Wood anatomy chronologies of Scots pine in the foothills of the Western Sayan(Siberia)

Recent methodological advances in quantitative wood anatomy have provided new insights into the climatic responses of radial growth at the scale of cell structure of tree rings. This study considered long-term chronologies of tracheid measurements, indexed by a novel approach to separate their specific climatic responses from signal recorded in cell production(closely reflected in tree-ring width). To fill gaps in understanding the impact of climate on conifer xylem structure, Scots pine(Pinus sylvestris L.)trees > 200 years old were selected within the forest-steppe zone in southern Siberia. Such habitats undergo mild moisture deficits and the resulting climatic regulation of growth processes. Mean and maximum values of cell radial diameter and cell wall thickness were recorded for each tree ring.Despite a low level of climatogenic stress, components of cell chronologies independent of cambial activity were separated to obtain significant climatic signals revealing the timing of the specific stages of tracheid differentiation. Cell expansion lasted from mid-April to July and was impacted similarly to tree-ring width(stimulated by precipitation and stressed by heat), maximum cell size formed late June. A switch in the climatic responses of mean anatomical traits indicated transition to latewood in mid-July. Secondary wall deposition lasted until mid-September, suppressed by end of season temperatures. Generally, anatomical climatic responses were modulated by a less dry May and September compared with summer months.

Opinions of Students on the Contribution of the DIVA 3D Virtual Dissection Table to the Teaching of Anatomy at the Faculty of Medicine and Odontostomatology of Bamako

Objective: Study the contribution of the DIVA 3D dissection table in the teaching of anatomy at the Faculty of Medicine and Odontology of Bamako. Material and Methods: This was a qualitative study carried out from November 1 to December 30, 2023 at the clinical and morphological anatomy laboratory of the Faculty of Medicine and Odontostomatology of Bamako. Included in this study were students who participated in practical and tutorial sessions. The variables studied during this study were: the previous performance of dissection on a cadaver by the students, the opinion of the students on dissection on a cadaver, the replacement of dissection on a cadaver by virtual dissection in the absence of a body, the level student satisfaction. Results: We surveyed 130 participants. The average age was 22 ± 0.2 years with extremes of 17 and 29 years. 95.3% of participants were students. According to 66.7% of participants, virtual dissection is a good palliative in the absence of a corpse. 95.3% of participants found using the virtual dissection table easy with an average of 7.88 ± 1.4. The overall assessment was well rated by 99.3% of participants. Conclusion: According to the results of this study, the virtual dissection table should be improved by integrating commented videos. The use of the DIVA 3D virtual dissection table during practical and tutorial sessions is well appreciated by the students. We believe that the teaching of anatomy using 3D digital technology should be included in the study programs of the Faculty of Medicine and Odontostomatology.

Getting physical with medical education:Exercise based virtual anatomy review classes for medical students

The benefits of regular physical activity are well known.Yet,few studies have examined the effectiveness of integrating physical activity(PA)into curricula within a post-secondary setting.To investigate the incorporation of PA into medical curriculum,we developed a series of optional exercise-based review sessions designed to reinforce musculoskeletal(MSK)anatomy course material.These synchronous sessions were co-taught by a group fitness instructor and an anatomy instructor.The fitness instructor would lead students through both strength and yoga style exercises,while the anatomy instructor asked questions about relevant anatomical structures related to course material previously covered.After the sessions,participants were asked to evaluate the classes on their self-reported exam preparedness in improving MSK anatomy knowledge,PA levels,and mental wellbeing.Thirty participants completed surveys;a majority agreed that the classes increased understanding of MSK concepts(90.0%)and activity levels(97.7%).Many(70.0%)felt that the classes helped reduce stress.The majority of respondents(90.0%)agreed that the classes contributed to increased feelings of social connectedness.Overall,medical students saw benefit in PA based interventions to supplement MSK course concepts.Along with increasing activity levels and promoting health behaviours,integrating PA into medical curriculum may improve comprehension of learning material,alleviate stress and foster social connectivity among medical students.

