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Purpose: A number of patients operated on for Hirschsprung disease continue to have constipation and abdominal distension for years after surgery. Some authors have proposed that ischemia during surgery may induce secondary aganglionosis. The aim of the present study was to study the effects of ischemia on the enteric nervous system of sigmoid colon in an animal model., Methods: A surgical model of colonic ischemia was created. 34 adult Sprague-Dawley rats underwent a laparotomy where the marginal arterioles of the sigmoid colon were ligated. After that, a section in the middle segment of the sigmoid colon was performed followed by an anastomosis. The presence of ischemia was assessed by measurement of visible light spectroscopy tissue oximetry and histological examination. Colonic function was assessed by evaluation of stool weight. Rats were killed at 1, 8 and 12 weeks after the operation. 12 rats were sham-operated. Enteric nervous system was evaluated by means of immunohistochemistry with NGFR p75. Quantitative analysis of the number of ganglia and ganglion cells in the myenteric plexus was performed., Results: The surgical model of colonic ischemia significantly decreased tissue oxygenation (pre-surgical = 54.69 ± 7.32 %; post-surgical = 27.37 ± 9.2 %; p < 0.001). There was no disturbance in body-weight gaining in experimental groups and daily stool output did not vary after surgery (pre-surgical = 4.24 ± 0.94 g; post-surgical = 3.82 ± 1 g; p = 0.09). All experimental groups showed persistent ganglia. However, there was a significant decrease in the number of ganglia in all the experimental groups compared to control (1w: 45.91 ± 7.66; 8w: 44.17 ± 10.56; 12w: 36.17 ± 15.06 vs control: 56.88 ± 8.66; p < 0.01). The number of total ganglion cells was significantly reduced only in the experimental group killed at week 12 compared to control (1w: 539 ± 167.58; 8w: 488.58 ± 154.41; 12w: 343.94 ± 161.91 vs control: 513.96 ± 126.97; p < 0.01). The rate of ganglion cells per ganglia was significantly higher in the groups killed at week 1 and 8 versus control group (1w: 11.63 ± 2.53; 8w: 11.11 ± 2.56; 12w: 9.34 ± 1.16 vs control: 9.02 ± 1.81; p < 0.05)., Conclusion: Long-term follow-up after surgically induced colonic ischemia in the rat showed a decreased number of ganglion cells and ganglia. Nevertheless, it did not produce aganglionosis.

Background: Lower gastrointestinal complications are rare after cardiac surgery with cardiopulmonary bypass (CPB). However, if they occur, they are associated with a high mortality. Endothelin (ET) expression and microcirculatory dysfunction have been shown to be involved in a variety of diseases of the lower gastrointestinal tract. The aim of this study was to analyze whether CPB with or without additional vasopressin administration affects the rectosigmoidal mucosal microcirculation and whether this involves the ET system., Methods: Pigs were randomized in three groups (n = 6 each): I Sham, II CPB: 1 hour CPB, III CPB + vasopressin: 1 hour CPB and vasopressin (0.006 U/min kg) administration maintaining baseline arterial pressure. All animals were reperfused for 90 minutes. During the experiment hemodynamics and rectosigmoidal mucosal microcirculation were measured continuously. The rectosigmoidal mucosal expression of endothelin-1 (ET-1) and its receptor subtypes A (ETA ) and B (ETB ) were determined using PCR and Western blot analysis., Results: CPB did not change rectosigmoidal microvascular blood flow compared to baseline (68.1 ± 4.0 vs. 75.5 ± 6.6 AU; p = 0.4), but increased ET-1 (gene, 7.8 ± 1.5 vs. 2.3 ± 0.6 RQ; p = 0.002 and protein, 12.0 ± 0.5 vs. 6.9 ± 0.3 OD mm(2) ; p < 0.001), ETA (gene, 2.3 ± 0.6 vs. 0.6 ± 0.1 RQ; p < 0.001 and protein, 11.0 ± 0.3 vs. 6.2 ± 1.1 OD mm(2) ; p = 0.006) and ETB (gene, 6.7 ± 1.2 vs. 1.9 ± 0.3 RQ; p < 0.001 and protein, 25.6 ± 1.4 vs. 14.9 ± 1.5 OD mm(2) ; p = 0.002) expression compared to Sham. Vasopressin during CPB reduced the rectosigmoidal blood flow compared to baseline (26.5 ± 4.9 vs. 75.5 ± 6.6 AU, p < 0.001), and blunted the CPB-induced increase of ET-1 (gene, 1.2 ± 0.4 RQ, p = 0.1 and protein, 8.1 ± 1.6 OD mm(2) , p = 0.5 vs. Sham), ETA (gene, 0.6 ± 0.1 RQ, p = 1.0 and protein, 7.0 ± 0.6 OD mm(2) , p = 0.6 vs. Sham) and ETB (gene, 1.3 ± 0.3 RQ, p = 0.1 and protein, 19.4 ± 2.1 OD mm(2) , p = 0.1 vs. Sham)., Conclusion: CPB does not significantly affect rectosigmoidal mucosal microcirculation; however, it upregulates ET-1, ETA , and ETB . Vasopressin blunts the CPB-induced elevation of ET-1, ETA , and ETB and induces rectosigmoidal mucosal ischemia during CPB., (© 2013 Wiley Periodicals, Inc.)

