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Gastrojejunostomy without gastric resection is performed to bypass the distal stomach or the duodenum. Gastrojejunal stoma (GJ) obstruction is an unusual complication. Pancreatic injuries are usually subtle to identify by different diagnostic imaging modalities or intraoperatively, as the classic features are absent during the first 24 h and even for several days. Symptoms of injury to other intra-abdominal organs or structures commonly mask or supersede that of pancreatic injury, both early and late in the course of trauma. Hence, these injuries are often overlooked. We present a case of gastrojejunal stoma obstruction after a primary repair of traumatic American Association for the Surgery of Trauma" (AAST) grade IV duodenal injury. The surgery included repair of the duodenum over a T-tube, a pyloric occlusion, a retrocolic loop gastrojejunostomy, and feeding jejunostomy. And thereafter, successful management of postoperative complication with adhesiolysis, necrosectomy, and revised antecolic isoperistaltic Roux-en-Y gastrojejunostomy for retrocolic GJ stoma obstruction due to post-traumatic pancreatitis. [ABSTRACT FROM AUTHOR]

• During its 70 years of existence, obesity and metabolic surgery has seen the emergence of multiple surgical procedures. • Currently, four procedures have been validated due above all to their years of experience: adjustable gastric band, sleeve gastrectomy, Roux-en-Y gastric bypass and bilio-pancreatic diversion with duodenal switch. • Roux-en-Y gastric bypass and sleeve gastrectomy have overall very similar results with an advantage for SG for short-term complications and a greater effectiveness of RYGB in some diabetic patients. • The most widely used emerging technique is the Omega gastric bypass which is not officially validated but which combines simplicity and efficacy comparable to bilio-pancreatic diversion. • Malabsorptive techniques that involve extensive intestinal bypass (omega gastric bypass and bilio-pancreatic diversion) are marked by a higher risk of undernutrition. In the 70 years that bariatric surgery has existed, many different surgical procedures have been developed. Four procedures are officially accepted by all learned societies: adjustable gastric banding (AGB), sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB) and bilio-pancreatic diversion (BPD). Gastric banding has the lowest short-term surgical risk, but it has the highest re-operation rate. Compared to SG, RYGB presents about twice the risk of early complications. Late complications seem equivalent between the two procedures but studies with follow-up > 10 years are rarer for SG. SG has become the most commonly performed bariatric procedure worldwide, followed by RYGB, which is still the standard. BPD remains very marginal but the omega gastric bypass, an alternative technique that is still under evaluation, now competes with RYGB. The effectiveness of these different procedures on weight loss remains difficult to compare. SG and RYGB seem to be equivalent for weight loss results and remission of type-2 diabetes (T2DM). Their results are superior to AGB. Procedures that result in greater lengths of intestinal bypass (bilio-pancreatic diversion, omega bypass) seem to have a greater weight-loss effect but are burdened by more side effects. In conclusion, the choice of a procedure is conditioned firstly by the benefit–risk ratio and in relation to patient-related parameters, particularly the body mass index (BMI) and co-morbidities. Long-term results are also linked to factors other than surgery and in particular patient behavioral factors. Obesity is a chronic disease that indicates the need for real long-term medical and surgical management. [ABSTRACT FROM AUTHOR]

Roux-en-Y gastric bypass (RYGB) is a surgical technique described in 1970 and performed laparoscopically since 1993. Occlusions are late complications that most often occur more than 6 months after surgery. Internal hernias and intussusception are the two clinical situations that can occur after RYGB. The presentation is that of an occlusion or chronic abdominal pain. Diagnosis can be made by imaging, including abdominal and pelvic CT scans, with ingestion and injection of contrast agents if possible. Treatment is based on surgical exploration. [ABSTRACT FROM AUTHOR]

Advanced pelvic malignancy, regardless of the cancer of origin, is often multivisceral and complex. The management of advanced pelvic malignancy is resource-intensive and requires multidisciplinary input. The definition of resectability is evolving with improving multimodal therapy, preoperative staging and optimisation, perioperative care, and advanced surgical techniques. Pelvic exenteration is a highly morbid procedure and has been shown to improve survival and quality of life when performed with a curative intent. Unresectable distant solid organ or lymph node metastases and an inability to achieve a clear resection margin preclude curative pelvic exenteration. Patients with advanced pelvic malignancy who are deemed palliative are mostly managed by non-operative treatment such as chemo-, radio-, immuno-, hormonal therapy, pain management and palliative care, as well as allied health and psychosocial support team. These patients may present with severe and debilitating symptoms including intractable pain, ulcerating/proliferating tumour, pelvic fistula/sepsis/bleeding, urinary and bowel obstruction/incontinence. Interventional radiological and surgical procedures such as percutaneous drainage, nephrostomy, intestinal and urinary diversion, intestinal bypass, and venting gastrostomy have an important role in symptom control and improving quality of life. Palliative pelvic exenteration should be carefully considered along with life expectancy, patient wishes and tumour characteristics. Comprehensive discussion with patient is crucial to achieve realistic expectations. These patients should not only be discussed in a multidisciplinary team meeting with palliative care input, but also be referred for a formal palliative care consultation. Tumour anatomical extent should be considered both for and against pelvic exenteration whether involving the posterior compartment i.e. sacrectomy; lateral compartment incorporating neurovascular bundle and the anterior compartment requiring pubic bone excision as all can be associated with high morbidity rates. Patient recovery may be protracted too if surgery is complicated by perineal wound or flap breakdown in cases necessitating wide perineal skin and soft tissue excision. Furthermore, evidence from quality of life and cost-effectiveness studies do not provide robust data to support pelvic exenteration with palliative intent. Whilst a relatively 'straightforward' central soft tissue pelvic exenteration may offer reasonable symptomatic relief in a patient with an acceptable life expectancy, palliative pelvic exenteration overall should only be considered in highly selected patients. [ABSTRACT FROM AUTHOR]

In patients with familial adenomatous polyposis (FAP), extensive nonmalignant duodenal polyposis not amenable to endoscopic management demands surgical resection for which pancreas-preserving total duodenectomy (PPTD) offers a pancreatic parenchyma sparing approach. This is a retrospective cohort study including consecutive patients who underwent PPTD for FAP. Reconstruction involved a Billroth II anastomosis with a short isolated jejunal limb to facilitate future endoscopic surveillance. Short and long-term outcomes were evaluated. Overall, 30 patients underwent PPTD for Spigelman stage III (n = 6) or IV (n = 24). Sixteen patients experienced a severe complication (Clavien–Dindo grade III/IV) including postoperative pancreatic fistula (ISGPS grade B/C) in twelve. There was no all cause in-hospital and 90-day mortality. During follow-up (median 125 months), five patients developed acute pancreatitis, one new-onset diabetes and one exocrine pancreatic insufficiency. During endoscopic surveillance in 27 patients, jejunal adenomas were detected in 22 and advanced adenomas in 11. An additional surgical resection was required in four patients with extensive jejunal polyposis. None developed jejunal cancer. The 10-year overall survival rate was 93.3%. Postoperative morbidity after PPTD is substantial but on the long-term, rates of pancreatic insufficiencies are low. Most patients develop jejunal adenomas at follow-up, highlighting the need for endoscopic surveillance. [ABSTRACT FROM AUTHOR]

Formation of calcium oxalate (CaOx) crystal, the most common composition in kidney stones, occurs following supersaturation of calcium and oxalate ions in the urine. In addition to endogenous source, another main source of calcium and oxalate ions is dietary intake. In the intestinal lumen, calcium can bind with oxalate to form precipitates to be eliminated with feces. High intake of oxalate-rich foods, inappropriate amount of daily calcium intake, defective intestinal transporters for oxalate secretion and absorption, and gastrointestinal (GI) malabsorption (i.e., from gastric bypass surgery) can enhance intestinal oxalate absorption, thereby increasing urinary oxalate level and risk of kidney stone disease (KSD). The GI microbiome rich with oxalate-degrading bacteria can reduce intestinal oxalate absorption and urinary oxalate level. In addition to the oxalate-degrading ability, the GI microbiome also affects expression of oxalate transporters and net intestinal oxalate transport, cholesterol level, and short-chain fatty acids (SCFAs) production, leading to lower KSD risk. Recent evidence also shows beneficial effects of urinary microbiome in KSD prevention. This review summarizes the current knowledge on the aforementioned aspects. Potential benefits of the GI and urinary microbiomes as probiotics for KSD prevention are emphasized. Finally, challenges and future perspectives of probiotic treatment in KSD are discussed. [ABSTRACT FROM AUTHOR]

Background: Pancreas-sparing duodenectomy (PSD) offers definitive therapy for duodenal polyposis associated with familial adenomatous polyposis (FAP). We reviewed the long-term complications of PSD and evaluated the incidence of high-grade dysplasia (HGD) and cancer in the remaining upper gastrointestinal tract.Methods: Forty-seven FAP patients with duodenal polyposis undergoing PSD from 1992 to 2019 were reviewed. Long-term was defined as > 30 days from PSD.Results: All patients were treated with an open technique, and 43 (91.5%) had Spigelman stage III or IV duodenal polyposis. Median follow-up was 107 months (IQR, 26-147). There was no 90-day mortality. Seven patients died at a median of 10.5 years (IQR, 5.4-13.3) after PSD, with one attributed to gastric cancer. Pancreatitis occurred in 10 patients (21.3%), and two required surgical intervention. Seven patients (14.9%) developed an incisional hernia, and all underwent definitive repair. Forty-one patients (87.2%) had postoperative surveillance endoscopy over a median follow-up of 111 months (IQR, 42-138). Three patients (6.4%) developed adenocarcinoma (two gastric, one jejunal), and four (8.5%) had adenomas with HGD (two gastric, two jejunal) with a median of 15 years (IQR, 9-16) from PSD. One patient with gastric adenocarcinoma and all patients with HGD or adenocarcinoma of the jejunum required surgical intervention.Conclusion: PSD can be performed with a low but definable risk of long-term morbidity. Risk of gastric and jejunal carcinoma rarely occurs and was diagnosed decades after PSD. This demonstrates the need for lifelong endoscopic surveillance and educates us on the risk of carcinoma in the remaining gastrointestinal tract. [ABSTRACT FROM AUTHOR]

