Retroileal colorectal anastomosis: an old technique, still relevant.

Retroileal colorectal anastomosis is an infrequently used technique providing tension-free anastomosis after extended left-sided colonic resection, which was first described by Turnbull in 1972. The authors describe the use of a retroileal colorectal anastomosis in a patient with chronic Candida albicans and Enterococcal retroperitoneal abscess. The patient's condition was most likely secondary to an anastomotic leak and colonic fistula post en bloc resection for recurrence of a left renal cell carcinoma. After failure of antimicrobial therapy and percutaneous drainage, surgical intervention was required. This involved resection of the existing colocolonic anastomosis and drainage of the retroperitoneal abscess. A retroileal colorectal anastomosis was then necessary to ensure a tension-free anastomosis. To the best of our knowledge, this is the first reported case of retroileal anastomosis used for this purpose. It highlights the importance of this technique in the surgeon's armamentarium.

Adhesions after laparoscopic and open ileal pouch-anal anastomosis surgery for ulcerative colitis.

BACKGROUND: Emerging evidence suggests that a laparoscopic approach to colorectal procedures generates fewer adhesions. Even though laparoscopic ileal pouch-anal anastomosis (IPAA) is a lengthy procedure, the prospect of fewer adhesions may justify this approach. The aim of this study was to assess abdominal and adnexal adhesion formation following laparoscopic versus open IPAA in patients with ulcerative colitis. METHODS: A diagnostic laparoscopy was performed at time of ileostomy closure. All abdominal quadrants and the pelvis were video recorded systematically and graded offline. The incisional adhesion score (IAS; range 0-6) and total abdominal adhesion score (TAS; range 0-10) were calculated, based on the grade and extent of adhesions. Adnexal adhesions were classified by the American Fertility Society (AFS) adhesion score. RESULTS: A total of 43 patients consented to participate, of whom 40 could be included in the study (laparoscopic 28, open 12). Median age was 38 (range 20-61) years. There was no difference in age, sex, body mass index, American Society of Anesthesiologists grade and time to ileostomy closure between groups. The IAS was significantly lower after laparoscopic IPAA than following an open procedure: median (range) 0 (0-5) versus 4 (2-6) respectively (P = 0·004). The TAS was also significantly lower in the laparoscopic group: 2 (0-6) versus 8 (2-10) (P = 0·002). Applying the AFS score, women undergoing laparoscopic IPAA had a significantly lower mean(s.d.) prognostic classification score than those in the open group: 5·2(3·7) versus 20·0(5·6) (P = 0·023). CONCLUSION: Laparoscopic IPAA was associated with significantly fewer incisional, abdominal and adnexal adhesions in comparison with open IPAA.

Melena as an unusual presentation of gastrointestinal stromal tumour, a case report.

INTRODUCTION: Gastrointestinal Stromal Tumors (GISTs) are a rare slow growing malignancy, accounting for less than 1% of all gastrointestinal (GI) tract tumors. These tumors are usually discovered incidentally by endoscopy, surgery or radiology. However on occasions they may present with significant symptoms including GI blood loss. This case report discusses an atypical presentation of a GIST in a 57-year-old female. CASE PRESENTATION: A 57-year-old woman presented to the emergency department following one episode of melena. This occurred on a background of two previous presentations with melena over a 10-year period. She had a preceding surgery for a Meckel's Diverticulum. She was admitted for monitoring and investigation. An emergency upper endoscopy showed no upper gastrointestinal pathology to account for the bleeding. Her condition deteriorated with development of hypovolemic shock, requiring blood transfusion. An urgent CT angiogram identified a large mass in the distal ileum. The patient underwent an emergency laparotomy, where a 9.1 cm tumor located on the distal one-third of the ileum was resected. Histopathology confirmed the mass was a GIST. The patient had a successful post-operative period and subsequent treatment with Imatinib. DISCUSSION: The majority of GISTs are found incidentally. This case report describes an unusual presentation of a GIST in which the tumor bled into the intestinal lumen causing significant melena and life threatening hemorrhage. CONCLUSION: We conclude that GIST should be considered as a possible differential in rare cases of GI bleeding where more common causes have been ruled out.

Entero-enteric fistula from the stump of an end-to-side ileocolic anastomosis mimicking cancer recurrence.

Enteric fistulae are a complex and technically frustrating complication of any bowel surgery. The constellation of associated non-specific symptoms often leads to extensive investigation and, in this case, suspicion of disease recurrence. A 71-year-old gentleman with a history of previous colorectal cancer presented with chronic diarrhoea, weight loss and left lower quadrant pain. Elective exploratory laparoscopy was performed to investigate possible disease recurrence due to elevated carcinoembryonic antigen levels and a positron emission tomography positive area within the mesentery. A jejunal-ileal fistula was found at laparotomy where the blind ileal stump of the end-to-side ileocolic anastomosis had fistulated into the jejunum. Resection of the affected jejunum was performed with end-to-end jejuno-jejunal re-anastomosis and stapling of the ileal stump. Specimen histology was negative for recurrence. Intestinal fistulae represent a diagnostic challenge. This is the first case report describing an enteric fistula mimicking cancer recurrence.

Humero-radio-ulnar synostosis: a new case and review.

