Bladder Substitution: The Role of Tissue Engineering and Biomaterials

Tissue engineering could play a major role in the setting of urinary diversion. Several conditions cause the functional or anatomic loss of urinary bladder, requiring reconstructive procedures on the urinary tract. Three main approaches are possible: (i) incontinent cutaneous diversion, such as ureterocutaneostomy, colonic or ileal conduit, (ii) continent pouch created using different segments of the gastrointestinal system and a cutaneous stoma, and (iii) orthotopic urinary diversion with an intestinal segment with spherical configuration and anastomosis to the urethra (neobladder, orthotopic bladder substitution). However, urinary diversions are associated with numerous complications, such as mucus production, electrolyte imbalances and increased malignant transformation potential. In this context, tissue engineering would have the fundamental role of creating a suitable material for urinary diversion, avoiding the use of bowel segments, and reducing complications. Materials used for the purpose of urinary substitution are biological in case of acellular tissue matrices and naturally derived materials, or artificial in case of synthetic polymers. However, only limited success has been achieved so far. The aim of this review is to present the ideal properties of a urinary tissue engineered scaffold and to examine the results achieved so far. The most promising studies have been highlighted in order to guide the choice of scaffolds and cells type for further evolutions.

Quantitative fluorescence angiography aids novice and experienced surgeons in performing intestinal resection in well-perfused tissue

Background Anastomotic leakage (AL) after gastrointestinal resection is a devastating complication with huge consequences for the patient. As AL is associated with poor blood supply, tools for objective assessment of perfusion are in high demand. Indocyanine green angiography (ICG-FA) and quantitative analysis of ICG-FA (q-ICG) seem promising. This study aimed to investigate whether ICG-FA and q-ICG could improve perfusion assessment performed by surgeons of different experience levels. Methods Thirteen small bowel segments with a varying degree of devascularization, including two healthy sham segments, were constructed in a porcine model. We recruited students, residents, and surgeons to perform perfusion assessment of the segments in white light (WL), with ICG-FA, and after q-ICG, all blinded to the degree of devascularization. Results Forty-five participants fulfilled the study (18 novices, 12 intermediates, and 15 experienced). ICG and q-ICG helped the novices correctly detect the healthy bowel segments to experienced surgeons’ level. ICG and q-ICG also helped novice surgeons to perform safer resections in healthy tissue compared with normal WL. The relative risk (RR) of leaving ischemic tissue in WL and ICG compared with q-ICG, even for experienced surgeons was substantial, intermediates (RR = 8.9, CI95% [4.0;20] and RR = 6.2, CI95% [2.7;14.1]), and experienced (RR = 4.7, CI95% [2.6;8.7] and RR = 4.0, CI95% [2.1;7.5]). Conclusion Q-ICG seems to guide surgeons, regardless of experience level, to safely perform resection in healthy tissue, compared with standard WL. Future research should focus on this novel tool’s clinical impact.

P182 Bowel wall thickness as seen on point-of-care intestinal ultrasound correlates with endoscopic severity in children with Inflammatory Bowel Disease: A North American diagnostic cross-sectional study

Background In pediatric patients with Inflammatory bowel disease (IBD), delay in diagnosis can lead to progression of disease and bowel damage. In North America, the current methods to visually assess disease activity are limited to ileocolonoscopies and MR enterography. Point-of-care intestinal ultrasound (IUS) is a non-invasive, cost-efficient tool for assessing intestinal inflammation. We aim to evaluate the correlation between IUS and endoscopic disease activity in children suspected to have IBD. Methods In this cross-sectional study, we recruited consecutive patients newly diagnosed with IBD, presenting to the IBD outpatient clinic, or hospitalized in our pediatric center between August 2020 and February 2021. In addition to ileocolonoscopy, they underwent IUS performed by one gastroenterologist who was blinded to ileocolonoscopy results at the time of performing IUS. Bowel wall thickness (BWT) was measured systematically across different bowel segments (terminal ileum, ascending, transverse, descending, sigmoid colon, and rectum) and recorded twice in longitudinal view and twice in axial view. An average segmental BWT of more than 3 mm was considered inflamed. The inflammation seen on endoscopy was graded using segmental scores of the SES-CD for patients with Crohn’s disease (CD) and the UCEIS for patients with ulcerative colitis (UC). Segments were classified as healed, mild, moderate, or severe disease activity. The association between the BWT and disease severity on endoscopy was assessed using the Kruskal-Wallis test. Numerical correlation between BWT and continuous values of the endoscopic scores was performed using Kendall’s Tau-b. Results Fifteen patients completed both IUS and ileocolonoscopy. A total of 74 bowel segments were assessed. There were 7 girls, median age of 15 years (IQR 12.5–15.5 years). 8 patients were diagnosed with CD, 5 with UC, and 2 had a normal endoscopy. Median PCDAI was 32.5 (IQR 30.0–40.0), and median PUCAI was 70 (IQR 70–75). The Kruskal-Wallis test showed that BWT was significantly associated with disease severity as measured by the SES-CD (chi-square = 14.3, p <0.001, df = 2) for patients with CD, and that the BWT was also significantly associated with disease severity as measured by the UCEIS (chi-squared=12.0, p<0.001, df=3). The numerical correlation between BWT and SES-CD for all segments was 0.43 (p<0.001, 95%CI 0.3–0.58), while the correlation with the UCEIS was 0.52 (p<0.001, 95%CI 0.4–0.66). Conclusion In pediatric patients with IBD, we found that endoscopic disease severity correlates with the degree of BWT seen on IUS. These findings support the use of IUS as an evaluation tool of disease activity in North American pediatric clinical practice.