Intracranial magnetic resonance venography in healthy individuals:normal anatomy and variations of the cerebral venous system

Objective:To evaluate the basic appearance and variation of the venous sinuses and veins in healthy individuals.Methods:Prospectively-recruited healthy volunteers completed a questionnaire and underwent magnetic resonance imaging plus contrast-enhanced magnetic resonance venography(CE-MRV)to measure their sinus diameters.Anatomical variations of cerebral venous sinuses were evaluated.Results:Fifty-eight individuals were included.The mean diameter of the left transverse sinus(LTS)(5.37±1.35 mm)was significantly smaller than that of the right transverse sinus(RTS)(6.65±1.57 mm)(P<0.001),and the average discrepancy was 19.2%.RTS dominance was noted in 55.1%of cases.Four superior sagittal sinus(SSS)anatomical variations were found.Type A was the most common and was present in 43 participants(74.1%).The SSS preferentially drained into the RTS in 32 patients(55.2%),and arachnoid granulation was observed in the transverse sinus(TS)and SSS in patients.According to our reclassification combined with Osborn’s previous research,we found that the SSS commonly drained into the RTS and that the straight sinus(StS)branched into both TSs.Conclusions:A 19%difference between the LTS and RTS provides a threshold for TS lateral dominance instead of a TS abnormality.Clinicians and radiologists should not ignore the influence of acquired pathology when the SSS drains in a non-RTS-dominant manner.Anatomical variations of the torcular herophili are frequent;the most commonly observed was the StS branching into both TSs,with the SSS draining into the RTS.

The HIF-1α/PLOD2 axis integrates extracellular matrix organization and cell metabolism leading to aberrant musculoskeletal repair

While hypoxic signaling has been shown to play a role in many cellular processes,its role in metabolism-linked extracellular matrix(ECM)organization and downstream processes of cell fate after musculoskeletal injury remains to be determined.Heterotopicossification(HO)is a debilitating condition where abnormal bone formation occurs within extra-skeletal tissues.Hypoxia andhypoxia-inducible factor 1α(HIF-1α)activation have been shown to promote HO.However,the underlying molecular mechanisms bywhich the HIF-1αpathway in mesenchymal progenitor cells(MPCs)contributes to pathologic bone formation remain to beelucidated.Here,we used a proven mouse injury-induced HO model to investigate the role of HIF-1αon aberrant cell fate.Usingsingle-cell RNA sequencing(scRNA-seq)and spatial transcriptomics analyses of the HO site,we found that collagen ECM organizationis the most highly up-regulated biological process in MPCs.Zeugopod mesenchymal cell-specific deletion of Hif1α(Hoxa11-CreER^(T2);Hif1a^(fl/fl))significantly mitigated HO in vivo.ScRNA-seq analysis of these Hoxa11-CreER^(T2);Hif1a^(fl/fl)mice identified the PLOD2/LOXpathway for collagen cross-linking as downstream of the HIF-1αregulation of HO.Importantly,our scRNA-seq data and mechanisticstudies further uncovered that glucose metabolism in MPCs is most highly impacted by HIF-1αdeletion.From a translational aspect,a pan-LOX inhibitor significantly decreased HO.A newly screened compound revealed that the inhibition of PLOD2 activity in MPCssignificantly decreased osteogenic differentiation and glycolytic metabolism.This suggests that the HIF-1α/PLOD2/LOX axis linked tometabolism regulates HO-forming MPC fate.These results suggest that the HIF-1α/PLOD2/LOX pathway represents a promisingstrategy to mitigate HO formation.