A 34-year-old man affected by grade IV idiopathic varicocele with mild testicolar pain, severe oligoasthenozoospermia and infertility, underwent an antegrade sclerotherapy according to Tauber surgical technique. After 5 days, the patient underwent a laparoscopic left colon resection with colonstomy due to a segmental infarction of the sigmoid colon.

Vaginal reconstructive options commonly include the use of split-thickness skin grafts or intestinal conduits. When a colonic segment is chosen, the sigmoid colon is favored because of its location, size, and durability. When circumstances preclude the use of sigmoid colon and a colonic conduit is preferred, creative means of mobilization are required. This article describes a case and technique utilizing the descending colon in a tension-free vaginoplasty.

Background: There is no demonstrated benefit of high-tie versus low-tie vascular transections in colorectal cancer surgery., Objective: The aim of this study was to compare the effects of high-tie and low-tie vascular transections on colonic length after oncological sigmoidectomy, the theoretical feasibility of colorectal anastomosis at the sacral promontory, and straight or J-pouch coloanal anastomosis after rectal cancer surgery with total mesorectal excision., Design: This study is an anatomical study on surgical techniques., Settings: This study was conducted in a surgical anatomy research unit., Patients: Thirty fresh nonembalmed cadavers were randomly assigned to high-tie and low-tie groups (n = 15)., Interventions: Oncological sigmoidectomy followed by total mesorectal excision was performed., Main Outcome Measures: The distances from the proximal colon limb to the lower edge of the pubis symphysis were recorded after each step of vascular division., Results: The successive mean gains in length in high-tie vs low-tie vascular transections were 2.9±1.2 cm vs 3.1 ± 1.8 cm (p = 0.83) after inferior mesenteric artery division, 8.1 ± 3.1 cm vs 2.5 ± 1.2 cm (p = 0.0016) after inferior mesenteric vein division at the lower part of the pancreas, 8.1 ± 3.8 cm vs 3.3 ± 1.7 cm (p = 0.0016) after sigmoidectomy. The mean cumulative gain in length was significantly higher in high-tie vs low-tie vascular transections (19.1 ± 3.8 vs 8.8 ± 2.9 cm, p = 0.00089). After secondary left colic artery division, the gain in length was similar to that of the high-tie group (17 ± 3.1 vs 19.1 ± 3.8 cm) (p = 0.089). Colorectal anastomosis at the promontory and straight and J-pouch coloanal anastomosis feasibility rates were 100% in the high-tie group, 87%, 53%, and 33% in the low-tie group, but 100%, 100%, and 87% after secondary left colic artery division., Limitations: This anatomical study, based on cadavers rather than live patients, does not evaluate colon limb vascularization., Conclusions: The gain in colonic length is 10 cm greater for high-tie vascular transections. With low-tie vascular transections, high inferior mesenteric vein division produced a small additional gain in length, and secondary left colic artery division produced the same length gain as high-tie vascular transections.

43 patients with sigmoid cancer stage I--III were operated on. The mean operative time was 206.2±73.0 min, considering the sceletonization of the lower mesenteric artery together with the paraaortic lymphadenectomy took 28±9 min. The long-term follow-up was performed in all the patients. The median follow-up time was 39.35±13.1 months. 4 patients had died, 3 of them because of the cancer progression. The paraaortic lymphadenectomy with the lower mesenteric artery sceletonization is now considered to be the method of choice in treatment of sigmoid cancer. The operation is reasonably safe considering the rate of intra- and postoperative complication rate.

Background: Many reports have described sigmoid volvulus, but fatal hemorrhagic shock resulting from the rupture of the involved artery has not been reported as a complication of a sigmoid volvulus., Case Report: A 71-year-old man with slight abdominal pain and obstipation in hypotension died at a nursing home without seeing a doctor. At autopsy, a mesenteric hematoma and hemoperitoneum was observed with approximately 1,000 ml of blood in the abdominal cavity. The sigmoid colon and the mesentery were twisted at an adhesion site of a sigmoid colon to an ileum, and the condition was determined to be a sigmoid volvulus. The volvulus was observed to be loosened. The inferior mesenteric artery was incorporated into the twisted part of the mesentery, but remained patent, and its peripheral branch near the hematoma ruptured without histological abnormality., Conclusions: Since ischemic-reperfusion injury occurs with a temporarily occluded artery, the acute re-loading of blood flow may injure the distal vessels after spontaneous reduction of compression by loosening of the volvulus.