The Pitfalls and Strategies of Endoscopic Localization in Laparoscopic Colectomy: A Case Report

Background: laparoscopic segmental colectomy is suitable for removing difficult polyps that are large, broad-based, or located in tortuous bowel segments. As we know, accurate segmental resection depends on precise localization. So far, intraoperative labeling of lesions by colonoscopy is increasingly performed for achieving appropriate resection margins, but a certain deviation is also found. There is no unified and standard endoscopic polyp localization method at present.Case presentation: A 63-year-old woman was admitted because she was diagnosed as a large and broad-based colonic polyp which was unsuitable for colonoscopic polypectomy. During endoscopy-assisted laparoscopic segmental colectomy, the irradiation angle of colonoscopy light on the polyp head was responsible for the localization errors. We proposed three-step measures of correct endoscopic polyp localization to ensure the accurate resection in laparoscopic segmental colectomy.Conclusions: Three-step measures of correct endoscopic polyp localization ensured the successful resection of colonic polyps in laparoscopic colectomy. Their advantages include simplicity, practicality and reliable localization.

Prepare for the Rare: Innovation Simulation for Managing Abdominal Wall Defects

The incidence of abdominal wall defects like gastroschisis and omphalocele are relatively rare. Gastroschisis occurs approximately in 2 to 3 births in every 5,000, and omphalocele occurs in fewer than 2 births in every 10,000. However, our Level III NICU was informed that we were going to receive 2 infants with gastroschisis and one infant with an omphalocele in the same year. Because of the infrequency of these defects, our novice NICU nurses expressed concern about their lack of exposure to and familiarity with these defects. It became apparent that a thorough review of the clinical care and emergency interventions was needed before the anticipated deliveries. The challenge, however, was to develop an innovative, interactive learning experience for the NICU nurse that would provide both a didactic review and hands-on education to care for these patients. We opted to employ simulation. Infant mannequins were used along with moulage to create realistic-looking loops of bowel, herniated bowel segments, and umbilical cord. Scenarios were created that covered the various unpredictable clinical directions these cases could take. These scenarios included the emergency equipment, maneuvers, and interventions that could be required for the anticipated deliveries. Ten sessions for each abdominal wall defect were held; 51 NICU nurses participated in each simulation. NICU nurses reported increased comfort and readiness to care for each infant.

Diagnostic yield of colon capsule endoscopy for Crohn’s disease lesions in the whole gastrointestinal tract

Background Crohn’s disease (CD) can involve the upper gastrointestinal (GI) tract as well as the small and large bowel. PillCam colon capsule endoscopy (PCCE-2) enables observation of the whole GI tract, but its diagnostic yield for CD lesions in the whole GI tract remains unknown. Aim To elucidate the diagnostic yield of PCCE-2 in patients with CD. Methods Patients with CD who underwent PCCE-2 and double-balloon endoscopy (DBE) using oral and anal approaches were evaluated for CD lesions in the whole GI tract. We divided the small bowel into three segments (jejunum, ileum, and terminal ileum), and the large bowel into four segments (right colon, transverse colon, left colon, rectum). Detection of ulcer scars, erosion, ulcers, bamboo joint-like appearance, and notch-like appearance was assessed in each segment. The diagnostic yield of PCCE-2 was analyzed based on the DBE results as the gold standard. Results Of the total 124 segments, the sensitivities of PCCE-2 for ulcer scars, erosion, and ulcers were 83.3%, 93.8%, and 88.5%, respectively, and the specificities were 76.0%, 78.3%, and 81.6%, respectively. For the 60 small bowel segments, the sensitivities were 84.2%, 95.5%, and 90.0%, respectively, and the specificities were 63.4%, 86.8%, and 87.5%, respectively. For the 64 large bowel segments, the sensitivities were 80.0%, 90.0%, and 83.3%, respectively, and the specificities were 84.7%, 72.2%, and 77.6%, respectively. Conclusion PCCE-2 provides a high diagnostic yield for lesions in the whole GI tract of patients with CD. Thus, we recommend its use as a pan-enteric tool in clinical settings.

