharin- vs. saline-infused rats of both strains. However, the abundance of SGLT3b mRNA, a putative glucose sensor, was higher in the common limb vs. BP/Roux limb in both strains of bypassed rats and was significantly decreased in the Roux limb after saccharin infusion. We concluded that failure of BP limb exposure to saccharin to increase Roux limb glucose uptake suggests that isolation of T1R2/3 is unlikely to be involved in metabolic benefits of RYGB, as restimulation failed to reverse changes in intestinal glucose absorption capacity. The altered expression pattern of SGLT3 after RYGB warrants further investigation of its potential involvement in resolution of T2D after RYGB.

Knowledge and attitudes of medical students towards organ donation and transplantation

Knowledge and attitudes of medical students towards organ donation and transplantation

PWE-025 Increased Adenoma Detection In The Right Colon At Surveillance Colonoscopy Compared To Index Colonoscopy Within The Bcsp

IntroductionColonoscopy has been shown to be effective in reducing the incidence of colorectal cancer (CRC), presumably resulting from the removal of premalignant adenomas. There are data, however, to suggest that...

Endoscopic holmium laser lithotripsy to extract a large gallstone impacted in the terminal ileum

The patient was a 72-year-old woman who presented with abdominal pain and nausea/vomiting. CT revealed a calcified focus in the terminal ileum with proximal bowel dilatation, reflecting a partial obstruction (Fig. 1A). With worsening symptoms and poor surgical candidacy, endoscopic therapy was attempted.

Natural orifice specimen extraction (NOSE) and transanal extracorporeal anvil placement during laparoscopic low anterior resection

Natural orifice specimen extraction allows laparoscopic colorectal resections only through 5–12-mm trocar orifices on the abdominal wall without any additional incisions [1, 2]. Here, we describe a technique that facilitates laparoscopic coloanal anastomosis after retrieval of the colorectal specimen through the anus. A 62-year-old male presented with abdominal pain and rectal bleeding. He had no history of surgery and no severe comorbidity. His body mass index was less than 30 kg/m. A mobile mass was palpated on digital rectal examination. Colonoscopy revealed an ulcerated vegetating tumor 5 cm in diameter located 10 cm from the anal verge. The pathologist reported adenocarcinoma. Computed tomography scanning showed a rectal tumor not invading surrounding tissues. No preoperative radiotherapy was planned. The patient was hospitalized for surgical treatment. Following preoperative mechanical bowel preparation and antibiotic prophylaxis, the patient was placed in the modified lithotomy position. A 10–12-mmHg pneumoperitoneum was established. We used a five-port technique: Two 5-mm ports were placed in the upper and lower left quadrants, and a 10-mm umbilical port and two 12-mm ports were placed in the upper and lower right quadrants. The peritoneum was incised on the promontory, and dissection extending to the inferior mesenteric artery and vein was commenced. These vascular structures were transected after clip placement. The left and sigmoid colons were mobilized with medial-to-lateral dissection. The rectum was suspended in the cranial direction, sharp dissection was extended along the avascular plane between the presacral fascia and mesorectum, and dissection with Ligasure (Covidien, Mansfield USA) was carried out laterally up to the levator ani muscle. Following mobilization, the rectum was transected at the rectosigmoid junction using a 60-mm laparoscopic stapler. The anus was dilated gently using two fingers, and the stapled stump was retracted transanally using an ovarian clamp (Figs. 1a, 2). The rectum was transected 5 cm distally from the mass (Fig. 1b). The proximal closed colonic segment in the abdomen was delivered transanally using an ovarian clamp under laparoscopic guidance. The closed end of the proximal bowel was opened, and following placement of the anvil, and fixation with 2–0 prolene sutures, it was returned to the abdomen (Fig. 1c). The rectum was closed using a stapler device (TA 60 mm, Covidien), and the closed stump was inverted back into the abdomen (Figs. 1d, 3). Using a transanally placed 28-mm circular stapler, anatomic continuity was provided under laparoscopic guidance (Fig. 1e). Intraoperative air leak testing of the anastomosis was negative. We created a diverting loop ileostomy for protection of the distal anastomosis. The patient’s postoperative course was uneventful except for urinary incontinence that was treated conservatively. He was discharged after 5 days. The histopathology findings were adenocarcinoma T2N0M0. The patient underwent two courses of postoperative chemotherapy and radiotherapy for 25 days. His ileostomy was reversed after 5 months, and there was no anal or urinary incontinence at 7-month follow-up. A. H. Alam Rabia Balkhi Hospital, Kabul, Afghanistan