Objectives: There is no ideal method to monitor colonic perfusion after abdominal aortic aneurysm (AAA) repair. The aim was to evaluate extraluminal sigmoid colon tonometry, comparing with the established intraluminal method., Methods: Eighteen patients were monitored with both methods, 10 after elective and eight after ruptured AAA repair. One tonometric catheter was placed inside the sigmoid colon (intraluminal) and another extraluminally in close contact with the serosa of the sigmoid colon (extraluminal). Intra- and extraluminal partial pressure of carbon dioxide (pCO(2)) were measured every 10 min during 48 h postoperatively, 1536 simultaneous measurements. Intraluminal pH (pHi) and extraluminal pH (pHe) were calculated, and intra-abdominal pressure (IAP) was measured, every 4 h. Colonic ischaemia was defined as pHi ≤ 7.1., Results: Mean pHi was 7.18 ± 0.11 and mean pHe was 7.28 ± 0.09. With a pHe cut-off value of ≤ 7.2, the sensitivity and specificity to detect colonic ischaemia were 95% and 95%, respectively. Accuracy was 95% and the positive and negative predictive values 0.80 and 0.99, respectively. The positive likelihood ratio was 19 and the negative likelihood ratio 0.05., Conclusion: Extraluminal tonometry may serve as a screening test: A pHe-value < 7.2 indicates suspected colonic ischaemia, meriting further investigation. It was not able to evaluate the severity of ischaemia., (Copyright © 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Stercoral perforation of the colon due to fecaloma is a rare disease and less than 100 cases have been described in the literature. The disease mainly involves the rectosigmoid colon. The condition is correlated with longstanding decubitus, chronic constipation, abuse of laxatives and/or constipating agents (anticholinergics, neuroleptics, etc). We report a case of 82-year old woman who presented a covered colonic perforation due to fecaloma, related with a history of longstanding decubitus because of senile dementia, chronic constipation and use of anticholinergic drugs.

Background: Anastomotic leak after sigmoidectomy for diverticular disease can have devastating consequences. Preservation or sacrifice of the descending colon or rectal arterial supply may affect the anastomosis. The aim of this study was to evaluate whether preservation of the inferior mesenteric artery (IMA) or superior rectal artery (SRA) was associated with a decreased anastomotic leak rate., Methods: A retrospective review of adult patients undergoing sigmoidectomies from 2 military tertiary care centers was performed, evaluating patient demographic and operative variables for their effects on anastomotic leak rate., Results: A total of 130 patients were identified. The overall anastomotic leak rate was 5.4%. Laparoscopy was used in 41%, and stapled anastomoses were used in 91%. The IMA was sacrificed in 29% and the SRA in 37%. There were no significant differences in leak rates when the IMA or SRA was sacrificed (0% and 3.7% with the IMA and SRA sacrificed, 9.3% and 6.5% with the vessels preserved; P = .140 and P = .610, respectively). Laparoscopic technique (P = .843), emergency surgery (P = .29), and operative time (P = .78) did not affect leak rate. Hand-sewn anastomoses were associated with a higher leak rate (33% vs 2%; odds ratio, 3.44; 95% confidence interval, 1.514-7.817; P < .001)., Conclusions: IMA or SRA preservation or sacrifice was not associated with an increased leak rate from colorectal anastomoses after sigmoidectomy for diverticular disease. Stapled anastomoses were associated with a lower leak rate than hand-sewn anastomoses., (Published by Elsevier Inc.)

Congenital aganglionic mega colon (Hirschsprung's disease) is a motor disorder in the gut, due to a defect in the craniocaudal migration of the neuroblast originating from the neural crest that occurs during the first twelve weeks of gestation, causing a functional intestinal obstruction, with its attendant complications, in infants. Despite modern pediatric practice, with emphasis on early diagnosis, Hirschsprung's disease is seen in adults in regions where perinatal care is limited. We report two cases of Nigerian adults with longstanding, recurrent constipation, getting relieved by laxatives and herbal enemata, and then presented to our Emergency Department with a history of progressive abdominal distention, colicky pain, occasional vomiting, and weight loss. Per rectal examination revealed a gripping sensation in the rectum, 10 cm from the anal verge, with rectal fecal load. Barium enema showed a grossly distended proximal large colon, with high fecal retention, with the transition zone at the middle one-third of the rectum. Due to difficulty in bowel preparation of these patients, emergency laparotomy was done. The first case had a diverting sigmoid colostomy and later had a low anterior resection. The second case had a one-stage procedure. Histology of both the cases showed aganglionosis of the stenotic segment and a normal distal rectum. Both patients had complete resolution of the symptoms, without complications, in a three-year follow-up. The related literatures were reviewed. Hirschsprung's disease should be considered in adults patient presenting with chronic constipation. Low anterior resection of the rectum would be a surgical option for the treatment of short and zonal segment of adult Hirschsprung's disease.

