Forensic medical evaluation of an isolated injury of the small bowel mesentery and its vessels (literature review extended with expert case report)

This work summarizes information from the modern scientific literature devoted to the issues of morphology and mechanisms of an isolated mesenteric injury, which is rare in expert practice. Apart from classic forensic medical papers, publications over 2000 – 2020, devoted to abdominal organ injuries, were analyzed. In the search engines PUBMED and eLibrary.ru, a selection of sources was made according to the keywords: “rupture of the mesenteric root of the small intestine,” “diagnostics,” “forensic medical evaluation.” The results of the literature analysis were used in the study of the repeated forensic medical examination materials of a case of rapid death (in 1.5 hours) due to a traumatic rupture of the mesentery of the small bowel and its large vessels. The combined analysis of the expert case report and special scientific literature allows us to devise the following conclusions: 1. A forensic expert must have expert knowledge in the normal anatomy of the abdominal aorta’s unpaired vessels and their accompanying veins location and know about their variable topographic and anatomical features. 2. Life-threatening bleeding from the damaged vessel of the mesentery of the small bowel occurs in a wide time interval after the mechanical damage. 3. The development of life-threatening intra-abdominal bleeding is due to the scope of damage and the rate of blood flow from the damaged vessel. 4. Thorough examination of the area of rupture of the mesenteric vessel and the state of the tissues in the circumference of the rupture allow to establish the mechanism of injury. 5. Ignorance of the mechanism of injury and specifics of the formation of injuries is the cause of expert errors and scientifically unfounded conclusions. 6. There is no reference material on the rate of blood flow from a damaged large vessel.

Mesenteric Vessel Thrombosis Treatment Experience

BACKGROUND: One of the most serious diseases among all emergency abdominal pathology is an acute violation of the mesenteric blood circulation. The rapid development of intestinal ischemia results in its infarction and necrosis. AIM: The study aims to assess the survival rate of patients with mesenteric vascular thrombosis, taking into account, the predictor characteristics influence of disease development factors. METHODS: The study presents a retrospective analysis of mesenteric vascular thrombosis clinical cases for 2016–2019. During this period, there were 147 patients with an established diagnosis at the Irkutsk Clinical Hospital No. 1, 21 of them met the study criteria. RESULTS: According to the type of thrombosis, there were two groups – occlusive (Group I, n = 11) and non occlusive (Group II, n = 10). Four patients (36.3%) of Group I and 7 patients (70%) of Group II (p = 0.388) recovered from the disease. Three patients (27.2%) of Group I and 4 patients (40%) of Group II (p = 0.662) received conservative therapy, 2 of them (66.6%) in Group I and 4 (100%) in Group II (p = 0.724) recovered from the disease. In addition, the authors performed a mortality assessment, according to the timing of the visit to a medical institution. Four (50%) out of eight patients who applied in the first 12 h, 2 (66%) out of three – in the first 12–24 h, and 5 (50%) out of 10 for more than 24 h of illness had a positive treatment result in the combined group. CONCLUSION: The patients over 70 years old with peritoneal symptoms and established intestinal necrosis have an extremely unfavorable prognosis. The primary mesenteric vessel thrombosis with additional contrast angiography still gives a moderate treatment prognosis.

Use of Polyamide (Nylon) Cable Ties for Vascular Ligation of Healthy Equine Jejunal Mesentery

