Seromuscular Layer Research Articles

Development of a novel reflux‐free bilioenteric anastomosis procedure by using a bioabsorbable polymer tube

Bilioenteric anastomosis allows reflux of bowel fluid into bile ducts, resulting in reflux cholangitis. We sought to develop a reflux-free procedure of bilioenteric anastomosis endowed using an artificial bile duct (ABD). The study was performed in four groups of pigs. In Group A, end-to-side choledochoduodenostomy using the interposed ABD with its distal end wrapped by the duodenal seromuscular layer was performed. In Group B, conventional end-to-side choledochoduodenostomy using the ABD was performed. In Group C, conventional end-to-side choledochoduodenostomy was performed. In Group D, sham operation was performed. In each groups, 12 weeks later, animals were evaluated. Bile amylase levels were significantly lower in Group A (36.9 +/- 21.7 U/L) compared with Group B (469 +/- 140.9 U/L). No significant differences were observed in bile amylase levels between Groups A and D or between Groups B and C. On histology, the neo-bile duct in Group A was covered with the duodenal muscular layer at the orifice into the intestinal tract. This study suggests that the ABD is useful in the regeneration of extrahepatic bile ducts and that to bury the ABD in the duodenum can be a preventive measure against reflux of bowel fluid to bile ducts.

Use of a New Multi-Tasking Platform for Endoscopic Full Thicknes Resection (EFTR) in a Porcine Model

Background: The advent of NOTES has accelarated the development of new technology in the field of gastrointestinal endoscopy. Various suturing devices or multi-tasking platforms are expected to be valuable for endoluminal surgery as well as single port surgery or NOTES. We reported first experience of endoscopic full thickness resection of gastric wall by using “EndoSAMURAI” (Olympus Medical Systems Corp. Tokyo, Japan). The aim of this study was to evaluate the feasibility of EFTR by using this new multi-tasking platform. Materials and Methods: EndoSAMURAI has three parts, which are the main body, flexible scope section and the over tube.Two arms are equipped in the tip of the flexible endoscope which is designed that each arm can insert various forceps from the main body. Exclusive forceps for EndoSAMURAI are designed on the basis of the device for laparoscopic surgery. Two ex-vivo porcine models and two anesthetised pigs were used for this study. Based on our previous reports, perctaneous gastric lifting was used as the assistance of EFTR procedures. Circumferential cutting of gastric wall was performed with needle knife and IT knife. Large defect resulted from EFTR was sutured with Brace bar (Olympus Medical Systems Corp. Tokyo, Japan), which is a prototype suturing device on the basis of tissue anchoring technology. Outcome measurements included time to perform the procedure, adequacy and size of the resection specimen, and clinical complications and their resolution. Results: All EFTR procedures were successfully accomplished. There was no adverse event in all anethtetised pigs. One massive bleeding occoured during circumferential cutting of sero-muscular layer, but it could be stopped endoscopically. Mean diameter of resected specimen was 5.3 cm. All specimens included serosal surface and were proved full thickness of gastric wall. Mean times required for the EFTR procedure (from circumferential cutting till closure of gastric wall) was 17.5 min. Conclusion: A new multi-tasking platform “EndoSAMURAI” was able to perform EFTR procedures in a porcine model. This successful result showed that a multi-tasking platform which is one of the new technology developed for NOTES procedures would be useful for advanced endoluminal surgery such as ESD or EFTR as well as NOTES.