This study was designed to assess the safety of transcatheter arterial embolization (TAE) with n-butyl cyanoacrylate-lipiodol (NBCA-Lp) for the large bowel and to investigate the vital response to NBCA-Lp in a swine model. In nine swine, nine arteries nourishing the colon were embolized with NBCA-Lp (1 ml of NBCA mixed with 4 ml of lipiodol): sigmoid-rectal branch artery in six swine, right colic branch artery in two, and middle colic branch artery in one. The amount of NBCA-Lp was 0.1-0.4 ml. Sacrifice was conducted 3 days after TAE to identify histological infarction. Classification was conducted retrospectively: group A, vasa recta without NBCA-Lp embolization despite TAE; group B, three or fewer vasa recta with NBCA-Lp embolization; and group C, five or more vasa recta with NBCA-Lp embolization. In one swine in group A, no necrotic focus was observed. In group B, three of four swine experienced no ischemic damage. The remaining one swine experienced necrosis of mucosal and submucosal layers in one-fourth of the circumference. In group C, all four swine with marginal artery and five vasa recta or more embolized experienced total necrosis of mucosa, submucosa, and smooth muscle layers of the whole colonic circumference. Significant difference on the extent of ischemic damage was observed between groups B and C (P < 0.05). Microscopically, NBCA-Lp induced acute vasculitis. Embolization of three or fewer vasa recta with NBCA-Lp induced no ischemic damage or limited necrosis, whereas embolization of five or more vasa recta with NBCA-Lp induced extensive necrosis.

We present a case of a child with ongoing lower gastrointestinal bleeding caused by a rectosigmoid arteriovenous malformation. To reduce perioperative bleeding, we performed preoperative angioembolization followed by subsequent resection by low anterior resection. Here we present the case and review the literature regarding neoadjuvent embolization for gastrointestinal and pelvic arteriovenous malformations., (Copyright 2010 Elsevier Inc. All rights reserved.)

This report describes a case of hepatic portal venous gas (HPVG) in a patient with intestinal ischaemia and necrosis resulting from an obstructing lesion in the sigmoid colon. CT images demonstrating a large amount of HPVG are presented.

Purpose: The objective of this study is to introduce a modified Soave procedure for the treatment of vascular malformations involving the anorectum and sigmoid colon (VMARS) in children., Methods: Cases of 12 children with VMARS between 2000 and 2008 were reviewed and analyzed. The confirmed diagnosis was established by barium enema, colonoscopy, computed tomography, and magnetic resonance imaging. All the patients underwent a modified Soave procedure. In 11 patients, Sarasola-Klose hemorrhoidectomy was used for the distal part of endorectal dissection., Results: The mean length of resected bowel was 22.5 cm, ranging from 17 to 28 cm. Histologically, the surgical specimens showed that the lesions were venous malformation. Postoperative recovery was uneventful. The patients had good continence with no rectal bleeding, but intermittent fecal soiling was noted in one case., Conclusions: VMARS forms a unique subset of patients with vascular malformations who have rectal bleeding. The combination of Soave procedure and Sarasola-Klose hemorrhoidectomy is a safe and effective procedure for VMARS.

A 45-year-old woman with poorly controlled hypertension and diabetes mellitus presented with left iliac fossa pain, constipation alternating with diarrhea, and weight loss. She had been diagnosed with idiopathic cardiomyopathy five years previously. Echocardiogram had shown a left ventricular ejection fraction (LVEF) of 35%; coronary angiogram was normal. Colonoscopy revealed sigmoid colitis with stenosis. Abdominal computed tomography revealed a 5 cm right adrenal tumor. Twenty-four hour urinary free catecholamines and fractionated metanephrine excretion values were elevated, confirming pheochromocytoma. Her colitis resolved after one month of adrenergic blockade. Repeat echocardiogram showed improvement of LVEF to 65%. After laparoscopic right adrenalectomy, the patient's hypertension resolved, and diabetic control improved. Timely management avoided further morbidity and potential mortality in our patient.

