Assessment of perianal fistulizing Crohn’s disease activity with endoanal ultrasound: A retrospective cohort study

BACKGROUND Perianal fistulas pose dual challenges to Crohn's disease(CD)patients.Low patient compliance due to the complexity of existing examination methods plagues the treatment and follow-up management of perianal CD.AIM To determine the accuracy of endoanal ultrasound(EUS)and shear wave elastography(SWE)for evaluating perianal fistulizing CD(PFCD)activity.METHODS This was a retrospective cohort study.A total of 67 patients from August 2022 to December 2023 diagnosed with CD were divided into three groups:Non-anal fistula group(n=23),low-activity perianal fistulas[n=19,perianal disease activity index(PDAI)≤4],high-activity perianal fistulas(n=25,PDAI>4)based on the PDAI.All patients underwent assessments including EUS+SWE,pelvic magnetic resonance[pelvic magnetic resonance imaging(MRI)],C-reactive protein,fecal calprotectin,CD activity index,PDAI.RESULTS The percentage of fistulas indicated by pelvic MRI and EUS was consistent at 82%,and there was good consistency in the classification of perianal fistulas(Kappa=0.752,P<0.001).Significant differences were observed in the blood flow Limberg score(χ^(2)=8.903,P<0.05)and shear wave velocity(t=2.467,P<0.05)between group 2 and 3.Shear wave velocity showed a strong negative correlation with magnetic resonance novel index for fistula imaging in CD(Magnifi-CD)score(r=-0.676,P<0.001),a weak negative correlation with the PDAI score(r=-0.386,P<0.05),and a weak correlation between the Limberg score and the PDAI score(r=0.368,P<0.05).CONCLUSION EUS combined with SWE offers a superior method for detecting and quantitating the activity of perianal fistulas in CD patients.It may be the ideal tool to assess PFCD activity objectively for management strategies.

Gallbladder perforation with fistulous communication

BACKGROUND The management of gallbladder perforation(GBP)with fistulous communication(Neimeier type I)is controversial.AIM To recommend management options for GBP with fistulous communication.METHODS A systematic review of studies describing the management of Neimeier type I GBP was performed according to the PRISMA guidelines.The search strategy was conducted in Scopus,Web of Science,MEDLINE,and EMBASE(May 2022).Data extraction was obtained for patient characteristics,type of intervention,days of hospitalization(DoH),complications,and site of fistulous communication.RESULTS A total of 54 patients(61%female)from case reports,series,and cohorts were included.The most frequent fistulous communication occurred in the abdominal wall.Patients from case reports/series had a similar proportion of complications between open cholecystectomy(OC)and laparoscopic cholecystectomy(LC)(28.6 vs 12.5;P=0.569).Mortality was higher in OC(14.3 vs 0.0;P=0.467)but this proportion was given by only one patient.DoH were higher in OC(mean 26.3 d vs 6.6 d).There was no clear association between higher rates of complications of a given intervention in cohorts,and no mortality was observed.CONCLUSION Surgeons must evaluate the advantages and disadvantages of the therapeutic options.OC and LC are adequate options for the surgical management of GBP,with no significant differences.

Is delayed gastric emptying so terrible after pylorus-preserving pancreaticoduodenectomy? Prevention and management

AIM： To explore some operative techniques to prevent the occurrence of delayed gastric emptying （DGE） alter pylorus-preserving pancreaticoduodenectomy （PPPD）.METHODS： One hundred and eighty-six patients in a single medical center who accepted PPPD were retrospectively studied. The incidence of DGE was investigated and the influence of some operative techniques on the prevention of DGE was analyzed.RESULTS： During the operative process of PPPD, the methods of detached drainage of pancreatic fluid and bile and gastric fistulization were used. Postoperatively, six patients suffered DGE among the 186 cases; the incidence was 3.23% （6/186）. One of them was complicated with intraabdominal infection at the same time, and two with pancreatic leakage.CONCLUSION： Appropriate maneuvers during operation are essential to avoid postoperative DGE in PPPD. The occurrence of DGE is avoidable. It should not be used as an argument to advocate hemigastrectomy in PPPD.