Small Bowel Obstruction from Strongyloides Stercoralis: Case Report

Strongyloides Stercoralis is a nematode and infection from it is common in Sub-Saharan and South East Asia continent. It is mostly asymptomatic but if it presents, then is usually seen with vague gastrointestinal complaints. Small bowel obstruction is a poorly recognized and possibly underreported complication. We hereby present a case of partial small bowel obstruction from S. Stercoralis. A 35 year old man from Africa presented with one year history of post prandial nausea, abdominal bloating and bilious vomiting along with significant weight loss. His abdomen X ray and CT scan were consistent with partial proximal bowel obstruction. He presented to different hospitals and was treated for his symptoms, but a definite diagnosis could not be made. We performed upper endoscopy and biopsy which was consistent with S. Stercoralis infection. He was treated aggressively with Ivermectin and Albendazole until his stool cultures became negative for infectious larvae. He was followed up after 3 and 6 months with complete resolution of symptoms. We conclude that, since S. Stercoralis is an uncommon etiology for proximal bowel obstruction, high index of suspicion should be exercised in patients presenting as above and recent travel to areas endemic for S. Stercoralis.

Role of bulking agents in improving continence postoperatively in patients with Hirschsprung′s disease

Background: The bulking agents have provided an effective means of treating adults with internal sphincter (IS) incompetence. The damages to IS in pull-through operation and in those who had hypermotile proximal bowel segments have increased the need for increasing the IS pressure. Materials and Methods: 35 children with fecal incontinence after pull-through, who presented to our unit from January 2008 to February 2012, were enrolled in the study and investigated with endoanal sonography and anorectal manometry. The bulking agent was injected into the sub-mucosal anal plane of IS. The assessments undertaken were clinical assessment of the functional score and anorectal manometery for 6-12 months. Data were analyzed with IBM SPSS version 21 using repeated measure analysis of variance (ANOVA). Friedman test was used for analyzing soilage score changes during the study. Results: Manometry readings before and 6 months after intervention were 21.8 ± 4.2 and 25.2 ± 4.7 mmH 2 O, respectively. High-pressure zone area changed from 1.98 ± 0.63 to 2.8 ± 0.75 cm ( P Conclusion: Bulking of internal anal sphincter defects causes an improvement in fecal continence and the function.

Acute pancreatitis and superior mesenteric artery syndrome

Superior mesenteric artery syndrome (SMAS) has been proposed as a rare cause of proximal bowel obstruction resulting from compression of the third portion of the duodenum secondary to narrowing of the space between the aorta and superior mesenteric artery. The main risk factors associated with SMAS are significant weight loss, corrective spinal surgery and congenital or acquired anatomic abnormalities. Its association with acute pancreatitis has been reported in very few cases. We present a critical review of this topic, with the report of a patient allegedly diagnosed of SMAS and acute pancreatitis.

