The isolated bowel segment: angiographic visualization of the developing vascularity

An isolated bowel segment (IBS) is created by a two-stage procedure: (1) initial coaptation of the bowel segment to host organs such as abdominal wall muscle, liver, or intestine; and (2) division of its mesentery several weeks later. Between operations, vascular collaterals develop across the coaptation to preserve viability of the IBS. IBS motility and absorption have been observed in previous studies; this experimental study was designed to angio-graphically observe the vascular collaterals. An IBS was created in four dogs by myoenteropexy between the undersurface of the rectus abdominis muscle and a segment of jejunum or colon. Both IBS ends were exteriorized and intestinal continuity was restored. Four weeks later, the IBS mesentery was divided in three dogs and a sham operation was performed in the fourth. Three weeks thereafter, the animals were killed and appropriate arteries related to the IBS were injected with Microfil radiopaque silicone yellow rubber compound at a pressure of 150 mmHg. After the dye had polymerized, soft tissue X-ray was employed to identify vascular collaterals to the IBS. With ipsilateral deep inferior epigastric artery injection in the dogs with IBS mesentery division, the intramural vessels of the IBS filled via collaterals over the myoenteropexy. Dye injected into the IBS mesenteric artery in the fourth dog outlined the abdominal wall vessels via collaterals that had developed across the myoenteropexy. These observations suggest that the IBS is nourished by the abdominal wall vessels through vascular collaterals that have developed across the myoenteropexy during the interval between the staged procedures, and that viability of the IBS is preserved after IBS mesenteric division.     

Diphallus with ectopic bowel segment: a case report

A 1-year-old boy presented with complete duplication of the penis, with an ectopic bowel segment as an associated anomaly. The boy had duplicated epispadiac urethras. The right one ended blindly whereas the left one was patent, leading into the bladder. There was separation of the symphysis pubis and bifid scrotum. Investigations revealed no other anomalies. A review of the literature concerning diphallus showed a preponderance of associated anomalies such as exstrophy, bladder duplication, ureteral or renal defects, and imperforate anus, but no cases with an ectopic bowel segment. We report this case because of its extreme rarity.     

The omentum-pedicled intestinal segment: an experimental model for bowel lengthening

Various experiments designed to increase the absorptive surface of the intestine to minimize dependence on total parenteral nutrition in short-bowel syndromes have been challenged by the limitations of the vascular supply to the gut. We have investigated the feasibility of small-bowel lengthening in a rabbit model by creating a neo-mesentery for a segment of jejunum. In this method the serosa of the antimesenteric aspect of the jejunum is removed and a flap of omentum is attached to this surface. Intestinal segments were separated from their original mesentery after 5, 6, and 7 weeks of omental revascularization and specimens examined histologically 24 h after vascular division. Our data support the hypothesis that intestinal segments with both omental and mesenteric pedicles are viable and that the small bowel can be divided longitudinally and remodelled for elongation with the vascular support of the two distinct sources.     

Anatomic and histologic variability of epithelial apoptosis in small bowel transplants

Pasternak BA, Collins MH, Tiao GM, Rudolph JA, Alonso MH, Ryckman FC, Kocoshis SA. Anatomic and histologic variability of epithelial apoptosis in small bowel transplants.
Pediatr Transplantation 2010: 14: 71–76. © 2009 Wiley Periodicals, Inc.
Abstract:  Surveillance ileoscopies are performed regularly immediately post-transplantation to prevent allograft rejection. We investigated whether variability in apoptosis exists between proximal and distal intestinal limbs of double-barreled ileostomies, and if detection varies according to number of biopsies taken and sections prepared for evaluation. We retrospectively analyzed endoscopy/pathology reports of patients who underwent simultaneous proximal and distal ileoscopies during surveillance. We re-reviewed three sections of selected biopsies for the presence of apoptotic bodies and viral inclusions. Seven patients underwent 26 endoscopies in which both distal and proximal limbs were investigated simultaneously. Apoptosis was identified in each limb simultaneously in 21/26 cases (81%). Of the discrepant results, 3/5 (60%) revealed apoptosis in the proximal limb with normal distal limb and 2/5 (40%) had apoptotic bodies identified in the distal limb and normal proximal biopsies. Re-reviewing discrepant biopsies, two patients had at least one piece of mucosa without apoptosis and apoptotic bodies were seen in only 47% of sections. Histologic variability exists between proximal and distal limbs of double-barreled ileostomies and detection of apoptosis increases with number of pieces obtained and sections examined. Investigating both limbs with adequate sample size and rigorous processing may have clinical implications.     

