Peroral Pyloromyotomy.

Peroral pyloromyotomy, an innovative intramural endoscopic surgery procedure, is a successful management option for appropriately selected patients who suffer from medically refractory gastroparesis. Gastroparesis is a debilitating disorder of the gastrointestinal tract, which significantly decreases quality of life and overall survival. This article describes the history and background, the indications for, the diagnosis of, and the preparation, technique, and short-term outcomes of peroral pyloromyotomy.

The Distance between the Pylorus and Left Vagus Nerve during Sleeve Gastrectomy.

The sleeve gastrectomy (SG) can be performed with or without antral preservation (distance from the pylorus <50 mm). The objective of this study was to evaluate the distance between the pylorus and the end of the left vagus nerve in order to determine whether it could be used as a constant anatomical landmark to start gastric transection. This was a prospective, nonrandomized study of 120 patients undergoing SG from January to October 2018. The distance measurement between pylorus and vagus nerve was performed at the beginning of the SG. The primary endpoint was the distance between the beginning of the pylorus and the end of the second branch of the vagus nerve on the upper edge of the antrum. The secondary endpoints was the correlation factors between the preoperative data and the position of the end of the vagus nerve. A total of 120 patients, with a mean body mass index of 42.2 kg/m2 , underwent primary SG. The mean distance between pylorus and the end of the vagus nerve was 50.4 mm (35-64) on the upper part of the antrum. When considering the inferior part of the antrum, the minimum distance was 50 mm. No correlations were found between preoperative data and distance measurements. The vagus nerve can be considered as a constant and reliable anatomical landmark for performing SG with antral preservation. However, no correlation was found between the preoperative data and the location of the end of the vagus nerve. Clin. Anat. 33:562-566, 2020. © 2019 Wiley Periodicals, Inc.

Características morfológicas do estômago de jaguatirica (Leopardus pardalis - Linnaeus, 1758) / Morphological characteristics of the stomach of the ocelot (Leopardus pardalis - Linnaeus, 1758)

Leopardus pardalis é uma das espécies de felinos neotropicais mais estudadas em seus aspectos ecológicos, porém informações de questões morfofisiológicas do trato digestório não são encontradas na literatura. Visando contribuir com tais informações, o objetivo deste artigo foi caracterizar a morfologia do estômago dessa espécie. Nesta pesquisa, foram utilizados cinco exemplares adultos, coletados após óbito por atropelamento ou doados pelo IBAMA ao Laboratório de Zoologia e Morfologia Animal da Universidade do Estado de Mato Grosso - Alta Floresta. Os animais foram fixados com solução aquosa de formaldeído a 10%, dissecados por meio de técnicas anatômicas. Além dos estudos anatômicos, também foram coletados tecidos para microscopia. As análises macroscópicas revelaram que o estômago era do tipo unicavitário, com presença de pequena e grande curvatura, localizado no antímero esquerdo e constituído pelas regiões características do órgão. Em seus aspectos microscópicos, mostrou-se formado pelas quatro túnicas usuais do tubo digestório: túnica mucosa, submucosa, muscular e serosa, cada uma com as particularidades características de cada região, principalmente na túnica mucosa. O estômago de L. pardalis revelou uma morfologia semelhante às espécies domésticas e selvagens, com particularidades histomorfológicas na região pilórica. Esse padrão pode estar relacionado a adaptações evolutivas no processo digestivo dessa espécie.(AU)

The species Leopardus pardalis is one of the species of neotropical felines more studied in its ecological aspects, however, information of morphophysiological questions of the digestive tract are not found in the literature. Aiming to contribute with such information, the objective of this work was to characterize the morphology of the stomach of this species. Five adult specimens, collected after death by trampling, or donated by IBAMA to the Laboratory of Zoology and Animal Morphology of the University of the State of Mato Grosso - Alta Floresta, were used in this research. The animals were fixed with aqueous solution of formaldehyde 10%, dissected through the basic techniques and instruments of anatomy, and later the material was collected for microscopy. The macroscopic analysis revealed that the stomach was of the unicavitary type, with small and great curvature, located in the left antimer and constituted by the characteristic regions of the organ. In its microscopic aspects it was formed by the four usual tunics of the digestive tube: tunica mucosa, submucosa, muscular and serosa, each one with the peculiarities characteristic of each region, mainly in the tunica mucosa. The stomach of L. pardalis revealed similar morphology to the domestic and wild species, with small histomorphological peculiarities in the pyloric region, which may be related to evolutionary adaptations in the digestive process of this species.(AU)

An endoscopic method for semi-quantitatively measuring internal pyloric diameter in healthy cats: A prospective study of 24 cases.

