Drain-site recurrence of an ileocaecal valve adenocarcinoma.

Drain-site recurrence following colorectal cancer resection is a rare event and is described in few case reports. The majority of these reports are following minimally invasive surgery. This report describes a case of an isolated drain-site recurrence of primary colorectal cancer in a male patient in his 50s. He previously underwent an open right hemicolectomy and segmental small bowel resection for an obstructing ileocaecal valve adenocarcinoma. This was followed by adjuvant chemotherapy. Two years into surveillance, a redo ileocolic resection was performed for an anastomotic recurrence. While undergoing surveillance imaging, a new deposit was detected at a right-sided surgical drain site. Subsequently, a full thickness en bloc resection was performed. To date, the postoperative course has been uneventful. This case describes a drain-site recurrence from a colorectal primary.

Occult bleeding from a false-in-true non-Meckelian ileal diverticulum.

Ileal diverticula can be congenital or acquired and are rare even among the already rare entity of small bowel diverticula. What has never been reported, as far as we know, is false diverticula arising within the true non-Meckelian diverticulum with mesenteric erosion causing an occult gastrointestinal bleed. We present a patient with occult gastrointestinal bleeding from a false-in-true ileal diverticulum. Multiple investigations were required to localise the bleeding site after which the patient was taken to the operating room for a laparoscopic ileocaecectomy with complete resolution of symptoms. Preoperative localisation of the bleeding site may be difficult but is critically important in occult gastrointestinal bleeding. Procedure choice for a bleeding ileal diverticulum is dictated by the distance from the ileocaecal valve and the etiopathology of the bleed.

MicroRNAs modulate immunological and inflammatory responses in Holstein cattle naturally infected with Mycobacterium avium subsp. paratuberculosis.

MicroRNAs (miRNAs) regulate the post-transcriptional expression of genes by binding to their target mRNAs. In this study, whole miRNA sequencing was used to compare the expression of miRNAs in ileocecal valve (ICV) and peripheral blood (PB) samples of cows with focal or diffuse paratuberculosis (PTB)-associated lesions in gut tissues versus (vs) control cows without lesions. Among the eight miRNAs differentially expressed in the PB samples from cows with diffuse lesions vs controls, three (miR-19a, miR-144, miR32) were also down-regulated in cows with diffuse vs focal lesions. In the ICV samples, we identified a total of 4, 5, and 18 miRNAs differentially expressed in cows with focal lesions vs controls, diffuse lesions vs controls, and diffuse vs focal lesions, respectively. The differential expression of five microRNAs (miR-19a, miR-144, miR-2425-3p, miR-139, miR-101) was confirmed by RT-qPCR. Next, mRNA target prediction was performed for each differentially expressed miRNA. A functional analysis using the predicted gene targets revealed a significant enrichment of the RNA polymerase and MAPK signaling pathways in the comparison of cows with focal vs no lesions and with diffuse vs focal lesions, respectively. The identified miRNAs could be used for the development of novel diagnostic and therapeutical tools for PTB control.

Underwater cap-suction pseudopolyp formation for endoscopic mucosal resection: a simple technique for treating flat, appendiceal orifice or ileocecal valve colorectal lesions.

BACKGROUND: We aimed to evaluate the safety and technical success of an easy-to-use technique that applies underwater cap suction pseudopolyp formation to facilitate the resection of flat lesions or those at the appendiceal orifice or ileocecal valve. METHODS: We retrospectively analyzed a register of consecutive cap suction underwater endoscopic mucosal resection (CAP-UEMR) procedures performed at two centers between September 2020 and December 2021. Procedures were performed using a cone-shaped cap, extending 7 mm from the endoscope tip, to suction the lesion while submerged underwater, followed by underwater snare resection. Our primary end point was technical success, defined as macroscopic complete resection. RESULTS: We treated 83 lesions (median size 20 mm; interquartile range [IQR] 15-30 mm) with CAP-UEMR: 64 depressed or flat lesions (18 previously manipulated, 9 with difficult access), 11 from the appendix, and 8 from the ileocecal valve. Technical success was 100 %. There were seven intraprocedural bleedings and two delayed bleedings, all managed endoscopically. No perforations or other complications occurred. Among the 64 lesions with follow-up colonoscopy, only one recurrence was detected, which was treated endoscopically. CONCLUSIONS: CAP-UEMR was a safe and effective technique for removing nonpolypoid colorectal lesions, including those arising from the appendiceal orifice or ileocecal valve.