We aimed to investigate the hypothesis that preoperative thickness of the abdominal cavity influenced on the gastrojejunostomy position and the incidence of delayed gastric emptying (DGE) after pancreatoduodenectomy. Between January 2009 and December 2018, consecutive patients who underwent subtotal stomach-preserving pancreatoduodenectomy were retrospectively reviewed. Thickness of the abdominal cavity at the level of the celiac axis (TACC) and umbilicus (TACU) were measured using computed tomography before surgery. The ventral deviation of the gastrojejunostomy was evaluated as the sagittal fundus anastomotic angle (SFAA) using sagittal computed tomography images taken after surgery. A total of 281 patients were included. Of these, clinically relevant DGE (CR-DGE) was observed in 47 patients. TACC was significantly correlated with SFAA (R = 0.53, P < 0.001). Both TACC and SFAA were significantly greater in patients with CR-DGE compared to those without CR-DGE. In contrast, TACU was not associated with SFAA and the incidence of CR-DGE. Multivariate analysis revealed that TACC >110 mm (odds ratio, 3.07; p = 0.002) and pancreatic fistula (odds ratio, 2.71; p = 0.013) were identified as independent risk factors for CR-DGE. Thickness of the upper abdominal cavity had a significant influence on gastrojejunal anatomic position and the development of CR-DGE after pancreatoduodenectomy. [ABSTRACT FROM AUTHOR]

Background: The path of the biliopancreatic limb for reconstruction of the pancreatic anastomosis during pancreatoduodenectomy for pancreatic ductal adenocarcinoma can be trans-mesocolon or through the ligament of Treitz. Even after curative intent pancreatoduodenectomy, incidence of recurrence in the surgical bed remains high and may lead to obstruction of the biliopancreatic limb. However, the association between path of jejunal limb and incidence of biliopancreatic limb obstruction has not been studied. Primary aim was to determine whether path of reconstruction predisposes to biliopancreatic limb obstruction in the setting of local recurrence.Methods: Patients who underwent pancreatoduodenectomy for pancreatic ductal adenocarcinoma (2008-2018) from a single institution were identified. As disease recurrence is the predominant cause of biliopancreatic limb obstruction, analysis was limited to patients with known recurrence at date of last follow-up. Given a known median time to recurrence of 8 to 10 months after resection for pancreatic ductal adenocarcinoma, analysis was further limited to patients with at least 8 months of follow-up. Primary outcome was incidence of biliopancreatic limb obstruction.Results: Among the 517 patients identified, 182 were included. Median age was 65 years; 51% were male. Median follow-up was 22 months. Path of reconstruction was trans-mesocolon in 35% (n = 64) and through ligament of Treitz in 65% (n = 118). There was no difference between the two groups in clinicopathologic factors including age, tumor differentiation, grade, T-stage, N-stage, LVI, or PNI (all p > 0.05). Importantly, there was no difference in retroperitoneal margin positivity between groups (trans-mesocolon 8% vs ligament of Treitz 10%, p = 0.79). Both groups had similar post-operative outcomes including median length-of-stay (trans-mesocolon 6 days vs ligament of Treitz 6 days, p = 0.89) and median follow-up (trans-mesocolon 21 months vs ligament of Treitz 23 months, p = 0.68). Biliopancreatic limb obstruction was detected in 8% (n = 14) of which 14% (n = 2) were in the trans-mesocolon group and 86% (n = 12) were in the ligament of the Treitz group. Therefore, incidence of biliopancreatic limb obstruction was 3.1% in the trans-mesocolon group and 10.4% in the ligament of the Treitz group resulting in an absolute risk increase of 7.3%, risk ratio of 3.4, and relative risk increase of 2.3. There was no difference in median time to biliopancreatic limb obstruction between the groups (17.6 months vs 18.5 months, p = 1.0). Biliopancreatic limb obstruction was caused by locally recurrent pancreatic ductal adenocarcinoma in 93% (n = 13) and kinking of the duodenojejunal anastomosis in 7% (n = 1). Intervention was performed in 71% (n = 10) and included surgical bypass in 29% (n = 4), percutaneous drain in 21% (n = 3), and endoscopic/surgical decompression in 21% (n = 3).Conclusion: Biliopancreatic limb obstruction is a known complication after pancreatoduodenectomy for pancreatic ductal adenocarcinoma due to local recurrence in the surgical bed. This study shows that path of jejunal limb through the ligament of Treitz may be associated with a higher incidence of biliopancreatic limb obstruction compared with trans-mesocolon as the position of the biliopancreatic limb in the surgical bed may be more predisposed to obstruction after local recurrence. Larger studies are needed; however, given this potential risk of subsequent obstruction, these data suggest that the reconstruction paths may not be equivalent when performing pancreatoduodenectomy for pancreatic ductal adenocarcinoma. [ABSTRACT FROM AUTHOR]

Background: Gastrointestinal (GI) surgery involving gastric resection and bypass of intestinal segments was reported to facilitate glucose control in obese patients with type 2 diabetes (T2D).Aim: Our aim was to assess whether the type of post-gastrectomy GI reconstruction also influences glucose control in T2D patients with BMI below 35 kg/m2 submitted to gastrointestinal surgery without bariatric intention.Methods: A cohort of T2D Caucasian patients (n = 40) with upper GI malignancy (n = 33) or complicated reflux disease (n = 7) were submitted to either a gastrectomy plus Billroth II (BII) gastrojejunal anastomosis (n = 17), a gastrectomy plus Roux-en-Y gastrojejunostomy (RY) reconstruction (n = 18; subtotal gastrectomy n = 7 and total gastrectomy n = 11), or atypical gastrectomy without reconstruction (no-R) (n = 5). Patients were evaluated before and 2 years after surgery for body weight, Hb1Ac, need of glucose lowering drugs, and presence of diabetes.Results: Body mass index (BMI) decreased after every surgical procedure when compared to baseline (- 0.9 ± 0.8 kg/m2 for BII vs - 4.3 ± 2.6 kg/m2 for RY vs - 4.6 ± 2.5 kg/m2 for no-R, p < 0.05), which was only significantly different after RY surgeries. Diabetes remission occurred in 5.9% of BII patients, in 27.8% of RY patients, and 0% of no-R patients, while in patients with persistent T2D, the needs for glucose-lowering drugs were significantly also decreased after RY (31.3% BII vs 66.7% RY vs 25% no-R, p = 0.03).Conclusions: T2D Caucasian patients undergoing post-gastrectomy GI reconstructions without a bariatric intention experience a significant improvement of T2D, in a magnitude that could be influenced by the technical procedure performed in favor of RY reconstruction. Thus, presence of T2D should be taken into consideration when deciding for the type of post-gastrectomy GI reconstruction. [ABSTRACT FROM AUTHOR]

Gastrointestinal stromal tumors (GISTs), with a primary occurrence in the duodenum and proximal jejunum, are rare and treatment is poorly understood. This study aimed to evaluate the main factors influencing the prognosis of GIST resection in this complex anatomical structure. This retrospective study included 47 patients who underwent surgery for primary GIST of the duodenum (20) and proximal jejunum (27) between 2012 and 2017. Perioperative clinical data as well as relapse and survival information were collected. All patients underwent negative margin resection (R0) of duodenal and proximal jejunum GISTs. Complications occurred more frequently in treatment of duodenal GISTs than proximal jejunum GISTs (p = 0.003). GISTs in D3 (the 3rd portion of duodenum) were related to larger tumor size (p = 0.001), higher probability of severe complication rate (p = 0.042), longer hospital stays (p = 0.023) and fasting time (p = 0.020). More complications were found for patients with digestive reconstruction than limited resection (p = 0.010). Additionally, patients with a tumor mass larger than 5 cm or a mitotic index greater than 5 mitoses/50 HPFs showed poorer therapeutic outcomes. The 1- and 3-year overall survival was 97.9% and 86.1%, respectively and were not influenced by operation type (p = 0.061) or GIST position (p = 0.447). With negative operational margins, limited resection is a safe and feasible procedure for duodenal and proximal jejunum GIST patients and unnecessary digestive reconstruction should be avoided. Considering the severe complication rate, resection for GISTs in D3 should be performed with care. [ABSTRACT FROM AUTHOR]