FUT8-mediated aberrant N-glycosylation of SEMA7A promotes head and neck squamous cell carcinoma progression

SEMA7A belongs to the Semaphorin family and is involved in the oncogenesis and tumor progression.Aberrant glycosylation has been intricately linked with immune escape and tumor growth.SEMA7A is a highly glycosylated protein with five glycosylated sites.The underlying mechanisms of SEMA7A glycosylation and its contribution to immunosuppression and tumorigenesis are unclear.Here,we identify overexpression and aberrant N-glycosylation of SEMA7A in head and neck squamous cell carcinoma,and elucidate fucosyltransferase FUT8 catalyzes aberrant core fucosylation in SEMA7A at N-linked oligosaccharides(Asn 105,157,258,330,and 602)via a direct protein‒protein interaction.A glycosylated statue of SEMA7A is necessary for its intra-cellular trafficking from the cytoplasm to the cytomembrane.Cytokine EGF triggers SEMA7A N-glycosylation through increasing the binding affinity of SEMA7A toward FUT8,whereas TGF-β1 promotes abnormal glycosylation of SEMA7A via induction of epithelial–mesenchymal transition.Aberrant N-glycosylation of SEMA7A leads to the differentiation of CD8^(+)T cells along a trajectory toward an exhausted state,thus shaping an immunosuppressive microenvironment and being resistant immunogenic cell death.Deglycosylation of SEMA7A significantly improves the clinical outcome of EGFR-targeted and anti-PD-L1-based immunotherapy.Finally,we also define RBM4,a splice regulator,as a downstream effector of glycosylated SEMA7A and a pivotal mediator of PD-L1 alternative splicing.These findings suggest that targeting FUT8-SEMA7A axis might be a promising strategy for improving antitumor responses in head and neck squamous cell carcinoma patients.

Henry Vandyke Carter (1831-1897): the forgotten co-author of Gray’s Anatomy

Henry Vandyke Carter(1831–1897),physician and illustrator from Saint George’s Hospital in London,England.He worked with Henry Williamson Gray(1827–1861)on anatomical dissections and Carter’s illustrations contributed significantly to the success of the Treaty of Anatomy,Descriptive and Surgical.Henry Carter never achieved any credit or royalty for his work.This book is currently regarded as one of the most influential human anatomy textbooks.The paper aims to present a brief review of Henry Carter’s contributions to the medical field.

Improved maceration techniques to study the fruit vascular anatomy of grape

The visualization and evaluation of fruit vascular bundles in grape are indispensable for understanding the development and growth of the fruit. The vascular bundles in grape are as thin as human hair, and strongly adhere to flesh cells, making it difficult to isolate individual intact vessel elements. Currently there is little information about methods to characterize grape vascular tissue. In this study, we describe an easy and effective technique to visualize the xylem cell structure of the ‘Red Globe' grape(Vitis L.). The intact vascular bundles of the grape were isolated through enzymatic degradation of flesh cells by hydrolases which were effective in removing flesh cells from vascular bundles. This enabled the illustration of the fine surface structure of vessel elements and their arrangement in the vascular bundles of the grape. This modified method to separate the vascular bundles into individual vessel elements was more effective than former methods of manually shaking to isolate individual vessels. Clear images of xylem vessel arrangement and structural characteristics of individual vessel element were acquired by light microscopy(BX51, Olympus, Tokyo, Japan), transmission electron microscopy(Tecnai 12, Philips, Netherlands) and scanning electron microscopy(GeminiSEM 300, Carl Zeiss, Germany). In addition, the 3D structure of vessel elements was observed using confocal laser scanning microscopy(Zeiss: model: LSM-880, Oberkochen, Germany). The imaging techniques for visualizing and analyzing the structure of xylem vessels in grape described in this study are an improvement of past methods. An effective method to isolate grape vascular bundles from flesh cells was also developed, which enables the imaging of the fine surface structure of vessel elements and their arrangement in grape vascular bundles. By adjusting the process of maceration of vascular bundles, an easy and effective method was developed to gently disrupt the plant tissue and isolate individual vessel elements. These improved techniques are suitable to observe the intact morphology of vascular bundles in the grape, improve experimental efficiency and accelerate new discoveries on the anatomical structure of the grape.