Background: The aim was to investigate the association between colonic ischaemia and intra-abdominal pressure (IAP) after surgery for ruptured abdominal aortic aneurysm (rAAA)., Methods: Sigmoid colon perfusion was monitored with an intramucosal pH (pHi) tonometer. Patients with a pHi of 7.1 or less were treated for suspected hypovolaemia with intravenous colloids and colonoscopy. IAP was measured every 4 h. Patients with an IAP of 20 mmHg or more had neuromuscular blockade, relaparotomy or both., Results: A total of 52 consecutive patients had open rAAA repair; 30-day mortality was 27 per cent. Eight patients died shortly after surgery. Fifteen were not monitored for practical reasons; mortality in this group was 33 per cent. IAP and pHi were measured throughout the stay in intensive care in the remaining 29 patients. Monitoring led to volume resuscitation in 25 patients, neuromuscular blockade in 16, colonoscopy in 19 and relaparotomy in two. One patient died in this group. Twenty-three of 29 patients had a pHi of 7.1 or less, of whom 15 had a pHi of 6.9 or less. Sixteen had an IAP of 20 mmHg or more, of whom ten also had a pHi below 6.90. Peak IAP values correlated with the simultaneously measured pHi (r = -0.39, P = 0.003)., Conclusion: Raised IAP is an important mechanism behind colonic hypoperfusion after rAAA repair. Monitoring IAP and timely intervention may improve outcome., ((c) 2009 British Journal of Surgery Society Ltd.)

A 75-year-old woman presented with pink papules over the trunk and limbs. Over the next few weeks, the papules became umbilicated and then developed into porcelain-white lesions with a rose or violaceous rim. A biopsy of one of these lesions revealed superficial and deep dermal lymphohistiocytic inflammation, mainly perivascular with a central zone of infarction consistent with Degos' disease. Three years later, she presented with increasing abdominal pain, anaemia, raised inflammatory markers and an abdominal bruit. Angiography showed splanchnic vessel stenosis possibly secondary to vasculitis and she underwent successful balloon dilatation. Treatment with prednisolone was commenced. There has been no recurrence of lesions in the 12 months since the balloon dilatation.

In this paper we report a technique for laparoscopic lymph node (LN) dissection for descending and proximal sigmoid colon cancer with the preservation of the superior rectal artery (SRA) to maintain the blood supply to the distal sigmoid colon. Five (5) cases were included from November 2004 to March 2005. For D3 LN dissection, the root of inferior mesenteric artery was exposed with ultrasonic cutting and coagulating surgical device to avoid bleeding. The arterial wall was then exposed with a spatula-type electric cautery down to the left colic artery (LCA). The LCA was then clipped and cut while preserving the SRA. The inferior mesenteric vein was divided at the caudal side of the LCA and prior to joining to the splenic vein. All cases underwent a LN dissection laparoscopically. There were no cases of complications originating from the LN dissection. Although long-term outcomes should be investigated, our results indicate that this is a safe, applicable method.

We report the unique association of a rectosigmoid venous malformation and an aneurysm of the portal vein in a 7-year-old child. Doppler ultrasonography allowed the diagnosis; MRI confirmed the diagnosis and demonstrated the extent of the abnormality. The treatment and evolution over a period of 6 years is recorded. The relationship between these two entities and treatment is discussed.

Sudeck's critical point at the rectosigmoid junction is described as the point of origin of the last sigmoid arterial branch, originating from the inferior mesenteric artery (IMA). There is controversy on the importance of Sudeck's point, and the frequency in which the anastomosis is found. Furthermore, the diameter of the anastomosis, if present, may also impact on the viability of the caudal stump. This study aimed to determine the frequency in which a macroscopic anastomosis occurs, between the superior rectal artery and the last sigmoidal branch, in a cadaver population; the diameter of this anastomosis and the distance from the origin of the IMA to Sudeck's point. Sixty-four cadavers were included in the study, excluding those with previous surgery to the rectosigmoid junction. Sudeck's point was carefully identified and dissected to establish the presence of an anastomosis. Subsequent measurements were performed using a digital caliper (accuracy = 0.01 mm). A macroscopic anatomosis was absent in three cases (4.7%). The mean diameter of the anastomosis when present was 1.9 mm (SD: 0.5 mm), and the distance from the origin of the IMA to Sudeck's point was 55.5 mm (SD: 14.6 mm). Although an anastomosis is present in the majority of cases, the vessel is very small in diameter, and may not be sufficient to meet the demands of the caudal stump. The distance from the origin of the IMA to Sudeck's point is sufficient enough to allow for ligation of the IMA proximal to Sudeck's point.

Mesenteric inflammatory veno-occlusive disease is a rare but recognized cause of intestinal ischemia, who can be defined as phlebitis or venulitis affecting mesentery or the bowel, without any evidence of coexisting of an obvious predisposing cause or a coexisting arterial inflammatory involvement. We report the case of a male patient, 63 year old, admitted in the Emergency County Hospital of Craiova, who after presenting with an acute abdomen, underwent exploratory laparotomy and resection of the ischemic sigmoid, temporary colostomy and after four months we reintroduced descendent colon in the digestive transit. The resected specimen of the patient was examined histopathologically, and distinctive histopathological characteristics of the mesenteric inflammatory veno-occlusive disease were identified.