Enteral stents: from esophagus to colon

Because of significant advances in endoscopic techniques and the development of high-quality stents, endoscopic enteral stent placement is increasingly being performed for the management of malignant GI obstruction. Palliative stenting is now routinely performed for malignant esophageal, gastric, duodenal, and colon obstruction. In addition to palliative indications, preoperative stenting in the colon may be performed as a bridge to surgery to achieve immediate decompression and convert an emergent surgery into an elective, 1-stage procedure.The realm of enteral stenting has recently expanded to include management of benign conditions such as leaks, fistulas, and benign strictures in the GI tract. Further research is required to study the use of enteral stents in benign conditions and to adequately compare endoscopic stent placement with surgical intervention. Promising new technologies such as biodegradable stents and drug-eluting stents also require further investigation. With continued innovation in endoscopic techniques and stenting devices, the field of enteral stenting is likely to expand further, with an increase in indications and improvement in outcomes.

Complete laparoscopic surgery for early colorectal cancer after endoscopic resection

Laparoscopic-assisted colorectal surgery requires a mini-laparotomy to extract the specimen and insert the anvil head of the circular stapler into the proximal colon. However, such a mini-laparotomy occasionally causes local pain and surgical-site infection. To avoid mini-laparotomy, we invented a new laparoscopic technique, complete laparoscopic surgery for colorectal cancer. Sigmoid colon or rectal cancer patients who had undergone colonoscopic excision for T1 cancer and subsequently required bowel resection due to unfavorable histology were recruited. This new procedure used both the double stapling technique and the rectal-prolapsing technique, where the anvil was transanally inserted into the proximal colon and bowel resection was extracorporeally performed after pulling out the colon-rectum via the anus. This procedure was attempted in 17 patients and successfully achieved in 13 patients. Total laparoscopic colorectal surgery has some problems such as bacterial contamination or infection, as well as dissemination caused by intraluminal exfoliated cancer cells. This procedure is limited to post-endoscopic resection patients who are suited for reconstruction by double stapling technique, and it may be impossible in patients with thick mesentery or anal stenosis. Moreover, this method resolves issues of peritoneal contamination and dissemination. However, a new protection method for implantation of exfoliated cancer cells needs to be established, so that complete laparoscopic surgery can be employed in patients with small cancers.

Bouveretʼs Syndrome: An Uncommon Complication of Cholelithiasis

Purpose: An 84-year-old Caucasian female presented with nausea, vomiting, and abdominal pain. Four years previously, she had an episode of cholecystitis and cholelithiasis that was treated with antibiotics. She declined surgical therapy but was asymptomatic in the ensuing years. During the current illness, her abdomen was soft with mild palpable tenderness in the mid-epigastrium. Bowel sounds were normal and no masses were noted. Laboratory testing including CBC, electrolytes, liver enzymes, and amylase were normal. CT scan showed air in the biliary tree with distention of the duodenum and stomach. Jejunum and ileum were not dilated. Abdominal series showed air fluid levels in the stomach and duodenum, and air in the biliary tree, but no free air was noted. During upper GI endoscopy, the esophagus and stomach were normal; the duodenal bulb contained two ulcers and an ulcerated fistula that led to the gall bladder. Large stones were found in the gallbladder. Retained solid food was in the duodenal bulb. The second portion of the duodenum below the ampulla was obstructed by a large gallstone. The stone could not be removed via endoscopy. The patient underwent an exploratory laparotomy resulting in an enterolithotomy with fistula repair and cholecystectomy. An obstructing gallstone measuring approximately 5 cm was found at the ligament of Treitz. The patient made an uneventful recovery and was discharged home after 9 days. Bouveret's syndrome is an uncommon complication of gall bladder disease resulting from passage of a gallstone through a cholecystoenteric fistula that causes a proximal bowel obstruction. It is a form of gallstone ileus resulting from an impacted gallstone in the duodenum or pylorus. Patients typically present with epigastric pain, nausea, and vomiting. The average age of a patient with the syndrome is 74.1 years of age (SD±11.1) and is more frequent in women (1.86 female/male ratio). Less than 0.5% of patients with cholelithiasis will develop gallstone ileus; however, in patients over 65 years of age it accounts for 25% of nonstrangulated bowel obstructions. Gallstone ileus only accounts for 1-4% of cases of intestinal obstruction. Of gallstone ileus cases, only 1-3% are Bouveret's Syndrome. The majority of gallstones in the bowel impact at the ileoceaccal junction. Rigler's triad of gallstone ileus includes pneumobilia, small bowel obstruction, and a gallstone. CT scan will detect all three signs of Rigler's triad in 78% of cases. Diagnosis of Bouveret's Syndrome is made in 69% of cases by upper GI endoscopy. If removal is not possible endoscopically, enterolithotomy with or without cholecystectomy and fistula repair is the most common surgical therapy.