Helicobacter Pylori Infection: Epidemiological, Clinical and Pathological Aspects in a Digestive Endoscopy Unit and the Pathological Anatomy Service of Parakou in Benin Republic

Introduction: Helicobacter pylori (Hp) infection is the most common bacterial infection in the world. World Health Organization has classified this bacterium as a Class I carcinogen. The objective of this work is to study the epidemiological, clinical and pathological aspects of Helicobacter pylori infection among adults in a digestive endoscopy unit and the pathological anatomy service of Parakou. Patients and Methods: This was a descriptive and analytical cross-sectional study conducted from January 2020 to September 2020 in the digestive endoscopy unit and pathological anatomy service at the Departmental University Hospital Center of Borgou. Patients aged 18 years and older, who had undergone a gastroscopy with biopsies and who gave their oral consent were included. Three antral biopsies and two fundic biopsies were performed. The search for Hp was done under an optical microscope after staining with hematoxylin eosin. Results: A total of 151 patients were included and 51.66% were infected with Hp. Their average age was 40.63 ± 15.32 years and the sex ratio was 0.9. Epigastric pain was the most reported symptom (71.01%). Endoscopically, the prevalence of erythematous gastropathy was 98.72%. The study of chronic Hp gastritis according to Sydney system had shown signs of activity in 100% of patients with Hp and glandular atrophy in 83.33% of them. Intestinal metaplasia and dysplasia accounted for 24.35% and 29.48% of cases, respectively. Factors associated with Hp infection were: absence of proton pump inhibitor intake prior to examination, absence of handwashing with soap and water before eating, erythematous aspect of gastritis on gastroscopy, absence of intestinal metaplasia of the fundus, active and chronic aspects of gastritis on histology. Conclusion: The frequency of Hp infection in hospitals among adults admitted to the Digestive Endoscopy Unit of Parakou is high. To reduce this prevalence, it will be necessary to act on the factors identified.

New classification system for radical rectal cancer surgery based on membrane anatomy

BACKGROUND Total mesorectal excision along the“holy plane”is the only radical surgery for rectal cancer,regardless of tumor size,localization or even tumor stage.However,according to the concept of membrane anatomy,multiple fascial spaces around the rectum could be used as the surgical plane to achieve radical resection.AIM To propose a new membrane anatomical and staging-oriented classification system for tailoring the radicality during rectal cancer surgery.METHODS A three-dimensional template of the member anatomy of the pelvis was established,and the existing anatomical nomenclatures were clarified by cadaveric dissection study and laparoscopic surgical observation.Then,we suggested a new and simple classification system for rectal cancer surgery.For simplification,the classification was based only on the lateral extent of resection.RESULTS The fascia propria of the rectum,urogenital fascia,vesicohypogastric fascia and parietal fascia lie side by side around the rectum and form three spaces(medial,middle and lateral),and blood vessels and nerves are precisely positioned in the fascia or space.Three types of radical surgery for rectal cancer are described,as are a few subtypes that consider nerve preservation.The surgical planes of the proposed radical surgeries(types A,B and C)correspond exactly to the medial,middle,and lateral spaces,respectively.CONCLUSION Three types of radical surgery can be precisely defined based on membrane anatomy,including nerve-sparing procedures.Our classification system may offer an optimal tool for tailoring rectal cancer surgery.

Endoscopic ultrasound guided biliary drainage in surgically altered anatomy: A comprehensive review of various approaches

Endoscopic retrograde cholangiopancreatography(ERCP)is the preferred modality for drainage of the obstructed biliary tree.In patients with surgically altered anatomy,ERCP using standard techniques may not be feasible.Enteroscope assisted ERCP is usually employed with variable success rate.With advent of endoscopic ultrasound(EUS),biliary drainage procedures in patients with biliary obstruction and surgically altered anatomy is safe and effective.In this narrative review,we discuss role of EUS guided biliary drainage in patients with altered anatomy and the various approaches used in patients with benign and malignant biliary obstruction.

