Morphometric measurement of submucosal thickness in areas of fat deposition in the terminal ileum and colonic sections, with correlation with body mass index, weight and age: a male autopsy study.

AIMS: An increased amount of submucosal (SM) fat in the colon on imaging is considered to be characteristic of inflammatory bowel disease (IBD); however, a recent study in patients without IBD reported a correlation between colonic SM fat deposition and body weight (BW). The aim of this study was to perform a morphometric investigation of SM thickness in areas of fat deposition in the terminal ileum (TI), ileocaecal valve (ICV), and colonic sections, to determine whether there are variations by site, and whether it shows a correlation with BW, body mass index (BMI), or age. METHODS AND RESULTS: Representative samples of TI, ICV and colonic sections were collected prospectively from 115 autopsy cases without IBD. All of the study subjects were male (Veterans Hospital). SM thickness was measured in areas of fat deposition. Correlation analysis was performed between SM thickness and BW, BMI, and age. Fat deposition was common; however, with the exception of the ICV, it was neither consistent nor prominent, and it did not show a statistical correlation with BW, BMI, or age. CONCLUSIONS: SM fat deposition is common but not uniform or conspicuous in the TI or colon. In contrast to extravisceral intra-abdominal fat, it does not show a correlation with BW or BMI, and is not associated with ageing. As all study subjects were male, gender-dependent variability cannot be excluded.

Revision surgery for one anastomosis gastric bypass with anti-reflux mechanism: a new surgical procedure using only not previously operated intestine / Cirugía de revisión de bypass gástrico de una anastomosis con mecanismo anti-reflujo: un nuevo procedimiento quirúrgico utilizando solo intestino no operado anteriormente

Introduction: Obesity is now an epidemic in industrialized countries with high prevalence (U.S. with 67%, Europa from 40% to 50%). This had led to the development of many bariatric procedures. Nevertheless, the primary surgery could fails due to several conditions. There is no standard re-operative procedure of revision for primary bariatric failure. Re-operate in the place of the primary surgery imply high rate of risks. We have developed a new procedure for revision surgery working only on not previously operated tissue. Methods: We measure the common channel from gastro- jejunal anastomosis until the ileocecal valve. Depending on the measure, we decide the length of intestine to be excluded (biliopancreatic limb and common channel). We interrupt the afferent loop before gastro-jejunostomy and the efferent loop 20 cm below the gastro-jejunostomy. For restoring the gastro-intestinal transit, we anastomose the upper part of the afferent and efferent loop side-to-side and the efferent loop segment to the upper part of the new common channel. Discussion: There is no standard procedure for revision of primary surgery. Even, the gold standard surgery Roux-en-Y gastric bypass is one of the most failed procedure (≤ 35%). We have developed the revision for One Anastomosis Gastric Bypass (BAGUA) working always in healthy tissue not previously used. Conclusions: A few number of patients with tailored BAGUA for morbid obesity will require a surgical rescue procedure due to excess or insufficient weight loss or weight regain. This new procedure has been proven to be easy and safe, avoiding the surgical difficulties of the classical revision through the scar tissue (AU)

Introducción: La obesidad es ahora una epidemia en los países industrializados con una alta prevalencia (Estados Unidos con el 67%, Europa desde el 40% al 50%). Esto ha llevado al desarrollo de muchos de los procedimientos bariátricos. Sin embargo, la cirugía primaria puede fallar debido a diversas condiciones. No existe un procedimiento quirúrgico standard para realizar revisión para la cirugía bariátrica que ha fallado. Re-operar en el lugar de la cirugía primaria implicar una alta tasa de riesgos. Nosotros hemos desarrollado un nuevo procedimiento para la cirugía de revisión trabajando únicamente en el tejido no operado previamente. Métodos: Nosotros medimos el canal común desde de la anastomosis gastro-yeyunal hasta la válvula ileocecal. Dependiendo de la medición, decidimos la longitud del intestino para ser excluido (asa biliopancreática y canal común). Interrumpimos el asa aferente antes gastro-yeyunostomía y el asa eferente a 20 cm por debajo de la gastro- yeyunostomía. Para restaurar el tránsito gastro-intestinal, anastomosamos la parte superior del asa aferente y eferente en forma latero-lateral, y el segmento del asa eferente a la parte superior del nuevo canal común. Discusión: No existe un procedimiento estándar para la revisión de la cirugía primaria. Incluso, la cirugía Gold standard el bypass gástrico Roux-en-Y, es uno de los procedimientos con más fracasos (≤ 35%). Hemos desarrollado la revisión del Bypass Gástrico de Una Anastomosis (BAGUA) trabajando siempre en tejido sano no utilizado previamente. Conclusiones: Un escaso número de pacientes con BAGUA a medida para obesidad mórbida requerirá un procedimiento de rescate quirúrgico debido a exceso de peso o pérdida de peso insuficiente, o la re-ganancia del peso. Este nuevo procedimiento ha demostrado ser fácil y seguro, evitando las dificultades quirúrgicas de la revisión clásica a través del tejido cicatrizado (AU)

Three-dimensional determination of variability in colon anatomy: applications for numerical modeling of the intestine.