The objectives of this study were to describe an endoscopic technique for semi-quantitative measurement of the internal pyloric diameter and apply this method to determine its typical size in a population of healthy cats. Twenty-four healthy adult cats, privately owned or originating from catteries, were prospectively recruited. Endoscopies were performed by the same investigator and cats with moderate to marked macroscopic inflammation were excluded. The internal pyloric diameter was measured with bespoke interchangeable biocompatible 'olives' (ranging from 4 to 12 mm in diameter) that could be attached to a guidewire. Attempts were made to pass the olives through the pylorus, in decreasing order of size, and the internal pyloric diameter was assumed to be equivalent to the size of the first olive that could successfully be passed. The median duration of the endoscopic procedure was <5 (interquartile range 2.7-5.4) minutes and all cats recovered quickly from the procedure without any complications. The median internal pyloric diameter in this population was 9 (interquartile range 9-10) mm, with most (23/24) cats having an internal pyloric diameter within ±1 mm of this measurement. There was no apparent effect of age, sex, breed or weight on the pyloric size. This study is the first to describe a quick and safe method for semi-quantitatively assessing the internal pyloric diameter in healthy adult cats. A prospective study is now warranted in order to determine the impact of gastrointestinal disease on pyloric diameter, for example cats with possible pyloric stenosis.

[Quick confirmation of nasointestinal tube placed below pylorus in critically ill patients by duodenal bulb ultrasonic anatomy locating method].

Objective: To investigate the value of duodenal bulb ultrasonic anatomy locating method quickly confirm nasointestinal tube placed below pylorus in critically ill patients. Methods: A total of 56 critically ill patients with nasointestinal tube posting surgery by blindly inserting method were collected from March 1 st, 2016 to August 1 st, 2016 in the Department of Critical Care Medicine of Zhejiang Provincial People's Hospital.In these patients, the duodenal bulbs were rapidly detected and located by ultrasonic anatomy locating method and at the same time observed whether nasointestinal tube echogram were in them or not. If nasointestinal tube echogram was observed in duodenal bulbs that meant nasointestinal tube placed below pylorus successfully. If disturbed by ultrasound artifacts or other reasons, injected gas into the nasointestinal tube could help to confirm when hyperechoic strip emerged. Gastrointestinal decompression or gastrointestinal motion promoting drug could help to reduce the interference of abdominal cavity or bowel gas if necessary. The results were compared with the abdominal X examination to vertify the accuracy of this method, and at the same time recorded its total time-consuming and its related complications. Results: The duodenal bulbs were rapidly located by ultrasonic anatomy locating method in 53 cases(94.6%) time-consuming(42±23)s. Nasointestinal tubes observed in duodenal bulb were confirmed to be placed below pylorus successfully in 52 cases(92.9%)time-consuming(140±94)s.There were no obvious complications in all patients. Conclusion: Duodenal bulb ultrasonic anatomy locating method is a safe, simple and convenient method with high accuracy that can quickly confirm whether nasointestinal tube placed below pylorus in critically ill patients or not.

The Impact of Different Surgical Techniques on Outcomes in Laparoscopic Sleeve Gastrectomies: The First Report from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).

