Intestinal ultrasound for monitoring therapeutic response in patients with ulcerative colitis: results from the TRUST&UC study.

OBJECTIVE: Prospective evaluation of intestinal ultrasound (IUS) for disease monitoring of patients with ulcerative colitis (UC) in routine medical practice. DESIGN: TRansabdominal Ultrasonography of the bowel in Subjects with IBD To monitor disease activity with UC (TRUST&UC) was a prospective, observational study at 42 German inflammatory bowel disease-specialised centres representing different care levels. Patients with a diagnosis of a proctosigmoiditis, left-sided colitis or pancolitis currently in clinical relapse (defined as Short Clinical Colitis Activity Index ≥5) were enrolled consecutively. Disease activity and vascularisation within the affected bowel wall areas were assessed by duplex/Colour Doppler ultrasonography. RESULTS: At baseline, 88.5% (n=224) of the patients had an increased bowel wall thickness (BWT) in the descending or sigmoid colon. Even within the first 2 weeks of the study, the percentage of patients with an increased BWT in the sigmoid or descending colon decreased significantly (sigmoid colon 89.3%-38.6%; descending colon 83.0%-42.9%; p<0.001 each) and remained low at week 6 and 12 (sigmoid colon 35.4% and 32.0%; descending colon 43.4% and 37.6%; p<0.001 each). Normalisation of BWT and clinical response after 12 weeks of treatment showed a high correlation (90.5% of patients with normalised BWT had symptomatic response vs 9.5% without symptomatic response; p<0.001). CONCLUSIONS: IUS may be preferred in general practice in a point-of-care setting for monitoring the disease course and for assessing short-term treatment response. Our findings give rise to the assumption that monitoring BWT alone has the potential to predict the therapeutic response, which has to be verified in future studies.

Laparoscopic surgery for colorectal cancer with persistent descending mesocolon.

BACKGROUND: Persistent descending mesocolon (PDM) is caused by the absence of fusion of the descending colon to the retroperitoneum. We herein report two colorectal cancer cases with PDM that were treated with laparoscopic surgery. CASE PRESENTATION: Case 1: a 50-year-old man with sigmoid colon cancer and synchronous liver metastasis. After neoadjuvant chemotherapy, he underwent laparoscopic sigmoidectomy with lymph node dissection cutting the root of the inferior mesenteric artery (IMA) and synchronous liver resection. He experienced postoperative stenosis of the reconstructed colon possibly due to an impaired arterial blood flow in the reconstructed colon. Case 2: a 77-year-old man with rectal cancer. Laparoscopic low anterior resection preserving the left colic artery (LCA) was performed. Intraoperative infrared ray (IR) imaging using indocyanine green (ICG) showed good blood flow of the reconstructed colon. He had no postoperative complications. In cases of PDM, the mesentery of the descending and sigmoid colon containing the LCA is often shortened, and the marginal artery of the reconstructed colon is located close to the root of the LCA. Lymph node dissection accompanied by cutting the LCA carries a risk of marginal artery injury. Therefore, we recommend lymph node dissection preserving the LCA in colorectal cancer patients with PDM in order to maintain the blood flow of the reconstructed colon. If the IMA and LCA absolutely need to be cut for complete lymph node dissection, the marginal artery should be clearly identified and preserved. In addition, intraoperative IR imaging is extremely useful for evaluating colonic perfusion and reducing the risk of anastomotic complications. CONCLUSION: In colorectal cancer surgery in patients with PDM, surgeons should be aware of these tips for maintaining the blood flow of the reconstructed colon and thereby avoid postoperative complications caused by an impaired blood flow.

Sublingual microcirculation: a case report.

INTRODUCTION: Sublingual microcirculation monitoring is suitable for bedside use in critically ill patients. We present a case in which severely impaired sublingual microcirculation was the first alarming sign of an early deterioration of the patient's medical situation. CASE PRESENTATION: This is the case of a 58-year-old white woman admitted to our intensive care unit after the removal of parts of her small intestine due to a volvulus. Her microcirculation was checked the day after surgery in terms of an ongoing study and predicted a massive deterioration of her clinical situation. CONCLUSIONS: This case highlights the potential value of monitoring the microcirculation in critically ill patients. Two full hours could have been saved for diagnostic workup and earlier treatment had we considered the impaired microcirculation alone as a warning sign. Regardless of the supposed cause, impaired microcirculation should alert the responsible physician and should be followed by a diagnostic workup. Sublingual microcirculation monitoring can be useful in intensive care units to detect a deteriorated microcirculation earlier than with standard monitoring.