The optimal intestinal segment length for experimental size‐mismatched intestinal transplantation: Defining the maximum length with the lowest blood flow needs in a porcine model

Transplanted Intestinal Segments (IS) must match the perfusion capacities of the recipient. This can be challenging during a size‐mismatched SBTX. In this study, we defined the maximum IS length with lowest blood flow needs in a porcine model by evaluating the physiological perfusion rates of different IS lengths. Blood flow in the SMA, aorta segment four, and general circulatory parameters were monitored before and after sequential intestinal resection. IS lengths of 30 cm, 60 cm, 120 cm, and 300 cm (n = 8 each) were compared. The IS blood flow requirements increased with IS length (30 cm: 19.5 ± 3.4 mL/min; 60 cm: 16.9 ± 6.7 mL/min; 120 cm: 34.9 ± 8.5 mL/min; 300 cm: 62.9 ± 11.6 mL/min). Absolute IS blood flow (P = .004), percentage IS blood flow uptake from the SMA (P = .001), and percentage IS blood flow uptake from the aorta (P = .005) increased significantly between 60 cm and 120 cm. We concluded that 60 cm was the maximum IS length before blood flow demands significantly increased in a porcine model.     

Small bowel obstruction in children: Review of 10 years experience

Small bowel obstruction, excluding postoperative adhesive ileus, in patients > 1 month old treated between June 1982 and May 1992 at Gunma Children's Hospital Medical Center is reviewed. There were 32 patients, 22 boys and 10 girls, whose ages ranged from 1 month to 6 years (median 9 months). Intussusception was the most frequent cause of obstruction and was seen in 17 patients (53.1%). Causative lesions were identified in five patients, and were ileal duplication cysts in four and Meckel's diverticulum in one. Incarcerated inguinal hernia and mesenteric cysts resulted in bowel obstruction in six and three patients, respectively. Other causes included mesodiverticular band, ileal volvulus without malrotation, abnormal adhesion of omentum, abnormal band, vitelline duct remnant and trapping in a mesenteric defect. As for the age distribution, there was no significant correlation between the causes of obstruction and the age of patients. Ultrasonography was useful in differential diagnosis, and this modality should therefore be used in every patient with signs of small bowel obstruction.     

Twenty-one cases of small bowel intussusception: the pathophysiology of idiopathic intussusception and the concept of benign small bowel intussusception

Ultrasonography (US) was used to study intussusceptions prospectively at Kiyama Hospital in 1999 and 2000 under the classification of small bowel intussusception (SBI) and large bowel or ileo-ileo-colic intussusception (LBI). The clinical features, management, outcome and etiology were analyzed. All LBIs and SBIs with ischemic symptoms and SBIs complicated by LBI were treated by enema reduction, whereas SBIs considered to be nonischemic were observed. SBI was seen in 21 patients with a mean age of 62.6±31.2 months. Four cases (19.0%) were diagnosed during the course of LBI. US showed mesenteric lymphoid hyperplasia in 15 (71.4%). Hydrostatic enema reduction was successful in 9/9, and SBI reduced naturally in the other 12 (benign SBI). LBI occurred in 38 patients with a mean age of 27.8±21.2 months. Mesenteric lymphoid hyperplasia was observed in 29 (76.3%). Hydrostatic enema reduction was successful in 37/38. SBI occurs more frequently and in a wider age group than previously considered. Many SBIs reduced naturally, suggesting that they were only transient invagination phenomena and should be called benign SBI. The frequent association of SBI with LBI and also the frequent association of mesenteric lymphoid hyperplasia with both SBI and LBI seem the key to the pathophysiology of intussusception.     