Jejunal vascular ligation is an essential step in performing jejunojejunostomy. Hand sewn ligation is typically used and can increase operative time with long sections of bowel to be removed. Nylon cable ties (NCT) have been used for vascular ligation in horses but are yet to be investigated for application on the mesenteric vasculature of the gastrointestinal tract. Our objective was to evaluate the efficacy and short-term safety of NCT jejunal mesenteric vessel ligation in healthy horses. Eight healthy adult horses underwent midline celiotomy. A segment of jejunal mesentery was identified (≥4 arcades). Briefly, three fenestrations (proximal, middle, distal) were made 5–10 mm apart adjacent to the first and last vascular arcade to be ligated. Two sterilized NCT were passed to encircle the mesentery through the proximal and middle fenestrations, separated by intact mesentery. NCT were closed tightly and the vascular pedicle transected with Mayo scissors through the distal fenestration. Jejunojejunostomy was then performed and the mesentery sutured closed. The number of vascular arcades and time to ligate using NCT were recorded. At 2 weeks, horses underwent repeat celiotomy to assess the healing of the NCT ligation site and an equal number of vascular arcades were hand sewn double ligated using 2-0 Polyglactin 910 as a timed comparison. NCT mesenteric ligation was significantly faster than hand sewn methods (P < 0.01). Effective hemostasis was achieved in all cases. There was no evidence of local infection or adhesions at 14 days post-operatively. Further investigation in the long-term effects in horses as well as horses with strangulating jejunal lesions are needed for clinical application.

Evaluation of the Bleeding Complications in Laparoscopic Cholecystectomy in a Tertiary Care Hospital: A Cross-Sectional Study

Objective: To determine the frequency of various sources of bleeding in laparoscopic cholecystectomy with special preference to gallbladder bed excluding port site. Methods: This cross-sectional study was consisted of 163 patients admitted through the outpatient department from Peoples Medical College Hospital Nawabshah. Ultrasound of abdomen was done as diagnostic modality and for assessment of gallstone disease. Finally the cases of gallstone were operated through laparoscopic cholecystectomy procedure and observed for sources of bleeding. Results: Out of 163 patients included in this study 138(84.7%) were female and 25(15.3%) patients were male; with female to male ratio of 5.52:1. The mean age was 41.85±7.83 years. Common sources of bleeding in laparoscopic cholecystectomy from liver bed side were 44(27%) cases followed by cystic artery in 17(10.4%) cases, hepatic artery and mesenteric vessel in 1(0.6%) case was observed. Conclusion: Bleeding during laparoscopic cholecystectomy are almost equally common and can prove to be lethal if not identified and managed during the operation. Good surgical technique, awareness and early recognition and management of such cases are keys to success when dealing with this problem.

Mesenteric Vessel Abnormalities Detected With Sonography: A Possible Gateway to the Early Diagnosis of Various Gastrointestinal Anomalies

Background: In pediatric sonography, mesenteric vessel abnormalities can be used as a sign of malrotation or volvulus. This study was aimed at evaluating the diseases associated with mesenteric vessel abnormalities in children, except for rotational anomalies. Methods: From 2017 to 2020, pediatric patients with abdominal complaints were referred for a full abdominal sonogram and were evaluated for mesenteric vascular abnormalities. During this period, 62 children (aged <12 years), with mesenteric vessel abnormalities, were discovered with sonography. They were also examined for associated anomalies and were followed until a final diagnosis was determined. Results: Mesenteric vessel displacement was reported in 37 patients (60%); in 24 cases, the vein was located to the left of superior mesenteric artery (SMA), and in others (13 cases), in the anterior position. Abnormal pathways in mesenteric vessels were reported in 33 patients (53%); 18 cases showing a right side turn and 15 cases showing a left side turn. The whirlpool sign was seen in 16 patients (27%). These three patterns of vessel abnormality were associated with disorders such as diaphragmatic hernia, bowel obstruction, and space occupying lesions (masses). The location of the mesenteric abnormality was in the proximal part of mesenteric vessels in 45 cases (72.5%) and in its distal part in 17 cases (27.5%). Malrotation (eight cases), obstruction, and volvulus were the most common causes of a distal abnormality. Conclusions: Mesenteric vessel abnormalities, noted with sonography, may not be exclusive to the diagnosis of malrotation and midgut volvulus. In this cohort, bowel obstruction, diaphragmatic hernia, and space occupying lesions were the other most common anomalies associated with mesenteric vessel abnormalities. In reviewing one-third of mesenteric vessels, abnormalities were only seen in the distal part of vessels; therefore, a thorough examination is warranted.