Anomalous inferior mesenteric artery supplying the ascending, transverse, descending, and sigmoid colons.

We have encountered in our anatomical practice the first case and an extremely rare second case in which the ascending, transverse, descending, and sigmoid colons were supplied by the inferior mesenteric artery. The causes of colic artery anomalies are generally explained in conjunction with the development of the superior mesenteric artery, which is intimately related to embryonic elongation and midgut rotation. However, this embryological model was inapplicable to both cases. This difficulty motivated us to seek possible relationships with reported anomalous inferior mesenteric arteries in adults as well as their embryological causes. We consider that the aberrant right colic artery found in 2009 is an "intermesenteric artery" which anastomoses the superior (or its middle colic branch) and inferior mesenteric artery, but secondarily lost its origin from the superior mesenteric artery. The aberrant colic artery found in 2010 is a "middle-inferior mesenteric artery" in which the inferior mesenteric artery formed a common trunk with remnant middle mesenteric artery.

Evaluation of intestinal perfusion by ICG fluorescence imaging in laparoscopic colorectal surgery with DST anastomosis.

BACKGROUND: Decreased blood perfusion is an important risk factor for postoperative anastomotic leakage (AL). Fluorescence imaging with indocyanine green (ICG) provides a real-time assessment of intestinal perfusion. This study evaluated the utility of ICG fluorescence imaging in determining the transection line of the proximal colon during laparoscopic colorectal surgery with double stapling technique (DST) anastomosis. METHODS: This was a prospective single-institution study of 68 patients with left-sided colorectal cancers who underwent laparoscopic colorectal surgery between August 2013 and December 2014. After distal transection of the bowel, the specimen was extracted extracorporeally and then the mesentery was divided along the planned transection line determined by the surgeons' judgement under normal q. After ICG was injected intravenously, intestinal perfusion of the proximal colon was assessed in the fluorescent imaging mode. Intestinal perfusion was examined in relation to the patient-, tumor- and surgery-related variables using univariate and multivariate analyses. RESULTS: ICG fluorescence imaging showed that intestinal perfusion was present at 3 mm (median) distal to the initially planned transection line. ICG fluorescence imaging resulted in a proximal change of the transection line by more than 5 mm in 18 patients (26.5 %) and, particularly, by more than 50 mm in 3 patients (4.4 %), compared with the initially planned transection line. Univariate analysis revealed that diabetes mellitus, anticoagulation therapy, preoperative chemotherapy and operative time were significantly associated with poor intestinal perfusion. Multivariate analysis identified anticoagulation therapy (P = 0.021) and preoperative chemotherapy (P = 0.019) as independent risk factors for poor intestinal perfusion. Three patients (4.5 %) with a change of transection line developed AL. CONCLUSIONS: ICG fluorescence imaging is useful for determining the transection line in laparoscopic colorectal surgery with DST anastomosis. Anticoagulation therapy and preoperative chemotherapy are important risk factors for poor intestinal perfusion.

Evaluating distribution of the left branch of the middle colic artery and the left colic artery by CT angiography and colonography to classify blood supply to the splenic flexure.

INTRODUCTION: CT angiography has gained widespread acceptance for preoperative evaluation of blood supply in patients with colorectal cancer. However, there have been few reports that pertain to the splenic flexure, for which surgery is technically difficult. We used preoperative CT angiography and CT colonography to evaluate blood supply to the splenic flexure. METHODS: We defined the splenic flexure as the junction of the distal third of the transverse colon and the proximal third of the descending colon. We reviewed 191 cases and considered the descending colon as divided into the proximal third and the distal two-thirds; we then determined which part of the descending colon the left colic artery (LCA) entered. We also considered the transverse colon as divided into the proximal two-thirds and the distal third, and evaluated which part of the transverse colon the left branch of the middle colic artery entered. RESULT: We classified blood supply to the splenic flexure into six types, described by the feeder vessels: type 1, the LCA (39.7%); type 2, the left branch of the middle colic artery (17.8%); type 3, the LCA and the left branch of the middle colic artery (9.9%); type 4, the accessory left colic artery (4.1%); type 5, the LCA and the accessory left colic artery (2.6%); and type 6, the marginal artery (25.6%). CONCLUSION: We classified blood supply to the splenic flexure into more complex types than previous reports had. Because we dissect the lymph nodes according to the type of blood supply, knowing the type before splenic flexure surgery is crucial.

