Tamás Cserni

Spiral intestinal lengthening and tailoring — first in vivo study

INTRODUCTION Spiral Intestinal Lengthening and Tailoring (SILT) offers a new opportunity for the surgical treatment of short bowel syndrome. SILT requires less manipulation on the mesentery than the Bianchi procedure and does not alter the orientation of the muscle fibers like serial transverse enteroplasty (STEP). This study reports the first SILT results in a surviving animal model. MATERIAL AND METHODS Vietnamese minipigs (n=6) underwent interposition of a reversed intestinal segment to produce proximal small bowel dilation. Five weeks later the reversed segment was resected, and the wall of the dilated intestine was cut spirally at 45°-60° to its longitudinal axis. The bowel was lengthened longitudinally, and the spiral shaped intestinal wound was sutured. Five weeks later, the animals were explored, and the lengthened segments were measured. Haematoxylin and eosin, picrosirius, neuron specific enolase, S-100, C-kit, and immunohistochemistry were performed. RESULTS Mean lengthening was 74.8% ± 29.5% and mean tailoring (lumen reduction) was 56.25% ± 18.8%. No instances of necrosis, perforation, suture break down, or peritonitis were observed in 6/6 animals. Four of six animals recovered uneventfully with viable lengthened segments. Statistical analysis showed no significant difference in length (p=0,078) and width (p=0,182) after 5 weeks. Two animals developed bowel obstruction due to narrowed lumen, adhesion, and strangulation after 14 and 24 days of surgery. In both animals the lumen was tailored by more than 70% to less than 1.5 cm diameter. The mucosa and the muscle layers in the operated segment had become hypertrophic, but the orientation of the circular and longitudinal muscle fibres remained normal after the SILT procedure. There were no signs of chronic ischemia or collagen accumulation after the SILT. The myenteric and submucosal plexuses and the Cajal cell network appeared normal. CONCLUSION The bowel remained viable macroscopically and microscopically after SILT, such that SILT may be an alternative or an addition to the present technical repertoire of intestinal lengthening. However the limitations of tailoring should be kept in mind.

New Insights into the Neuromuscular Anatomy of the Ileocecal Valve

The neuroanatomy of the ileocecal valve (ICV) is poorly understood. A better understanding of this important functional component of the gastrointestinal tract would enable surgeons to reconstruct an effective valve following surgical resection of the ICV. ICVs were examined in young pigs (N = 5) using frontal and transverse paraffin embedded and frozen sections. Hematoxylin+Eosin (H+E) staining, acetylcholinesterase (AchE), and NADPH‐diaphorase (NADPH‐d) histochemistry and protein gene product 9.5 (PGP 9.5) and C‐kit immunohistochemistry were performed. The H+E staining revealed that the ICV consists of three muscle layers: an external circular muscle layer continuous with that of the ileal circular muscle layer, an inner circular muscle layer continuous with that of the cecal circular muscle layer, and a single longitudinal muscle layer, which appears to be secondary to a fusion of the ileal and cecal longitudinal muscle layers. The AchE, NADPH‐d, and PGP 9.5 staining revealed two distinct coaxial myenteric plexuses, together with superficial and deep submucosal plexuses. The C‐kit immunostaining showed a continuous myenteric ICC network within the ICV. The structure of the neuromuscular components within the ICV suggests that the valve is a result of a simple intussusception of the terminal ileum into the cecum. This knowledge may help surgeons in their future attempts at reconstructing more anatomically and functionally suitable ICVs following surgical resection of native ICVs. Anat Rec 2009.

Atresia of the ileocecal junction with agenesis of the ileocecal valve and vermiform appendix: report of a case.

Intestinal atresia involving the ileocecal region is a very rare intestinal malformation, and the presence or absence of the ileocecal valve influences its surgical management. We report the case of a male newborn with a provisional diagnosis of distal ileal atresia, in whom laparotomy revealed that the entire ileocecal region was atretic with an absent ileocecal valve and appendix vermiformis. We resected the dilated terminal ileum together with the atretic segment and performed an ileocolic anastomosis between the terminal ileum and the transverse microcolon without valve reconstruction. When last seen, 8 months after the operation, the baby was developing normally. Ileocolic anastomosis without valve replacement appears to be sufficient if an ileocecal valve is completely absent and only a short segment of the terminal ileum is lost.