Inflammatory bowel diseases: the paediatric gastroenterologist's perspective

Inflammatory bowel diseases (IBDs), including Crohn disease (CD) and ulcerative colitis (UC), often affect children and adolescents. Their diagnosis is based on the integration of clinical, biological, endoscopic, histological and radiological data. The paediatric radiologist may help the clinician in many ways. In children presenting with symptoms compatible with IBD, gut exploration by US may identify those who will benefit from more invasive explorations including endoscopy. During the process of diagnosis, small bowel exploration has a crucial role in differentiating CD from UC and in classifying the disease into subphenotypes. Finally, new imaging methods are useful during patient follow-up for assessing disease activity and for the diagnosis of complications.     

Isolated biotin-resistant 3-methylcrotonyl-CoA carboxylase deficiency: Long-term outcome in a case with neonatal onset

A patient with early-onset 3-methylcrotonyl coenzyme A carboxylase (MCC) deficiency showing a severe clinical course is described. Abnormal eye and head movements suggestive of seizures were noticed soon after birth. Tonic convulsions at the age of 10 weeks led to admission. Urinary organic acid analysis using gas chromatography-mass spectrometry at 3 months of age revealed elevated concentrations of 3-hydroxyisovaleric acid (3HIVA) and 3-methylcrotonylglycine but normal levels of lactate, 3-hydroxypropionate and methylcitrate suggesting isolated MCC deficiency. This was confirmed by enzyme assays in lymphocytes and cultured skin fibroblasts: MCC activity was virtually undetectable whereas activities of propionyl-CoA and pyruvate carboxylases were within the normal range. A low protein (0.8–1.5 g/kg/day) diet supplemented with a leucine-free amino acid mixture resulted in a marked decrease of 3HIVA excretion.l-Carnitine and biotin administration had no effect on the clinical condition or metabolite exretion. Supplementation with glycine resulted in only a temporary fall of 3HIVA excretion and was therefore discontinued.l-Carnitine therapy was reintroduced later because of secondary carnitine deficiency. Compliance with treatment was poor until the age of 27 months resulting in a severe episode with seizures and coma. The general clinical condition of the patient was always good but his psychomotor development was delayed and seizures were not continuously under good control due to poor therapy compliance. The boy is now 10.5 years old and attending a school for children with learning handicaps.     

Neonatal bowel strangulation: Rare presentation of congenital diaphragmatic hernia

We report a case of congenital diaphragmatic hernia (CDH) with perinatal bowel strangulation requiring intestinal resection. Ten hours after birth, the newborn started to be lethargic and developed bilious emesis. X‐ray documented distended loops of bowel with air fluid levels in the abdomen and a gasless, non‐homogeneous opacity of the left hemithorax, a right mediastinal shift and loss of the sharp left hemidiaphram line. On gastrographin enema the left colon was above the adjacent left diaphragm. Emergency surgery was performed at 16 h of age. The entire small bowel appeared reddish and compromised. After 24 h, second‐look laparotomy was performed and only 25 cm of small bowel were viable. The postoperative period was uneventful. Neonatal bowel strangulation in CDH should be taken into account when estimating postnatal morbidity and mortality and, even if CDH treatment is not an emergency procedure, if gastrointestinal symptoms prevail over respiratory symptoms, surgery should be carried out without delay.     

Advances in short bowel syndrome: an updated review

Short bowel syndrome (SBS) continues to be an important clinical problem due to its high mortality and morbidity as well as its devastating socioeconomic effects. The past 3 years have witnessed many advances in the investigation of this condition, with the aim of elucidating the cellular and molecular mechanisms of intestinal adaptation. Such information may provide opportunities to exploit various factors that act as growth agents for the remaining bowel mucosa and may suggest new therapeutic strategies to maintain gut integrity, eliminate dependence on total parenteral nutrition, and avoid the need for intestinal transplantation. This review summarizes current research on SBS over the last few years.     