BACKGROUND: Precise knowledge of variability in colonic anatomy is of great importance for numerical modeling studies of the abdomen. This knowledge would allow the creation of personalized models for the gastrointestinal tract used for surgical simulations or in studies of virtual trauma. MATERIALS AND METHODS: To determine the colonic configuration in the general population and define its variability by gender, age, and corpulence, the layout of the colon was determined via the following reference points: ileocecal junction, left and right colonic flexures, and colosigmoid junction (CSJ). Three-dimensional coordinates for each point were recorded on scanned sections of 100 healthy adults to examine the colonic layout under physiological conditions. Coordinates were repositioned in a new anatomical reference for comparison. The average points' coordinates, standard deviations, and distances between them were compared for each group. RESULTS: The right colonic flexure was the most variable point. The CSJ was the least variable. Gender affected mainly the height of the colonic flexures and the length of its segments. Age affected the length of the transverse mesocolon root. Corpulence affected both the position of the ileocecal and CSJs and the length of the right colon. Differences in size and perivisceral fat distribution between groups explained these differences. Three-dimensional anatomical models of the colon were defined for each group by statistical equations. CONCLUSION: These equations, combined with data concerning the actual lengths of the colonic segments, enable reconstruction of different anatomical models of the colon that are representative according to gender, age, and corpulence.

The human ileocaecal junction: anatomical evidence of a sphincter.

PURPOSE: The human ileocaecal junction (ICJ) is a major transition zone regulating intestinal transit. Historically, it has often been considered a valve rather than a sphincter. The microscopic anatomy of this junction was studied searching for evidence of an anatomical sphincter and neuromuscular specialisation. METHODS: Ileocaecal specimens were obtained from ten cadavers and five surgical donors (7 male, mean age 81 years, age range 68-94) and examined by histology and immunohistochemistry. Quantitative analyses of muscle thickness and submucosal vascularity were performed together with immunohistochemical studies of innervation and the distribution of interstitial cells of Cajal. RESULTS: The thickness of the muscular layer in both the ileum and the colon increased significantly over a distance of 1 cm leading up to the base of the ileal papilla where it reached a maximum (4.19 ± 2.0 mm) before gradually tapering towards the tip of the papilla. Submucosal vascularity in the ileal papilla was not increased compared to the adjacent ileum or caecum/colon. Neuronal density was less in the caecum and ileal papilla compared to the terminal ileum (P < 0.05). Interstitial cells of Cajal were identified within the myenteric plexus of the ICJ but their density was similar to the adjacent bowel. CONCLUSIONS: A localised muscle thickening at the base of the ileal papilla is consistent with an intrinsic anatomical sphincter. There was no evidence that the ICJ has increased submucosal vascularity or a greater density of innervation compared to the adjacent bowel. The term ileocaecal valve is misleading and should be replaced by ileocaecal junction.

Ileocecal junction: anatomic, histologic, radiologic and endoscopic studies with special reference to its antireflux mechanism.

AIM: The aim of the study was to perform histomorphologic, endoscopic, and radiologic studies of the ileocecal junction (ICJ). A clearer understanding of the anatomical structure of the ICJ may shed some light on its function. METHODS: Histomorphologic studies were performed in 18 cadavers and radiologic in 22 and endoscopic in 10 healthy volunteers. Morphologic studies were done with the help of a magnifying loupe: histologic sections were stained with hematoxylin and eosin and Masson's trichrome. The ICJ was studied radiologically using the method of small bowel meal. Endoscopic study was done under controlled air inflation using a video endoscope. RESULTS: A nipple (1.5-2 cm long) with transversely lying stoma protruded from the medial wall of the cecum. A fornix was found on each side. The nipple stoma was surrounded by two lips: upper and lower. A mucosal fold started at both angles of the stoma and extended along the cecal circumference. It was marked on the outer cecal aspect by a groove. CONCLUSION: The ileocecal nipple is a muscular tube with a transversely lying stoma and is suspended to the cecal wall by a "suspensory ligament". The morphologic structure of the ileocecal nipple was confirmed endoscopically and radiologically. The ileocecal nipple was closed at rest and opened upon terminal ileal contraction to deliver ileal contents to the cecum. It evacuated the barium periodically into the cecum. The ileocecal nipple structure seems to be adapted to serve the function of cecoileal antireflux.

