Advancing perioperative optimization in Crohn's disease surgery with machine learning predictions

This editorial offers commentary on the article which aimed to forecast the likelihood of short-term major postoperative complications(Clavien-Dindo grade≥III),including anastomotic fistula,intra-abdominal sepsis,bleeding,and intestinal obstruction within 30 days,as well as prolonged hospital stays follow-ing ileocecal resection in patients with Crohn’s disease(CD).This prediction re-lied on a machine learning(ML)model trained on a cohort that integrated a no-mogram predictive model derived from logistic regression analysis and a random forest(RF)model.Both the nomogram and RF showed good performance,with the RF model demonstrating superior predictive ability.Key variables identified as potentially critical include a preoperative CD activity index≥220,low preope-rative serum albumin levels,and prolonged operation duration.Applying ML ap-proaches to predict surgical recurrence have the potential to enhance patient risk stratification and facilitate the development of preoperative optimization strate-gies,ultimately aiming to improve post-surgical outcomes.However,there is still room for improvement,particularly by the inclusion of additional relevant clinical parameters,consideration of medical therapies,and potentially integrating mole-cular biomarkers in future research efforts.

Colonoscopy evaluation after short-term anti-tuberculosis treatment in nonspecific ulcers on the ileocecal area

AIM: To evaluate the eff icacy of colonoscopy follow-up after short-term anti-tuberculosis treatment in patients with nonspecific ulcers on ileocecal areas being suspicious of tuberculous colitis. METHODS: We prospectively analyzed the colonoscopic fi ndings before and after short term anti- tuberculosis treatment in 18 patients with nonspecifi c ulcers on the ileocecal area and compared them with 7 patients of confi rmed tuberculous colitis by acid-fast bacilli or caseating granuloma on colonic biopsy. RESULTS: Mean duration for short-term follow- up was 107.3 d with combined chemotherapy containing isoniazid, rifampicin, ethambutol and pyrazinamide. Seven patients with tuberculous colitis showed complete healing of active ulcers after short- term medication. After short-term anti-tuberculosis treatment, follow-up colonoscopy findings devided 18 patients with nonspecific ulcers into two groups by ulcer state. One is the "suspicious tuberculous colitis group" showing healing of ulcers and erosions and another is the "suspicious inflammatory bowel disease group" showing active ulcers with or without aggravation of the lesion. Finally, all 9 of the "suspicious tuberculous colitis group" were diagnosed as tuberculous colitis showing no recurrence of ulcers after termination of 9 mo of anti-tuberculosis medication. Patients of the "suspicious inflammatorybowel disease group" were f inally diagnosed as Crohn's disease or nonspecifi c colonic ulcers during long-term follow up. CONCLUSION: Follow-up colonoscopy shows a healing stage ulcer or scarring change without an active ulcer with just 2 mo to 3 mo of medication in patients with tuberculous colitis. Colonoscopy follow-up after short term anti-tuberculosis trial in patients with nonspecif ic ulcers on the ileocecal area is valuable in making early differential diagnosis of tuberculous colitis.

Primary colonic melanoma presenting as ileocecal intussusception: Case report and literature review

Primary malignant melanoma originating in the colon is an extremely rare disease.Herein,we report a case of primary melanoma of the ascending colon.The patient was a 57-year-old male who was admitted to our hospital for persistent abdominal pain and episodes of bloody stool,nausea and vomiting.A computed tomography scan revealed lower intestinal intussusception and enlarged lymph nodes in the abdominal cavity and retroperitoneum.During laparoscopic operation,multiple enlarged lymph nodes were found.Several segments of the proximal small intestine were incarcerated into the distal small intestine,forming an internal hernia and obstruction.The necrotic terminal ileum was invaginated into the ascending cecum.Subsequently,adhesive internal hernia reduction and palliative right hemicolectomy were performed.Pathologic examination of the excised specimen revealed a polypoid mass in the ascending colon.Histological examination showed epithelioid and spindle tumor cells with obvious cytoplasmic melanin deposition.Immunohistochemical staining revealed that the tumor cells were positive for S-100,HmB-45 and vimentin,confirming the diagnosis of melanoma.The patient history and a thorough postoperative investigation excluded the preexistence or coexistence of a primary lesion elsewhere in the skin,anus or oculus or at other sites.Thus,we consider our case to represent an aggressive primary colon melanoma presenting as ileocecal intussusception and intestinal obstruction.