Metastatic clear-cell renal carcinoma: an exceptional cause of ileocolonic intussusception in adults

Introduction: Intussusceptions in adults are rare, representing 1% to 5% of intestinal obstructions in this age group. This condition can be caused by benign and malignant lesions acting as lead points, the latter being the most frequent. Furthermore, the diagnosis is challenging due to the non-specific symptoms with variable duration. Case Presentation: A 43-year-old man, with a history of localized clear-cell renal carcinoma (ccRCC) treated 9 years earlier with a right radical nephrectomy, presented with bowel obstruction symptoms. An abdominal computed tomography scan showed an ileocolonic intussusception. Hence, the patient required a right hemicolectomy with ileotransverse anastomosis. The histopathological analysis showed a metastatic ccRC to the terminal ileum causing the intussusception. Discussion: Adult intussusceptions are rare. However, they should be considered in the differential diagnosis of patients with abdominal pain and symptoms of bowel obstruction. Metastases of renal cancer to the small bowel are uncommon and even more so in the form of intussusception. Definitive treatment must be tailored to the patient's condition and underlying cause. (AU)

Ileocecal valve that cannot be intubated in Crohn's disease: is this a sign of poor prognosis?

BACKGROUND: In Crohn's disease (CD), the inability to intubate the ileocecal valve during colonoscopy may be associated with a poor disease prognosis. In this study, we aimed to compare the long-term outcomes of CD patients with and without ileocecal valve intubation during colonoscopy to assess its value as a prognostic parameter. METHODS: This retrospective study involved CD patients with isolated ileal involvement who underwent colonoscopy between 1993 and 2022. We compared the basic characteristics and long-term clinical outcomes of two groups of patients: those with intubated and non-intubated ileocecal valves during colonoscopy. RESULTS: Of the 155 participants, 97 (62.5%) patients' ileum could be intubated and 58 (37.5%) could not be intubated. The non-intubated group was younger at diagnosis (39 years versus 30.5 years, p = 0.002), but other baseline characteristics such as sex, smoking status, disease duration, perianal disease, and upper gastrointestinal involvements were similar. The non-intubated group had higher rates of steroid dependence (67.2% versus 46.4%; p = 0.012), biologic treatment (89.7% versus 58.8%; p < 0.001), CD-related hospitalization (81% versus 24.7%; p < 0.001), and major abdominal surgery (58.6% versus 15.5%; p < 0.001). In the logistic regression analysis, the positive predictors of successful ileum intubation were inflammatory type CD (OR: 14.821), high serum albumin level (OR: 5.919), and older age (OR: 1.069), while the negative predictors were stenosing (OR: 0.262) and penetrating (OR: 0.247) CD behavior. CONCLUSIONS: In Crohn's disease patients with isolated ileal involvement, ileocecal valve cannot be intubated during colonoscopy may indicate the severity of the disease.

Characterization of endoscopic features and histology of a distinct mucosal transition zone on the ileocecal valve (with video).

BACKGROUND AND AIMS: We have endoscopically encountered a zone of transitional mucosa between the colonic and ileal mucosa located in a 3- to 10-mm-wide ring around the ileocecal valve (ICV) orifice. We aimed to describe the features of the ICV transitional zone mucosa. METHODS: We used videos and photographs from normal ICVs and biopsy samples from normal colonic mucosa, transitional zone mucosa, and normal ileal mucosa to characterize the endoscopic and histologic features of the ICV transitional zone mucosa. RESULTS: The ICV transitional zone is identifiable on every ICV without a circumferential adenoma or inflammation that obliterates the zone. The zone is characterized endoscopically by an absence of villi, which distinguishes it from the ileal mucosa, but the pits are more tubular and with more prominent blood vessels compared with normal colonic mucosa. Histologically, the villi of the transitional zone are blunted, and the amount of lymphoid tissue is intermediate between the colonic mucosa and ileal mucosa. CONCLUSIONS: This is the first description of the normal transitional zone of mucosa on the ICV. This zone has unique endoscopic features that should be recognized by colonoscopists and that can potentially create difficulty in identifying the margins of adenomas located on the ICV.

Minimally invasive colonoscopy treatment of inflammatory fibroid polyps in the terminal ileum.

To identify the characteristics of inflammatory fibroid polyps (IFP) in the terminal ileum and to investigate the methods, safety, and efficacy of colonoscopic minimally invasive dissection and resection therapies for its treatment. Colonoscopy and colonoscopic ultrasonography were used to diagnose patients with protruding mucosal lesions in the terminal ileum, and the results suggested a high suspicion of IFPs. Colonoscopic minimally invasive dissection and resection were performed for these patients, and IFP was confirmed by postoperative pathological examination and immunohistochemical staining. Twelve cases of IFP from April 2016 to December 2020 in our hospital were examined pathologically and immunohistochemically. The IFPs in the terminal ileum were all successfully excised by colonoscopy. There were no postoperative perforation, bleeding, or recurrence cases during the follow-up. The features of the lesions, as well as the efficacy of colonoscopic minimally invasive dissection and resection, were reviewed. Terminal ileum IFPs have corresponding colonoscopic and endoscopic ultrasonographic features. For IFPs less than 2 cm in size and within 10 cm of the ileocecal valve, removal by colonoscopy was proven less invasive, safe, and effective.

Are large ileocecal valve lesions amenable with advanced endoscopic management to avoid bowel resection?