Where is the best skin incision for partial resection of the small intestine?

BACKGROUND/AIMS: For partial resection of the small intestine for benign disease such as Crohn's disease, a large incision has been placed in the mid-abdomen, for which ideal location and its length remain to be clarified. This study evaluated the validity of anthropometric placement of such an incision for partial resection of the small intestine. METHODOLOGY: Thirty consecutive patients with advanced rectal cancer (Age 30-82 {mean 60.1} years, 15 men and 15 women) who underwent anterior resection by open surgery between 2005 and 2006 were studied. The position of the viscera was projected on the anterior wall of the abdomen in relation to the umbilicus. RESULTS: The position of each viscera (Xcm, Ycm) was as follows; Duodenojejunal flexure (1.3 +/- 1.3, 9.4 +/- 2.1) and ileoceal valve (-7.3 +/- 1.0, -2.8 +/- 1.7). The small intestine which is not fixed to the retroperotoneum was located between the duodenojejunal flexure and the ileoceal valve. CONCLUSION: The ideal location of a small skin incision for small intestinal lesions is above the umbilicus for jejunal lesions, and below the umbilicus for ileal lesions.

New insights into the neuromuscular anatomy of the ileocecal valve.

The neuroanatomy of the ileocecal valve (ICV) is poorly understood. A better understanding of this important functional component of the gastrointestinal tract would enable surgeons to reconstruct an effective valve following surgical resection of the ICV. ICVs were examined in young pigs (N = 5) using frontal and transverse paraffin embedded and frozen sections. Hematoxylin+Eosin (H+E) staining, acetylcholinesterase (AchE), and NADPH-diaphorase (NADPH-d) histochemistry and protein gene product 9.5 (PGP 9.5) and C-kit immunohistochemistry were performed. The H+E staining revealed that the ICV consists of three muscle layers: an external circular muscle layer continuous with that of the ileal circular muscle layer, an inner circular muscle layer continuous with that of the cecal circular muscle layer, and a single longitudinal muscle layer, which appears to be secondary to a fusion of the ileal and cecal longitudinal muscle layers. The AchE, NADPH-d, and PGP 9.5 staining revealed two distinct coaxial myenteric plexuses, together with superficial and deep submucosal plexuses. The C-kit immunostaining showed a continuous myenteric ICC network within the ICV. The structure of the neuromuscular components within the ICV suggests that the valve is a result of a simple intussusception of the terminal ileum into the cecum. This knowledge may help surgeons in their future attempts at reconstructing more anatomically and functionally suitable ICVs following surgical resection of native ICVs.

Imaging of the ileocaecal valve.

The ileocaecal valve can cause concern when it is enlarged. We define the normal and abnormal appearances of the ileocaecal valve and illustrate the importance of using CT and endoscopy to make the correct diagnosis, avoiding any further unnecessary interventions.

The ileocolonic sphincter.

The human ileocolonic sphincter (ICS) develops a sustained tone mainly due to propagated and not propagated phasic motor activity. The ileocaecocolonic segment is also able to behave, yet uncommonly, as a synchronized segment involving propagated contractions originating from the ileum and migrating to the proximal colon. The ICS motor activity alone has a limited role towards forward flow. On the contrary, the functional entity corresponding to the distal ileum and the ICS provides a clearance mechanism for reflux of colonic contents into the small intestine. The presence of short chain fatty acids (SCFA) in the distal ileum, sensed either by endocrine cells or chemo-sensitive vagal afferents, is an important actor in triggering this clearance mechanism. The ICS tone is in part myogenic but a neuronal nitrergic component is also involved. Reflex excitatory and inhibitory responses of the ICS originating from ileal or colonic distension involve primarily spinal nitrergic and adrenergic pathways.

Ileocecal valve imaging on computed tomographic colonography.