Development and application of digital assistive teaching system for anatomy

Background Anatomy is a required course for all medicine-related industries.In recent decades,the teaching quality and effect of anatomy have been compromised by factors including a decrease in human body specimens,dampened enthusiasm for the discipline,reduced teaching hours of anatomy,scale expansion of medical education,and obstacles in performing field autopsies and observations.Methods Based on China's digitalized visible human research achievements,this article extracts the boundary information of anatomic structures from tomographic images,constructs three dimensional(3D)digital anatomical models with authentic texture information,and develops an anatomy assistive teaching system for teachers and students based on the knowledge points of anatomy,to meet the anatomy teaching requirements of different majors at various levels.Results This scientific,complete,and holistic system has produced over 60003D digital anatomical models,5000 anatomy knowledge points,50 anatomical operation videos,and 150 micro demonstration classes,with teaching contents for different majors and levels,such as systematic anatomy,topographic anatomy,sectional anatomy,anatomy of motion,and virtual anatomical operation table.Ranging from network terminals,desktops,touchscreen 3D displays,desktops,and projection 3D volumetric displays to augmented reality,its diversified interactive forms meet the requirements for a learning environment in different settings.Conclusions With multiple teaching and learning links covered,such as teaching environment,teaching resources,instructional slides,autonomous learning,and learning effect evaluation,this novel teaching system serves as a vital component and a necessary resource in anatomy teaching and functions as an important supplement to traditional anatomy teaching.Applied and promoted in most medical colleges and schools in China,this system has been recognized and approved by anatomy teachers and students,and plays a positive role in guaranteeing the effect and quality of anatomy teaching.

Carotid-subclavian bypass and endovascular aortic repair of Kommerell’s diverticulum with aberrant left subclavian artery:A case report

BACKGROUND Kommerell’s diverticulum(KD)with aberrant left subclavian artery is a rare congenital deformity and also has very little research literature about it(35%of case study).There are three types of aortic arch diverticulum.Even literature concerning the treatment options are limited.CASE SUMMARY We present a case report of a 50-year-old male with KD in the right aortic arch with aberrant left subclavian artery.We conducted a total endovascular repair procedure,which is innovative and will spread more light in the medical world.Our patient has no past medical history and is a non-smoker and non-alcoholic.Patient presented with shortness of breath,chest pain and dizziness for six months.Blood tests were done and computerized tomography(CT)angiogram of the chest confirmed the diagnosis,illustrating showed a 3.9 cm KD.On Day 1,the CT angiogram showed mild dilatation of the thoracic aorta,adjacent esophagus,trachea was compressed and displaced.Surgery was planned as the treatment modality.Carotid-Subclavian artery bypass and endovascular aortic repair was conducted.We used prolene 5-0 C1 sutures to precisely anastomose a 6-mm Dacron graft to the left subclavian artery.Haemostasis was secured and wounds were closed.Protamine was administered and patient was shifted to intensive care unit.Post-operative,patient responded favorably and was discharged.Regular follow-up is done.CONCLUSION The procedure we performed is novel.This will help the cardio-thoracic surgeons a better insight about the full procedures we conducted,thereby bringing more light and better treatment options in managing KD with aberrant subclavian artery.

A Preliminary Study on Anatomy of the Stem and Leaf of Premna microphylla Turcz.

[Objective] This study was to reveal the anatomic structure of Premna microphylla Turcz.stem and leaf.[Method] Using plant anatomy method,we performed anatomic analysis of Premna microphylla Turcz.stem and leaf.[Result] The stem of Premna microphylla Turcz.is axially symmetric organ,its primary structure consists of three parts of epidermis,cortex and vascular cylinder.The petiole consists of epidermis,cortex and vascular cylinder,of which epidermis is a layer of cells with cuticle and epidermal hair.The sun leaf in Premna microphylla is dorsi-ventral leaf,wich is consist of palisade tissue and spongy tissue;while its shade leaf of Premna microphylla almost are isobilateral leaf.[Conclusion] Our results provided reference for further the exploitation and utilization of Premna microphylla Turcz.resources.