INTRODUCTION: Mucosal lesions located at the ileocecal valve may be challenging for endoscopic intervention because of angulated anatomy and a thinner wall with narrower lumen when compared to other locations of the bowel. This study aimed to evaluate the management and outcomes of ileocecal valve lesions treated endoscopically. MATERIAL AND METHODS: Patients with mucosal neoplasms involving the ileocecal valve managed with advanced endoscopy at a quaternary care hospital between 2011 and 2021 were included from a prospectively collected database. Patient demographics, lesion characteristics, complications, and outcomes are reported. RESULTS: From 1005 lesions, 80 patients (8%) underwent resection for neoplasms involving ileocecal valve by ESD (n = 38), hybrid ESD (n = 38), EMR (n = 2), and CELS (n = 2). The median age of the study group was 63(37-84) years, and 50% of patients were female. The median lesion size was 34 mm (5-75). The mean procedure time was 66 ± 44 min(range:18-200). The dissection was completed as piecemeal in 41(51%) patients and 35(44%) had en-bloc dissection. Seven(8%) endoscopic interventions required conversion to laparoscopic surgery due to inability to lift the mucosa(n = 4) and perforation(n = 3). No immediate bleeding occurred in the study group. Five patients had late rectal bleeding and two were admitted with post-polypectomy pain within 30 days of intervention. Pathology revealed 4(5%) adenocarcinomas, 33(41.2%) tubular adenomas, 30(37.8%) tubulovillous adenomas, and 5(6.2%) sessile serrated adenomas. Sixty-seven (84.5%) patients completed at least one follow-up colonoscopy and were followed for a median of 11(0-64) months. Six (8.9%) patients had recurrence and were managed with subsequent endoscopic removal. CONCLUSION: Advanced endoscopy can be safely and effectively performed for the management of ileocecal valve polyps with low complication and acceptable recurrence rates. Advanced endoscopy promises an alternative approach to oncologic ileocecal resection while attaining organ preservation. Our study demonstrates the impact of advanced endoscopy for the treatment of mucosal neoplasms involving ileocecal valve.

Pyogenic granuloma of the terminal ileum diagnosed by colonoscopy: the relevance of ileocecal valve intubation.

Pyogenic granuloma is a benign vascular lesion that is most frequently found in the epidermis or mucosa of the oral cavity. Its finding in the ileum is rare, there are only a few case reports. In most reported cases, diagnosis is made with capsule endoscopy or double-balloon enteroscopy. We present a case of a lesion in the ileum, approximately 15 cm from the ileocecal valve, documented by colonoscopy.

First report of complete enteroscopy from ileocecal valve to pylorus by retrograde motorized power spiral endoscopy.

The development of capsule endoscopy and device-assisted enteroscopy (DAE) revolutionized minimally invasive examination and treatment of small bowel diseases. Limitations of DAE are a great time expenditure and low rates of complete enteroscopy. Recently motorized spiral enteroscopy (MSE) was introduced with shorter procedure times and concurrently greater insertion depths. MSE is also the first device that opens up the possibility to achieve complete enteroscopy in a relevant number of cases by the unidirectional, peroral approach.To our knowledge we present the first published case of complete enteroscopy by retrograde MSE in a 35-year-old female without prior abdominal surgery with direct endoscopic visualization of the pyloric ring. The patient suffered from colonic polyposis syndrome. For the exploration of both colorectum and the small bowel we performed retrograde MSE under propofol sedation. After 60 minutes of advancement, we achieved complete enteroscopy by retrograde identification of the pyloric ring. The procedure could be finished after withdrawal of the endoscope and cold snare polypectomy of 3 small colonic adenomas without any adverse events. Total procedure time was 82 minutes. The patient was discharged one day after the procedure without complaints.It has been proven already that great insertion depths are achievable by retrograde MSE, but this case shows for the first time that even a complete enteroscopy is possible. In conclusion, primary retrograde MSE with no need of tracheal intubation might be a key to more effective, time-preserving, and cost-effective concepts of small-bowel endoscopy in the future.

A new traction device (S-O clip) facilitating the endoscopic submucosal dissection of tumors in the ileocecal valve region.

BACKGROUND: Endoscopic submucosal dissection (ESD) is a method that can be used for en bloc resection, regardless of the size and form of the lesion. The special location of ileocecal tumors leads to insufficient counter-traction and poor field of vision, making ESD difficult. An S-O clip has been developed to simplify the attachment procedure, eliminating interference with the endoscope and improving accessibility. CASE PRESENTATION: The patient was a 70-year-old man who presented with abdominal pain and bloating. A colonoscopy revealed a flat-elevated-type lesion on the ileocecal valve, with the oral side of the lesion having progressed to the terminal ileum. The traction direction was adjusted from distal to proximal during the procedure using the S-O clip. Finally, with the help of the S-O clip, the tumor was safely removed and collected. CONCLUSION: The S-O clip was successful in ESD of a colorectal tumor. By removing and re-anchoring the loaded ring, the S-O clips allowed the adjustment of traction direction from distal to proximal during ESD.