BACKGROUND: The aim of our study was to describe the visualization, normal anatomy, and variations of the ileocecal valve with computed tomographic (CT) colonography to provide information about its optimal imaging. METHODS: We analyzed data in two- and three-dimensional rendering mode in 71 consecutive patients who underwent routine CT colonoscopy followed by conventional colonoscopy for confirmation of the radiologic findings. RESULTS: Complete visualization of the ileocecal valve was better achieved in the supine than in the prone position (82% vs. 62%, respectively); the ileocecal valve appeared in 64% of cases in the supine position when it was invisible in prone position (p < 0.0001). Partial visualization of the ileocecal valve was possible in 94% of cases. The ileocecal valve was of labial type in 76%, papillary type in 21%, and lipomatous in 3% of cases. The orifice was identified in 53% of ileocecal valves; in two cases of cecal carcinoma, the normal ileocecal valve morphology was grossly disrupted. CONCLUSION: The ileocecal valve was at least partly visualized by CT colonoscopy in 94% of cases, more frequently in the supine position. Its most common normal morphology is the labial type. The absence of orifice visualization alone is not a specific sign for neoplasia, but its presence helps distinguish physiologic bulging from neoplasia.

[Comparative-anatomical study of the formation of small and large intestinal (ileocecal) valve]. / Sravnitel'no-anatomicheskoe stanovlenie tonko-tolstokishechnogo (ileotsekal'nogo) zamykatel'nogo apparata.

The results of the comparative-anatomical investigation of the formation of ileocecal valve are presented. The study was based on the examination of the specimens obtained from 123 representatives of all vertebrate classes and 48 isolated preparations of ileocecal area of the intestine of corpses of humans aged 22-64 years. It was performed using anatomical, histological and morphometrical methods. It was shown that the formation of this closing mechanism followed the route from sphincter between small and large intestine to the development of a shutter and, eventually, of a valve. Using these concepts, the structural variants of ileocecal valve which were detected in humans were analyzed taking into consideration both its extreme variation forms (ileocecal morphological sphincter without the valve and ileocecal valve without the sphincter) and intermediate forms, which should be considered as the variants of norm.

[Morphological characteristics of glands of the ileocecal angle sphincter region in adults]. / Morfologicheskaia kharakteristika zhelez v oblasti sfinkterov podvzdoshno-slepokishechnogo ugla u vzroslogo cheloveka.

Structural feature of the large intestine glands (Liberkun crypts), located in the thickness of the ileocoecal angle valve and in the zone of appendix valve were studied using macro-microscopic methods. The material was obtained from cadaveres of 28 men and women who died at the age of 60-67. The causes of their deaths were not associated with digestive or immune system pathology. Morphometric investigations performed revealed that the density of the glands arrangement in these sphincter zones of the large intestine ileocecal angle, the area occupied by them and their length both on cross and longitudinal sections exceeded the same parameters in the zone of the coecum cone in all the observations.

[Age morphometric characteristics of the human ileocecal valve]. / Vozrastnaia morfometricheskia kharakteristika ileotsekal'noi zaslonki cheloveka.

The study was performed using 92 preparations of human ileocelal valve, taken from the corpses of men who in their lifetime did not suffer from diseases of digestive or immune systems. Diameters of ileum and cecum adjacent to the ileocelal valve were measured. The length and width of valve fraenula and lips were determined. The results of these measurements were compared among themselves and in age aspect and the regularities of velve development and growth in the course of postnatal ontogenesis were established. The features of changes in parameters of ileocelal valve structures characteristic to each age were detected. It was noted that the dimensions of frenula of the ileocelal valve increase with the increase of the diameter of cecal diameter, while the dimensions of valvular lips are increased with the increase of ileal diameter.

The "human"-like morphology of the swine papilla ilealis.

The morphology of the ileocecocolic transition, between the small and large intestine was studied in 33 male, adult pigs of unknown breed. The results were analyzed by the Wilcoxon Test (alpha < or = 0.05). The ileum opened into the large intestine, in all of the cases, at the level of the cecocolic junction in the form of a conical papilla (ileal papilla) turned towards the large intestine, with an oblique caudal and lateral direction, pointing to the cecal lumen. The cranial contour is higher than the caudal one, with average values of 3.0 cm, and 1.5 cm in the fresh specimens and 2.8 cm and 1.4 cm after fixation of the specimens. The average diameter of the papilla apex was 1.5 cm, both in the fresh specimens and in the fixed ones. In 100% of the cases the ileal papilla appeared with a star-shaped orifice in its apex in both the fresh and in the fixed specimens. Our studies showed that the transition between the small and large intestine of the swine is ileocecocolic, thus similar to humans and different from the ileocecal (Perissodactyla, Rodentia, Lagomorpha) and, according to most descriptions, ileocolic (dog) transitions found in other animals.