The reduced left lateral segment in pediatric liver transplantation: an alternative to the monosegment graft

Abstract:  Tailoring graft size to small paediatric recipients is a challenge. We have developed a reduced left lateral segment as an alternative to monosegment transplantation for small size recipients. Since November 2000, 89 children have been transplanted with 100 deceased donor liver grafts in our unit. Our median patient and graft survival is 89% and 88% respectively. Four of these cases were performed using a new technique of creating a small donor graft by reducing the left lateral segment. The median weight of the reduced liver graft was 264 g (range: 165–390 g). The median blood transfusion requirement was 101 mL/kg body weight (range 69–167 mL/kg). The median values of peak ALT were 1473 IU/L, INR 2.2 and bilirubin 293 μmol/L in the first two wk following surgery. One neonatal recipient died five days after transplantation from a massive intracranial haemorrhage despite satisfactory graft function. Another recipient with excellent graft function died 10 months later from primary pulmonary hypertension and secondary cardiac failure. Hepatic artery thrombosis occurred in one patient with successful revascularization but he was retransplanted three months later for chronic rejection. No biliary or venous outflow complications occurred in this group. This technique of reduced left lateral segment liver transplantation is an alternative to the monosegment graft and allows small recipients to be successfully transplanted with few technical complications related to graft preparation.     

Isolated bifid rib: Clinical and radiological findings in children

Background: Bifid rib is usually asymptomatic but sometimes occurs associated with other pathological conditions. The aim of this study was to investigate clinical and radiological characteristics in children with bifid rib. Methods: Nine children with the diagnosis of bifid rib between 2005 and 2010 were reviewed. Chest radiography and computed tomography (CT) were performed in all patients, and 3‐D images were additionally reconstructed in six patients. Results: Five girls and four boys with a mean age at presentation of 4.2 years had various types of unilateral bifid rib. Seven patients complained of a chest wall mass, whereas two patients whose costal abnormalities were incidentally detected on chest radiography were asymptomatic. Bifid ribs were confirmed on plain radiographs in six patients, while the other three patients were finally diagnosed on reconstruction 3D‐CT. One patient with a flared rib on a radiograph showed bifurcation of the costal cartilage on 3D‐CT. The other two patients with upper rib abnormalities on radiography had downward extension of the cervical or first rib articulating with the upper branch of the bifid first or second rib, respectively. Conclusion: Reconstruction 3D‐CT can demonstrate complicated thoracic abnormalities in patients with atypical appearance of the rib on plain radiographs. An isolated bifid rib may require no further intervention.     

Malrotation with midgut volvulus: CT findings of bowel infarction

Midgut volvulus, the most common serious complication of malrotation, can be diagnosed using conventional contrast fluoroscopy, US or CT. CT is a quick and comprehensive examination in the evaluation of complex acute abdominal pathology in children. Contrast-enhanced CT can readily help the radiologist recognize perfusion abnormalities of the bowel, which is vital for reducing morbidity and mortality in affected children. Our case emphasizes and demonstrates additional CT features of bowel infarction in a child with a proven malrotation with midgut volvulus.     

The clipped intestinal non-perforating anastomosis of small bowel: a new technique

