The sigmoid take-off: An anatomical imaging definition of the rectum validated on specimen analysis.

BACKGROUND: A pre-operative imaging landmark to define the rectum would optimise clinical care of rectal cancer patients and research efforts to improve outcomes. The sigmoid take-off has been suggested as an imaging landmark for the rectosigmoid junction (RSJ). This study aimed to investigate whether this imaging definition of the rectum was validated by surgical specimen analysis. METHODS: This prospective study recruited 20 patients undergoing surgery and undertook radiological and pathological analysis of their rectal specimens. The radiological landmark of the sigmoid take-off was identified on pre-operative magnetic resonance imaging (MRI), and the distance to the anterior peritoneal reflection was measured by two readers. After surgery, the distance from the beginning of the sigmoid mesocolon to the anterior peritoneal reflection to the beginning of the sigmoid mesocolon on the specimen was measured, and compared to the distance on MRI using Pearson's Correlation Coefficient and Bland-Altman plots. RESULTS: In 17 patients, the mean distance from the anterior peritoneal reflection to the RSJ on MRI was 20.3 mm and 23.1 mm for two readers, and on pathology was 20.6 mm. The mean differences between MRI and specimen measurements were -0.31 mm (-2.83 to 2.20 mm), and 2.51 mm (95% confidence interval -0.31 to 5.33 mm) for each reader, with correlation coefficients of 0.77 and 0.81. CONCLUSION: The sigmoid take-off has been validated on specimen analysis to be an imaging landmark that defines the termination of the rectum. This anatomical landmark can be used to classify tumours and guide treatment and research of sigmoid colon and rectal cancer.

A very persistent chicken bone: two separate perforations from the same foreign object 2 months apart.

A 56-year-old man presented acutely with abdominal pain and raised inflammatory markers. Initial CT images demonstrated acute inflammation in the right upper quadrant surrounding a high-density linear structure. The appearance was of a chicken bone causing a contained small bowel perforation. This was managed conservatively with intravenous antibiotics and the patient was discharged 10 days later. The same patient returned to the hospital 2 months later, once again with an acute abdomen. CT imaging on this occasion showed distal migration of the chicken bone as well as free gas and fluid indicative of a new small bowel perforation. The patient underwent an emergency laparotomy, washout and small bowel resection. No foreign body was found at laparotomy or in the histopathology specimen. The postoperative course was complicated by an anastomotic leak. A further CT on that admission demonstrated that the chicken bone had migrated to the rectum!

Surgical treatment in familial adenomatous polyposis.

Familial adenomatous polyposis (FAP) is a dominantly inherited condition caused by germline mutation of the APC gene resulting in formation of numerous large bowel adenomas in late childhood or adolescence. Unless these are removed, colorectal cancer inevitably develops. Prophylactic surgical treatment is required to prevent this. In surgical decision making, considerations should include genotype-phenotype correlation, perioperative morbidity and risk of impaired sexual and reproductive function in young patients after major pelvic surgery. Colectomy with ileorectal anastomosis remains an appropriate prophylactic procedure in many patients. However, in those with high-density polyposis or a genotype predictive of aggressive disease, restorative proctocolectomy is preferable. There is a range of other features, as FAP is essentially a systemic disease. These include duodenal and peri-ampullary adenomas and carcinoma, desmoid tumors, papillary-type thyroid carcinoma and pancreatic carcinoma among others. With improved management that reduces the risk of colorectal cancer, these extracolonic manifestations have become of increasing clinical significance. For all FAP patients, including those undergoing proctocolectomy, thorough surveillance is of vital importance as there remains a risk of developing neoplasia. Despite advances in surgical techniques, screening and surveillance, life expectancy in patients with FAP is still less than that of the general population.

Treatment of recurrent sigmoid volvulus in Parkinson's disease by percutaneous endoscopic colostomy.

The exact aetiology of sigmoid volvulus in Parkinson's disease (PD) remains unclear. A multiplicity of factors may give rise to decreased gastrointestinal function in PD patients. Early recognition and treatment of constipation in PD patients may alter complications like sigmoid volvulus. Treatment of sigmoid volvulus in PD patients does not differ from other patients and involves endoscopic detorsion. If feasible, secondary sigmoidal resection should be performed. However, if the expected surgical morbidity and mortality is unacceptably high or if the patient refuses surgery, percutaneous endoscopic colostomy (PEC) should be considered. We describe an elderly PD patient who presented with sigmoid volvulus. She was treated conservatively with endoscopic detorsion. Surgery was consistently refused by the patient. After recurrence of the sigmoid volvulus a PEC was placed.

Isolated Gallbladder Injury after Blunt Abdominal Trauma: a Case Report and Review.

We describe a case of isolated gallbladder contusion after deceleration trauma. On admission, no evident signs of intra-abdominal injury were present. However, after 24 h observation an explorative laparotomy was performed because of persistent abdominal complaints. A contusion of the gallbladder wall was found with intraluminal haematoma and a cholecystectomy was performed. Isolated injury of the gallbladder after blunt trauma is extremely rare. Risk factors are distention of the gallbladder, deceleration trauma and the presence of a relatively mobile gallbladder. Clinical signs often are very subtle. Delayed presentation is common with signs of hemobilia or obstruction due to intraluminal clots. Ultrasound and computed tomography are suitable diagnostic tools. However, the diagnosis is often missed if no other injuries are present. Signs pointing to gallbladder injury are a collapsed gallbladder with pericholecystic fluid or a hydroptic gallbladder with intraluminal hematoma. Hepatobiliary scintigraphy or angiography might be necessary if additional injuries are suspected. The choice of treatment depends on the kind of injury. Contusion of the gallbladder allows conservative treatment, but in case of a rupture, surgery will be necessary. Accompanying bile duct injuries can be treated by endoscopic stenting. If active arterial bleeding is present, selective embolization can be performed.

Isolated Gallbladder Injury after Blunt Abdominal Trauma: a Case Report and Review.

We describe a case of isolated gallbladder contusion after deceleration trauma. On admission, no evident signs of intra-abdominal injury were present. However, after 24 h observation an explorative laparotomy was performed because of persistent abdominal complaints. A contusion of the gallbladder wall was found with intraluminal haematoma and a cholecystectomy was performed. Isolated injury of the gallbladder after blunt trauma is extremely rare. Risk factors are distention of the gallbladder, deceleration trauma and the presence of a relatively mobile gallbladder. Clinical signs often are very subtle. Delayed presentation is common with signs of hemobilia or obstruction due to intraluminal clots. Ultrasound and computed tomography are suitable diagnostic tools. However, the diagnosis is often missed if no other injuries are present. Signs pointing to gallbladder injury are a collapsed gallbladder with pericholecystic fluid or a hydroptic gallbladder with intraluminal hematoma. Hepatobiliary scintigraphy or angiography might be necessary if additional injuries are suspected. The choice of treatment depends on the kind of injury. Contusion of the gallbladder allows conservative treatment, but in case of a rupture, surgery will be necessary. Accompanying bile duct injuries can be treated by endoscopic stenting. If active arterial bleeding is present, selective embolization can be performed.