Electrical stimulation induces propagated colonic contractions in an experimental model

Direct colonic electrical stimulation may prove to be a treatment option for specific motility disorders such as chronic constipation. The aim of this study was to provoke colonic contractions using electrical stimulation delivered from a battery-operated device. Electrodes were inserted into the caecal seromuscular layer of eight anaesthetized pigs. Contractions were induced by a neurostimulator (Medtronic 3625). Caecal motility was measured simultaneously by video image analysis, manometry and a technique assessing colonic transit. Caecal contractions were generated using 8-10 V amplitude, 1000 micros pulse width, 120 Hz frequency for 10-30 s, with an intensity of 7-15 mA. The maximal contraction strength was observed after 20-25 s. Electrical stimulation was followed by a relaxation phase of 1.5-2 min during which contractions propagated orally and aborally over at least 10 cm. Spontaneous and stimulated caecal motility values were significantly different for both intraluminal pressure (mean(s.d.) 332(124) and 463(187) mmHg respectively; P < 0.001, 42 experiments) and movement of contents (1.6(0.9) and 3.9(2.8) mm; P < 0.001, 40 experiments). Electrical stimulation modulated caecal motility, and provoked localized and propagated colonic contractions.

Angleplasty in gastric tube reconstruction after esophagectomy

Anastomotic leakage after radical esophagectomy is mostly caused by the hypoxia and high tension at the esophagogastric anastomotic site. Here, we introduce a new surgical technique, 'Angleplasty,' to enable the tensionless anastomosis at a highly oxygenic site of gastric conduit. In short, the seromuscular layer is cut for a perpendicular direction against a lesser curvature at a gastric angle and the gastric wall is carefully divided between the muscular and submucosal layers for longitudinal direction for 4-5 cm in length. Then, the wound is closed with seromuscular sutures for longitudinal direction. With this maneuver, the lesser curvature of the gastric roll is significantly elongated and the anastomosis site of the gastric conduit can be moved more distal on the greater curvature of the stomach where it is expected to receive more oxygen supply. This technique takes only several minutes, but provides highly favorable conditions for esophagogastric anastomosis and thus is clinically useful to reduce the risk of anastomotic leakage after esophagectomy.

Gastrointestinal microcirculation and cardiopulmonary function during experimentally increased intra-abdominal pressure*

The aim of this study was to assess gastric, intestinal, and renal cortex microcirculation parallel with central hemodynamics and respiratory function during stepwise increase of intra-abdominal pressure (IAP). Prospective, controlled animal study. Research laboratory, University Hospital. Twenty-six anesthetized and mechanically ventilated pigs. Following baseline registrations, CO2 peritoneum was inflated (n = 20) and IAP increased stepwise by 10 mm Hg at 10 mins intervals up to 50 mm Hg and subsequently exsufflated. Control animals (n = 6) were not insufflated with CO2. The microcirculation of gastric mucosa, small bowel mucosa, small bowel seromuscular layer, colon mucosa, colon seromuscular layer, and renal cortex were selectively studied at all pressure levels and after exsufflation using a four-channel laser Doppler flowmeter (Periflex 5000, Perimed). Central hemodynamic and respiratory function data were registered at each level and after exsufflation. Cardiac output decreased significantly at IAP levels above 10 mm Hg. The microcirculation of gastric mucosa, renal cortex and the seromuscular layer of small bowel and colon was significantly reduced with each increase of IAP. The microcirculation of the small bowel mucosa and colon mucosa was significantly less affected compared with the serosa (p < 0.01). Our animal model of low and high IAP by intraperitoneal CO2-insufflation worked well for studies of microcirculation, hemodynamics, and pulmonary function. During stepwise increases of pressure there were marked effects on global hemodynamics, respiratory function, and microcirculation. The results indicate that intestinal mucosal flow, especially small bowel mucosal flow, although reduced, seems better preserved in response to intra-abdominal hypertension caused by CO2-insufflation than other intra-abdominal microvascular beds.