Advances in Hirschsprung Disease Genetics and Treatment Strategies

Hirschsprung disease (HSCR) is a multigenic condition with variable presentation. Most commonly, it presents in the neonatal period as a functional intestinal obstruction secondary to failure of caudal migration of the enteric nervous system. Classically, this manifests as dilated proximal bowel and constricted distal bowel with absent ganglia and hypertrophic nerve trunks. When recognized early, medical and surgical therapies can be instituted to minimize associated morbidity and mortality. This article reviews current understanding of the etiology of HSCR, its multigenic associations, the historical evolution of HSCR diagnosis and treatment, and current HSCR therapies.

Gastrointestinal Bleeding in Patients with Ventricular Assist Devices Is Highest Immediately After Implantation

Ventricular assist device implantation is associated with gastrointestinal bleeding (GIB); however, outcomes in terms of initial and repeat GIB risk, severity, location of lesions, and endoscopic interventions need to be better defined. Consecutive patients from a database of adult patients with ventricular assist devices (VADs) implanted between January 1, 2000, and December 31, 2010, at a single center were reviewed and followed through May 31, 2011, in a retrospective manner. The GIB events were further classified by severity, lesion location, and lesion type. Hazard analysis models were calculated for the time to GIB events. Of 166 patients with a VAD, 38 patients experienced 84 GIB events. Seventeen patients experienced ≥2 GIB events. Maximal hazard for the first bleeding event was 2.23 events/patient-year at 21 days and declined to the constant hazard by 71 days postimplantation. The hazard for recurrent GIB was greatest immediately after the first GIB event. When considering all GIB events, most lesions (68%) were located in the proximal bowel. Angiodysplasia was the most common lesion type (17.5%) seen on endoscopy when all GIB events were considered, whereas ulcers were the most common type (13.8%) seen in initial GIB events. The actuarial risk of initial GIB events peaks in the first 3 months after VAD implantation followed by a stable lower risk of bleeding. The hazard for recurrent GIB events is substantially increased immediately after the initial GIB.

Ileal Crohn's disease with perforation misdiagnosed as ruptured appendicitis: A case report

Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, TaiwanReceived 2 July 2013; received in revised form 6 July 2013; accepted 9 July 2013Crohn’s disease (CD) is a chronic transmural inflammationof any part of the alimentary tract, especially the distalileum and the proximal large bowel. CD is diagnosedthrough history, diagnostic images, and pathological find-ings.

Sleeve gastrectomy: the ideal option for metabolic surgery?

I congratulate Michel Gagner for a wellarticulated argument favouring sleeve gastrectomy (SG) as ‘the ideal’ weight loss procedure in his News and Views article (Sleeve gastrectomy—the ideal choice for weight-loss surgery. Nat. Rev. Endocrinol. doi:10.1038/nrendo.2013.100).1 Although long-term data are still scarce, in the short to mid-term (1–3 years), weight loss after SG seems to be higher of that achieved after gastric banding and similar to Rouxen-Y gastric bypass (RYGB).2 The question is, however, if this is sufficient evidence to define SG as the ‘ideal’ choice. I am afraid that this is not the case. Unlike bariatric surgery, conceived as a weight loss intervention, metabolic surgery is based on treating obesity and type 2 diabetes mellitus (T2DM) from the perspective of metabolic illnesses. As recently shown by Rubino et al., such change in end points has several ramifications, distinguishing metabolic from bariatric surgery. Consistent with the intent to treat a disease, not weight per se, the choice of the intervention should be based on mechanisms of action and me tabolic outcomes, not simply on weight loss. Although both SG and RYGB share similar effects on certain mechanisms of glucose homeostasis (incretin levels), there is experimental evidence that re-routing the food through the gastrointestinal tract, excluding the proximal bowel (as is the case with RYGB), promotes specific, weight-independent effects on T2DM.3–5 In a recent randomized study comparing RYGB versus SG versus medical therapy in diabetic patients, Kashyap et al.6 found that 2 years after surgery, RYGB induced greater improvement of insulin sensitivity (Matsuda Index) and β-cell function (insulin disposition index), compared with SG, whereas weight loss was similar Sleeve gastrectomy: the ideal option for metabolic surgery?