One more chance of fistula healing in inflammatory bowel disease:Stem cell therapy

Patients with fistulizing inflammatory bowel disease are traditionally difficult to treat. This patient population often experiences delayed or insufficient healing of fistulas using current standard regimens including anti-biotics, immunomodulators, anti-tumor necrosis factor--α drug, placement of setons, and surgical repair. Several studies over the last ten to fifteen years have been conducted using stem cell therapies with promising results in this patient population. These studies show stem cell therapy in fistulizing disease to be successful in healing between 60%--88% compared to currently 50% with infliximab. Moreover, remission was seen 24 wk to 52 wk in these studies. Further research with a multi--approach treatment using medications, stem cell therapy, and surgical interventions will likely be the future of this innovative treatment approach.

Mineral Concentrations and Rumen Degradability of Biodegraded <i>Enterolobium cyclocarpum</i>(Jacq) and <i>Pterocarpus santalinoides</i>(L’Her) with <i>Aspergillus niger</i>

The effects of solid state fermentation on the mineral concentrations and in sacco degradation characteristics of dry matter in two multipurpose tree leaves was investigated. Biodegraded Enterolobium cyclocarpum (EC) and Pterocarpus santalinoides (PS) leaves were previously inoculated with Aspergillus niger and incubated at 30&degC for five incubation periods (0, 7, 14, 21 and 28 days). After each incubation period, samples were oven dried at 60&degC, allowed to cool and ground for mineral analysis and in sacco dry matter degradability. Three fistulated West African Dwarf (WAD) rams (Ovis aries) were then used for the dry matter degradability. Five grams of each sample was emptied into nylon bag (Polymon, Switzeland) with pore size of 4 μ and effective size of 5 cm × 18 cm and incubated in the rumen of the fistulated animals for 6, 12, 24, 48, 72, and 96 h. The results showed that the mineral contents of biodegraded EC samples were affected by incubation period. Mean values of Ca, Cu, K, Na, and Zn were significantly increased (0.05), while mean values of Fe, Mg, and Mn were first reduced before significantly increasing (0.05). However, the composition of P showed significant reduction (0.05) up to day 28 where no change was observed. Mineral concentrations in biodegraded PS were also affected by incubation periods. Values of Ca, Fe, K, Mg, Mn, Na, and Zn were significantly increased (0.05). However values of Cu, and Fe only increased after day 14, while the value of P was reduced significantly over the different incubation periods. Potential degradability (PD) for biodegraded EC was highest at day 0 (50.79%) but not significantly different from potential degradability of longer incubation periods to day 28 (48.68%). PS had higher PD than EC. In spite of high PD values, PS comparatively degraded faster than EC. Effective degradability (ED) for EC was highest for day28 (36.71%) and not significantly different from days 21 (34.83%) and 7 (35.29%) but significantly different from days 0 (31.32%) and 14 (31.75%) respectively. However, the ED for PS was highest for day 0 (31.39) samples and significantly differed from other incubation periods, further increase in period only showed lower but similar ED values for days 7 (27.52%), 14 (26.76%), 21 (27.42%) and 28 (26.86%) respectively. In this study, the continued reduction in P concentrations in both biodegraded EC and PS suggest that Aspergillus niger has preferential demand for P and in sacco degradation showed increase in PD and ED values for fungal biodegraded EC and reduction in PS, suggesting improved quality of EC.