Endometriomas as a Marker of Disease Severity

Study Objective Although superficial endometriosis can be treated effectively and safely by most gynecologic surgeons, deep infiltrating disease (DIE) needs to be treated in specialist endometriosis centers. For women to be treated in the most appropriate setting, it is necessary to identify if they have DIE. Design Prospective observational study (Canadian Task Force classification II-2). Setting Dedicated pelvic pain clinic attracting both secondary and tertiary referrals. Patients A total of 295 women with histologically confirmed endometriosis. Interventions Prospective intraoperative data were collected to investigate the role of endometriomas as a marker for DIE, and in particular, rectosigmoid disease. Measurements and Main Results In all, 61 (21%) women had an endometrioma. A significantly greater proportion of women with an endometrioma had accompanying endometriotic disease affecting the bowel compared with women without an endometrioma (77% vs 21%; p <.001). A strong relationship existed between presence of endometrioma and posterior cul-de-sac obliteration, rectosigmoid disease, and involvement of the seromuscular layer of the bowel. The presence of an endometrioma significantly increased the probability of having rectosigmoid disease, with a positive likelihood ratio of 6.96 (95% CI; 4.04–12.00). However, the absence of an endometrioma did not preclude having rectosigmoid disease, with a negative likelihood ratio of 0.55 (95% CI; 0.45–0.67). Conclusion Although endometriomas provide a useful marker for DIE, the absence of an endometrioma does not preclude the presence of DIE, although a significantly lower proportion of women without an endometrioma will have DIE when compared with women with an endometrioma.

Comparison of Transgastric Access Techniques for Natural Orifice Translumenal Endoscopic Surgery (NOTES)

Background: NOTES (natural orifice translumenal endoscopic surgery) is an area of active research in experimental endoscopy and has the potential to significantly advance the field of minimally invasive surgery. Several transgastric access techniques have been described to date. The aim of the current ex-vivo, experimental study was to evaluate different methods of transluminal access with regard to safe closure and leakage after the procedure. Methods: By using ex vivo porcine stomachs mounted on a custom-made board, the following endoscopic techniques for transgastric access were evaluated. The first arm used standard gastrotomy by needle knife incision; the second, a small gastrotomy and dilation with a controlled radial expansion (CRE) balloon. In the third arm a short (4 cm) submucosal tunnel was created by physically separating the mucosa from the muscularis. After the tract was initiated, the scope was advanced within its lumen and a needle knife was used to incise the seromuscular layer at the distal end of the submucosal tunnel. The fourth arm also used a submucosal tunnel, but with an extended tract (8 cm). In the interventional arms each mucosal incision was closed with endoscopic clips. Finally, hand-sewn gastric closure by a senior surgeon after needle knife incision served as positive control. Negative controls were stomachs in which the needle knife gastrotomy was not closed. Five stomachs were tested per study arm. After closure, each stomach was inflated with methylen blue stained water by an automated pressure gauge. The pressures to liquid leakage were recorded. Results: The unclosed controls demonstrated liquid leakage at 2.4 ± 1.8 mmHg (mean ± standard deviation), representing baseline system resistance. The hand-sewn gastric closure after linear incision leaked at 50.4 ± 7.0 mmHg. The needle knife gastrotomy, the balloon dilation, the short submucosal tunnel and the extended submucosal tunnel leaked at 37.4 ± 15.1 mmHg, 48.2 ± 25.0 mmHg, 43.7 ± 12.5 mmHg, and 88.6 ± 22.3 mmHg, respectively. There were significant differences in leak pressures between the group with the extended submucosal tunnel and all other transgastric access techniques. The techniques with submucosal tunneling required longer time than transgastric access by linear incision or balloon dilation (20.8 ± 7.8 min vs. 4.9 ± 3.0 min) and were technically more demanding. Conclusions: The extended submucosal tunnel yielded the best leak-resistance that is superior to standard transgastric access methods and rival hand-sewn interrupted stitches.