Fruit Anatomy of sect. Paracamellia with Reference to Their Significance of Germplasm Resources Exploitation

[Objective] To utilize the germplasm resources,new systematic evidence for the classification of sect.Paracamellia,genus Camellia is found in this article.[Method] Fruit anatomy of 10 species representing sect.Paracamellia was investigated.And the main component of sect.Paracamellia in the genus Camellia was studied by MVSP software.[Result] The exocarp was thin;mesocarp was broad,having a large number of stone cells;endocarp was lignified,and separated easily from seed.The principle components analysis suggested that the distance between species was far,showing far relation;the current study did not support the formation of Camellia grijsii（C.grijsii）and Camellia yuhsienensis（C.yuhsienensis）,Camellia shensiensis（C.shensiensis）should not be recognized as a variety of C.yuhsienensis.In addition,it also proved Ming＇s combining of Camellia confusa（C.confusa）and Camellia kissi（C.kissi）was unnatural.[Conclusion] The study provided theoretical basis for the development and application of sect.Paracamellia in the genus Camellia.

Modeling and simulation of an anatomy teaching system

Specimen observation and dissection have been regarded as the best approach to teach anatomy,but due to the severe lack of anatomical specimens in recent years,the quality of anatomy teaching has been seriously affected.In order to disseminate anatomical knowledge effectively under such circumstances,this study discusses three key factors(modeling,perception,and interaction)involved in constructing virtual anatomy teaching systems in detail.To ensure the authenticity,integrity,and accuracy of modeling,detailed three-dimensional(3D)digital anatomical models are constructed using multi-scale data,such as the Chinese Visible Human dataset,clinical imaging data,tissue sections,and other sources.The anatomical knowledge ontology is built according to the needs of the particular teaching purposes.Various kinds of anatomical knowledge and 3D digital anatomical models are organically combined to construct virtual anatomy teaching system by means of virtual reality equipment and technology.The perception of knowledge is realized by the Yi Chuang Digital Human Anatomy Teaching System that we have created.The virtual interaction mode,which is similar to actual anatomical specimen observation and dissection,can enhance the transmissibility of anatomical knowledge.This virtual anatomy teaching system captures the three key factors.It can provide realistic and reusable teaching resources,expand the new medical education model,and effectively improve the quality of anatomy teaching.

The Role of Anatomical Specimens in the Teaching of Anatomy

characteristics,complex content,and it is difficult to understand.In view of the nature of the subject,many different models and specimens are required during teaching,increasing the difficulty of its teaching.Although the mode of medical teaching is constantly updating,anatomical specimens are still important in the teaching of anatomy,as they help students to understand the organs,their positions,and structural forms as well as to better grasp the theoretical aspect.In addition,anatomical specimens and medical students contact condition can affect the teaching effect.Therefore,it is imperative to give full play to the role of anatomical specimens in anatomy teaching to improve the teaching effect.This paper summarizes the research on the use of anatomical specimens in the teaching of anatomy.

Anatomy and influence of the splenic artery in laparoscopic spleen-preserving splenic lymphadenectomy