In utero incarceration of congenital diaphragmatic hernia.

In utero diagnosis of incarcerated congenital diaphragmatic hernia has never been reported. In our case, congenital diaphragmatic hernia presented at 34 weeks of gestation with dilated bowel loops, pleural effusion, and ascites on fetal ultrasound. Preterm delivery and emergency exploration revealed a tight posterolateral diaphragmatic defect with extensive bowel infarction.

Recycling of bowel content: the importance of the right timing.

INTRODUCTION Extracorporeal stool transport (recycling of chyme discharged from the proximal stoma end to the distal end of a high jejunostomy or ileostomy) is thought to be beneficial in preventing malabsoprtion, sodium loss, cholestasis and atrophy of the distal intestine until restoration of the intestinal continuity becomes possible. However little is known about its adverse effects. Our aim was to investigate the microbiological safety of recycling. MATERIAL AND METHOD Native samples were taken from the proximal stoma in 5 premature neonates who underwent an ileostomy or a jejunostomy due to necrotising enterocolitis, for qualitative culture. The first sample was drawn immediately after the change of the stoma bag, further samples were sent from the stoma bag at 30, 60, 90, 120, 150, and 180min later. The samples were inoculated by calibrated (10 μl) loops onto blood agar (5% sheep blood), eosin-methylene blue agar and anaerobic blood agar, respectively (Oxoid). The aerobic plates were incubated for 18-20 h at 5% CO2, whereas the anaerobic plates were incubated for 24-48 h in an anaerobic chamber (Concept 400). The bacterial strains were identified to species level by specific biochemical reactions, RapID-ANA II system (Oxoid) and ID32E, Rapid ID 32 Strep ATB automatic system cards (bioMérieux). RESULTS The number of colony forming unit (CFU) of Gram-negative bacteria (mainly E. coli) exponentially increased after 30 min and reached 10(5)/ml after 120 min. Gram-positive strains (primarily E. faecalis) were detected after 60 min and CFU increased to 10(5)/ml after 120 min. The number of anaerobic (principally Bacteroides fragilis) CFU started to increase after 120 min. In two cases coagulase negative Staphylococcus strains were isolated the earliest in the chyme. The average of total CFU approached 10(5)/ml after 90 min and exceeded 10(5)/ml after 120 min. CONCLUSION The chyme in the stoma bag is colonized by commensal facultative pathogenic enteral/colonic as well as skin flora species after 120 min. Recycling of stoma bag content may be dangerous after 90 min.

Proximal large bowel volvulus in children: 6 new cases and review of the literature

BACKGROUND Proximal large bowel volvulus is considered as an extremely rare surgical emergency in children. Approximately 40 cases have been reported, and because of its rarity, the diagnosis is often missed or delayed. The purpose of this study was to review the presentation, treatment, and clinical outcome of proximal large bowel volvulus. METHODS A systematic review and analysis of the data relating to 6 patients from the authors practice and cases published in the English literature from 1965 to 2010 was performed. Detailed information regarding demographics, clinical presentation and methods of diagnosis, surgical procedure, complications, and outcome were recorded. RESULTS Thirty-six cases of proximal large bowel volvulus were retrieved from the English literature, and 6 cases, from the authors practice. The male-female ratio was 1:1, with a median age of 10 years. There were 29 (69%) cases with neurodevelopmental delay. Clinical presentation included 29 (69%) cases with constipation, 41 (98%) with colicky abdominal pain, 42 (100%) with abdominal distension, and 35 (83%) with vomiting. Plain radiography was specific in 64% (27/42) of cases, barium enema in 100% (15/15), and computed tomography in 100% (2/2). All patients underwent surgery, with resection and primary anastomosis in 24 (57%) cases, stoma formation in 11 (26%), and detorsion of volvulus without resection in 7 (17%) cases. Six patients (14%) died postoperatively. CONCLUSION A child with neurodevelopmental delay and a history of constipation presenting with an acute onset of colicky abdominal pain and progressive abdominal distension with vomiting should be suspected of having a cecal and proximal large bowel volvulus.