In Situ Autologous Bladder tissue culture for Bladder Autoaugmentation in Animal Model: Bladder wall as A Bioreactor

PURPOSE To introduce a new technique for bladder autoaugmentation using in situ autologous bladder tissue culture and expansion for augmentation cystoplasty in a rabbit model and report its preliminary surgical outcome. MATERIAL AND METHODS Twenty-four rabbits were divided into 3 groups. Group I underwent classical autoaugmentation. Group II underwent insertion of tissue expander in a 2x1 cm 2 frame of bladder wall between the mucosa and seromuscular layer for autoaugmentation marked by non-absorbable sutures. In group III all animals were allocated the same technique although the inserted tissue expander was implanted with autologous tissue fragments. In this group a 10x5 mm 2 full thickness bladder biopsy was dissected and separated smooth muscle cell (SMC) and urothelial cell (UC) tissue layers were minced into 20 fragments. The SMC fragments were coated on the separated mucosal layer beneath the tissue expander and UC fragments were seeded on the expander under the seromuscular layer. After 6 weeks the 2 recombinant bladder tissue layers were grafted to the remaining host bladder. Immediately before grafting and at 30 d intervals after grafting, bladder biopsies were obtained for determination of CD31/34, SMC α-actin, and cytokeratin AE1/AE3 following cystometric evaluations. RESULTS The bladder wall frames containing fragment-seeded tissue expanders, demonstrated organized bladder wall generation in two different expanded layers with mature urothelium and muscular layers. While number of CD34+ endothelial progenitor cells and CD31+ microvessels were significantly higher(P <0.05). Group III showed a significant bladder capacity increment as compared with groups I-II (P <0.001). CONCLUSIONS Our RESULTS demonstrate the bladder wall acted as an in situ bioreactor; preserved autologous bladder tissue culture with seeded fragments on a tissue expander provided a histologically organized bladder wall generated in vivo, adding 2 times more surfaces applicable in augmentation.

Seromuscular Tear of the Sigmoid Colon in the Absence of Trauma: A Case Report

A 16-year-old adolescent boy was admitted to our hospital with severe lower abdominal pain and was found to have peritonitis, probably caused by acute appendicitis. At laparotomy, we found a paper-thin, dilated sigmoid colon; the seromuscular layer on the antimesenteric side was torn, and the untorn mucosa showed a pinpoint perforation. The seromuscular defect had spread circumferentially to involve the entire circumference of the colon wall. We performed sigmoidectomy, and the patient recovered uneventfully. This case showed many similarities, both in terms of the macroscopic and pathological findings, to seromuscular tear, an entity specifically associated with seatbelt use. This case is noteworthy because seromuscular tear-like lesions of the colon without a history of trauma has not previously been reported.

An easier method for performing a pancreaticojejunostomy for the soft pancreas using a fast-absorbable suture

To clarify the usefulness of a new method for performing a pancreaticojejunostomy by using a fast-absorbable suture material irradiated polyglactin 910, and a temporary stent tube for a narrow pancreatic duct with a soft pancreatic texture. Among 63 consecutive patients with soft pancreas undergoing a pancreaticoduodenectomy from 2003 to 2006, 35 patients were treated with a new reconstructive method. Briefly, after the pancreatic transaction, a stent tube was inserted into the lumen of the pancreatic duct and ligated with it by a fast-absorbable suture. Another tip of the stent tube was introduced into the intestinal lumen at the jejunal limb, where a purse-string suture was made by another fast-absorbable suture to roughly fix the tube. The pancreaticojejunostomy was completed by ligating two fast-absorbable sutures to approximate the ductal end and the jejunal mucosa, and by adding a rough anastomosis between the pancreatic parenchyma and the seromuscular layer of the jejunum. The initial surgical results with this method were retrospectively compared with those of the 28 patients treated with conventional duct-to-mucosa anastomosis. The incidences of postoperative morbidity including pancreatic fistula were comparable between the two groups (new; 3%-17% vs conventional; 7%-14% according to the definitions). There was no mortality and re-admission. Late complications were also rarely seen. A pancreaticojejunostomy using an irradiated polyglactin 910 suture material and a temporary stent is easy to perform and is feasible even in cases with a narrow pancreatic duct and a normal soft pancreas.