Abstract P061: Identification Of Piezo1 Channels In Perivascular Adipose Tissue (pvat) And Their Potential Role In Vascular Function

The vasculature constantly experiences distension/pressure exerted by the blood and responds accordingly to maintain homeostasis. Perivascular adipose tissue (PVAT) is gaining support as a formal blood vessel layer and also experiences these changes. We hypothesized that activation of the mechanotransducer Piezo1 directly increases vascular contraction in a way that might be modified by PVAT. The presence of Piezo1 was investigated at the mRNA level via PCR; protein via immunohistochemistry; and contractility via isolated tissue bath. Rat superior and mesenteric arteries, thoracic aortae, human mesenteric vessels and their PVATs were studied. Piezo1 mRNA (beta2 microglobulin calibrator) was expressed in the aortic vessel (2 -ΔC T =0.011); aortic PVAT (2 -ΔC T =0.0172); mesenteric vessel (2 -ΔC T =.00302), and mesenteric PVAT (2 -ΔC T =0.0219). Both adipocytes (2 -ΔC T =0.0249) and stromal vascular fraction (2 -ΔC T =0.0159) of mesenteric PVAT expressed Piezo1 mRNA. Piezo1 mRNA expression was greater in magnitude (one-way ANOVA) than that of the mechanotransducers Piezo2, TRPV4, TMEM16, and Panx1. Piezo1 protein was present in rat aortic PVAT, rat mesenteric (mes) artery, vein, and PVAT, as well as in human artery, vein, and PVAT. The Piezo1 agonists Yoda and Jedi (1 nM - 10 μM) did not stimulate rat aortic contraction [max <10% phenylephrine (PE) 10 μM contraction] or relaxation independent from vehicle in tissues + or - PVAT (relaxation as % of half maximal PE contraction was: Veh-PVAT=45.3±7.0; Yoda-PVAT=46.7±25.6; Jedi-PVAT= 40.4±10.3; Veh+PVAT= 71.8±19.7; Jedi+PVAT=39.1±13.2; Yoda +PVAT=21.6±10.9). Slightly K+ depolarizing the aorta did not unmask contraction to Yoda. Finally, the Piezo1 antagonist Dooku [10 μM] did not shift the PE curve (-log EC50 values [M]: Veh-PVAT= 7.96±0.12; Dooku-PVAT=7.26±0.22, Veh+PVAT=7.29±0.08; Dooku+PVAT=6.96±0.07). Surprisingly, Dooku [10 μM] directly caused aortic contraction in the absence of PVAT (Dooku 27.2±11.7 vs vehicle 13.5±11.2 %PE contraction), but not in the presence of PVAT vs vehicle (Dooku 2.9±1.9 vs Vehicle 7.3±5.2% PE contraction). Thus, Piezo1 is present and functional in the isolated aorta, important knowledge given that this molecule may serve as a translator of vascular pressure.

Unusual presentation of rare complication following endoscopic gastroplasty: case report

A 35-years-old female post-endoscopic gastroplasty presented to the emergency department complaining of epigastric abdominal pain. The abdominal examination showed epigastric and tenderness. On abdomen computerized axial tomography (CAT) scan she had small bowel obstruction with twisting of mesenteric vessel. The patient taken to the operating room for diagnostic laparoscopy and proceed, laparoscopic examination showed proximal dilatation of small intestine with collapse of distal part of jejunum, the obstruction identified, as fibrous band originating from the stomach to the proximal part of jejunum, this band caused by suture penetrating the stomach wall, which is going with the previous history of the endoscopic gastroplasty, reduction of the internal hernia done by releasing of the fibrous band, the herniated segment was healthy. Internal hernia can present with variety of complications. To the best of our knowledge from the literature review, this is the first case to be reported as internal abdominal hernia secondary to endoscopic gastroplasty.