Case Report: 7-Year-Old Boy with Incarcerated Internal Hernia Leading to Extensive Intestinal Necrosis Due to a Large Congenital Mesenteric Defect

We present a case of a 7-year-old boy with acute abdominal symptoms initially misdiagnosed as constipation. Delayed imaging diagnostics revealed an ileus with contorted small intestine, so laparotomy was indicated. An acute bowel obstruction was found based on an incarcerated internal hernia. Small and large bowel segments were incarcerated into a large mesenteric defect leading to extended intestinal necrosis. About 30 cm of necrotic small bowel and 15 cm of large intestine were resected, two primary anastomoses were performed. The mesenteric defect was closed with two running sutures. The boy’s clinical outcome was very good. Two aspects are discussed: the initial clinical misdiagnosis of acute bowel obstruction in a child leading to a delay of diagnostics and therapy on the one hand and the origin of mesenteric defects on the other. In children with abdominal pain, ultrasound must be performed as soon as possible and pediatric surgeons have to be involved early. There should be an awareness of the fact, that mesenteric defects and other congenital malformations can occur more often than we suspect it. In the case of an internal hernia, a misjudgement of the clinical condition may be very harmful for the patient and can lead to a short bowel syndrome or even death.

Diagnostic Yield of Colon Capsule Endoscopy for Crohn’s Disease Lesions in the Whole Gastrointestinal Tract

BACKGROUNDCrohn’s disease (CD) can involve the upper gastrointestinal (GI) tract as well as the small and large bowel. PillCam colon capsule endoscopy (PCCE-2) enables to observe the whole GI tract, but its diagnostic yield for CD lesions in the whole GI tract remains unknown. AIMTo elucidate the diagnostic yield of PCCE-2 in patients with CD.METHODSPatients with CD who underwent PCCE-2 and double-balloon endoscopy (DBE) using oral and anal approaches were evaluated for CD lesions in the whole GI tract. We divided the small bowel into three segments (jejunum, ileum, and terminal ileum), and the large bowel into four segments (right colon, transverse colon, left colon, rectum). Detection of ulcer scars, erosion, ulcers, bamboo joint-like appearance, and notch-like appearance was assessed in each segment. The diagnostic yield of PCCE-2 was analyzed based on the DBE results as the gold standard.RESULTSOf the total 124 segments, the sensitivities of PCCE-2 for ulcer scars, erosion, and ulcers were 83.3%, 93.8%, and 88.5%, respectively, and the specificities were 76.0%, 78.3%, and 81.6%, respectively. For the 60 small bowel segments, the sensitivities were 84.2%, 95.5%, and 90.0%, respectively, and the specificities were 63.4%, 86.8%, and 87.5%, respectively. For the 64 large bowel segments, the sensitivities were 80.0%, 90.0%, and 83.3%, respectively, and the specificities were 84.7%, 72.2%, and 77.6%, respectively.CONCLUSIONPCCE-2 provides a high diagnostic yield for lesions in the whole GI tract of patients with CD. Thus, we recommend its use as a pan-enteric tool in clinical settings.

A rare case of acute idiopathic colocolic intussusception in an adult patient

Adult intussusception is a rare condition that is frequently associated with malignancy and requires surgical approach. Symptoms are often non-specific and of subacute or chronic character. Therefore, computerized tomography (CT) scan is the most commonly used modality for identifying adult intussusception. A 51-year-old female presented with a 1-day history of increasing abdominal pain. Abdominal ultrasound and CT scan revealed intussusception. Intra-operatively, colocolic intussusception was present and laparoscopically reduced. A lead point was found neither intra-operatively nor in post-operative ileocolonoscopy and resection of involved bowel segments was not necessary.

Recurrence hernia in the broad ligament of the uterus: a case report

Background Bowel herniation through a defect in the broad ligament of the uterus is a rare disease and few cases of recurrence have been reported. We report herein a recurrence case of a patient with broad ligament hernia (BLH), along with a review of the literature. Case presentation A 53-year-old woman complaining of abdominal pain was transported to our hospital. She had a history of laparotomy for small-bowel obstruction associated with hernia in the broad ligament of the uterus 10 years ago at a local hospital. Abdominal pelvic contrast-enhanced computed tomography revealed that the mesentery of the dilated bowels converged at a thick band in the pelvis, suggesting closed loop obstruction of the small bowel. The patient underwent urgent laparotomy and was diagnosed with bowel herniation through an opening in the broad ligament of the uterus on the right side, which was ipsilateral with the previous surgery. The hernia orifice was widened by incision and incarcerated bowel segments were released and preserved because ischemia was reversible. The membranous defect of BLH was closed by suture with braded silk strings. Conclusions Although BLH is a rare disease, patients face a significant risk of disease recurrence. Nonabsorbable suture may be advisable for closure of the hernia orifice in BLH.