Calcium (Ca) and phosphorus (P) are essential minerals involved in many biological processes including bone development and mineralization. Plasma concentration of both minerals is tightly regulated, and Ca and P homeostasis is maintained via intestinal absorption, bone storage and exchange, and renal reabsorption. In the current broiler production systems, chicks are deprived of food and water for up to 72 h due to uneven hatching, hatchery procedures, and transportation time to farms. Post-hatch (PH) feed delay results in lower body and organ weight, higher feed conversion ratio and mortality, and delayed PH growth and GIT development. Little is known about the effects of early neonatal development and delayed or immediate feeding PH on Ca and P transporters. Therefore, the aim of the present study was to characterize expression patterns of Ca and P transporter genes in small intestine during the first 2 wk PH in chickens fed immediately after hatch (FED) or subjected to 48 h delayed feeding (NOTFED). Expression of all Ca and P transporters in jejunum and ileum was significantly (P < 0.05) affected by age. Among Ca transporter genes, only mRNA expression of Calbidin D28k in jejunum and Ca sensing receptor (CaSR) in ileum were significantly (P < 0.05) affected by delay in feed access. For P transporter genes' expression, only P transporter type III (PIT1) mRNA was significantly affected by age, delay in feed access, and their interaction (P < 0.05). In summary, we have shown, for the first time, early developmental changes of Ca and P transporter genes in broiler chickens. Results suggest that an increase in gene expression of some of the transporters corresponds with the switch from yolk to high starch diet. Overall, our results can be helpful in better understanding of Ca and P homeostasis in broilers. [ABSTRACT FROM AUTHOR]

Abstract Background and Aims Placement of the duodenal-jejunal bypass liner (DJBL) leads to rapid weight loss and restoration of insulin sensitivity in a similar fashion to bariatric surgery. Increased systemic bile acid levels are candidate effectors for these effects through postprandial activation of their receptors TGR5 and FXR. We aimed to quantify postprandial bile acid, GLP-1 and FGF19 responses and assess their temporal relation to the weight loss and metabolic and hormonal changes seen after DJBL placement. Methods We performed mixed meal testing in 17 obese patients with type 2 diabetes mellitus (DM2) directly before, one week after and 6 months after DJBL placement. Results Both fasting and postprandial bile acid levels were unchanged at 1 week after implantation, and greatly increased 6 months after implantation. The increase consisted of unconjugated bile acid species. 3 hour-postprandial GLP-1 levels increased after 1 week and were sustained, whereas FGF19 levels and postprandial plasma courses were unaffected. Conclusions DJBL placement leads to profound increases in unconjugated bile acid levels after 6 months, similar to the effects of bariatric surgery. The temporal dissociation between the changes in bile acids, GLP-1 and FGF19 and other gut hormone responses warrant caution about the beneficial role of bile acids after DJBL placement. This observational uncontrolled study emphasizes the need for future controlled studies. Highlights • The duodenal-jejunal bypass liner reduces weight and insulin resistance. • Bile acids may beneficially affect metabolism via activation of FXR and TGR5 receptors. • DJBL increases unconjugated bile acid levels similar to bariatric surgery. • Time dependent changes in gut hormones warrant caution on the role of bile acids. [ABSTRACT FROM AUTHOR]

Laparoscopic sleeve gastrectomy (LSG) is one of the most commonly performed bariatric surgery in recent years, and some modifications have emerged to improve its efficacy. Melissas has described SG plus jejuno-ileal bypass (JIB), which has reported good results in a few studies. We performed this procedure in 21 cases and in one case, we observed acute liver failure (ALF) that has not been reported before. A 38-year-old female (BMI: 56.1 kg/m2) underwent laparoscopic SG plus JIB. There was no sign of diarrhea, malnutrition or liver failure for eight months and her BMI was 43.0 kg/m2. At the 9th month, she was hospitalized for abdominal pain, jaundice and ALF. The patient was treated by plasmapheresis and molecular absorptive recirculation system. She was planned to undergo liver transplantation but died of multiorgan failure on the 40th day of hospitalization. ALF can be observed following SG plus JIB. JIB reversal before compromising liver functions should be taken into consideration. [ABSTRACT FROM AUTHOR]

Graphical abstract Abstract The number of highly lipophilic active pharmaceutical ingredients (APIs) in pharmaceutical development has been constantly increasing over recent decades. These APIs often have inherent issues with solubility and dissolution, limiting their oral bioavailability. Traditionally, a reduction in particle size to the micrometer range has been used to improve dissolution. More recently, size reduction to the nanometer range has been introduced, which further increases the dissolution rate, but may also involve other mechanisms for increasing bioavailability. The effect of particle size on the absorption of aprepitant was investigated using the single-pass intestinal perfusion (SPIP) model in the rat jejunum. Phosphate buffer, fasted-state simulated intestinal fluid (FaSSIF), and fed-state simulated intestinal fluid (FeSSIF) were used as perfusion media to increase understanding of the processes involved and the effects of colloidal structures. The role of mucus on intestinal absorption was investigated by adding the mucolytic agent N -acetyl-cysteine (NAC). The absorption of aprepitant from the nanosuspensions was similar with all perfusion media (buffer = FaSSIF = FeSSIF), whereas food had a pronounced effect on absorption from the microsuspensions (FeSSIF > FaSSIF > buffer). The colloidal structures hence contributed to absorption from the microsuspensions. Partitioning of aprepitant from the nanosuspension into the colloidal structures decreased the amount of nanoparticles available, which offset the effect of food. The appearance flux of aprepitant in blood was non-significantly decreased for nanosuspensions of aprepitant with NAC versus without NAC in buffer (ratio of 2:1), indicating that particle deposition in the mucus may have been decreased as the layer thinned, with subsequently reduced intestinal absorption. The study also showed that the SPIP model is suitable for investigating detailed absorption mechanisms using complex perfusion media, which increase the biorelevance of the model. [ABSTRACT FROM AUTHOR]

Highlights • Jejunoileal bypass is a surgery of the past however still affects patients being see by surgeons today. • The pathophysiology is complicated and it should be known these patients suffer from chronic kidney disease, liver failure, chronic diarrhea and many vitamin deficiencies. • Bypass reverseal can help preserve kidney function but may not reverse damages already done. • From our experience, Bypassed bowel incorporation back into enteric tract can produced a immune response causing functional obstruction only relieved by removal of this bowel. Abstract Introduction Jejunoileal bypass (JIB) was an effective treatment for morbid obesity in the 1970s, but shortly after it fell out of favor due to horrific side effects, including liver failure, nephrolithiasis and drastic vitamin deficiencies. Although there are few living people with JIB, the management of these patients can be challenging. Case presentation We describe a case of a 58-year-old female with a history of JIB 46 years prior who had an impending renal failure due to nephrolithiasis. She underwent a jejunostomy feeding tube prior to reversal. After reversal, our patient developed failure to thrive with functional obstruction of the newly incorporated small bowel. This bypassed bowel underwent a severe inflammatory transformation after the introduction of enteric feeds, suggesting an immunological type response to antigens in food. It wasn't until a long and debilitating 12 months and resection of this inflamed bowel that our patient was able to regain bowel function and gain weight. Conclusion Jejunoileal bypass is an archaic procedure for morbid obesity. Due to its debilitating and at times lethal side effects, it has been replaced with newer techniques. Despite advances, there are still patients out there who have had a jejunoileal bypass. This case report and review of the literature details our experience with this procedure. [ABSTRACT FROM AUTHOR]

KIBRA has been recognized as a memory-related gene, which is abundant in the brain and kidney of mammals. However, the expression pattern of KIBRA in the “second brain”-enteric nervous system (ENS) is still unknown, especially in neurodegenerative disorders. In this study, we aimed to investigate the detailed expression pattern of KIBRA in the intestinal myenteric nerve plexus of APP/PS1 and wild type mice by whole mount staining technology. The deposition of Aβ and increased levels of phosphorylated Tau (p-Tau) and total Tau (T-Tau) protein were observed in the intestinal myenteric nerve plexus of APP/PS1 mice. Interestingly, the amount of Tuj+ cells remained unchanged between these two groups. Compared to the control mice, the protein levels of KIBRA significantly increased in the jejunal myenteric plexus of APP/PS1 mice, and the proportion of KIBRA+ GABAergic neurons in both the jejunal myenteric nerve plexus and the cortex was much higher in the APP/PS1 mice. But there was no significant difference in the number of KIBRA+ cholinergic neurons and KIBRA+ nitrergic neurons between APP/PS1 and wild type mice. In summary, our study further confirmed that typical pathology features of Alzheimer’s disease (AD) not only existed in the central nervous system but also in the ENS. [ABSTRACT FROM AUTHOR]

Objective Bariatric surgery could improve pancreatic beta cell function, thereby leading to the remission of the type 2 diabetes mellitus (T2DM). However, the specific mechanism underlying this phenomenon is yet to be revealed. The aim of this study is to test the hypothesis that Nod-like receptor family pyrin domain containing 3 (NLRP3) inflammasome in infiltrating macrophages plays an important role in the modulation of beta cell function after duodenal-jejunal bypass (DJB) surgery. Methods DJB and sham surgery were performed in diabetic Sprague-Dawley (SD) rats induced by high-fat diet (HFD) and streptozotocin (STZ). Body weight, food intake, and glucose tolerance test (GTT) were measured at indicated time points. Apoptosis of the beta cells was measured by Terminal deoxynucleotidyl transferase mediated dUTP Nick End Labeling (TUNEL) assay. We also assessed the macrophage content and NLRP3 expression in the rat model. Furthermore, macrophage reconstitution was performed after DJB surgery. Beta cell function and NLRP3 inflammasome pathway were re-evaluated in wild-type macrophage reconstitution group and NLRP3-knockdown macrophage reconstitution group. Results DJB surgery group rats displayed rapid and sustained improvement in glucose tolerance. Decreased apoptosis and improved secretion function of the beta cells were observed in DJB surgery group. NLRP3 inflammasome pathway in infiltrating macrophages was also suppressed after DJB surgery. Moreover, diabetic remission acquired by DJB sustained in NLRP3-knockdown macrophage reconstitution group, while extinguished in group reconstituted with wild-type macrophage. Conclusions NLRP3 inflammasome deactivation in infiltrating macrophages is involved in marked beta cell function improvement after DJB surgery. [ABSTRACT FROM AUTHOR]