Background: When we perform laparoscopic lymph node dissection around the inferior mesenteric artery (IMA), we preserve the left colic artery (LCA) to maintain the blood supply to the proximal sigmoid colon. In this study, we present our laparoscopic D2 and D3 lymph node (LN) dissection technique and evaluate its applicability and safety., Methods: We performed LN dissection on 23 rectal and lower sigmoid colon cancer cases from April 2002 to December 2004. For D3 LN dissection, the incision to the mesosigmoid extends to just before the root of the IMA, which is exposed with an ultrasonic cutting and coagulating surgical device to avoid bleeding. Then, the arterial wall is exposed with a dissecting electrocautery spatula down to the LCA, at least 2 cm of which is exposed. Adipose tissue surrounding the IMA and inferior mesenteric vein is dissected. For D2 LN dissection, we partially expose the IMA to confirm the location of the LCA., Results: The mean times taken for D2 and D3 LN dissections were 36.2 and 68.2 min, respectively. Both procedures took longer in male patients. There was a trend for the procedure overall to take less time in female patients. However, D2 dissection took significantly longer in male than female patients (p < 0.05). In women, D3 dissection took significantly longer than D2 (p < 0.05), but this trend was not seen in men. Increased experience among surgeons with this procedure was associated with significantly faster LN dissections in men (p < 0.05), but not in women (p = 0.493). Pearson product moment analysis identified a relationship between body mass index (BMI) and the time taken for D2 LN dissection (r = 0.765), but not D3 LN dissection (r = 0.158). There was no treatment-related morbidity with this technique., Conclusions: This method was safe and feasible for all patients in this series, but takes longer to perform in male patients.

Idiopathic myointimal hyperplasia of mesenteric veins (IMHMV) is a rare and poorly understood disease that occurs in the rectosigmoid colon of predominantly young, previously healthy male patients. IMHMV typically requires segmental resection due to complications after a relatively protracted clinical course. This disease presents a challenging diagnostic dilemma for the clinician because it is initially often confused with chronic idiopathic inflammatory bowel disease. We report a case of IMHMV, illustrate endoscopic and histopathologic features, and review key characteristics of this rare entity.

Background: Pneumoperitoneum has been associated with a decreased flow in the superior mesenteric artery and portal venous system. Intestinal blood flow was studied during a 2-h pneumoperitoneum with carbon dioxide (CO2) or helium in a porcine model using colored microspheres., Methods: For this study, 12 pigs were divided into two groups (6 CO2 and 6 helium). Different colored microspheres were injected directly into the left ventricle before, 40, 80, and 120 min after insufflation with either gas at a pressure of 15 mmHg. Microsphere concentration was measured in the mucosa and muscularis/serosa layers of the jejunum, cecum, and sigmoid colon to calculate blood flow., Results: Intestinal perfusion initially increases with insufflation and returns to near baseline levels during pneumoperitoneum of 2 h. The effect of helium on tissue perfusion is similar to that of carbon dioxide., Conclusions: Intestinal perfusion does not change significantly during prolonged pneumoperitoneum at a pressure of 15 mmHg with CO2 or helium.

Background: This study characterized the initial modes of colonic mucosal injury during aneurysm surgery and correlated these with proinflammatory cytokine release into the colonic and systemic circulations., Methods: Twenty-four patients undergoing conventional open aortic aneurysm repair and ten who had endovascular aneurysm repair (EVAR) were recruited. Mucosal biopsies were taken from the sigmoid colon immediately before and after surgery, for histological examination. Inferior mesenteric vein (IMV) and peripheral blood from patients who had conventional surgery was assayed for interleukin (IL) 1 beta, IL-6 and tumour necrosis factor (TNF) alpha. Only peripheral blood from patients who had EVAR was assayed., Results: Conventional aneurysm repair resulted in a threefold increase in columnar epithelial apoptosis. There was a 26-fold increase in IL-6 in IMV blood within 5 min of reperfusion, with an equivalent rise in peripheral blood after 30 min. A 20-fold rise in peripheral blood TNF-alpha was observed after surgery. Splanchnic IL-6 correlated positively with cross-clamp time and increased apoptosis. No histological changes were seen after EVAR. There were no intraoperative cytokine changes during EVAR, although a postoperative increase in IL-6 and TNF-alpha was observed., Conclusion: The lack of columnar epithelial apoptosis following EVAR reflects the relatively minor ischaemic injury incurred during this procedure.

