Right retrocolic intrasaccular duodenum: Is it a novel variant of isolated duodenal nonrotation? A case report

Background: Almost all of the studies on anomalies of the midgut rotation and fixation in the literature and related sections in textbooks were designed according to Dott's classification. Focusing only on common rotation anomalies has led to the exclusion and neglect of other rare variants. Isolated pure duodenal nonrotation is such a variant. Case Presentation: We report a case of an unusual form of isolated pure duodenal nonrotation, in a 3-day-old newborn presenting with bilious vomiting. Ultrasonographic examination revealed the sign of 'whirlpool'. When this finding was evaluated together with bilious vomiting, midgut volvulus was considered and the patient was operated on urgently. Peroperatively, it was observed that the jejunum entered between the leaves of the terminal ileum mesentery. Proximally, the duodenum was located posterior to the right colon in a "sack". This "sack" was surrounded by thick Ladd's bands laterally, mesentery of the ascending colon medially, the posterior surface of the cecum and ascending colon anteriorly, and by the posterior abdominal wall posteriorly. Conclusion: In isolated duodenal nonrotation, the duodenum may be completely retro-colic. Consequently, the duodenojejunal junction and the ileocecal region may almost overlap. Unlike isolated duodenal nonrotation cases, in the surgical treatment of this variant, separation of Ladd bands alone is not sufficient, additionally, the right colon should be placed in a nonrotation position and care should be taken not to kink the terminal ileum under the cecum.

Expression of Oxidative Phosphorylation Complexes and Mitochondrial Mass in Pediatric and Adult Inflammatory Bowel Disease

Introduction. Inflammatory bowel disease (IBD), which includes Crohn’s disease (CD) and ulcerative colitis (UC), is a multifactorial intestinal disorder but its precise etiology remains elusive. As the cells of the intestinal mucosa have high energy demands, mitochondria may play a role in IBD pathogenesis. The present study is aimed at evaluating the expression levels of mitochondrial oxidative phosphorylation (OXPHOS) complexes in IBD. Material and Methods. 286 intestinal biopsy samples from the terminal ileum, ascending colon, and rectum from 124 probands (34 CD, 33 UC, and 57 controls) were stained immunohistochemically for all five OXPHOS complexes and the voltage-dependent anion-selective channel 1 protein (VDAC1 or porin). Expression levels were compared in multivariate models including disease stage (CD and UC compared to controls) and age (pediatric/adult). Results. Analysis of the terminal ileum of CD patients revealed a significant reduction of complex II compared to controls, and a trend to lower levels was evident for VDAC1 and the other OXPHOS complexes except complex III. A similar pattern was found in the rectum of UC patients: VDAC1, complex I, complex II, and complex IV were all significantly reduced, and complex III and V showed a trend to lower levels. Reductions were more prominent in older patients compared to pediatric patients and more marked in UC than CD. Conclusion. A reduced mitochondrial mass is present in UC and CD compared to controls. This is potentially a result of alterations of mitochondrial biogenesis or mitophagy. Reductions were more pronounced in older patients compared to pediatric patients, and more prominent in UC than CD. Complex I and II are more severely compromised than the other OXPHOS complexes. This has potential therapeutic implications, since treatments boosting biogenesis or influencing mitophagy could be beneficial for IBD treatment. Additionally, substances specifically stimulating complex I activity should be tested in IBD treatment.

Assessing The Inflammatory Severity of The Terminal Ileum In Crohn Disease Using Radiomics Based On MRI

Background: Evaluating inflammatory severity using imaging is essential for Crohn’s disease (CD), but it is limited by potential interobserver variation and subjectivity. We compared the efficiency of magnetic resonance index of activity (MaRIA) collected by radiologists and a radiomics model in assessing the inflammatory severity of terminal ileum (TI).Methods: 121 patients were collected from two centers. Patients were divided into ulcerative group and mucosal remission group based on the TI Crohn's disease Endoscopic Severity Index (tCDEIS). The consistency of bowel wall thickness (BWT), relative contrast enhancement (RCE), edema, ulcer, MaRIA and features of the region of interest (ROI) between radiologists were described by weighted k coefficient and intraclass correlation coefficient (ICC), and developed receiver operating curve (ROC) of MaRIA. The radiomics model was established using reproducible features of logistic regression based on arterial staging of T1WI sequences. Delong test was used to compare radiomics with MaRIA.Results: The consistency between radiologists were moderate in BWT (ICC=0.638), fair in edema (k=0.541), RCE (ICC=0.461), MaRIA (ICC=0.579) and poor in ulcer (k=0.271). Radiomics model was developed by 6 reproducible features (ICC=0.93-0.96) and equivalent to MaRIA which evaluated by the senior radiologist(0.872 vs 0.883 in training group, 0.824 vs 0.783 in testing group, P=0.847, 0.471), both of which were significant higher than MaRIA evaluated by junior radiologist(AUC: 0.621 in training group, 0.557 in testing group, all, PB0.05).