In contrast to adult surgery, the neonatal small intestine confronts the surgeon, depending on the age of the patient, with variable diameters of the intestine. Therefore, anastomoses are usually performed by hand with interrupted sutures. In the presented study, a new technique is demonstrated. An anastomosis in the distal ileum of Sprague Dawley rats was performed with a single clamp applicator (Anastoclip). Small bowel anastomoses were performed in 32 rats. The clipped bowel anastomosis was evaluated concerning stenosis, leakage, and adhesions in comparison to the sutured anastomosis. Tension test and X-ray examination were performed to measure the stability. The rats were sacrificed at day 3 or 14 after laparotomy. The clipped anastomosis is feasible, and faster to perform than the conventional hand-sutured anastomosis (Operation time: control group: 18.5 min versus clipped group 4 min; p > 0.05). Furthermore, there were differences in the mechanical stability, with higher tension forces needed for rupturing the clipped anastomosis. There were fewer stenoses (16.5 mm stenotic diameter in the control group versus 20.6 mm in the clipped group) and fewer adhesions in the group of the clipped anastomosis. Histological examinations were performed and did not show significant differences between the two groups. In the animal model presented, the clipped, intestinal, non-perforating anastomosis (CINPA) shows advantages compared to the common hand-sutured anastomosis.     

Intestinal loop lengthening: early treatment of vanishing bowel

Bianchi’s procedure experience for short bowel syndrome in children is positive. This technique is generally performed after the first year of life. Here the authors propose a case of gastroschisis with prenatal spontaneous closure of abdominal defect and vanishing gut presenting as intestinal atresia, absence of ileo-cecal valve, and residual short intestinal dilatation, treated by early gut lengthening (ILP).     

Irritable bowel syndrome: the commonest cause of recurrent abdominal pain in children

Apley, working in Bristol, UK, defined recurrent abdominal pain (RAP) in 1958. After extensive investigations, he found that 8% of children presenting to his clinic with RAP had an organic pathology. The aims of this study were to identify (1) causes of RAP using modern methodology, (2) factors associated with organic RAP and (3) children with none-organic RAP who fulfill the diagnostic criteria for irritable bowel syndrome (IBS). Children, aged over 3 years, presenting with RAP were prospectively recruited to this study. They had a detailed questionnaire completed, a full examination with screening tests (blood for coeliac screen, Helicobacter pylori antibody titre, inflammatory markers, serum amylase, liver function tests, and full blood count, urine and stool analyses and abdominal ultrasonography). Endoscopy and oesophageal pH monitoring were performed if clinically indicated. IBS was diagnosed if the child had no organic pathology and fulfilled the Rome II criteria. Out of 103 children (median age of 10 years, mean 10.04, SD ±3.44,), 31 children (30%) had organic pathologies. Factors associated with organic pain were nocturnal symptoms (P<0. 01) and abdominal tenderness (P<0.005) and with non-organic pain were periumbilical locality (P<0.002), pain alleviation on defaecation (P<0.04) and low fibre diet (P<0.005). Of children with non-organic pain, 37/52 (51%) fulfilled the criteria for IBS (36% of the total). Conclusion:of children presenting with recurrent abdominal pain in a hospital setting, 30% have a diagnosable organic aetiology compared to 8% in Apleys time. Irritable bowel syndrome, however, may be the commonest cause of recurrent abdominal pain and should be considered.Abbreviations CRP C-reactive protein - GORD gastro-oesophageal reflux disease - IBS irritable bowel syndrome - RAP recurrent abdominal pain     

Neonatal short bowel syndrome: 'rectal feeding' in order to stimulate intestinal growth

Short bowel syndrome (SBS) is characterized by a state of malabsorption following extensive resection of the small bowel, resulting in insufficient nutritive supply requiring artificial nutrition with long-term parenteral nutrition. Here we present an illustrative case report of a premature infant born with gastroschisis and SBS, who was treated with enteral refeeding via rectum. The infant developed during the period of rectal feeding with jejunostomy loses bowel lengthening and could be fed orally within a few months after birth. Rectal feeding with ostomy loses could stimulate bowel growth and adaptation in neonatal SBS.
Conclusion: The purpose of this report is to describe an illustrative case of short bowel syndrome due to gastroschisis and to share a novel technique of rectal feeding to stimulate bowel growth and adaptation.     

Metastatic osteosarcoma to the small bowel with resultant intussusception: a case report and review of the literature

Intussusception resulting from osteosarcoma metastasis to the small bowel is a rare diagnosis. This case report describes a patient with this diagnosis, demonstrates the CT appearance of this lesion, and reviews the literature.