OBJECTIVE: Questions remain regarding best surgical techniques to use for a laparoscopic sleeve gastrectomy (LSG) including the use of staple line reinforcement (SLR), bougie size (BS), and distance from the pylorus (DP) where the staple line is initiated. Our objectives were to assess the impact of these techniques on 30-day outcomes and to evaluate the impact of these techniques on weight loss and comorbidities at 1 year. METHODS: Using the MBSAQIP data registry, univariate analyses and hierarchical logistical regression models were developed to analyze outcomes for techniques of LSG at patient and surgeon-level. RESULTS: A total of 189,477 LSG operations were performed by 1634 surgeons at 720 centers from 2012 to 2014. Eighty percent of surgeons used SLR, 20% did not. SLR cases were associated with higher leak rates (0.96% vs 0.65%, odds ratio [OR] 1.20 95% confidence interval [CI] 1.00-1.43) and lower bleed rates (0.75% vs 1.00%, OR 0.74 95% CI 0.63-0.86) compared to no SLR at patient level. At the surgeon level, leak rates remained significant, but bleeding events became nonsignificant. BS ≥38 was associated with significantly lower leak rates compared to BS <38 at patient and surgeon level (patient level: 0.80% vs 0.96%, OR 0.72, 95% CI 0.62-0.94; surgeon level: 0.84% vs 0.95%, OR 0.90, 95% CI 0.80-0.99). BS ≥40 was associated with increased weight loss. DP had no impact on leaks or bleeds but showed an increase in weight loss with increasing DP. CONCLUSION: LSG is a safe procedure with a low morbidity rate. SLR is associated with increased leak rates. A surgeon should consider risks, benefits, and costs of these surgical techniques when performing a LSG and selectively utilize those that, in their hands, minimize morbidity while maximizing clinical effectiveness.

A flow visualization model of duodenogastric reflux after esophagectomy with gastric interposition.

BACKGROUND: Our goal was to verify surgical factors that affect duodenogastric reflux (DGR) after esophagectomy through the use of a flow visualization model that would mimic an intrathoracic gastric tube. METHODS: Transparent gastric tube models for different routes (retrosternal space [RS] and posterior mediastinum [PM]) were fabricated. Various distal pressures were applied to the experimental model filled with water, and the flow was recorded with a high-speed camera. The volume and maximum height of the refluxate through the pylori of two different sizes (7.5 mm, 15 mm) in two different postures (upright, semi-Fowler) was measured by analyzing the video clips. RESULTS: For the large pylorus setting, when the pressures of 20, 30, and 40 mmHg were applied in the upright position, the volumes of the refluxate in the RS/PM tubes were 87.7 ± 1.1/96.4 ± 1.7 mL, 150.8 ± 1.1/158.0 ± 3.2 mL, and 156.8 ± 3.3/198.0 ± 4.7 mL (p < 0.05), and the maximum heights were 101.6 ± 4.8/113.4 ± 2.9 mm, 151.4 ± 2.2/165.4 ± 1.5 mm, and 166.1 ± 1.7/193.7 ± 6.6 mm (p < 0.05). The data for the small pylorus setting or in the semi-Fowler position showed similar tendencies. For any given route, posture or pressure setting, DGR in the large pylorus model was definitively higher than that for small one. CONCLUSIONS: This fluid mechanics study demonstrates posterior mediastinal gastric interposition or pyloric drainage procedure, or both, is associated with high reflux of duodenal contents.

Variations in the activity of digestive enzymes along the intestine of the burbot Lota lota expressed by different methods.

The activities of major digestive hydrolases (proteases, amylase, lipase and esterases) along the intestine were studied in the burbot Lota lota (L.) using different methods of activity expression. The enzyme activities were determined both in the whole gut segments and in the isolated mucosa, and then expressed in terms of tissue mass and protein content in the samples. Further, the cumulative activities of these enzymes in the pyloric caeca were compared with those in the rest of the intestine to estimate the overall contribution of these regions to digestion. The data obtained suggest the essential role of the pyloric caeca in the digestion of the burbot. In addition, the variations in the pH values along the intestine and the changes in the enzyme activities with incubation temperature were examined. The study proved the method of enzyme activity expression to be a key factor influencing the outcome of the experiment.

Gross anatomical features of the gastrointestinal tract (GIT) of blue-and-yellow macaws (Ara ararauna) - oesophagus to cloaca.