AIM: To investigate the splenic hilar vascular anatomy and the influence of splenic artery(Sp A) type in laparoscopic total gastrectomy with spleen-preserving splenic lymphadenectomy(LTGSPL).METHODS:The clinical anatomy data of 317 patients with upper- or middle-third gastric cancer who underwent LTGSPL in our hospital from January 2011 to December 2013 were collected. The patients were divided into two groups(concentrated group vs distributed group) according to the distance between the splenic artery's furcation and the splenic hilar region. Then, the anatomical layout, clinicopathologic characteristics, intraoperative variables, and postoperative variables were compared between the two groups.RESULTS: There were 205 patients with a concentrated type(64.7%) and 112 patients with a distributed type(35.3%) Sp A. There were 22 patients(6.9%) with a single branch of the splenic lobar vessels, 250(78.9%) with 2 branches, 43(13.6%) with 3 branches, and 2 patients(0.6%) with multiple branches. Eighty sevenpatients(27.4%) had type?Ⅰ?splenic artery trunk, 211(66.6%) had type Ⅱ, 13(4.1%) had type Ⅲ, and 6(1.9%) had type Ⅳ. The mean splenic hilar lymphadenectomy time(23.15 ± 8.02 vs 26.21 ± 8.84 min; P = 0.002), mean blood loss resulting from splenic hilar lymphadenectomy(14.78 ± 11.09 vs 17.37 ± 10.62 m L; P = 0.044), and number of vascular clamps used at the splenic hilum(9.64 ± 2.88 vs 10.40 ± 3.57; P = 0.040) were significantly lower in the concentrated group than in the distributed group. However, the mean total surgical time, mean total blood loss, and the mean number of harvested splenic hilar lymph nodes were similar in both groups(P > 0.05 for each comparison). There were also no significant differences in clinicopathological and postoperative characteristics between the groups(P > 0.05).CONCLUSION: It is of value for surgeons to know the splenic hilar vascular anatomy when performing LTGSPL. Patients with concentrated type Sp A may be optimal patients for training new surgeons.

Anatomy of the lateral ligaments of the rectum: A controversial point of view

The existence and composition of the lateral ligaments of the rectum (LLR) are still the subjects of anatomical confusion and surgical misconception up to now. Since Miles proposed abdominoperineal excision as radical surgery for rectal cancer, the identification by "hooking them on the finger" has been accepted by many surgeons with no doubt; clamping, dividing and ligating are considered to be essential procedures in mobilization of the rectum in many surgical textbooks. But in cadaveric studies, many anatomists could not find LLR described by the textbooks, and more and more surgeons also failed to find LLR during the proctectomy according to the principle of total mesorectal excision. The anatomy of LLR has diverse descriptions in literatures. According to our clinical observations, the traditional anatomical structures of LLR do exist; LLR are constant dense connective bundles which are located in either lateral side of the lower part of the rectum, run between rectal visceral fascia and pelvic parietal fascia above the levator ani, and covered by superior fascia of pelvic diaphragm. They are pathways of blood vessels and nerve fibers toward the rectum and lymphatic vessels from the lower rectum toward the iliac lymph nodes.

Innovations and techniques for balloon-enteroscopeassisted endoscopic retrograde cholangiopancreatography in patients with altered gastrointestinal anatomy

Endoscopic retrograde cholangiopancreatography(ERCP) remains challenging in patients who have undergone surgical reconstruction of the intestine.Recently,many studies have reported that balloonenteroscope-assisted ERCP(BEA-ERCP) is a safe and effective procedure.However,further improvements in outcomes and the development of simplified procedures are required.Percutaneous treatment,Laparoscopy-assisted ERCP,endoscopic ultrasoundguided anterograde intervention,and open surgery are effective treatments.However,treatment should be noninvasive,effective,and safe.We believe that these procedures should be performed only in difficult-to-treat patients because of many potential complications.BEA-ERCP still requires high expertiselevel techniques and is far from a routinely performed procedure.Various techniques have been proposed to facilitate scope insertion(insertion with percutaneous transhepatic biliary drainage(PTBD) rendezvous technique,Short type single-balloon enteroscopes with passive bending section,Intraluminal injection of indigo carmine,CO2 inflation guidance),cannulation(PTBD or percutaneous transgallbladder drainage rendezvous technique,Dilation using screw drill,Rendezvous technique combining DBE with a cholangioscope,endoscopic ultrasound-guided rendezvous technique),and treatment(overtube-assisted technique,Short type balloon enteroscopes) during BEA-ERCP.The use of these techniques may allow treatment to be performed by BEA-ERCP in many patients.A standard procedure for ERCP yet to be established for patients with a reconstructed intestine.At present,BEA-ERCP is considered the safest and most effective procedure and is therefore likely to be recommended as firstline treatment.In this article,we discuss the current status of BEA-ERCP in patients with surgically altered gastrointestinal anatomy.