Aims The main function of the colon is water and electrolyte absorption. Total colectomy eliminates this colonic function and may alter the absorptive capacity of the small intestine for nutrients. This study examines the effect of total colectomy on jejunal glucose absorption and investigates the potential role of aldosterone in mediating the alterations in glucose uptake post-colectomy using the aldosterone antagonist spironolactone. Main methods Total colectomy with ileo-rectal anastomosis was performed on anesthetized rats. Sham rats were identically handled without colon resection. Two days post-surgery, groups of colectomized rats were injected with either a daily subcutaneous dose of spironolactone or sesame oil for 12 days. Body weight changes and food and water intake were measured in all experimental groups. Glucose absorption was measured by in-vivo single pass perfusion in the rat jejunum of control, sham, colectomized, colectomized with spironolactone, and colectomized with sesame oil treatment. Na/K ATPase, SGK1, SGLT1 and GLUT2 expressions were determined in jejunal mucosa in control, colectomized and colectomized/spironolactone injected rats by Western blot analysis. Histological assessment was performed on jejunal sections in control and colectomized groups. Key findings Glucose absorption significantly increased in colectomized rats with an observed increase in Na/K ATPase and SGK1 expression. No significant expression change in SGLT1 and GLUT2 was detected in the jejunum in colectomized rats. Spironolactone, however, significantly decreased the glucose uptake post-colectomy and normalized Na/K ATPase and SGK1 expression. Significance Our results suggest that jejunal glucose uptake increases post-colectomy as a possible consequence of an aldosterone-mediated function. [ABSTRACT FROM AUTHOR]

Introduction: The small intestine is one of the most ischemia-sensitive organs used in transplantation. To better preserve the intestinal graft viability and decrease ischemia-reperfusion injury, a device for extracorporeal perfusion was developed. We present the results for the first series of perfused human intestine with an intestinal perfusion unit (IPU).Methods: Five human intestines were procured for the protocol. (1) An experimental segment was perfused by the IPU delivering cold preservation solution to the vascular and luminal side continually at 4 ºC for 8 h. (2) Control (jejunum and ileum) segments were preserved in static cold preservation. Tissue samples were obtained for histopathologic grading according to the Park/Chiu scoring system (0 = normal, 8 = transmural infarction).Results: Jejunal experimental segments scored 2.2 with the Park/Chiu system compared to the control segments, which averaged 3.2. Overall scoring for ileum experimental and control segments was equal with 1.6.Conclusion: This data presents proof of concept that extracorporeal intestinal perfusion is feasible. The evidence shows that the IPU can preserve the viability of human intestine, and histopathologic evaluation of perfused intestine is favorable. Our early results can eventually lead to expanding the possibilities of intestinal preservation. [ABSTRACT FROM AUTHOR]

The aim of this study was to evaluate the effect of dietary curcumin supplementation on growth performance and intestinal mucosal barrier function of weaned piglets. Fifty piglets, weaned at 21 ± 2 days of age, were randomly allotted to five treatments for 21 days. The dietary treatments were the control (basal diet), and the basal diet supplemented with 50 mg/kg quinocetone, or 200 mg/kg, 300 mg/kg or 400 mg/kg curcumin. The piglets were housed in individual pens and orally challenged with enterotoxigenic Escherichia coli (ETEC) during the preliminary trial period. The jejunal morphology and histology analysis were detected under light microscope. The plasma d -lactate and diamine oxidase (DAO) were determined by using enzymatic spectrophotometric assay. Immunohistochemistry assays were used to examine secretory immunoglobulin (sIgA) protein expression. Real-time PCR was used to determine mRNA levels of cytokine and Toll-like receptor 4 (TLR4) in jejunal mucosa. The results showed that, compared with the control, dietary addition of 300 mg/kg or 400 mg/kg curcumin decreased ( P < 0.05) feed/gain ratio and crypt depth, improved ( P < 0.05) villus height and villus height:crypt depth ratio, reduced ( P < 0.05) plasma d -lactate and DAO activity, up-regulated the protein expression of sIgA ( P < 0.05), increased ( P < 0.05) the number of goblet cells (GCs) and reduced ( P < 0.05) the number of intraepithelial lymphocytes (IELs). The mRNA levels of interleukin 1β (IL-1β) and TLR4 and tumor necrosis factor α (TNF-α) were also decreased ( P < 0.05), but mRNA level of interleukin 10 (IL-10) was increased ( P < 0.05). There was no difference in the above parameters between the 300 mg/kg and 400 mg/kg curcumin groups. Pigs fed with 50 mg/kg quinocetone also decreased ( P < 0.05) feed/gain ratio, increased villus height:crypt depth ratio ( P < 0.05), and reduced ( P < 0.05) crypt depth and mRNA levels of TLR4. In conclusion, curcumin and the quinocetone have similar effects in improving piglet growth, but dietary addition of 300 mg/kg or 400 mg/kg curcumin was more effective than quinocetone in improving intestinal mucosal barrier integrity, morphology, and immune status of weaned pigs. This indicates that curcumin could be used as a potential feed additive replacing quinocetone in weaned piglets. [ABSTRACT FROM AUTHOR]

Effects of nutrient restriction and realimentation on growth, cellularity of visceral organs and jejunal morphology in lambs were investigated. Forty Wu Zhu Mu Qin lambs were divided into control group (CG), moderately protein-restricted group (PR), moderately energy-restricted group (ER) or severely protein- and energy-restricted group (PER). The experiment included an adaptation period (0–30 days), nutritional restriction period (31–90 days), and realimentation period (91–180 days). Weight of lambs was measured weekly. Four lambs of each group were slaughtered at 90 days and 180 days. After slaughter, visceral organs were weighed, and subsamples were obtained to evaluate visceral DNA and protein contents, and jejunal morphology. Final body weight (BW), dry matter intake (DMI) and average daily gain (ADG) of lambs in PR, ER and PER were significantly less ( P <0.01) than those of CG lambs during the restriction period. On d 180, no significant difference was observed for BW among PR, ER and CG, however, BW of lambs in PER was still less ( P <0.01) than that of CG, PR and ER; ADG of nutrition restricted lambs was significantly greater than ( P <0.01) that of CG. Visceral organ weight, on wet tissue basis, decreased with nutrition restriction ( P <0.05); there was no difference ( P >0.05) of visceral organ weights among treatments on d 180. As compared with CG, PR had decreased DNA concentration of the liver ( P <0.05), DNA and protein concentration of the pancreas ( P <0.05), protein concentration and protein:DNA of kidney and omasum ( P <0.05) on d 90; ER had decreased DNA concentration of the heart ( P <0.05); and PER had decreased DNA concentration of the liver ( P <0.01). Intestinal cellularity was not affected by treatment on d 90. Except for DNA concentration of the duodenum of lambs in ER, and DNA concentration of the jejunum of lambs in PR and ER, no significant differences were observed among treatments in cellularity of visceral organs on d 180. Compared with CG, crypt depth and muscle thickness of the jejunum were decreased ( P <0.01) in lambs of PR, ER and PER on d 90. Villus height, crypt depth, muscle thickness and mucosa thickness of lambs in PR and ER were similar to CG lambs on d 180. Results indicate that nutritional restriction of 60 days can retard the growth, cellularity of visceral organs and jejunal morphological development of lambs, and retarded cellularity achieves complete compensatory growth after realimentation of 90 days. [ABSTRACT FROM AUTHOR]

Ulcer perforation is a rare cause of peritonitis in children. The cases reported in the literature are caused by peptic ulcer. We report on a case of peritonitis caused by jejunal ulcer perforation, discovered in a girl's abdomen during an acute surgical procedure. The treatment consisted of a resection of the perforation followed by an end-to-end anastomosis. Postoperative period was uneventful. [ABSTRACT FROM AUTHOR]

Direct-fed microbials (DFM) are used to improve livestock health and performance. The effects of 2 DFM products, a blend of 3 Bacillus strains (DFMB) and a Propionibacteriumspp. (DFMP), on broiler performance, nutrient utilization, and immune responses were investigated. Day-old (n = 120) male broilers were divided into 24 groups of 5 birds and fed 3 wheat-based diets in mash form (8 groups per diet) from d 1 to 22. The control diet was fed without or with 7.5 × 104 cfu/g of either DFMB or DFMP. From d 19 to 21 fecal samples were collected for determination of total tract apparent retention (TTAR) of nutrients and AMEn. On d 21, feed intake and BW were determined. On d 22, 5 birds per treatment were killed by cervical dislocation to collect jejunal and ileal contents for determination of digesta viscosity and apparent ileal digestibility (AID) of nutrients, respectively, and ileum, cecal tonsil, and spleen tissues for Toll-like receptors (TLR) and cytokine expressions. Compared with the control, DFM did not affect BW gain and feed intake but DFMP reduced G:F (P < 0.01). Compared with the control (2,875 kcal/kg), birds fed on DFMB and DFMP had higher AMEn (2,979 and 2,916 kcal/kg, respectively; P < 0.05), whereas both DFM reduced the AID of DM (P < 0.001) and CP (P < 0.01). Furthermore, DFMP reduced TTAR of NDF (29.0 vs. 18.4%; P < 0.001), whereas both DFM increased TTAR of DM and fat (P < 0.001). Supplementing DFMP downregulated ileal expression of TLR-2b, IL-2, IL-4, IL-6, IL-10, and IL-13, whereas DFMB downregulated TLR-2b, IL-2, IL-4, and IL-6 in all 3 tissues, IL-10 in the spleen, and upregulated IL-13 in the spleen. In conclusion, the DFM did not improve performance but increased the AMEn of diet by possibly increasing DM and fat retention. Overall, both DFM showed an antiinflammatory effect in the ileum, but DFMB had more effects on local and systemic immunity than DFMP. [ABSTRACT FROM PUBLISHER]