Physiological Role of Bile Acids Modified by the Gut Microbiome

Bile acids (BAs) are produced from cholesterol in the liver and are termed primary BAs. Primary BAs are conjugated with glycine and taurine in the liver and then released into the intestine via the gallbladder. After the deconjugation of glycine or taurine by the gut microbiome, primary BAs are converted into secondary BAs by the gut microbiome through modifications such as dehydroxylation, oxidation, and epimerization. Most BAs in the intestine are reabsorbed and transported to the liver, where both primary and secondary BAs are conjugated with glycine or taurine and rereleased into the intestine. Thus, unconjugated primary Bas, as well as conjugated and unconjugated secondary BAs, have been modified by the gut microbiome. Some of the BAs reabsorbed from the intestine spill into the systemic circulation, where they bind to a variety of nuclear and cell-surface receptors in tissues, whereas some of the BAs are not reabsorbed and bind to receptors in the terminal ileum. BAs play crucial roles in the physiological regulation of various tissues. Furthermore, various factors, such as diet, age, and antibiotics influence BA composition. Here, we review recent findings regarding the physiological roles of BAs modified by the gut microbiome in the metabolic, immune, and nervous systems.

A Curious “Appendicitis”, Magnetic Foreign Bodies Ingestion In a Five Year Old Girl With Ileal Perforation. Case Report and Review of Literature.

BackgroundForeign body ingestion is common in children. Ingestion of multiple magnetic foreign bodies poses a significant risk of complications as they are unlikely to pass spontaneously. Case presentationWe present our interesting case of a 5 Year old girl, complaining of right iliac fossa pain not relieved with paracetamol, associated with 2 episodes of vomiting and one episode of loose bowel motion. Abdominal examination revealed tender right iliac fossa with weak rebound and mild guarding with no rigidity. WBC was 16.9, with 12.68 neutrophils, with normal urea, creatinine, amylase, CRP and liver function tests. Patient was admitted for suspected appendicitis versus gastroenteritis. Abdominal ultrasound showed free fluid in the pelvis, appendix was not seen and there was a mass in the right iliac fossa. The patient was started on intravenous co-amoxiclav and diagnostic laparoscopy revealed a normal appendix with free fluid in pelvis. The omentum was stuck to terminal ileum with two necrotic patches and a perforation in the terminal ileum with magnetic foreign bodies protruding from the perforation site.There was no peritoneal contamination. Laparotomy was performed via right lower transverse incision with resection & anastomosis of necrotic perforated bowel segment and removal of three magnetic foreign bodies from the terminal ileum. Patient had smooth postoperative recovery. ConclusionThe Ingestion of multiple magnets, or a magnet with a metallic object should be considered an impending surgical emergency as it is unlikely to pass spontaneously and complications are more likely. There are no reports where more than one magnet was passed spontaneously. The possibility of foreign body ingestion should always be considered in a young child presenting with abdominal symptoms. Early intervention is indicated if the history, clinical findings and imaging are suggestive of multiple magnetic ingestion to prevent serious life threatening complications.

Ductus Omphalocele Mesenteric Persisten: A Case Reports

Background: The ductus omphalomecenterica is a normal embryological structure where it serves to connect the midgut of the fetus to the yolk sac. Usually, this ductus will disappear at 9 weeks gestation. However, if this condition does not occur, then it can cause various anomalies to appear in the fetus. Case Presentation: The patient was reported to be hospitalized with the chief complaint of choking. Echocardiography examination with the results of the examination found the presence of cyanotic congenital heart disease (CHD). The patient was referred to pediatric surgery with a diagnosis of persistent mesenteric duct omphalocele. Terminal ileum anastomoses resection laparotomy was performed. Conclusion: After surgery due to complications of pneumonia and sepsis, the patient died.

Ischemic Conditioning in the Right Colon and Terminal Ileum: An Experimental Rat Model