Morphological studies of the gastrointestinal tract of blue-and-yellow macaws (Ara ararauna) are scarce. In view of the paucity of information regarding the digestive tract of macaws, this study aims to describe the gross anatomical features (oesophagus to cloaca) as part of a broad study of the gastrointestinal tract (GIT) of these birds. Three animals (two males and one female) adult macaws were anatomically dissected from the oropharynx to the cloaca to expose the GIT. The oesophagus was identified as a muscle-membranous tube continuous with the crop, which was intimately attached to the skin. The internal longitudinal folds of the cervical oesophagus were sparser cranial to the crop and less evident compared to the portion caudal to the crop. The duodenum began in the pylorus and was grey-coloured exhibiting a large lumen. The jejunum was formed by loops in a spiral-fashion model supported by mesojejunum. The ileum was also composed by small loops and was continuous with the colo-rectum forming the large intestine, because the caeca were absent. The large intestine was short, median in position, suspended in the dorsal wall of the abdominal cavity by mesentery and ended in the cloaca. The GIT was similar to the basic patterns in birds, in general, and also presented new unreported morphological data that might be important when studying nutrition and health of the macaws.

Ultrasonographic characterization of the feline cardia and pylorus in 34 healthy cats and three abnormal cats.

A prospective study was performed in 34 fasted healthy cats to describe the normal ultrasonographic anatomy of the cardia and pylorus. Measurements were obtained for the caudal esophageal wall thickness (Ew), cardia wall thickness (Cw), pyloric wall thickness (Pw), thickness of the pyloric muscularis (Mp), length of the thicker part of the proximal duodenal submucosa (Dl). Among the 34 cats, 24 were examined using a linear transducer, and 10 with a microconvex transducer. Ew and Cw could be measured in 70% of the cats when a linear transducer was used, in 100% of the cats when a microconvex probe was used, Pw and Mp could be measured in 100% of the cats whatever probe was used. The submucosa of the most proximal part of the duodenum was thicker in half of the cats in longitudinal section. The muscularis layer of the pylorus was triangular in longitudinal section and thicker than the muscularis of the proximal duodenum. The mean for Ew, Cw, Pw, Mp, and DI was 4.9 mm (SD = 1.1), 5 mm (SD = 0.6), 4.4 mm (SD = 0.6), 2.5 mm (SD = 0.5), and 4.7 mm (SD = 2.38), respectively. Three cats with abnormalities of the cardia and pylorus are also described to illustrate clinical implications.

Hyalinization of the pyloric stomach in CD-1 mice following oral (dietary) administration of the corticosteroid agonists mometasone furoate, budesonide, and flunisolide.

The purpose of this study was to compare the toxicity of three marketed corticosteroid receptor agonists (mometasone furoate, budesonide, or flunisolide) to the stomach of female CD-1 mice following oral administration via the diet for up to 52 weeks, with a 16-week recovery period (budesonide and flunisolide). A range of tissues was examined by light microscopy, accompanied by clinical pathology measurements to assess anticipated corticosteroid effects as a surrogate marker of systemic drug exposure. Microscopic changes seen in the stomach with each corticosteroid included pyloric hyalinization. This previously unreported finding was investigated using histochemical and immunohistochemical techniques and was found to consist of hyalinized collagen, in association with increased immunohistochemical signal for transglutaminase-2 and osteopontin. The significance of the osteopontin finding is unclear; however, the ability of transglutaminase-2 to facilitate the formation of degradation resistant protein bonds implies this protein may be involved in the pathogenesis of this change. Furthermore, published evidence that transglutaminase-2 may be induced by a corticosteroid agonist raises the possibility that pyloric stomach hyalinization may be a class effect of corticosteroids via the action of this enzyme.

Is anterior mediastinum route a shorter choice for esophageal reconstruction? A comparative anatomic study.

OBJECTIVE: The reconstruction of the alimentary tract after esophagectomy is usually achieved by either anterior or posterior route through the mediastinum. Previous anatomic studies in comparing the length of both routes applied different methods and yielded inconsistent results. In order to resolve this important debate, we went back to cadavers to clarify the anatomic truth. METHODS: With strictly defined anatomic models, the distance of both routes between the proximal reference point (the cricoid cartilage) and the distal reference points (the celiac axis, the gastroduodenal artery, and the pyloric ring) was obtained on 20 cadavers. RESULTS: The length of the anterior route was significantly longer than the posterior route using the celiac axis (34.9 ± 2.5 vs 32.4 ± 2.3 cm, P < 0.0001), but was significantly shorter using either the gastroduodenal artery (35.4 ± 2.6 vs 36.7 ± 2 .7 cm, P = 0.0177) or the pyloric ring (34.9 ± 2.8 vs 36.4 ± 2.9 cm, P = 0.0168) as the distal reference point which is more clinically relevant. CONCLUSIONS: Compared with the posterior route, the anterior route may be considered as a shorter choice for the conduit to reach the cervical region for esophageal reconstruction.