Avaliação histomorfométrica e ultra-estrutural da mucosa do cólon menor eqüino submetido a distensão

Estudos recentes demonstraram que a distensão luminal do cólon menor, apesar de ter promovido redução da irrigação da camada seromuscular resultando em inflamação intensa, não acarretou em lesões histopatológicas aparentes na mucosa. O objetivo do presente estudo foi avaliar, por meio de histomorfometria e microscopia eletrônica de varredura (MEV), os efeitos da distensão intraluminal sobre a mucosa do cólon menor. Utilizaram-se 16 eqüinos. No Grupo distendido (GD), nove deles foram submetidos a quatro horas de distensão intraluminal do cólon menor por um balão inflado com pres são de 40mm de Hg. No Grupo instrumentado (GI), o balão foi introduzido no lume, mas sem provocar distensão. Colheram-se amostras intestinais antes e ao fim da obstrução e após 1,5 e 12 horas de reperfusão. À MEV observou-se em GD que a superfície da mucosa adquiriu um aspecto liso, aplainado, após a distensão, retornando ao aspecto rugoso após descompressão. Ao fim do experimento, a superfície da mucosa se apresentava com aspecto um pouco mais irregular, com pontos de fragmentação. À histomorfometria observou-se em GD uma redução da espessura da mucosa em relação ao controle após a distensão, retornando a valores semelhantes aos basais após descompressão. Concluiu-se que a mucosa, apesar de ter seu aspecto alterado e sua espessura reduzida, conseguiu suportar a distensão promovida pelo aumento de pressão intraluminal, retornando às suas características originais sem apresentar lesões significativas.

Case Report: Laparoscopic Partial Cystectomy with Endo-GIA Stapling Device in Bladder Diverticular Carcinoma

The incidence of bladder diverticular carcinoma is low, ranging from 0.8% to 10%. Traditionally, treatment consisted of open surgical excision or transurethral resection. More recently, laparoscopic surgery has become widely accepted. We report here a case of bladder diverticular carcinoma treated with laparoscopic partial cystectomy. A 56-year-old man presented with gross hematuria and was found to have transitional-cell carcinoma in a bladder diverticulum. We performed transurethral resection of the tumors and laparoscopic partial cystectomy. A 45-mm Endo-GIA stapler (U.S. Surgical Corp., Norwalk, CT) was used for direct resection of the diverticular tissue, and the specimen was removed en bloc. Suture of the seromuscular layer was performed with the intracorporeal knotting technique. Lymph-node dissection also was performed. At 3-month follow-up, it was noted that there was tumor recurrence that was not at the original diverticular site, and transurethral resection was carried out. After 1 year, cystoscopy and CT scans showed neither recurrence nor metastasis. No encrustation or erosion was induced by the staples. Laparoscopic partial cystectomy can be an alternative treatment for bladder diverticular carcinoma.

Laparoscopic continent appendicocecostomy

Purpose Most of the previously reported techniques to construct a laparoscopic appendicocecostomy (LA) for antegrade continent enemas (ACE) do not create a continence mechanism with a submucosal tunnel, which carries the risk of leakage of stool. We report a technique to construct a LA for ACE, which creates a submucosal tunnel, mimicking the open technique (Modified Malone). Material and methods The appendix was isolated and the cecum mobilized. A 4 cm seromuscular incision was done from the base of the appendix along the tenia and the proximal appendix was placed in a submucosal tunnel created by reapproximatiion of the seromuscular layer of the cecum with interrupted sutures. Under laparoscopic vision the appendix was brought out through the umbilical site and anastomosed to the V flap previously prepared in the umbilical skin. A catheter was left in place for four weeks. Results There were two patients, 8.5 and 8.6 years old. Diagnosis were neurogenic bowel dysfunction secondary to lipomeningocele and tethered spinal cord in 1 child and high imperforated anus and tethered spinal cord in the other. Mean operative time was 3.5 hours. Blood loss was negligible. There were no complications. Patients were discharge home at 3 and 4 days postoperatively. At 9 and 14 months after surgery there has not been difficulties with catheterization or stoma related complications. Both patients are compliant with antegrade enemas, continent of stool and very satisfied with the procedure. Conclusions The appendicocecostomy for ACE created with a submucosal tunnel and located at the umbilicus with open surgery provides a concealed stoma with easy access and no leaking problems. Following the same principles we were able to reproduce these technique laparoscopically to provide a reliable channel with the advantages of minimal invasiveness and improved cosmesis.