We report on a patient with humero-radio-ulnar synostosis and upper limb oligoectrosyndactyly. All cases have been sporadic including discordance in monozygotic twins, and similar findings have occurred in thalidomide embryopathy. Further observations of similarly affected patients are needed to elucidate the nature of this upper limb defect and its cause.

Mirror image duplication of the hands and feet: report of a sporadic case with multiple congenital anomalies.

Mirror image duplication of the hands and feet is a rare entity. Based on 3 previous reports, findings include nasal abnormalities, dimelia of ulna and fibula, tibial hypoplasia and mirror image duplication of hands and feet. We report on a sporadic case in which mirror image duplication was associated with multiple congenital anomalies. Although these cases may represent variable expression of the same dominantly transmitted complex polysyndactyly syndrome, it is possible that mirror image duplication of the hands and feet is a manifestation common to a number of distinct clinical entities. During limb bud development, duplication and aberrant positioning of the zone of polarizing activity in relation to the apical ectodermal ridge may account for the anatomic abnormalities of the hands and feet in these patients.

Microcephalic osteodysplastic dysplasia.

We present two patients with a distinct facial phenotype, short stature, brachydactyly, clubfoot deformities, cataracts, microcephaly, and normal intelligence. Similar radiographic abnormalities of the spine, long bones, hands, and feet were noted. These patients are similar to 2 males previously described by Saul and Wilson [1990: Am J Med Genet 35:388-393]. These 4 patients appear to have a unique skeletal dysplasia characterized by microcephaly, distinct facial phenotype, multisystem abnormalities, and short stature of postnatal onset.

Giant pharyngeal gland nuclei of Ascaris: unusual cytology suggests a novel pathway for transport of ribosomal proteins to the nucleus.

We describe the unusual giant pharyngeal gland nuclei of the parasitic roundworm Ascaris lumbricoides suum and attempt to reconcile the relationships among its uncommon, and in some instances unique, collection of constituents. The nuclei were studied by light and electron microscopy, Feulgen cytophotometry, nuclear size analysis and histochemical methods, including those for detection of DNA, RNA, acidic and basic proteins, lipids and carbohydrates. A highly active nucleus is revealed: an extensive system of intranuclear annulate lamellae (IAL); membrane-bounded, acidophilic bodies which contain non-basic proteins; an abundance of free nucleoli; and an exceedingly large chromocenter containing a core of DNA surrounded by nucleoli (an apparent nucleolar organizing region, NOR). The relationships among the various nuclear constituents suggest that the acidophilic bodies consist of nucleolus-related proteins imported from the cytoplasm to the NOR, and that the annulate lamellae mediate this transport. Incidental findings include rounded cytoplasmic invaginations into the nucleus, thread-like structures with dense cores and surrounding small granules found among concentrations of nucleoli, and bundles of 12 nm filaments closely associated with these nucleoli. The significance of such huge, morphologically complex and highly polyploid nuclei, derived from chromatin-diminished progenitor cells early in development, and the possible interrelationship of these phenomena, remain obscure.

Haematoma in a hydrocele of the canal of Nuck mimicking a Richter's hernia.

We report a haematoma in a hydrocele of the canal of Nuck in a 69-year-old female. She presented with a right-sided groin swelling, the differential for which included an irreducible inguinal hernia or haematoma given her aspirin and clopidegrel use. Successful treatment involved evacuation of the haematoma with excision of the sac. Despite a high index of suspicion for a haematoma, these swellings should ideally be explored given the potential for co-existence of a hernia.

Pregnancy in renal transplant recipients: case report.

Pregnancy in a renal homograft recipient resulted in an emergency cesarean section at 32 weeks' gestation secondary to maternal small bowel obstruction with necrotic bowel and subsequent intestinal perforation. The 1814 gm female product of this pregnancy had a moderate degree of in utero asphyxia, which subsequently, based on radiologic studies, had to be differentiated from the possibility of a congenital viral infection. Several concerns arose regarding the effects on the fetus by maternal immunosuppressive therapy, the risk factors faced by both the fetus and the mother secondary to the mother's renal disease, and the general outcome of the increasing number of pregnancies in this population.

Hypertension and thromboembolism in idiopathic retroperitoneal fibrosis.

Of 36 patients with idiopathic retroperitoneal fibrosis treated surgically, 8 have died and 26 have suffered 67 post-operative complications during 1 to 24 years of follow-up. Four patients died as a consequence of hypertension. Hypertension and thromboembolism accounted for 49% of the post-operative complications in 69% of the patients who developed complications. Attention to these 2 factors is at least as important as prevention of recurrent obstructive uropathy.

Use of 99Tcm-DMSA as a static renal imaging agent.

The use of 99Tcm-labelled DMSA as a static renal imaging agent has been analyzed semi-quantitatively in 366 patients. Study with this agent proved to be of most value in patients with equivocal space-occupying lesions of the kidney, provided useful information in various destructive diseases of the kidney when used for determining divided renal function but was of little value in chronic renal failure. In 33 patients, the uptake of 99Tcm-DMSA at 3 h as a measure of divided renal function was compared with the uptake of 99Tcm-DTPA from 30 to 150 sec following injection and was found to correlate well. In a series of 7 dogs with induced unilateral renal impairment, divided function determined with 99Tcm-DMSA was found to correlate well with results obtained using 51Cr-EDTA.