Abstract: Free jejunal transfer has been used in pharyngeal reconstruction for many years, but many have criticised it as being unreliable, poorly tolerant of radiotherapy, and susceptible to stenosis and dysphagia. Recently, the trend has been to use the anterolateral thigh (ALT) flap to overcome these problems, and many authors have reported good results. At the University of Birmingham we used the jejunal free flap for pharyngeal reconstruction for many years, but in view of recent reports we changed to the ALT flap. We retrospectively analysed all patients who had pharyngeal reconstruction with an ALT flap in our unit since changing from the jejunal flap. Only circumferential defects were included. Six patients had pharyngeal resection and required reconstruction of a circumferential defect between 2007 and 2010. All the defects were reconstructed with a tubed ALT flap. No flaps failed and there was no partial necrosis. However, stricturing still occurred and the diet of many patients was restricted. Three patients required the flap to be replaced with a jejunal free flap. Although no flaps failed, we have not been able to replicate the results of other surgeons and have therefore abandoned use of the ALT flap and returned to use of the jejunal free flap for the reconstruction of circumferential pharyngeal defects. [Copyright &y& Elsevier]

Abstract: We retrospectively audited operative complications, success of flaps, and speech and swallowing outcomes in patients with head and neck cancer who had reconstruction with jejunal free tissue transfer to the pharynx. A total of 104 patients had jejunal free flaps between 1987 and 2009 at University Hospital, Birmingham. Management was by a multidisciplinary team, and the same vascular surgeon did all the anastomoses. We investigated the relations between patients, operative factors, and postoperative complications, and noted the ischaemic time of the flaps and coexisting conditions of the patients. Outcomes measured included initial and final survival rates of flaps, donor and recipient site complications, and speech and swallowing outcomes on discharge and up to 2 years postoperatively. Of the 104 patients, 14 (13%) had initial flap complications but overall flap survival was 97%. A total of 11 (11%) patients developed a fistula at a mean of 15 days postoperatively and 11 (11%) had minor donor site complications. A total of 95 (91%) were able to resume oral diet on discharge. Of the 44 who were followed up on discharge, 32 (73%) were able to maintain oral intake at 2 years and 31 (70%) could use their voice in everyday situations. The jejunal free flap enables the tumour to be removed, and reconstruction and restoration of function to be done in a single operation using tissue that is versatile. The operation is associated with low morbidity at the donor and recipient sites, and results in good speech and swallowing outcomes. The flap can also be used to reconstruct pharyngolaryngeal defects. [Copyright &y& Elsevier]

Smart nanocarriers have recently attracted attention for their effective delivery of biomolecules to the intestine without degradation in the oral delivery field. In this study, we prepared a stimulus-responsive polymer complex containing liposomal nanocarriers, termed capsosomes, and examined their multi-level release properties in the oral delivery of hydrophilic molecules. The capsosomes were constructed as a trilaurin-based solid lipid nanoparticle (SLN) assembly coated with chitosan (CSLNs), with liposomal subcompartments. We investigated the pH sensitivity and behavior of capsosomes in vitro under simulated gastrointestinal (GI) conditions. Positively charged CSLNs with negatively charged liposomal subcompartments were complexed by electrostatic forces, and their thermodynamic characteristics were examined using isothermal titration calorimetry. The optimized formulation was a 1.6 M ratio of liposomes to CSLNs, yielding physically stable capsosomes. The complexed liposomes were released from capsosomes at pH 7.0. We compared the structural integrity and retention times of free liposomes and capsosomes using an in vitro digestion model. The capsosomes showed improved stability and prolonged retention time under small intestinal conditions and bypassed the GI tract. Approximately 87% of the complexed liposomes were released and transferred to the small intestinal membrane. These results demonstrate the potential application of pH-sensitive capsosomes for the oral delivery of food nutraceuticals. [Display omitted] • Stimuli-responsive polymer complex containing liposomal nanocarrier (capsosome) was fabricated. • Capsosomes were formed via electrostatic interactions between chitosan coated on solid lipid nanoparticles and liposomes. • The complexed liposomes were specifically released from capsosomes at pH 7.0 and small intestinal condition. • The capsosomes exhibited improved stability and prolonged retention time under small intestinal condition. [ABSTRACT FROM AUTHOR]

Introduction: Gallstone ileus is an uncommon disease and accounts for 1–4 % of all cases of mechanical intestinal obstruction. The physiopathology is related to the presence of a bilioenteric fistula. Method: We report two cases of gallstone ileus in patients operated on biliointestinal bypass for morbid obesity. The anastomosis of the gallbladder to the proximal end of the bypassed jejunum allowed the transit of gallstones in the excluded ileum and its impaction in anti-reflux valvular system. Results: Preoperative exams were unable to solve the diagnostic query, and the diagnosis was achieved only at laparotomy. One-stage combined enterolithotomy and cholecystectomy were performed. Conclusion: The two patients had an uneventful recovery. To our knowledge, this is the first report of gallstone ileus after biliointestinal bypass. [ABSTRACT FROM AUTHOR]

High dietary zinc concentrations are used to prevent or treat diarrhea in piglets and humans, but long-term adaptation to high zinc supply has yet not been assessed. Intestinal zinc uptake is facilitated through members of zinc transporter families SLC30 (ZnT) and SLC39 (ZIP). Whereas in rodents, regulation of zinc homeostasis at low or adequate zinc supply has been described, such mechanisms are unclear in piglets. A total of 54 piglets were fed diets containing 57 [low dietary zinc (LZn)], 164 [normal dietary zinc (NZn)], or 2425 [high dietary zinc (HZn)] mg/kg dry matter zinc. After 4 wk, 10 piglets/group were killed and jejunal tissues taken for analysis of zinc transporters SLC30A1 (ZnT1), SLC30A2 (ZnT2), SLC30A5 (ZnT5), SLC39A4 (ZIP4), divalent metal transporter 1 (DMT1), and metallothionein-1 (MT). Weight gain was higher (P < 0.05) in pigs fed HZn than in the LZn and NZn groups during the first 2 wk. Food intake did not differ between groups. The digesta and jejunal tissue zinc concentrations were higher (P < 0.05) in the HZn pigs than in NZn and LZn pigs. Expression of ZnT1 was higher (P < 0.05) and ZIP4 lower (P < 0.05) in HZn pigs than in the 2 other groups, whereas expression of ZnT5 and DMT1 did not differ between treatments. Expression of ZnT2 was lower (P < 0.05) in the LZn group than in the HZn and NZn groups. The mRNA expression and protein abundance of MT was higher (P < 0.05) in the HZn group than in the NZn and LZn groups. Studies with intestinal porcine cell line intestinal epithelial cell-J2 confirmed the dose-dependent downregulation of ZIP4 and upregulation of ZnT1 and MT (P < 0.05) with increasing zinc concentration within 24 h. In conclusion, high dietary zinc concentrations increase intracellular zinc, promote increased zinc export from intestinal tissues into extracellular compartments, and decrease zinc uptake from the gut lumen. The adaptive process appears to be established within 24 h; however, it does not prevent tissue zinc accumulation. [ABSTRACT FROM AUTHOR]

BACKGROUND: After pancreaticoduodenectomy, severe pancreatic fistula may require salvage relaparotomy in patients with largely disrupted pancreaticojejunal anastomosis. Completion pancreatectomy remains the gold standard but yields high mortality and severe long-term repercussions. The authors report the results of a pancreas-preserving strategy used in this life-threatening condition. METHODS: Two hundred fifty-four pancreaticoduodenectomies with pancreaticojej unal anastomosis were performed between 2005 and 2011; 21 patients underwent salvage relaparotomy for grade C pancreatic fistula. Largely dehiscent pancreaticojejunal anastomoses were dismantled in 16 patients. Four patients underwent completion pancreatectomy, whereas in 12 patients detailed here, the remain- ing pancreas was preserved and drained by wirsungostomy with exteriorization or closure of the jejunal stump. Repeat pancreaticojejunal anastomosis was later planned to preserve pancreatic function. RESULTS: One patient died of recurrent hemorrhage on day 1 after wirsungostomy (8.3%). All but 1 survivor developed postoperative complications, and 3 needed reoperation before hospital discharge. The median hospital stay was 62 days (range, 29 to 156 days). After a median delay of 130 days (range, 91 to 240 days) from salvage relaparotomy, repeat pancreaticojejunostomy was attempted in 10 patients and was successful in 9 (1 completion pancreatectomy was performed). One patient died postopera- tively (10%). Long-term endocrine function was unaltered in 66% of patients who benefited from this conservative strategy. CONCLUSIONS: This pancreas-preserving strategy yielded a whole mortality rate of 17% for largely disrupted pancreaticojej unal anastomosis requiring salvage relaparotomy. It compares favorably with systematic completion pancreatectomy and achieved preservation of remnant pancreatic function in' 75% of patients. [ABSTRACT FROM AUTHOR]