Intestinal gangrene due to small bowel volvulus masquerading as strangulated inguinal hernia – A diagnostic dilemma.

Complicated inguinal hernia is a common surgical emergency. Rarely, hernias may pose a great surprise and complexity in their management.We report a 55 year old gentleman witha long standing history of irreducible right inguinal hernia who presented in shock with sudden increase in size of scrotum and obstipation for 1 day.A diagnosis of strangulated inguinal hernia was made and the patient was taken up for emergency surgery.On exploration the content in the sac was normal small bowel and faeculant smelling fluid. Abdomen was explored for inspecting the proximal bowel and to facilitate reduction of contents.But as a surprise small bowel volvuluswith gangrenous bowel was noted. Resection and anastomosis was done.This paper stresses the importance of having a high index of suspicion in all cases of strangulated hernia of a concomitant small bowel volvulus as its recognition and early surgical intervention is paramount in reducing the mortality associated with it.

Image quality of myocardial perfusion-gated studies: effect of ingestion of different fat content in the reduction of extra-myocardial abdominal signal

Myocardial perfusion-gated-SPECT (MP-gated-SPECT) imaging often shows radiotracer uptake in abdominal organs. This accumulation interferes frequently with qualitative and quantitative assessment of the infero-septal region of myocardium. The objective of this study is to evaluate the effect of ingestion of different fat content on the reduction of extra-myocardial uptake and to improve MP-gated-SPECT image quality. In this study, 150 patients (65 ± 18 years) who were referred for MP-gated-SPECT underwent a 1-day-protocol including imaging after stress (physical or pharmacological) and resting conditions. All patients gave written informed consent. Patients were subdivided into five groups: GI, GII, GIII, GIV and GV. In the first four groups, patients ate two chocolate bars with different fat content. Patients in GV – control group (CG) – had just water. Uptake indices (UI) of myocardium (M)/liver(L) and M/stomach–proximal bowel(S) revealed lower UI of M/S at rest in all groups. Both stress and rest studies using different food intake indicate that patients who ate chocolate with different fat content showed better UI of M/L than the CG. The UI of M/L and M/S of groups obtained under physical stress are clearly superior to that of groups obtained under pharmacological stress. These differences are only significant in patients who ate high-fat chocolate or drank water. The analysis of all stress studies together (GI, GII, GIII and GIV) in comparison with CG shows higher mean ranks of UI of M/L for those who ate high-fat chocolate. After pharmacological stress, the mean ranks of UI of M/L were higher for patients who ate high- and low-fat chocolate. In conclusion, eating food with fat content after radiotracer injection increases, respectively, the UI of M/L after stress and rest in MP-gated-SPECT studies. It is, therefore, recommended that patients eat a chocolate bar after radiotracer injection and before image acquisition.