All ileo-cecal ulcers are not Crohn's:Changing perspectives of symptomatic ileocecal ulcers

To investigated clinical, endoscopic and histopathological parameters of the patients presenting with ileocecal ulcers on colonoscopy. METHODSConsecutive symptomatic patients undergoing colonoscopy, and diagnosed to have ulcerations in the ileocecal (I/C) region, were enrolled. Biopsy was obtained and their clinical presentation and outcome were recorded. RESULTSOut of 1632 colonoscopies, 104 patients had ulcerations in the I/C region and were included in the study. Their median age was 44.5 years and 59% were males. The predominant presentation was lower GI bleed (55, 53%), pain abdomen ± diarrhea (36, 35%), fever (32, 31%), and diarrhea alone (9, 9%). On colonoscopy, terminal ileum was entered in 96 (92%) cases. The distribution of ulcers was as follows: Ileum alone 40% (38/96), cecum alone 33% (32/96), and both ileum plus cecum 27% (26/96). The ulcers were multiple in 98% and in 34% there were additional ulcers elsewhere in colon. Based on clinical presentation and investigations, the etiology of ulcers was classified into infective causes (43%) and non-infective causes (57%). Fourteen patients (13%) were diagnosed to have Crohn’s disease (CD). CONCLUSIONNon-specific ileocecal ulcers are most common ulcers seen in ileo-cecal region. And if all infections are clubbed together then infection is the most common (> 40%) cause of ulcerations of the I/C region. Cecal involvement and fever are important clues to infective cause. On the contrary CD account for only 13% cases as a cause of ileo-cecalulcers. So all symptomatic patients with I/C ulcers on colonoscopy are not Crohn’s.

Hybrid natural orifice transluminal endoscopic surgery for ileocecal resection

Although laparoscopic colectomy is commonly performed around the world,an operative wound formed during the surgery is large but not sufficient enough to convert for the majority of open surgery.Thus,a certain sized skin incision is required to remove the resected colon.Here we report the case of a pure laparoscopic ileocecal resection which involves transanal specimen extraction.We present a case characterized by a laterally spreading type of tumor of the cecum.We performed a pure laparoscopic ileocecal resection and the resected specimen was removed transanally using colonoscopy.Intracorporeal functional anastomosis was then performed using a flexible linear stapling device under supporting barbed suture traction.The patient was discharged without complications on postoperative day 4.Laparoscopic colectomy performed with minimal incision could essentially increase the usage of this surgical technique.Although our method is restricted to flat or small lesions,we think it is a feasible and realistic solution for minimization of operative invasion because it involves specimen extraction through a natural orifice.

Endoscopic submucosal dissection for large laterally spreading tumors involving the ileocecal valve and terminal ileum

Endoscopic submucosal dissection is a challenging technique that enables en-bloc resection for large colorectal tumors, as laterally spreading tumors, particularly difficult, if the ileocecal valve and terminal ileum is involved. Herein, we report on one of 4 cases. The procedures, using a bipolar needle knife (B-Knife) to reduce the perforation risk and carbon dioxide instead of conventional air insufflation for patient comfort, achieved curative resections without any complications.

Enteroenteroanastomosis near adjacent ileocecal valve in infants

AIM:To investigate the feasibility and the effectiveness of ileoileostomy in the region adjacent to the ileocecal valve,which can retain the ileocecal valve in infants.METHODS:This is a retrospective review of 48 patients who underwent ileoileostomy in the region adjacent to the ileocecal valve(group 1) and 34 patients who underwent ileocecal resections and ileotransversanastomosis(group 2).Patients were monitored for the time to flatus,resumption of eating,length of hospital stay after surgery,serum total bile acid,vitamin B12 and postoperative complications.RESULTS:The time to flatus,time until resumption of eating and post-operative length of hospital stay showed no statistically significant differences between the two groups.Serum total bile acid and vitamin B12were not significantly different between the two groups at post-operative day 1 and day 3,but were significantly decreased at 1 wk after operation in group 2.None of the patients died or suffered from stomal leak in these two groups.However,the incidence of diarrhea,intestinal infection,disturbance of acid-base balance and water-electrolytes in group 1 was lower than in group 2.CONCLUSION:Ileoileostomy in the region adjacent to the ileocecal valve is safe and results in fewer complications than ileotransversanastomosis in infants.