Abstract: Background: Although women disproportionately undergo bariatric surgery, the rodent models investigating the mechanisms of bariatric surgery have been limited to males. Female rodent models can also potentially allow us to understand the effects of surgical intervention on future generations of offspring. Sleeve gastrectomy is an attractive weight loss procedure for reproductive-age female patients because it avoids the malabsorption associated with intestinal bypass. We sought to evaluate the effect of sleeve gastrectomy on young female rats with diet-induced obesity at the University of California, Los Angeles, David Geffen School of Medicine. Methods: Sprague-Dawley female rats were fed a 60% high-fat diet. At 12 weeks of age, the rats underwent either sleeve gastrectomy or sham surgery. The rats were killed 4 weeks after surgery. A chemistry panel was performed, and the serum adipokines and gut hormones were assayed. The homeostasis model assessment score was calculated. The liver histologic findings were graded for steatosis. The 2-sample t test was used to compare the results between the 2 groups. Results: Sleeve gastrectomy was associated with significant weight loss (5% ± 6% versus −4% ± 6%; P < .001), lower leptin levels (1.3 ± 1.2 versus 3.5 ± 2.3 ng/mL; P < .01), and higher adiponectin levels (.43 ± .19 versus .17 ± .14 ng/mL; P < .004) compared with the sham-operated rats. No significant differences were found in the fasting ghrelin levels. Furthermore, we did not observe evidence of insulin resistance or steatohepatitis after 11 weeks of high-fat diet. Despite these limitations, additional gender-specific studies are warranted given that most bariatric surgeries are performed in women. Conclusion: Sleeve gastrectomy appears to result in weight loss and improvements in adiponectin and leptin by way of mechanisms independent of ghrelin levels in a female model of diet-induced obesity. [Copyright &y& Elsevier]

Summary: Background: The Jejunal Free Flap (JFF) was first described by Seidenberg in 1957 for the reconstruction of pharyngolryngectomy defects. Historically, its outcome profile has been better than alternative reconstructions. Recently, the use of tubed Fasciocutaneous Free Flaps (FCFF) has been increasing as series reporting outcomes superior or equivalent to JFF are published. Our experience with JFF has been more positive than recently published reports suggest. This study aims to provide an accurate and up-to-date assessment of outcomes in JFF reconstruction of pharyngolaryngectomy defects and to compare these results to those of contemporary alternative techniques. Methods: 368 Consecutive free jejunum reconstructions were performed for pharyngolaryngectomy defects between 1977 and 2010. All patients had been assessed by a multidisciplinary Head and Neck Clinic prior to surgery. A systematic review of recent literature pertaining to pharyngolaryngectomy reconstruction outcomes was undertaken for comparison with our dataset. Results: 70.9% of tumours in this series were T-grade 3 or 4. Perioperative mortality was 3.8% and flap failure occurred in 2.98%. The incidence of anastomotic leak was 8.2% and stricture occurred in 10.9%. A full oral diet was maintained by 91.6% of patients by day 12 on average. 70.6% underwent primary tracheo-oesophageal puncture and of these 78.1% had effective speech. Conclusions: Overall, our data compares favourably with other series. The strengths of the JFF reconstruction are the capacity to maintain an oral diet, low stricture and leak rates and the versatility to reconstruct long segment defects. We have observed variability in leak rates throughout the study period, which may be operator dependant. The gap between outcomes for FCFF and JFF reconstructions has narrowed but the latter remains our reconstruction of choice for pharyngolaryngectomy defects. [ABSTRACT FROM AUTHOR]

Abstract: To study whether ischemic preconditioning (IPC) attenuated intestinal dysfunction caused by ischemia (I) and reperfusion (R), rats were underwent 60 minutes of I which was produced by occlusion of the superior mesenteric artery, and/or 120 minutes R. The IPC group had the I procedure previously stimulated for 5 minutes and the R for 10 minutes. IPC and sham groups were injected with saline solution (SS) via the femoral vein 5 minutes before the I and R, and for R. After I or I/R, 2-cm jejunal segments were mounted in an organ bath to study neurogenic contractions stimulated by electrical pulses or KCl using a digital recording system. Thin jejunal slices were stained with hematoxylin and eosin for optical microscopy. Compared with the sham group, jejunal contractions were similar in the IPC + I and the IPC + I/R groups, but reduced in the I + SS and the I/R + SS groups. The jejunal enteric nerves were damaged in the I + SS and the I/R + SS groups, but not in the IPC groups. These results suggested that ischemic preconditioning attenuated intestinal dysfunction caused by I and I/R. [Copyright &y& Elsevier]

Background: Bariatric surgery frequently results in the resolution of type 2 diabetes mellitus (T2DM). One of the many factors that could explain such findings is the duodenal exclusion of the alimentary tract. To test this hypothesis, a surgical model that induces glycemic control without significant weight loss would be ideal. In the present study, we evaluated the early metabolic changes that occur in overweight diabetic patients after laparoscopic duodenal-jejunal bypass (DJB) and determined the factors associated with success in T2DM resolution. The setting was a private practice. Methods: A total of 35 patients (20 men and 15 women) were included in the present study. The mean preoperative body mass index was 28.4 ± 2.9 kg/m2. DJB was performed in all patients, and the anthropometric data and blood samples were collected at baseline (preoperatively) and 3, 6, 9, and 12 months after surgery. Success was defined when patients reached a glycated hemoglobin level of <7% without diabetic medication. Results: T2DM remission was observed in 14 (40%) of 35 patients. No differences in the homeostasis model assessment insulin resistance index levels and patient weight were observed before and 12 months after DJB surgery. Gender, duration of T2DM, previous use of insulin, preoperative homeostasis model assessment insulin resistance index, and C-peptide levels were not significant predictive factors of success or nonsuccess. The only factor that significantly predicted postoperative positive outcomes was a waist circumference reduction of ≥7% compared with baseline within the first 6 months after surgery. Conclusion: DJB improves glycemic control; however, it does not increase insulin sensitivity in overweight diabetic patients. These changes were observed without significant weight loss. [ABSTRACT FROM AUTHOR]

Summary: Radiotherapy is an accepted primary treatment modality for head and neck malignancies. However, in severe cases, the chronic radiation damage has resulted in dysphagia, aspiration and choking. Failure in conservative therapeutic strategies for this swallowing dysfunction will result in either preservation of voice with loss of oral feeding, or vice versa. We introduce our surgical technique based on the free jejunal diversionary conduit flaps, which helps patients to resume oral feeding and preserves vocal function, while reducing the risk of aspiration. Method: Six patients suffering from swallowing dysfunction following radiotherapy were enrolled. All were dependent on tube feeding. A subcutaneously transferred free jejunal flap connected the left buccogingival sulcus to the cervical oesophagus, which permanently separates the airway from the native aerodigestive tract by creating a new inlet for food passage. Simultaneously created pharyngostomy drains accumulation of saliva and food residue in the epiglottic vallecula and the pyriform sinus. For the cases with tight fibrotic neck skin, we divided this technique into two stages. Results: All cases could take at least semi-solid food orally, with some minor complications in the initial four cases. Five cases were independent of tube feeding. Two recent cases with modifications did not experience any complication and could start oral intake much earlier (7 days after surgery) than previous cases (118 days on average). Conclusion: The free jejunal diversionary conduit flaps offer post-radiotherapy patients with swallowing dysfunction the option to resume oral feeding while preserving their voice and reducing the risk of aspiration. [ABSTRACT FROM AUTHOR]

Background: Totally laparoscopic gastrectomy represents the evolution of laparoscopy-assisted gastrectomy. Most surgeons prefer laparoscopy-assisted gastrectomy rather than totally laparoscopic procedures because of technical difficulties of intracorporeal anastomosis. We created one novel stapling anastomosis without hand-sewn technique in totally laparoscopic Billroth II gastrectomy. The feasibility and early surgical outcomes of totally laparoscopic Billroth II gastrectomy with stapling anastomosis and with hand-sewn anastomosis were introduced in this study. Methods: We retrospectively analyzed early surgical outcomes in 70 patients who underwent totally laparoscopic Billroth II distal gastrectomy for gastric cancer between January 2010 and July 2011. The patients were divided into hand-sewn and device groups according to whether intracorporeal anastomosis was performed by only hand-sewn technique ( n = 36) or only stapling devices ( n = 34). In the device group, the gastrojejunostomy was performed using a circular stapler, and an additional side-to-side jejunojejunostomy was made at the site of jejunal enterotomy. Results: There was no difference in the mean number of lymph nodes retrieved in both groups. The blood loss (hand-sewn group 205.8 ± 37.4 vs. device group 201.2 ± 51.2 ml, p > 0.05) and hospital stay (hand-sewn group 6.5 ± 3.7 vs. device group 5.9 ± 4.1 days, p > 0.05) were similar in both groups. We found that intracorporeal anastomosis by totally stapling devices was associated with decreased operative time (hand-sewn group 239.0 ± 40.1 vs. device group 203.6 ± 27.9 min, p < 0.05). Conclusion: We suggest that intracorporeal anastomosis using only stapling devices in the described method was as safe and feasible as by hand-sewn technique. Moreover, it is a simple and time-saving method without any difficult hand-sewn procedures. [ABSTRACT FROM AUTHOR]