This report presents a case of endometrioid adenocarcinoma arising from endometriosis of the mesenterium of the sigmoid colon following total abdominal hysterectomy and bilateral salpingo-oophorectomy for leiomyoma of the uterus and infiltrating pelvic endometriosis, and hormone replacement therapy. A 62-year-old woman presented with an abdominal tumor. Based on the diagnosis of mesocolonic tumor, sigmoidectomy with lymph node resection was performed. The tumor cells were immunopositive for cytokeratin 7, but negative for cytokeratin 20, and the tumor was histologically diagnosed as endometrioid adenocarcinoma of the mesocolon. Hyperestrogenism has been implicated as a risk factor for the development of cancer from endometriosis. The patient had been receiving high-dose unopposed estrogens for 14 years after a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Physicians should recognize that endometriosis-associated neoplasms are able to cause symptoms or signs such as abdominal and/or pelvic pain, pelvic mass, and vaginal bleeding, especially if the patient has been treated with hormone replacement therapy. It is important to recognize the possibility of tumors arising from endometriosis when evaluating intestinal or mesenteric neoplasms in women, even in the patient who has previously undergone total abdominal hysterectomy and bilateral salpingo-oophorectomy, particularly if the patient has a history of endometriosis and has received hormone replacement therapy.

The Dieulafoys lesion is a rare cause of severe gastrointestinal hemorrhage. The lesion is usually located in the stomach, although it may occur anywhere in the gastrointestinal tract. It is characterized by severe bleeding from a minute submucosal arteriole that bleeds through a punctate erosion in an otherwise normal mucosa. We describe an elderly patient who presented with severe lower gastrointestinal bleeding caused by a colonic Dieulafoy-like lesion. This is the third report of colonic Dieulafoys lesion treated successfully with endoscopic hemoclipping. We review the pathophysiology, clinical presentation, diagnosis, and treatment of this rare disease.

Sigmoid resection is indicated in the treatment of complete rectal prolapse (CRP) in patients with prolonged colorectal transit time (CTT). Its use, however, has been limited because of fear of anastomotic leakage. This study challenges the current practice of dividing the mesorectum by prospectively evaluating the impact of sparing the superior rectal artery (SRA) on leak rates after laparoscopic sigmoid resection (LSR) for CRP. During a 30-month period, data on 33 selected patients with CRP were prospectively collected. Three patients were withdrawn from the analysis, as they had neither resection nor anastomosis. Twenty-nine women and 1 man (median age 55 range 21-83 years) underwent LSR with preservation of SRA for a median CRP of 8 (3-15) cm. There were 20 ASA I and 10 ASA II patients. Ten patients had undergone previous surgery. Four patients complained of dyschezia, whereas incontinence was present in 26 patients. Anal ultrasound showed isolated internal sphincter defects in 2 patients. Four young adults (21-32 years) had normal CTT, whereas 26 older patients had a median CTT of 5(4-6) days. Defecography demonstrated 10 enteroceles, two sigmoidoceles, and one rectal hernia through the levator ani muscle. Mortality was nil. Median operating room time was 180 (120-330) min, suprapubic incision length 5(3-7) cm, estimated blood loss 150 (50-500) mL, specimen length 20 (12-45) cm, solid food resumption 3(1-6) days, and length of stay 4.5(2-7) days. Thirty-day complications were not related to anastomosing and occurred in 20% of the patients. Median follow-up was 34.1 (18-48) months. One patient had a recurrence. Although the evidence provided by the present study suggests that sparing SRA has a favorable impact on anastomotic leak rates, these nonrandomized results need further evaluation. The division of the mesorectum at the rectosigmoid junction seems not necessary, and its sparing should therefore be considered as it may contain anastomotic leak rates.

Gastroesophageal varices are the major complication of portal hypertension. Ectopic varices develop in various organs such as the duodenum, colon, and gallbladder. However, varices other than at gastroesophageal or rectal sites is a rare entity. We report a 53-year-old patient with primary biliary cirrhosis complicated by sigmoid colonic varices. Computed tomographic angiography was useful to understand the entire status of the varices.

Background: An anatomic study about the arterial vascularization of the sigmoid was performed in order to obtain guidelines for the surgical treatment of rectal carcinoma., Aim: In the proposed technique, the sigmoid is brought down to the perineum, after radical anal-rectal resection, including sphincterectomy., Material and Methods: Thirty-three anatomical pieces were obtained through in situ dissection of formolized corpses (22 were male and 11 female). Turpentine solution, red marking, polyvinyl chloride were the materials used for preparation after catheterization of the inferior mesenteric artery., Results: The inferior mesenteric artery originated in most cases from the left side of the abdominal aorta, approximately 4.3 cm fromits bifurcation point; the left colonic artery, in 25 cases, originated straight from the inferior mesenteric artery below the left colonic artery, after which the sigmoid would be brought down to the perineum., Conclusion: Knowledge about arterial vascularization of the sigmoid could be helpful in the surgical management of rectal cancer.