Decreased Incidence of Appendix Testis in Cryptorchidism with Intraoperative Survey

Objective: Several authors have investigated the background of the process of testicular descent, but the role of the appendix testis has not been studied. The human appendix testis was found to express both estrogen and androgen receptors. We determined and compared the occurrence of testicular appendices intraoperatively in descended and undescended testes. Methods: The number of appendix testis was evaluated retrospectively in 208 boys who underwent uni- or bilateral orchiopexy, hydrocele or hernia repair and the testis was visible during operation. Results: The incidence of appendix testis was 76% (78 in 103) in descended and 24% (30 in 125) in undescended testes. Mean age at orchiopexy was lower in patients without appendix testis (39 months) compared to those patients who were found with appendix (61 months). Conclusion: The incidence of appendix testis was significantly lower (p < 0.05) in undescended testes, suggesting that the appendix testis might play a role in the process of testicular descent.

Hydrostatic Characteristics of the Ileocolic Valve and Intussuscepted Nipple Valves: An Animal Model

The ileocolic valve, in the dog, decelerates the passage of stools and prevents fecal reflux. A loss of anterograde resistance worsens the symptoms of short bowel syndrome. The absence of fecal reflux control enhances the risk of recurrence of Crohns disease. The aim of the present study was to examine what length of intussusception-like nipple valve (INV) should be constructed in order to restore the hydrostatic characteristics of the normal ileocecal valve. The anterograde and retrograde hydrostatic resistances of INVs of different lengths (4, 5, 6, or 7 cm) were compared with those of the normal ileocolic valve by using a contrast enema and x-ray monitoring in a canine model. It was found that the 4-cm-long INV may be sufficient to achieve an appropriate antireflux efficacy (59.60 ± 4.26 cm H2O) versus the ileocolic valve (25.80 ± 4.92 cm H2O), but this does not furnish an anterograde resistance comparable to that of the normal ileocolic valve (10.70 ± 1.15 cm H2O vs. 21.60 ± 3.96 cm H2O). We found that the appropriate length of the INV with which the anterograde resistance of the ileocolic valve could be attained in our model was between 6 and 7 cm. Thus, the shortest possible constructed INV should be effective in clinical conditions such as Crohns disease, but the recommended length in short bowel syndrome should be greater than this.

Reliability of colour Doppler ultrasound in the differential diagnosis of acute scrotum

Az akut scrotum hattereben allo heretorzio a here rapid irreverzibilis ischaemias karosodasa miatt surgős, szinte azonnali műteti exploraciot igenyel. Ugyanakkor a lenyegesen gyakoribb herefuggelek- (appendix testis) torzio es az epididymitis akar konzervativan is kezelhető. A fizikalis vizsgalaton alapulo elkulonitő korisme bizonytalansaga miatt sok esetben kerul sor felesleges exploraciora. A color Dopplerrel (CD) kiegeszitett here-ultrahangvizsgalat egyre nepszerűbb a gyermekkori akut scrotum differencialdiagnosztikajaban, ugyanakkor megbizhatosagat meg sokan vitatjak. Anyag es modszer: A szerzők tanulmanyukban osszevetettek a Debreceni Egyetem Orvos- es Egeszsegtudomanyi Centrum Gyermekgyogyaszati Intezeteben az elmult 10 ev soran akut scrotum diagnozissal kezelt 124 beteg 129 esetenek a fizikalis vizsgalat, a klinikai lefolyas es a 111 műteti exploracio alapjan megallapitott vegleges diagnozisat, valamint az első here-ultrahangvizsgalat eredmenyet. Eredmenyek: A vegleges diagnozis 100 esetben herefug...

Extralobar Pulmonary Sequestration in the Right Upper Thoracic Region

We present an extremely rare case of extralobar pulmonary sequestration in the right upper thoracic region, with a wide tracheal communication and a right subclavian arterial blood supply. The MRI scan suggested a bronchogenic cyst. Although preoperative color Doppler and angiography were not performed, successful resection was carried out. The histology indicated a diagnosis of extralobar pulmonary sequestration.