Arrangement of the tunica muscularis of the ileum, cecum and colon at the transition between the small and the large intestines of swine.

The arrangement of the bundles of muscular fibers in the transition between the small and the large intestines was studied in 12 male adult crossbred swine by dissection, after immersion in 50% nitric acid solution. The connection between the small and the large intestines was formed by the association of the muscular tissue, the connective tissue and the fat tissue. The tunica muscularis of these organs was organized in thin thread-like bundles and wide ribbon-like bundles of variable width and thickness. The superficial bundles of the longitudinal stratum of the tunica muscularis of the ileum established the continuity with the large intestine; the deep bundles penetrated into the ileal papilla. The limit between the cecum and the ascending colon was externally marked by the sulcus cecocolicus dorsalis and ventralis. The connection between the cecum and the ascending colon was formed by bundles of muscular fibers coming from the ileum, and the taeniae ventralis, lateralis and medialis of the cecum. Some bundles of muscular fibers from the ascending colon and the cecum headed toward the sulcus cecocolicus. The median bundles of muscular fibers of the taenia ventralis of the cecum, near the termination of the ileum, were arranged to form a loop around the termination of the ileum, mixing with the musculature of the ascending colon at the level of this junction.

Localization of nitric oxide synthase in canine ileocolonic and pyloric sphincters.

The distribution of neurons containing NAD-PH-diaphorase (NADPH-d) activity and nitric oxide synthase-like immunoreactivity (NOS-LI) in the canine pyloric and ileocolonic sphincters was studied. Cells within the myenteric and submucosal ganglia were positive for NADPH-d. These cells generally had the morphology of Dogiel type-I enteric neurons, however, there was some diversity in the morphology of NADPH-d-positive neurons in the myenteric plexus of the pylorus. Intramuscular ganglia were observed in both sphincters, and NADPH-d was found in a sub-population of neurons within these ganglia. Dual staining with an antiserum raised against nitric oxide synthase (NOS) demonstrated that almost all cells with NOS-LI were also NADPH-d positive. Varicose fibers within ganglia and within the circular and longitudinal muscle layers also possed NOS-LI and NADPH-d activity. Dual staining with anti-VIP antibodies showed that some of the NADPH-d-positive cells in the myenteric and submucosal ganglia also contained VIP-LI, but all VIP-LI-positive cells did not express NADPH-d activity. These data are consistent with recent physiological studies suggesting that nitric oxide serves as an inhibitory neurotransmitter in the pyloric and ileocolonic sphincters. The data also suggest that VIP is expressed in a sub-population of NADPH-d-positive neurons and may therefore act as a co-transmitter in enteric inhibitory neurotransmission to these specialized muscular regions.

The ileocaecal junction.

The ileocaecal junction remains a controversial region of the gut. There are still a lot of questions concerning its anatomical structure and function. In this review, a concise overview is given of the recent and older literature on the embryology, anatomy, including the intrinsic and extrinsic innervation, and the pharmacology of this region. Based on the available data from the literature, evidence is accumulating for a sphincteric function.

Enzyme-histochemical study on the fine distribution of the intramural lymphatics at the ileocecal junction of the monkey intestine.

The fine distribution of the intramural lymphatics at the ileocecal junction of the monkey intestine, especially in the lamina propria of the ileocecal valve, was examined by light and electron microscopy using enzyme-histochemical staining. The distinction between the lymphatics and the blood vessels was made by light microscopy on cold glycol methacrylate resin (JB-4) sections using 5'-nucleotidase (5'-Nase)-alkaline phosphatase (ALPase) double staining. The lymphatics were found to show strong 5'-Nase activity and to comprise irregularly shaped vessels or spaces. The central lymphatic vessels (central lacteals) in low villi were seen to lie deep within the ALPase-positive subepithelial capillary network. In the ileum side of the ileocecal junction, the 5'-Nase-positive lymphatics were seen both in the superficial layer and the deep layer of the lamina propria. On the contrary, in the cecum side the mucosal lymphatics were less numerous in the superficial layer and were distributed mainly in the deep layer near the lamina muscularis mucosae. These lymphatics ran through the lamina muscularis and merged into the lymphatic network in the submucosa. The submucosal lymphatics communicated with each other at the ileocecal junction and formed a well-developed network. Collecting lymphatics with valves were also seen near the tunica muscularis (sphincter muscle) in the deep submucosa. These lymphatics traversed the muscle layer and drained into the subserosal lymphatics.