Abstract: The trial objective was to investigate the efficacy of a yeast derivative (YD) on performance, health status, distal jejunal structure, and blood profile of broiler chickens. In a 35day feeding trial, 1day-old broilers were allocated to 3 experimental groups with 8 replicates (26/pen): control, treatment 1 (1kg YD/t feed) and treatment 2 (2kg YD/t feed). Feed and water were provided ad libitum. On day 35 the distal jejunum was collected from 8 chickens per group (1/pen) for morphometric measurements. Blood samples were collected (1/pen) on day 35 and analyzed by flow cytometry for leukocyte, heterophil, lymphocyte and monocyte enumeration. In the course of the trial a positive influence was observed by supplementation of YD. On day 35 body weight (BW) (1520g) and daily weight gain (42.37g/day) were greater in birds receiving 1kg/t of YD compared to the control (1374g BW, 38.18g/day, respectively; P=0.05). Supplementation with 2kg/t of YD did not improve 35day BW but did improve cumulative feed-to-gain ratio by 13% (P<0.05) versus birds fed the control diet. Histological evaluation demonstrated greater goblet cell density in birds fed either concentration of YD (P<0.05). Villus height and crypt depth, however, were unaffected. Apoptotic enterocytes were decreased by both concentrations of YD (P=0.02). Supplementation of YD had no effect on blood cell counts (P>0.05). The inclusion of YD in diets of broilers was able to improve broiler performance, intestinal goblet cell numbers and to reduce numbers of enterocytes undergoing apoptosis. [Copyright &y& Elsevier]

The prevalence of obesity has reached epidemic proportions. Conceptualization of obesity as a chronic disease facilitates greater understanding its treatment. The NIH Consensus Conference on Gastrointestinal Surgery for Severe Obesity provides a framework by which to manage the severely obese – specifically providing medical versus surgical recommendations which are based on scientific and outcomes data. Medical treatments of obesity include primary prevention, dietary intervention, increased physical activity, behavior modification, and pharmacotherapy. Surgical treatment for obesity is based on the extensive neural-hormonal effects of weight loss surgery on metabolism, and as such is better termed Metabolic Surgery. Surgery is not limited to the procedure itself, it also necessitates thorough preoperative evaluation, risk assessment, and counseling. The most common metabolic surgical procedures include Roux-en-Y gastric bypass, adjustable gastric band, sleeve gastrectomy, and biliopancreatic diversion. Surgical outcomes for metabolic surgery are well studied and demonstrate superior long-term weight loss compared to medical management in cases of severe obesity. [Copyright &y& Elsevier]

Abstract: The prevalence of obesity has grown dramatically over the last decades, with nonalcoholic steatohepatitis increasingly observed. Therapeutic options for morbid obesity include bariatric surgery. Fatal liver failure (LF) has been recorded after jejunoileal bypass (JIB) but is controversial after biliopancreatic diversion (BPD, Scopinaro operation). We performed a survey on the frequency of liver transplantation (LT) after bariatric surgery in Belgium. An enquiry was sent to all Belgian liver transplant centers to investigate the occurrence of subacute and chronic LF after bariatric surgery. After weight-reduction surgery, 10 patients in 3 Belgian transplant centers were listed for LT due to severe hepatocellular failure. Nine of them had undergone a Scopinaro operation and 1 a jejunoileal bypass. The median time to develop LF was 5 years. The patient with JIB developed chronic LF after 25 years. Seven patients were transplanted; two died awaiting a graft and one is still on the waiting list. After LT, 1 patient developed rapid reappearance of LF at 10 months, requiring retransplantation. Two recipients died after LT because of multiorgan failure shortly after transplantation. In another case, a de novo cancer was fatal at 6 years'' follow-up. The remaining recipients were doing well. According to this survey, the BPD operation carries a potential risk of LF. However, because there were only 10 cases, we remain unaware of the actual incidence of Scopinaro operation–induced LF. We advise strict follow-up of liver function and timely dismantling of BPD. [Copyright &y& Elsevier]

Abstract: Background: Weight loss after bariatric surgery often improves fertility but can pose substantial risks to maternal and fetal outcomes. Women who have undergone a bariatric surgical procedure are currently advised to delay conception for up to 2 years. Study Design: We conducted a systematic review of the literature, from database (PubMed) inception through February 2009, to evaluate evidence on the safety and effectiveness of contraceptive use among women with a history of bariatric surgery. Results: From 29 articles, five met review inclusion criteria. One prospective, noncomparative study reported 2 pregnancies among 9 (22%) oral contraceptive (OC) users following biliopancreatic diversion, and one descriptive study reported no pregnancies among an unidentified number of women taking OCs following laparoscopic adjustable gastric banding. Of two pharmacokinetic studies, one found lower plasma levels of norethisterone and levonorgestrel among women having had a jejunoileal bypass, as compared to nonoperated, normal-weight controls. The other study found no difference in plasma levels of D-norgestrel between women having a jejunoileal bypass of either 1:3 or 3:1 ratio between the length of jejunum and ileum left in continuity, but women with a 1:3 ratio had significantly higher plasma levels of D-norgestrel than extremely obese controls not operated upon. Conclusions: Evidence regarding OC effectiveness following a bariatric surgical procedure is quite limited, although no substantial decrease in effectiveness was identified from available studies. Evidence on failure rates for other contraceptive methods and evidence on safety for all contraceptive methods was not identified. [Copyright &y& Elsevier]

Background: Recent studies suggest that patients undergoing Roux-en-Y gastric bypass (RYGB) for morbid obesity are at risk for hyperoxaluria, nephrolithiasis, and oxalate nephropathy. Our objective was to conduct a long-term prospective longitudinal study to establish the incidence, clinical progression, and severity of hyperoxaluria after RYGB. Study Design: Patients undergoing RYGB between December 2005 and April 2007 provided 24-hour urine collections for comprehensive stone risk analysis 1 week before and 3 months and 1 and 2 years after surgery. Primary outcomes were changes in 24-hour urinary oxalate excretion and relative supersaturation of calcium oxalate from baseline to 2 years post-RYGB. Results: The cohort consisted of 21 patients, including 5 (24%) men and 16 (76%) women. Mean preoperative age and body mass index (calculated as kg/m2) were 48.2 ± 10.5 years (range 25 to 64 years) and 50.5 ± 9.1 (range 39.7 to 66.6), respectively. Urinary oxalate excretion increased significantly after RYGB (33 ± 9 mg/day versus 63 ± 29 mg/day; p ≤ 0.001). De novo hyperoxaluria developed in 11 (52%) patients. Increasing age at the time of surgery was predictive of de novo hyperoxaluria developing (odds ratio = 1.162; 95% CI, 1.002–1.347; p = 0.046). The percentage of patients with hypocitraturia increased from 10% at baseline to 48% at 2 years. The relative supersaturation of calcium oxalate was unchanged (1.73 ± 0.67 versus 2.20 ± 2.07; p = 0.27). Conclusions: RYGB is associated with a long-term increase in urinary oxalate excretion and decrease in urinary citrate excretion. Although calcium oxalate relative supersaturation increases early in the postoperative period, this returns to baseline with long-term follow-up. These data suggest that patients who have undergone RYGB are at risk for oxalate nephropathy developing. [Copyright &y& Elsevier]

Abstract: Objective: There have been few reports addressing methods of dealing with free flap thrombosis after reconstructive surgery for head and neck cancer. The present study, through a detailed analysis of the subsequent course of patients who developed postoperative flap thrombosis, aims to clarify possible methods of salvage surgery in the event of vascular occlusion despite rigorous postoperative follow-up. Methods: We analyzed 59 cases of postoperative thrombosis in 1031 patients who underwent free flap transfer and considered the most appropriate salvage surgery in the event of total flap necrosis. Results: The flap salvage rate through vascular reanastomosis was highest for radial forearm flaps, with salvage of jejunal flaps being problematic if postoperative thrombosis occurred. For cases of postoperative thrombosis among patients who underwent reconstruction using a jejunal flap, the period of hospitalization was significantly extended for those patients in whom a second jejunal flap grafting was impossible. For cases of postoperative thrombosis among patients who underwent reconstruction using a radial forearm flap (FA), rectus abdominis flap (RA), or anterior lateral thigh flap (ALT), no significant difference was observed between those undergoing re-grafting with a free flap and those with a pedicled flap. Conclusion: We concluded that, among patients who undergo reconstruction using a jejunal flap, thrombosis should be discovered at an early stage to enable another jejunal flap re-grafting. For patients who undergo reconstruction using a FA, RA, or ALT, if thrombosis can be discovered at an early stage, there is a possibility of salvaging the flap by means of vascular reanastomosis. If it should prove impossible to salvage the flap, however, primary suture of the defect or reconstruction with a pedicled flap may also be considered. [Copyright &y& Elsevier]

Summary: Salvage reconstruction of the oesophagus is still considered a challenging procedure for all head and neck surgeons. The risk of postoperative infection and delayed wound healing is high because of thick scar formation and persistent inflammation. Furthermore, recipient vessels for free tissue transfer or vascular supercharge are not always available. Alimentary tract reconstruction with skin or musculocutaneous flap may be necessary, but this method is susceptible to fistula formation.[Nakatsuka T, Harii K, Asato H, et al. Comparative evaluation in pharyngo-oesophageal reconstruction: radial forearm flap compared with jejunal flap. A 10-year experience. Scand J Plast Reconstr Surg Hand Surg 1998; 32: 307–10] In the past 10 years, we have experienced 15 cases of salvage reconstruction of the oesophagus after prior cancer treatment or aorto-oesophageal fistula; the cervical oesophagus was reconstructed in five cases and the cervico-thoracic oesophagus in 10. In four cases of cervical oesophagus and six of cervico-thoracic oesophagus we performed free jejunal transfer including two long segment transfers with double vascular pedicle. The cervico-thoracic oesophagus was also reconstructed with pedicled alimentary tract transfer (colon interposition or jejunal pull-up) with vascular supercharge in four cases. In one case, cervical oesophageal defect was reconstructed with a latissimus dorsi musculocutaneous flap. We also used a deltopectoral flap to cover the skin defect in three cases. In three cases, a second salvage operation was necessary because of flap necrosis that was caused by unreliable recipient vessels resulting from scar formation and persistent inflammation. Successful restoration of the oesophagus and oral alimentation was achieved in 11 cases. From this study, we concluded that free jejunal transfer is a useful procedure for salvage reconstruction of the oesophagus, particularly for cervical oesophagus or short oesophageal defects. Nonetheless, surgeons should know the indications and limitations of this procedure thoroughly and always be ready to choose other reconstructive options if necessary. [Copyright &y& Elsevier]