Ileocecal valve dysfunction in small intestinal bacterial overgrowth: A pilot study

AIM: To explore whether patients with a defective ileocecal valve (ICV)/cecal distension reflex have small intestinal bacterial overgrowth. METHODS: Using a colonoscope, under conscious sedation, the ICV was intubated and the colonoscope was placed within the terminal ileum (TI). A manometry catheter with 4 pressure channels, spaced 1 cm apart, was passed through the biopsy channel of the colonoscope into the TI. The colonoscope was slowly withdrawn from the TI while the manometry catheter was advanced. The catheter was placed across the ICV so that at least one pressure port was within the TI, ICV and the cecum respectively. Pressures were continuously measured during air insufflation into the cecum, under direct endoscopic visualization, in 19 volunteers. Air was insufflated to a maximum of 40 mmHg to prevent barotrauma. All subjects underwent lactulose breath testing one month after the colonoscopy. The results of the breath tests were compared with the results of the pressures within the ICV during air insufflation. RESULTS: Nineteen subjects underwent colonoscopy with measurements of the ICV pressures after intubation of the ICV with a colonoscope. Initial baseline readings showed no statistical difference in the pressures of the TI and ICV, between subjects with positive lactulose breath tests and normal lactulose breath tests. The average peak ICV pressure during air insufflation into the cecum in subjects with normal lactu-lose breath tests was significantly higher than cecal pressures during air insufflation (49.33 ± 7.99 mmHg vs 16.40 ± 2.14 mmHg, P = 0.0011). The average percentage difference of the area under the pressure curve of the ICV from the cecum during air insufflations in subjects with normal lactulose breath tests was significantly higher (280.72% ± 43.29% vs 100% ± 0%, P = 0.0006). The average peak ICV pressure during air insufflation into the cecum in subjects with positive lactulose breath tests was not significantly different than cecal pressures during air insufflation 21.23 ± 3.52 mmHg vs 16.10 ± 3.39 mmHg. The average percentage difference of the area under the pressure curve of the ICV from the cecum during air insufflation was not significantly different 101.08% ± 7.96% vs 100% ± 0%. The total symptom score for subjects with normal lactulose breath tests and subjects with positive lactu-lose breath tests was not statistically different (13.30 ± 4.09 vs 24.14 ± 6.58). The ICV peak pressures during air insufflations were significantly higher in subjects with normal lactulose breath tests than in subjects with positive lactulose breath tests (P = 0.005). The average percent difference of the area under the pressure curve in the ICV from cecum was significantly higher in subjects with normal lactulose breath tests than in subjects with positive lactulose breath tests (P = 0.0012). Individuals with positive lactulose breath tests demonstrated symptom scores which were significantly higher for the following symptoms: not able to finish normal sized meal, feeling excessively full after meals, loss of appetite and bloating. CONCLUSION: Compared to normal, subjects with a positive lactulose breath test have a defective ICV cecal distension reflex. These subjects also more commonly have higher symptom scores.

New concept of ileocecal junction:Intussusception of the terminal ileum into the cecum

AIM: To prove that the terminal ileum is intussuscepted into the cecum creating the ileocecal junction,contrary to previous valvular concept which has been widely believed. METHODS: This study is based on gross and microscopic examinations of fresh specimens derived from colonic operations (right hemicolectomy or subtotal colectomy). Data compiled from observing and dissecting of specimens of seven patients are used to examine both gross and microscopic appearance of ileocecal junction. RESULTS: Intussusception of the terminal ileum was found in every specimen. However,the length of intussusception was different in each specimen. CONCLUSION: Gross and microscopic appearance studies suggest that the terminal ileum is intussuscepted into the cecum.

Malignant obstruction in the ileocecal region treated by selfexpandable stent placement under the fluoroscopic guidance: A case report

BACKGROUND Malignant tumors of the ileocecal region often cause intestinal obstruction.Emergency surgery is the main treatment for patients presenting with an obstruction.However,this procedure is associated with a high mortality rate and frequent complications.The placement of colon stents is commonly performed for obstructions in the distal colon and is a less invasive and safer procedure.However,obstructions in the proximal colon are more challenging to treat by stent placement due to the increased distance from the anus.CASE SUMMARY This case report concerns an 88-year-old man with malignant intestinal obstruction in the ileocecal region.He was contraindicated for general anesthesia and surgical enterostomy.The placement of a self-expandable metallic stent seems an alternative to surgery,although stenting in this area is thought to be difficult and few studies have been reported so far.After three attempts at different interventional approaches,a stent was successfully placed in the obstructed segment under fluoroscopic guidance.After the procedure,the patient's abdominal distension and abdominal pain were significantly better than before.CONCLUSION For patients with proximal colonic obstruction,self-expandable metallic stent placement under fluoroscopic guidance could be considered as a feasible treatment to relieve abdominal distension and pain in patients with acute bowel obstruction.It has the characteristics of high safety and high patient tolerance.However,further study is still needed.