Effects of Rice Straw Silicification and Characters of Extraction Biogenic Silicon on the Degradation of Fibrous Components in Rice Straw

Straw of seven rice varieties with early-, middle- and late maturity was collected from Huazhong Agricultural University in Hubei. A study was carried out for rice straw in the aspects of the characters of straw silicification and extraction biogenic silica (EBSi), the relationship between characters of EBSi and kinetic characteristics of degradation of fibrous components in fistulated cows, as well as the effect of urea treatment on rice straw desilicification. Although total silica content (ADISi) in rice straw was similar, the efficiency of extraction biogenic silica (EEBSi) and cellulose in early varieties were significantly higher than those in middle (18.9% and 9.1 %) and late ones (26.1% and 11.2%). The degradability of EBSi and cellulose of early varieties were higher than those of middle by 70.0% and 17.5%, and of late varieties by 47.8% and 23.7% , respectively. The in sacco degradability and in vitro VFA production of early varieties were also higher than those of middle by 14.5% and 19.0%, and late by 12.9% and 14.8%. Comparing the morphological fractions of the rice straws, EEBSi, cellulose content, and in vitro VFA production were different with the order of blade < sheath < stem. A significant correlation was found between the contents of EBSi and cellulose (r= 0.86), and the two contents were remarkably correlated with the potential straw degradability (a + b) by r = 0.90 and 0.84 respectively. Therefore, EBSi in rice straw was a main factor affecting the potential degradability of rice straw, rather than the ADISi of straw. Urea treatment improved rice straw degradability, degradation rate and potential degradability by 10.8% , 27.9% , and 10.1% respectively, compared to untreated straws.

Magnets, children and the bowel: A dangerous attraction?

Reports of magnet ingestion are increasing rapidly globally. However, multiple magnet ingestion, the subsequent potential complications and the importance of the early identification and proper management remain both under-recognized and underestimated. Published literature on such cases could possibly represent only the tip of an iceberg with press reports, web blogs and government documents highlighting further occurrence of many more such incidents. The increasing number of complications worldwide being reported secondary to magnet ingestion point not only to an acute lack of awareness about this condition among the medical profession but also among parents and carers who will be in most cases the first to pick up on magnet ingestion. There still seems to be no consensus on the management of magnet ingestion with several algorithms being proposed for management. Prevention of this condition remains a much better option than cure. Proper education and improved awareness among parents and carers and frontline medical staff is key in addressing this rapidly emerging problem. The goal of managing such cases of suspected magnet ingestion should be aimed at reducing delays between ingestion time, diagnosis time and intervention time.

An unusual presentation of fistulating Crohn's disease:Ascites

Whilst ascites is a common presenting complaint in patients with decompensated chronic liver disease and disseminated malignancy,in Crohn's disease however,it is exceptionally rare.We describe a patient with no prior history of inflammatory bowel or liver disease,presenting with rapid onset gross ascites and scrotal swelling.Further investigations revealed severe hypoalbuminemia and transudative ascitic fluid with normal other liver function tests and a negative liver screen.Computed tomography revealed widespread ascites and pleural effusions with no features of malignancy or portal hypertension,and a small bowel barium series showed features of fistulating small bowel Crohn's disease.An ileo-colonoscopy confirmed the presence of terminal ileal inflammatory stricture.The patient's clinical condition and serum albumin improved with a combination of diuretics,elemental diet,antibiotics and oral 5-aminosalicylic acid therapy.

Surgery of pineal region meningioma combining obstructive hydrocephelus

Objective:The aim of our study was to find out the best operative therapeutic regimen by reviewing the comprehension of operation,the improvement of operative method and the selection of operative approach concerning pineal region meningioma combining obstructive hydrocephalus.Methods:We retrospected the clinic data,comprehension of operation and prognosis of 6 cases of pineal region meningioma.Results:Six tumors were all removed,after that the back wall of the third ventricle was cut open.The 6 tumors were defined as meningioma by pathological examination.After 4-48 months follow-up,the manifestation of hydrocephalus disappeared,other symptoms were relieved more or less without any complication with one patient dismissing.The regular MRI examination indicated that the lesions had not reoccur and the cerebral ventricles had been normal.Conclusion:We identify the nourish arteries of the tumor and anatomy relationship between the tumor and its peripheral blood vessels through modern imaging devices,to select reasonable operative method are the premier therapy of pineal region meningioma.The back wall of the third ventricle becomes thin and the suprapineal recess develops shallow and wide,so the third ventricle-quadrigeminal cistern fistulation can effectively eliminate the obstructive hydrocephalus due to the long-term compression on the aqueduct after removing the tumor.