[[Technology Surgical Intervention in Ulcerative Colitis Modeling Descending Part of the Colon in Rats Line "Wistar"].]

BACKGROUND: Ulcerative colitis (UC) is a chronic immune inflammatory condition of the colon with an unknown aetiology, leading to disability and reduced quality of life of patients. UC primarily affects young adults. In most cases, inflammatory bowel disease (iBD) debuts at reproductive age. The incidence of UC and severe clinical course has increased overall across the world. The study of the mechanisms of pathogenesis and aetiology of this disease contributes to the development of new effective methods of treatment. OBJECTIVE: The aim of our study was to develop technology of the surgery directed to induction of reversible ischemic damage, the erosive-ulceration of gut mucosae (descending colon) at rats of the WISTAR line. MATERIALS AND METHODS: Experimental research was done using male rats < (n=40), their age was more than 6 months, weight of body is 280 - 350 grams. The animals were separated into 3 groups: 1 - (n=14) Sholimov's operative method, 2 group (n=16) - model using special technology, 3 group (n=10) - Coopr's H. S. induction ulcerative colitis. Observation was been done during 10 days. We offered special surgical technique: parietal ligation on every vasa recta of colon descendens of rats the length 3 cm along colon, on the apex vesicae and then vasa recta are cut. Then during 7 days 1% solution of dextran sulfate sodium (DSN) was given for experimental animals after postoperative period. By the histolog- ical biopsy of colon mucosa the results were estimated. RESULTS/CONCLUSION: we have created erosive-ulceration of gut mucosae (descending colon) of rat with productive inflam- mation, vasculitis and plasmatic impregnation of the vessel walls and intimal thickening. Our model of ulcerative colitis can be used for the development and testing of new methods for the study and treatment of this pathology.

Dynamic article: surgical anatomical planes for complete mesocolic excision and applied vascular anatomy of the right colon.

BACKGROUND: Lower local recurrence rates and better overall survival are associated with complete mesocolic excision with central vascular ligation for treatment of colon cancer. To accomplish this, surgeons need to pay special attention to the surgical anatomical planes and vascular anatomy of the colon. However, surgical education in this area has been neglected. OBJECTIVE: The aim of this study is to define the correct surgical anatomical planes for complete mesocolic excision with central vascular ligation and to demonstrate the correct dissection technique for protecting anatomical structures. DESIGN AND SETTINGS: Macroscopic and microscopic surgical dissections were performed on 12 cadavers in the anatomy laboratory and on autopsy specimens. The dissections were recorded as video clips. METHODS: Dissections were performed in accordance with the complete mesocolic excision technique on 10 male and 2 female cadavers. Vascular structures, autonomic nerves, and related fascias were shown. Within each step of the surgical procedure, important anatomical structures were displayed on still images captured from videos by animations. RESULTS: Three crucial steps for complete mesocolic excision with central vascular ligation are demonstrated on the cadavers: 1) full mobilization of the superior mesenteric root following the embryological planes between the visceral and the parietal fascias; 2) mobilization of the mesocolon from the duodenum and the pancreas and identification of vascular structures, especially the veins around the pancreas; and 3) central vascular ligation of the colonic vessels at their origin, taking into account the vascular variations within the mesocolonic vessels and the autonomic nerves around the superior mesenteric artery. LIMITATIONS: The limitation of this study was the number of the cadavers used. CONCLUSIONS: Successful complete mesocolic excision with central vascular ligation depends on an accurate knowledge of the surgical anatomical planes and the vascular anatomy of the colon.

Intracystic hemorrhage in a patient of polycystic kidney with renocolic fistula diagnosed by contrast-enhanced ultrasonography.

A 60-year-old woman with polycystic kidney presented with intracystic hemorrhage; renocolic fistula was diagnosed by contrast-enhanced. The patient was admitted due to hematuria, pyuria and pneumaturia. Abdominal B-mode ultrasonography showed that this renal cyst had thickened walls and debris-like internal echo. Truagent Detection, a power Doppler imaging mode, could depict intracystic color signals after Levovist injection by real-time scan. Enhanced spots had increased in the cyst, and were shown as minimal intracystic hemorrhage in real-time. The case of polycystic kidney with renocolic fistula is rare, however contrast-enhanced ultrasonography could successfully identify the site of minute bleeding.