History and Clinical Findings: A 60-year-old man had a dacron aortofemoral bypass graft inserted to replace a ruptured infrarenal aortic aneurysm rupture. He subsequently had tachyarrhythmic atrial fibrillation with heart failure, NYHA class IV, and diffuse abdominal pain associated with watery diarrhea., Investigations: Stool tests merely demonstrated Candida albicans. Abdominal ultrasound revealed intestinal loops with thickened walls and decreased peristalsis. Coloscopy demonstrated a retroperitoneal intestinal perforation with abscess formation resulting from ulcerative necrotizing rectosigmoid colitis which had also uncovered the vascular prosthesis near the abscess cavity., Diagnosis: Ischemic transmural necrotizing rectosigmoiditis with retroperitoneal intestinal perforation., Treatment and Course: The rectosigmoid colon was resected and an end-colostomy made with closure of the rectal stump (Hartmann's operation). The uncovered right limb of the vascular graft was covered completely and was discharged, being now mobile using a walking frame. There was no evidence of infection in the dacron prosthesis., Conclusion: A transmural progression of an ischemic colitis should be considered as a late sequela after emergency vascular reconstruction of the abdominal aorta. Even if symptoms are mild, early postoperative sigmoidoscopy is indicated.

Aim: Colon ischemia is a rare but serious complication in surgery of the infrarenal aorta, due to ligation of the inferior mesenteric artery and the ischemia-reperfusion syndrome. In order to investigate the degree of intestinal damage, we employed experimental surgery in pigs, applying the usual protocol for elective repair of the infrarenal aorta (AAA or Y graft)., Methods: Three groups of pigs were operated on. In Group A (n=4, 21-25 kg, mean 22.6) a sham operation was performed. In Group B (n=6, 21-26 kg, mean 24) the infrarenal aorta was cross-clamped along with the internal and external iliac arteries and a longitudinal incision was performed in the aorta, while in Group C (n=5, 20-27 kg, mean 23.8) a Pruitt-Inahara shunt was used to allow flow from the infrarenal aorta towards the iliac arteries and the inferior mesenteric artery during cross-clamping. The duration of cross-clamping was two hours (Group B and C). In all groups we evaluated sigmoid histology after reperfusion under light microscopy., Results: The pathologic examination of the sigmoid revealed increased postischemic injuries in Group B, while the protective effect of the shunt was obvious in Group C. The tissue samples of Group B presented hyperemia, submucosal edema, dilatation of the lymph vessels and severe inflammatory infiltration of the mucosa, muscularis propria and serosa, with cells showing acute and chronic inflammatory responses. In Group C all specimens presented hyperemic vessels and a slight inflammatory reaction of mucosa. In conclusion, Group B, presented the most severe inflammatory changes, involving all layers, while in Group C congestion and slight inflammatory reactions of the mucosa were observed. In Group A, no significant changes in normal histology were observed., Conclusion: The importance of these findings is evident, because in the clinical situation patients have variable degrees of arteriopathy, thus even short periods of ischemia might prove disastrous and this could occur in repair of the infarenal aorta as well as in other cases of inevitable risk, such as in surgery of the thoraco-abdominal aorta.

The case of a 37-year-old Caucasian female with a history of systemic lupus erythematosus, admitted to hospital due to progressively worsening abdominal pain and arthralgia. During hospitalisation, signs of acute abdomen developed. Laparotomy revealed perforation of the rectum, accompanied by necrosis of the rectosigmoid. Histologic examination revealed vasculitis involving small- and medium-sized vessels. This case report emphasizes the point that colonic and especially rectal involvement from vasculitis, though unusual, may present with profound and possibly life-threatening manifestations and stresses the difficulties in clinical and histological differential diagnosis from other causes of systemic lupus erythematosus-associated abdominal pain.

A 74-year-old man in shock was transferred to our hospital. A ruptured abdominal aortic aneurysm was diagnosed by computed tomography and an emergency operation was thereafter performed. At operation, a massive hematoma was encountered in the retroperitoneal space and a standard aneurysmectomy with bifurcated graft replacement was carried out. At the end of the operation, signs of sigmoid colonic ischemia were recognized, including mild discoloration and bowel spasm. After considering the recovery or deterioration from colonic ischemia, we chose to exteriorize the sigmoid colon. On the 4th postoperative day, patchy ischemic areas of an elevated sigmoid colon were noticed to worsen and as a result, we were forced to perform a sigmoid colectomy with end colostomy. Thereafter, the patient developed multisystem organ failure, but he recovered gradually. The patient was discharged from the hospital 3 months after the initial operation. As a complication after surgery for abdominal aortic aneurysms, colonic ischemia remains a serious problem, especially in cases of ruptured AAA. It is generally better to avoid an operation for both abdominal aortic aneurysms and a colon resection at the same time. In this case, an exteriorization of the sigmoid colon was selected for the 1st operation in order to treat a ruptured abdominal aortic aneurysm. This surgical modality was found to be useful for making a correct diagnosis of colonic ischemia before the perforation, while a 2nd look operation for colonic ischemia could thus be performed under conditions of a reduced risk of infection to the prosthetic graft. These operative procedures were considered to be important factors in saving the patient's life.