Introduction: Preoperative gastric ischemic conditioning (IC) improves the outcome of esophageal replacement gastroplasty and is associated with low morbidity. However, when the stomach cannot be used for esophageal replacement, a colonic replacement is required. The study aim was to assess the viability of right colon and terminal ileum IC in a rat model, the histological damage/recovery sequence, and determine if neovascularization is a potential adaptive mechanism. Methods: The study was conducted in Rattus norvegicus with ileocolic vascular ligation. Seven groups of animals were established (six rats per group) with groups defined by the date of their post-IC euthanasia (+1, +3, +6, +10, +15, and +21 days). Comparisons were made with a sham group. Viability of the model was defined as <10% of transmural necrosis. The evaluation of histological damage used the Chiu score in hematoxylin and eosin sections of paraffin-embedded specimens with CD31 immunohistochemical assessment of neovascularization by the median of submucosal vessel counts in five high-magnification fields. Results: Transmural colon necrosis occurred in 1/36 animals (2.78%) with no animal demonstrating transmural ileal necrosis. The maximum damage was observed in the colon on +1 day post-IC (average Chiu score 1.67, P = 0.015), whereas in the ileum, it was on days +1, +3, and +6 (average Chiu score 1.5, 1.3, and 1.17; P = 0.015, 0.002, and 0.015, respectively). In the +21-day group, histological recovery was complete in the colon in four (66.7%) of the six animals and in the ileum in five (83.3%) of six animals. There were no significant differences in quantitative neovascularization in any of the groups when compared with the sham group or when comparisons were made between groups. Conclusions: The tested animal model for IC of the colon and terminal ileum appeared to be feasible. Histological damage was maximal between the 1st and 3rd day following IC, but by day 21, recovery was complete in two-thirds of the rats. There was no evidence in this preliminary IC model that would suggest neovascularization as an adaptive mechanism.

Colon Capsule Endoscopy in the Assessment of Mucosal Healing in Crohn’s Disease

Background Patients with Crohn’s disease (CD) undergo frequent endoscopic procedures, with visualization of the gastrointestinal mucosa central to treatment decision-making. Subsequently, a noninvasive alternative to optical colonoscopy (OC) would be welcomed. One such technology is capsule endoscopy, including the PillCam COLON 2 (PCC2), though research validating its use in ileocolonic CD is limited. This study aims to compare PCC2 with ileocolonoscopy (OC) in assessing mucosal CD through use of a standardized scoring system. Methods At an Australian tertiary hospital, same-day PCC2 and ileocolonoscopy results of 47 CD patients, with known nonstricturing disease, were prospectively collected and analyzed for correlation and agreement. Deidentified recordings were reported by a single expert gastroenterologist. Mucosal disease was quantified using the Simple Endoscopic Score for Crohn’s Disease (SES-CD). The SES-CD results of paired endoscopic modalities were compared in total per bowel segment and per SES-CD variable. Results Of 47 PCC2 recordings, 68% were complete, fully assessing terminal ileum to rectum, and OC was complete in 89%. Correlation (r) between total SES-CD scores was strongest in the terminal ileum (r = 0.77, P &lt; .001), with the SES-CD variable of “ulcer detection” showing the strongest agreement. The PCC2 (vs OC) identified additional ulcers in the terminal ileum; ascending, transverse, and descending colon; and rectum; scores were 5 (1), 5 (3), 1 (1), 2 (1), and 2 (2), respectively. Conclusions The PCC2 shows promise in assessing ileocolonic mucosa, especially in proximal bowel segments, with greater reach of visualization in the small bowel. Given the resource and safety considerations raised by the Coronavirus disease 2019 pandemic, capsule endoscopy has particular significance. This article aims to contribute to the limited body of research surrounding the validity of capsule endoscopy technology in assessing ileocolonic mucosa in Crohn’s Disease patients. In doing so, an alternative option for patients enduring frequent endoscopies is given potential.

Clinical application of terminal ileum suspension in laparoscopic radical resection for low rectal cancer

Objectives: This paper introduces the surgical procedure of “terminal ileum suspension” in the radical resection for low rectal cancer patients and evaluates the possibility of its clinical application. Methods: This paper retrospectively analyzed the data of patients with low rectal cancer who underwent “terminal ileum suspension” during radical resection of rectal cancer (Dixon) in our hospital, and introduces the specific surgical procedures and key points of “terminal ileum suspension”. Observe the relevant conditions of patients during the operation, postoperative recovery and postoperative complications, and analyze the safety and feasibility of this operation (“terminal ileum suspension”). Results: The operation of all 8 patients went smoothly, and no anastomotic leakage, intestinal obstruction, and open diversion of suspended terminal ileum were found. The application of “terminal ileum suspension” in the operation of low rectal cancer has achieved ideal clinical effect, without increasing the rate of anastomotic leakage and rehospitalization, reducing the proportion of the secondary return operation, and reducing the pain of the patients. Conclusion: “Terminal ileum suspension” is a safe, effective and feasible surgical method for laparoscopic radical resection of low rectal cancer, which can be applied in clinical practice. doi: https://doi.org/10.12669/pjms.38.1.4721 How to cite this:Long-zhi Z, Bin Z, Jian-xin H, Wei L. Clinical application of terminal ileum suspension in laparoscopic radical resection for low rectal cancer. Pak J Med Sci. 2022;38(1):---------. doi: https://doi.org/10.12669/pjms.38.1.4721 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.