Summary: Although the supercharge (additional microvascular anastomosis) technique is often used in pedicled transfer of parts of the gastrointestinal tract, this is rarely performed during free jejunal transfer (FJT). The differences in blood circulation and outcomes between the usual single pedicle flap and a double pedicle flap are not well known. Therefore, we evaluated the effect of an additional arterial anastomosis in FJT. The FJT was performed using one venous and two arterial anastomoses after hypopharyngeal cancer ablation. To assess the effects of an arterial supercharge, blood–gas analysis, including the venous partial pressure of oxygen (pO2) and partial pressure of carbon dioxide (pCO2), was performed on samples drawn thrice from the jejunal vein: before harvest, after the anastomosis of a paired artery and vein and after an additional arterial anastomosis. The result revealed that the venous pO2 was elevated by the additional arterial anastomosis, compared with the two other measuring times (P =0.04). The venous pCO2 did not show significant changes. By being given a dominant artery, a jejunal flap can develop a physiological circulatory environment and can establish nutritional pathways without adverse effects. [Copyright &y& Elsevier]

Aim: Sleeve gastrectomy (SG) and modified duodenal jejunal bypass (MDJB) were compared as procedures for glucose control. We aim to form the initial conclusions with respect to the possibility of (1) whether gastric fundus exclusion is essential for the control of diabetes and (2) application as a low morbidity procedure.Materials and Methods: SG and MDJB were performed on 10- to 12-week-old Goto-Kakizaki rats that spontaneously develop type 2 diabetes. Rats were observed for 36 weeks after surgery, and glucose, insulin, glucagons-like peptide-1 (GLP-1), glucose tolerate, insulin sensitivity, cholesterol, triglycerides, and free fatty acid levels were measured.Results: Apart from distinct weight loss of SG and MDJB after 1 month compared with sham-operated rats (P < 0.001), SG showed strikingly improved blood glucose levels and significantly decreased Ghrelin secretion (P < 0.001). Furthermore, SG resulted in a shorter operative time (P < 0.01) and postoperative recovery time (P < 0.01) than MDJB group.Conclusions: SG shows better control in terms of glucose tolerance and other measurements. This study provides direct evidence that SG possesses better improvement of diabetes by reduction of Ghrelin. [ABSTRACT FROM AUTHOR]

Selecting chicken for improved meat production has altered the relative growth of organs in modern broiler lines compared with heritage lines. In this study, we compared the growth and feed efficiency of a heritage line, UIUC, with a modern production line, Ross 708, for 5 wk posthatch. During this period, the BW and feed efficiency of the modern strain was higher than that of the heritage line, indicating that the Ross 708 birds were more efficient than the UIUC birds at converting feed to body mass. The relative growth of the breast, heart, liver, and intestine were also compared during these 5 wk. The breast muscle of the heritage line constituted 9% of the total body mass at 5 wk, whereas in the modern line, the breast muscle was 18% of the total mass of the bird. In contrast, the relative size of the heart decreased after d 14 in the modern line, suggesting that selection for increased breast muscle has translated into relatively less weight of the heart muscle. The liver matured earlier in modern lines, possibly improving nutrient utilization as the birds shift from lipid- to carbohydrate-rich feed. Finally, jejunal and ileal sections of the intestine were 20% longer in the modern line, perhaps allowing for increased nutrient absorption. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: An ideal anastomosis between hollow viscera should be easily performed, strong, and operator independent. We hypothesized that transluminal attraction between magnets in the intestine could be harnessed to create an intestinal compression anastomosis (magnamosis) with these characteristics. We further hypothesized that variation of attraction force and geometry of compression would affect the quality of the intestinal anastomosis. Methods: We designed a self-orienting device composed of 2 neodymium-iron-boron magnets affixed to polytetrafluoroethylene moldings. Two topologies were evaluated: one designed with ‘uniform’ compression and the other with ‘gradient’ compression. Sixteen young adult pigs (Sus scrofa) underwent laparotomy with creation of a magnetic side-to-side anastomosis: 8 with the uniform device and 8 with the gradient device. Each also had a stapled anastomosis, and 5 had an additional hand-sutured anastomosis. Animals were euthanized at 1, 2, and 3 weeks after operation, then anastomoses were compared on the basis of gross appearance, histology, functional radiography, and mechanical integrity. Results: All magnetic devices formed patent anastomoses without leak. One stapled anastomosis resulted in a contained leak. Mechanical integrity of magnetic anastomoses was not statistically significantly different from staple or suture counterparts, and there was a trend toward greater strength with magnetic anastomoses. Comparison between device types revealed the gradient device trended toward greater strength and earlier patency (67% vs 33% at 1 week). There was no evidence of stenosis, and histologic examination demonstrated tissue remodeling with mucosal and serosal apposition across the magnamoses. Conclusions: The magnetic compression anastomosis (magnamosis) device is a safe and effective means of sutureless full-thickness intestinal anastomosis with serosal apposition in a pig model. Gradient compression is superior to uniform compression. This technique is compatible with endoscopic and natural orifice approaches. [Copyright &y& Elsevier]

Abstract: Background: Controversy exists in published reports regarding the influence of gastric pouch size on weight loss after gastric bypass (GB). The purpose of this study was to determine whether variations in the anatomic size of small-volume (≤20 cm3) gastric pouches correlate with weight loss 1 year after laparoscopic GB. Methods: We prospectively collected intraoperative data on gastric pouch size during laparoscopic GB in 231 morbidly obese patients. A divided, vertical, lesser curve-based gastric pouch was created using an orogastric tube for size and diameter determination. The height of the cylindrical pouch was measured by the number of staple fires. Results: The mean age was 45 ± 10 years, 90% were women, and 68% were white. The mean preoperative body mass index was 48 ± 6 kg/m2. The percentage of excess weight loss (%EWL) 1 year after GB was 66%. The calculated gastric pouch volume was 10–20 cm3. No significant difference was found in the %EWL at 1 year when stratified by gastric pouch size. The pouch size was not dependent on age, gender, preoperative weight, or body mass index. A significant inverse correlation was found between the %EWL and both preoperative weight and body mass index (P <.001). Blacks had significantly smaller gastric pouches than whites (P = .004); however, whites had a significantly greater %EWL at 1 year compared with blacks (67% versus 61%; P = .016). Conclusion: With construction of divided, vertical, lesser curve-based small-volume (≤20 cm3) gastric pouches, the actual size of the gastric pouch did not correlate with the %EWL at 1 year after laparoscopic GB. [Copyright &y& Elsevier]

Abstract: Background: Risk adjustment is a critically important aspect of outcomes research. Racial, geographic, cultural, and socioeconomic differences are nonclinical parameters that can affect clinical outcomes measurement after gastric bypass surgery. Methods: A single surgeon’s experience with 217 consecutive laparoscopic gastric bypass patients in private practice in Southern California was compared with the same surgeon’s experience with 124 consecutive patients in an academic institution in Philadelphia. Results: Of the Southern California and Philadelphia groups, 89%, 1%, 9%, and 1% and 55%, 38%, 6%, and 0% were white, black, Hispanic, and Asian, respectively. The average number of co-morbidities was 7.8 in the Southern California group versus 14.4 in the Philadelphia group (P <.001). The 60-day readmission to the hospital rate and emergency room admission rate was 1.4% versus 10.4% and 1.4% versus 18.5%. The insurer mix of private pay, private insurer, and federally funded insurer was 20%, 80%, and 0% in the Southern California group and 0.8%, 71%, and 28% in the Philadelphia group, respectively. Multivariate logistic regression analysis found Medicaid status and practice location independently predicted for the 60-day readmission rate (odds ratio [OR] 3.7, P = .04 and OR 5.6, P = .04, respectively) and a return to the emergency room (OR 3.2, P = .03 and OR 16.3, P <.001). Race, income, and the presence of diabetes were not independent predictors. Variables with nonsignificant differences between the Southern California and Philadelphia cohorts included average age, average body mass index, and major complications (return to surgery and intensive care unit admissions). Conclusion: The results of this study have shown that in comparing and predicting the outcomes after bariatric surgery, adjustment for demographic and insurance variables might be necessary to improve accuracy. [Copyright &y& Elsevier]

Summary: By using intraoperative papillary biopsy material from kidneys of idiopathic calcium oxalate, intestinal bypass for obesity, brushite, cystine, and distal renal tubular acidosis stone formers during percutaneous nephrolithotomy, we have determined that idiopathic calcium oxalate stone formers appear to be the special case, although the most commonly encountered one, in which stones form external to the kidney and by processes that do not involve the epithelial compartments. It is in this one group of patients that we find not only abundant interstitial plaque, but also strong evidence that the plaque is essential to stone formation. The initial site of plaque formation is always in the papillary tip, and must be in the basement membrane of the thin loop of Henle. With time, plaque spreads throughout the papilla tip to the urothelium, which under conditions we do not understand is denuded and thereby exposes the apatite deposits to the urine. It is on this exposed apatite that a stone forms as an overgrowth, first of amorphous apatite and then layers of calcium oxalate. This process generates an attached stone fixed to the side of a papilla, allowing the ever-changing urine to dictate stone growth and composition. [Copyright &y& Elsevier]