An overview of infantile hypertrophic pyloric stenosis.

In paediatric general surgery hypertrophic pyloric stenosis (HPS) is well-researched and documented (Dudgeon 2005, Panteli 2009). Significant medical advances have improved its diagnosis, treatment and prognosis, and there is now almost a 100 per cent success rate (Panteli 2009). However, the cause of this disease process remains poorly understood (Dudgeon 2005, Panteli 2009). This article reviews the literature on the cause and management of HPS.

Functional morphology of unguiculiform papillae of the reticular groove in the ruminant stomach.

The arrangement of the ruminant stomach in four gastric compartments with specialized mucosal papillae along the gastric groove (GG) has been previously described. However, a debate remains about functional implications of these morphological pecularities. This study was aimed to elucidate the relation between the papillar morphology and its putative functions. The GG was obtained from adult bovine stomachs (n=10) and subdivided into (1) proximal, (2) middle, (3) distal portion of the reticular groove (RG) and (4) the area of the reticulo-omasal sphincter (ROS). The specimens were processed for scanning electron microscopy and stereomicroscopy to analyze the density, shape and location of the papillae. Whereas the proximal portion of the RG was characterized by small (1.5mm), conically shaped, smooth papillae, the middle portion exhibited larger papillae (4mm) with sharp borders covered by keratin. Towards the ROS the papillae further increased in size (3-11mm) and showed compound or single processes resembling the shape of arrows, twisted hooks or thorns (unguiculliform papillae). At the ROS the unguiculliform papillae were distributed in clusters groups and along the border of the sphincter. Due to their peculiar morphological features it is suggested that unguiculliform papillae functions as a filter barrier preventing the passage of large-sized food particles into the omasum and avoiding subsequent obstruction of both the RG and the ROS. The data give further evidence that unguiculliform papillae are actively involved in the complex mechanisms of food processing taking place within the ruminant pluricavity stomach.

Quantification of the effect of various patient and image factors on ultrasonographic detection of select canine abdominal organs.

We assessed factors that affected ultrasonographic visualization of the pylorus, duodenal papilla, pancreas, adrenal glands, and jejunal and medial iliac lymph nodes in the dog. An abdominal ultrasonographic examination was performed on 100 canine patients, equally divided between two facilities. The pylorus was visible in 64% of the dogs, the major duodenal papilla in 42%, the left pancreatic lobe in 56%, the body of the pancreas in 60%, the right pancreatic lobe in 87%, the left adrenal gland in 91%, the right adrenal gland in 86%, the medial iliac lymph nodes in 54%, and the jejunal lymph nodes in 51%. The parameters that negatively influenced the visibility of these organs were the presence of air or food in the gastrointestinal tract (pancreas, duodenal papilla), age (lymph nodes), and body weight (pancreas, duodenal papilla). The parameters that positively influenced their visibility were the presence of air or food in the gastrointestinal tract (lymph nodes), body weight (lymph nodes), body condition score (right adrenal gland), and inherent image quality (left pancreatic lobe). There was a significant difference between the two institutes for the visualization of the pylorus, pancreas, and lymph nodes, which was probably related to different body positions used for scanning in each institution.

Pyloric tonsil as a novel gut-associated lymphoepithelial organ of the chicken.

The pyloric tonsil is a novel peripheral lymphoepithelial organ of the gastrointestinal tract in the chicken. It forms a complete lymphoid ring at the beginning of the duodenum, where crypts of Lieberkühn are transformed to tonsillar crypts with lymphoepithelial lining. The oesophageal (described previously) and pyloric tonsils are characteristic of the chicken, while they are absent in mammals. The lymphoid system develops from the middle germ layer, the mesoderm, and forms connections with the ecto- and endoderm, namely the skin and gut, respectively. These connections are based on the lymphoepithelial lining of the crypts, and provide gates for environmental antigens. Recent findings, taken together with the literature, suggest that in birds the lymphoid system forms connections with the endoderm-derived organs that are anatomically and histologically more extensive than the ectoderm-derived ones, which may be explained by the absence of regional lymph nodes, and the less developed lymphoid circulation of the skin.