Neural Crest Neuroblasts Can Colonise Aganglionic and Ganglionic Gut In Vivo

Neural crest (NC) cells differentiate IN VITRO into neuroblasts, precursors of the enteric nervous system (ENS), when stimulated by specific agents. We developed a study aimed at establishing whether NC-derived neuroblasts can survive and colonise IN VIVO when injected into a recipient mouse gut. The neuroblast precursors of the ENS were obtained from the vagal portion of the neural tubes of 296 CD-1 and GTROSA26 mouse embryos. The embryonic cells of GTROSA26 mice are identifiable through beta-galactosidase activity which allows recognition by blue staining. The host used in this study was the DOM/+ mouse, an animal model for Hirschsprung's disease (aganglionic megacolon). DOM/+ mouse pups (n = 43) received NC-derived cells inoculated into the seromuscular layer of the gut (33/43) or directly into the peritoneal abdominal cavity (10/43). All DOM/+ mice survived the procedure and were sacrificed after 7 or 14 days. Histochemical staining detected implanted cells in all mice. These showed specific myenteric colonisation into the aganglionic and ganglionic gut. The striking result of this study was the specific tropism of the injected NC-derived cells to target sites under the action of unknown chemotactic agents. This experimental procedure might represent a possible treatment option for specific forms of human ENS anomaly such as total intestinal aganglionosis.

Pancreatic fistula after pancreaticoduodenectomy: A comparison between the two pancreaticojejunostomy methods for approximating the pancreatic parenchyma to the jejunal seromuscular layer: Interrupted vs continuous stitches

The purpose of this study is to find a better operative technique by comparing interrupted stitches with continuous stitches for the outer layer of the pancreaticojejunostomy, i.e. the stitches between the stump parenchyma of the pancreas and the jejunal seromuscular layer, and other risk factors for the incidence of pancreatic leakage. During the period January 1997 to October 2004, 133 patients have undergone the end-to-side and duct-to-mucosa pancreaticojejunostomy reconstruction after pancreaticoduodenectomy with interrupted suture for outer layer of the pancreaticojejunostomy and 170 patients with a continuous suture at our institution by one surgeon. There were no significant differences between the two groups in the diagnosis, texture of the pancreas, use of octreotide and pathologic stage. Pancreatic fistula occurred in 14 patients (11%) among the interrupted suture cases and in 10 (6%) among the continuous suture cases (P = 0.102). Major pancreatic leakage developed in three interrupted suture patients (2%) and zero continuous suture patients (P = 0.026). In multivariate analysis, soft pancreatic consistency (odds ratio, 5.5; 95% confidence interval 2.3-13.1) and common bile duct cancer (odds ratio, 3.7; 95% CI 1.6-8.5) were predictive of pancreatic leakage. Pancreatic texture and pathology are the most important factors in determining the fate of pancreaticojejunal anastomosis and our continuous suture method was performed with significantly decreased occurrence of major pancreatic fistula. In conclusion, the continuous suture method is more feasible and safer in performing duct-to-mucosa pancreaticojejunostomy.

Suture-line ulcer after gastric surgery caused by non-absorbable suture materials.

Abstract Four cases of suture-line ulceration associated with non-absorbable suture material are presented. In 2 of these cases the suture had been placed only in the seromuscular layer. The diagnosis was made in each case by gastroscopy. Excision of the complete suture line is the most satisfactory form of treatment.

Proteinase-like peptidase activities in malignant and non-malignant gastric tissue.

