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.

Esophageal Dieulafoy Lesion: A Rare and Potentially Fatal Entity

A 35-year-old gentleman presented acutely to the emergency department with large volume haematemesis and melena. Following adequate initial resuscitation, the patient underwent emergency upper gastrointestinal endoscopy which revealed a dilated tortuous submucosal vessel which was actively bleeding at the midpoint of the esophagus. This was consistent with a Dieulafoy lesion. However, its position in the midpoint of the esophagus is rare. Our patient recovered well following intervention.

Definitive therapy of colonic angioectasia by submucosal coagulation

Background and study aims Colonic angioectasia are the most common vascular lesions in the gastrointestinal tract and are among the most common causes for chronic or recurrent lower gastrointestinal bleeding. Endoscopic treatment involves a variety of techniques, all of which focus on destruction of the mucosal abnormality. However, recurrent bleeding after endoscopic treatment is common, with more than one treatment frequently necessary. We report a technique for definitive treatment of colonic angioectasia by targeting the feeding submucosal vessel. Patients and methods Analogous to endoscopic mucosal resection, a submucosal injection is made beneath the target lesion which is then removed by electrocautery snare resection of the mucosal lesion. The exposed feeding vessel is then destroyed by application of coagulation current. The resection defect is closed by clips. Results Six patients with a total of 14 colonic angioectasia were treated over the study period. All lesions were destroyed without adverse events. Conclusion Elevation, hot snare resection and coagulation (ESC) of the visible vessel for treating colonic angioectasia appears safe and effective. Larger prospective comparative studies are required to assess its specific role.

A Report of Submucosal Intravascular Paraganglioma of the Gallbladder and Review of the Literature

Objectives The purpose of this case study and review of the literature is to allow pathologists to recall an appropriate differential diagnosis for submucosal epithelial tumors of the gallbladder. It is also important to note the immunohistochemical evaluation of a paraganglioma. Methods Intraoperative findings were multiple adhesions of the omentum to the gallbladder itself, with a mildly dilated cystic duct measuring 6 to 7 mm externally. The intraoperative cholangiogram was normal with no evidence of retained stones. The gallbladder was 9.5 cm and essentially unremarkable with no stones upon gross examination. Palpation revealed a 5 × 4 × 4-mm gray-tan cystic duct lymph node that was microscopically unremarkable. Microscopically, there was a 2.7-mm submucosal intravascular epithelioid tumor. Cytologically, the cellular infiltrate was cohesive, filled, and expanded a single submucosal vessel. A broad panel of immunohistochemical stains was performed, with the results listed below. Results Carbonic anhydrase IX: Negative; Monoclonal CEA: Negative; CK7: Negative; CK 20: Negative; Gata-3: Positive; Mart-1: Negative; OCT3/4: Strong diffuse positive; P 63: Negative; Pancytokeratin: Negative; PAX-8: Negative; S-100: Negative; WT1: Negative; PLAP: Negative; Hep par 1: Negative; AFP: Negative; CD117: Negative; CD 30: Negative; CDX2: Negative; Glypican 3: Negative; SALL4: Negative; Inhibin: Negative ERG: Negative; CD34: Negative; CD56: Strong diffuse positive; Synaptophysin: Strong diffuse positive; Chromogranin: Strong diffuse positive. Conclusion Expert opinion was requested to confirm the presumed diagnosis on this case. The consulting pathologist was in agreement that this was best classified as an intravascular paraganglioma. The patient was seen in follow-up and a CT of the chest, abdomen, and pelvis was ordered. Interestingly, a 1.9-cm enhancing upper pole right renal mass was identified. The patient was sent to urologic surgical consultation in which they believed this tumor to represent a stage 1a primary renal cell carcinoma and subsequently sent for radiofrequency ablation.

Rectal Dieulafoy’s Lesion: A Rare Etiology of Lower Gastrointestinal Hemorrhage

A Dieulafoy’s lesion is defined as a dilated submucosal vessel that erodes the overlying epithelium without evidence of a primary ulcer or erosion. It is a rare cause of gastrointestinal bleeding that is difficult to identify and subsequently manage. Most commonly, they occur in the upper gastrointestinal tract, namely the stomach. A Dieulafoy’s lesion of the rectum, however, is an exceedingly rare presentation that can lead to life-threatening gastrointestinal bleeding. Our case consists of an 84-year-old man, who presented with lower gastrointestinal bleeding secondary to a Dieulafoy’s lesion of the rectum.