Study of insulin-like growth factor-1 (IGF-1) and platelet-derived endothelial cell growth factor (PDEGF) expression in children with infantile hypertrophic pyloric stenosis.

BACKGROUND: The pathogenesis of infantile hypertrophic pyloric stenosis (IHPS) is not fully understood. Hypertrophy of the pyloric muscle is probably regulated by growth factors. Recent studies reported an increase in the local synthesis of insulin-like growth factor-1 (IGF-1). There are no reports concerning platelet-derived endothelial cell growth factor (PDEGF) playing an important role in the pathological angiogenesis. The aim of this study was to analyze the expressions of IGF-1 and PDEGF by immunohistochemistry (IHC) in the muscularis propria of the pyloric muscle in children with IHPS. MATERIAL/METHODS: Twenty-two muscle biopsies were obtained at the time of pyloromyotomy. The control group consisted of seven children. Specimens were evaluated by routine histopathological methods and by immunohistochemistry using monoclonal mouse anti-PDEGF or -IGF-1 antibodies. Cells showing positive reaction were counted in five random 200x high-power fields. Values were expressed as the mean +/-SD of the real expression area of the analyzed marker to the total analyzed area. RESULTS: In children with IHPS the average area of PDEGF expression was 62+/-52.5, whereas in the control group it was 15+/-12.1. The average area of IGF-1 expression was 1037+/-491.9) in study group and 259+/-221.44 in the controls. Statistically significant differences were found. CONCLUSIONS: These results show a local increase in the expressions of IGF-1 and PDEGF in the muscularis propria of the pyloric muscle in children with IHPS, which may have implications to the pathogenesis of the disease.

Osmoregulatory physiology of pyloric ceca: regulated and adaptive changes in chinook salmon.

Functions of the anatomically obvious, yet peculiar, pyloric ceca of the fish gut have been a source of conjecture for over two millennia since Aristotle hypothesized on digestive utilities. Here, we demonstrate regulated and adaptive changes in osmoregulatory physiology of ceca from chinook salmon (Onchorhynchus tshawytscha). Transfer of salmon from freshwater to seawater (both short- and long-term) significantly stimulated both fluid uptake from 5.1 to 8.3-9.3 microl/cm2/hr and also Na+/K+ -ATPase from 6.5 to 8.3-9.6 micromol/ADP/mg protein/hr. Similar changes were induced with implants of cortisol, which resulted in high physiological cortisol levels in plasma. Ceca, which can number about 200 in chinook salmon, were estimated to account for the majority of fluid uptake capacity of the intestine and, after long-term seawater adaptation, the proportion of uptake capacity was sixfold higher. Transport physiology of ceca is thus under environmental and endocrine control indicative of an important role in salt and water homeostasis.

The pylorus.

The pylorus controls the flow between a reservoir dedicated to mechanical and chemical digestion (the stomach) and a conduit dedicated to the absorption of nutrients (the intestines). The pylorus adjusts gastric outflow resistance to physiological needs. It allows the outflow of isotonic fluids yet selectively retains particles too large for delivery to the intestines and in concert with the antrum further processes them (gastric sieving). Unlike most gut sphincters, the pylorus, at least of man, maintains a patent lumen most of the time. It only intermittently becomes a tightly closed barrier that arrests all flow out of and into the stomach. The geometry of the pylorus changes dramatically from the relaxed open state to closure. Pyloric closure involves contraction of its proximal and distal muscle loops, and occlusion of its lumen by mucosal folds. Current studies that combine pressure recordings with imaging by magnetic resonance imaging or ultrasound and fluid-mechanical analysis shed new light on the role of the pylorus in gastric emptying and digestion. Much has been learned in recent years on the innervation of the normal pylorus particularly from studies on infantile hypertrophic stenosis, and attempts are being made to treat gastroparesis by interventions on the pylorus.