Activities of several proteinase-like peptidases have been determined in homogenates of malignant tissue, non-malignant tissue adjacent to the tumour (A-NM) and non-malignant tissue distant to the tumour (D-NM) from 17 patients undergoing surgery for histologically confirmed gastric malignancies. In homogenates of malignant tissues the activities of collagenase, cathepsin B, cathepsin (B+L), cathepsin H and cathepsin D were significantly higher than in D-NM tissues. By contrast, the levels of plasminogen activator were significantly lower in malignant tissues than in the D-NM tissues. Furthermore, the activities of collagenase-like and the cysteine-proteinase-like peptidases in the A-NM tissues were lower than in malignant tissues but higher than in the D-NM tissues. Separation of full-thickness non-malignant tissues into mucosal and seromuscular layers revealed significantly higher activities in the former. The elevated levels of these proteinase-like peptidases in homogenates of gastric cancer tissue suggests an important role for these enzymes in tumour invasion.

Optical-Access Visual Obturator Trocar Entry into Desufflated Abdomen During Laparoscopy: Assessment After 96 Cases

The introduction of optical-access laparoscopic trocars was met with enthusiasm and the impression that these devices provide safer access with decreased complication rates. However, serious complications have been reported. We retrospectively reviewed our first 96 consecutive cases (17 radical prostatectomies, 2 sacrocolpopexies, 6 adrenalectomies, and 71 renal procedures), performed between October 2001 and April 2003, of optical-access laparoscopic trocar placement as initial entry into the desufflated abdomen. After creating a 12-mm periumbilical or lateral-rectus incision, the 12-mm Endopath Bladeless visual obturator trocar (Ethicon Endosurgery, Cincinnati, OH) was inserted into the peritoneum while carefully observing the separation of the layers of fascia, muscle, and peritoneum. There were no vascular injuries. However, we observed 2 (2.1%) large-bowel injuries: a seromuscular injury and a through-and-through enterotomy of the mid-descending colon. In both cases, the visual obturator was placed lateral to the left rectus muscle, and the large colon was noted to be adherent to the anterior abdominal wall. The bowel injuries were repaired in two layers (running 3-0 Vicryl for the mucosa and 3-0 silk for the seromuscular layer). The operations were completed without open conversion and with uneventful recovery. Direct placement of an optical-access visual obturator trocar into the desufflated abdomen carries the potential for significant injury. Our current practice is to place the visual trocar after Veress-needle peritoneal insufflation.

Appendico-gastrostomy: a new technique for long-term feeding: Mohta A. Aust N Z J Surg 2004 (September);74:799-800

The author reports a new surgical technique for facilitating gastrostomy feeding, using the appendix as a conduit in those children with malrotation in which the appendix lay close to the stomach. The author performed the surgery open via a left subcostal incision. The appendix was mobilised on its vascular pedicle, a 6-8 Fr feeding tube passed through the appendix and the distal end anastomosed to the anterior wall of the stomach. The body of the appendix was then buried over a length of 2-3 cm in the seromuscular layer of the stomach wall, which was closed with an absorbable suture, to create a valve mechanism. The proximal end of the appendix was then passed through the anterior abdominal wall through a separate incision, completing the appendico-gastrostomy.

Late Regeneration of Infarcted Small Bowel Mucosa: A Case Report

Ischemic injury of the small bowel may recover after revascularization, provided that full-thickness infarction did not occur. Animal studies showed that if the mucosal crypts remain viable, rapid mucosal restitution occurs hours after injury. The treatment of transmucosal infarction that does not extend to full wall thickness, however, was not investigated thoroughly. The patient presented had a mesenteric event leading to resection of about half of his small bowel. The unresected segment had severe ischemic injury, which seemed to cause transmucosal, but not transmural, infarction. Imaging of the remaining small bowel revealed a seromuscular layer denuded of mucosa. The ischemic damage was too deep to allow rapid regeneration, and the patient had short-bowel syndrome. A year later, during operation for stricture complications, new mucosa covered parts of the small-bowel surface, encouraging the surgeon to elect a conservative approach. Sixteen months after the injury, normal mucosa covered the entire small bowel, and enteral feeding resumed successfully. This report shows that infarcted small-bowel mucosa may regenerate even months after injury.