Effects of aging on the architecture of the ileocecal junction in rats

AIM: To evaluate the structural organization of the elastic and collagen fibers in the region of the ileocecal transition in 30 young and old male Wistar rats. METHODS: Histology, immunohistochemistry(IHC), transmission electron microscopy and scanning electron microscopy were employed in this study. The results demonstrated that there was a demarcation of the ileocecal region between the ileum and the cecum in both groups. RESULTS: The connective tissue fibers had different distribution patterns in the two groups. IHC revealed the presence of nitric oxide synthase, enteric neurons and smooth muscle fibers in the ileocecal junctions(ICJs) of both groups. Compared to the young group, the elderly group exhibited an increase in collagen type Ⅰ?fibers, a decrease in collagen type Ⅲ fibers, a decreased linear density of oxytalan elastic fibers, and a greater linear density of elaunin and mature elastic fibers. CONCLUSION: The results revealed changes in the patterns of distribution of collagen and elastic fibers that may lead to a possible decrease in ICJ functionality.

Surgical Treatment of Small Intestinal Bleeding Caused by Arterial Gastrointestinal Fistula: A 2-Case Report

Background: This study aims to better understand diagnosing and treating arterial gastrointestinal fistulas. Methods: The diagnosis and treatment of two patients with arterial gastrointestinal fistulas were reported, and the experience with diagnosis and treatment was summarized. Results: In these two cases, both patients were admitted with bleeding as the primary complaint, both underwent emergency laparotomies, and both patients were diagnosed with small intestinal bleeding before surgery. the first patient died as a result of an abdominal aortic aneurysm rupture caused by chronic vascular repair and postoperative implant infection;the second patient underwent vascular repair on time, we treated him with third-generation cephalosporin, and after he was stabilized, we performed left total iliac stent placement and left internal iliac artery embolization;he had no fever after surgery, his incision was healed, and he was successfully discharged from the hospital. Conclusion: Aortic gastrointestinal fistula is rare and has a high mortality rate, attention should be paid to distinguishing it from small intestinal bleeding. Timely diagnosis and rapid surgical treatment are keys to improving survival.

Campylobacter jejuni enterocolitis presenting with testicular pain: A case report

BACKGROUND Common symptoms of Campylobacter colitis include abdominal pain,vomiting,diarrhea,and fever,among others.However,Campylobacter colitis also has a high incidence of extraintestinal symptoms.CASE SUMMARY We report the case of a 51-year-old man who presented with bilateral testicular pain.A scrotal examination failed to reveal any physical findings,but the patient exhibited mild tenderness in the right lower abdomen.Computed tomography revealed ileocecal wall thickening.Post-admission,the patient developed diarrhea,and a stool culture was submitted;Campylobacter jejuni infection was confirmed.Testicular pain is known to be caused by appendicitis.Consequently,we suggest that Campylobacter colitis,which causes ileocecal inflammation,caused the testicular pain in this case.CONCLUSION In patients with testicular pain and no other objective findings,diseases such as Campylobacter colitis should be considered.

What constitutes failure of medical therapy in the changing landscape of Crohn's disease?

The management of Crohn's disease has evolved rapidly in the era of immunomodulators and biologicals.Despite this,a significant proportion of patients with Crohn's disease ultimately require surgical management.One of the indications for operative management includes failure of medical therapy.We report two cases of patients with complicated Crohn's disease who have exhausted medical therapy and failed medical management.In both cases,the patients developed large complex intra-abdominal phlegmons and intractable symptoms of intermittent pain,partial obstruction and/or infectious complications requiring operative intervention.Crohn's disease can present with a wide spectrum of disease.Considering the complexity of management in Crohn's disease,it is important for both physicians and surgeons to be aware of what constitutes failure of medical therapy and when it may be important to consider surgical involvement.

Rare Case of Acute Peritonitis by Perforation of an Appendicular Schistosomiasis at the CHU BSS in Kati

Perforation of a pseudo appendicular tumor of bilharzial origin (bilharzia) is a rare etiology of acute peritonitis. His diagnosis is histopathological. The existence of comorbid malaria and surgical pathology is frequent in having a positive thick drop with Schistosoma mansoni eggs in his stool. After 3 months, the patient is doing well. In conclusion, we recommend the histopathological analysis of the surgical specimen after appendectomy and the detection of haematozoa for malaria in any case of fever in a surgical environment.