The use of indocyanine green fluorescence to assess anastomotic perfusion during robotic assisted laparoscopic rectal surgery

Decreased blood perfusion at an intestinal anastomosis may contribute to postoperative anastomotic leak (AL) resulting in substantial morbidity and mortality. Near-infrared (NIR) laparoscopy in conjunction with indocyanine green (ICG) allows for visualization of the microcirculation before formation of the anastomosis, thereby allowing the surgeon to choose the point of transection at an optimally perfused area. This is a retrospective case-control analysis examining the effectiveness of NIR + ICG in reducing the rate of AL after low anterior resection (LAR) for rectal cancer. Records of patients undergoing robot-assisted LAR for rectal cancer with and without ICG were analyzed for the years 2011 and 2012. Among the 40 patients who underwent robotic LAR, NIR + ICG was used in 16 cases (41 %). Male patients accounted for the majority of cases in both groups (74 %). The median level of the anastomosis was 3.5 cm in the NIR + ICG group and 5.5 cm in the control group. There was no difference in the use of diverting ileostomy. In 3 patients (19 %), the use of NIR + ICG resulted in revision of the proximal bowel (colonic) transection point before formation of the anastomosis. The distal transection point was never revised. The rate of AL in the NIR + ICG group was 6 % versus 18 % in control group. ICG fluorescence may play a role in anastomotic tissue perfusion assessment and affect the AL rate. Larger prospective studies are needed to further validate this novel technology.

Totally Transanal LESS Pull-Through Colectomy: A Novel Approach for Avoiding Abdominal Wall Incision in Children with Long-Segment Intestinal Aganglionosis

Abstract Introduction: Minimally invasive surgery in children with long-segment intestinal aganglionosis aims to reduce the number of abdominal wall incisions. Conventional laparoscopic and laparoendoscopic single-site (LESS) surgeries fulfill this goal. In children, natural orifice translumenal endoscopic surgery (NOTES™; American Society for Gastrointestinal Endoscopy [Oak Brook, IL] and Society for American Gastrointestinal and Endoscopic Surgeons [Los Angeles, CA]) has been limited because of fear of access site complications. We present a novel technique of totally transanal LESS pull-through colectomy (TLPC), avoiding abdominal wall incision, which combines LESS technology and the NOTES approach. Two boys and one girl (2.5 months, 6 months, and 5 years of age, respectively) with sigmoid and transverse colon aganglionosis underwent surgery. The TLPC procedure consisted of an endorectal technique with submucosal dissection starting 1 cm orally from the dentate line to above the peritoneal reflection, where the rectal muscle was divided circumferentially. After ligation of the rectal mucosa, the proximal bowel was replaced into the abdominal cavity, and a TriPort(®) (Olympus Surgical Technologies Europe, Hamburg, Germany) was introduced transanally. Mesenterial resection of the aganglionic bowel was accomplished via transanal LESS until the normoganglionic colon segment was reached and pulled down to the site of anastomosis. After removal of the port, a conventional pull-through procedure was performed. All children displayed normal bowel movements and were complication-free during the follow-up period of up to 7 months. TLPC combines the minimally invasive LESS surgery with the scarless concept of NOTES and allows resection of long-segment aganglionosis without abdominal incision. TLPC is a safe, effective, and feasible surgical procedure in children with long-segment intestinal aganglionosis.

A Case of Cecal Volvulus Presenting with Chronic Constipation in Lissencephaly

Cecal volvulus is uncommon in pediatric patients and there are few reports of cecal volvulus with cerebral palsy. Here, we report the case of a 19-year-old male patient who presented with abdominal distension, a history of cerebral palsy, refractory epilepsy due to lissencephaly, and chronic constipation. An abdominal x-ray and computed tomography without contrast enhancement showed fixed dilated bowel intensity in the right lower abdomen. Despite decompression with gastric and rectal tube insertion, symptoms did not improve. The patient underwent an exploratory laparotomy that revealed cecal volvulus. Cecal volvulus usually occurs following intestinal malrotation or previous surgery. In this patient, however, intestinal distension accompanying mental disability and chronic constipation resulted in the development of cecal volvulus. We suggest that cecal and proximal large bowel volvulus should be considered in patients presenting with progressive abdominal distension combined with a history of neuro-developmental delay and constipation.