Safer intestinal invagination for a solid pancre-atico-jejunal anastomosis in presence of a soft texture pancreatic remnant and non-dilated duct

Pancreatico-jejunal anastomosis after pancreato- duodenectomy still represents the Achilles＇ heel of the proce- dure： the failure of this anastomosis is relatively common and it is the main cause of post-operative morbidity and mortality. Studies have described different reconstruction strategies for the control of the development of post-operative pancreatic fistula, but the strategy to obtain a safer pancreatico-jejunal anastomosis is still far from satisfaction. We report a novel variation of the invagination technique based on preliminary clinical experience in 8 patients who underwent pancreatico- jejunal anastomosis after pancreatoduodenectomy in our hepatobiliopancreatic center from 2008 to 2014. The varia- tion could obtain a safer intestinal invagination for a solid pancreatico-jejunal anastomosis even in the presence of soft pancreatic remnant.

Jejuno-jejunal invagination due to intestinal melanoma

Cutaneous melanoma is one of the most studied neoplastic lesions in biology and clinical oncology. It has been well documented that this type of neoplasm presents a high metastatic rate, and is able to involve nearly every tissue. Non-cutaneous melanoma represents an unusual pattern of melanoma, and the small intestine is an uncommon anatomic localization. Herein we report an extremely rare clinical case of a young woman affected by a bleeding jejunal melanoma, whose early clinical presentation was an intestinal invagination.

Does Adult Intestinal Invagination Need Surgery? Report of a Case and Review of Literature

Benign intestinal tumors are the most frequent cause of small bowel intussusception in adults. This report presents a case of a 67-year-old male with abdominal pain, leukocytosis and C-reactive protein elevation. After ultrasonography and double contrast CT-scan consistent with ileal intussusception patient underwent laparoscopy, which confirmed diagnose. Intestinal resection and anastomosis were performed via minilaparotomy. Further histological study showed a fibroid inflammatory polyp or Vanek’s tumor as intussusception’s lead point.

Acute Intestinal Invagination of the Child at the Teaching Hospital of Bouaké: Ultrasound Diagnosis and Clinical-Echo-Surgical Correlation

Background: Acute intestinal invagination or intussusception is the most common abdominal surgical emergency in infants, but it can occur at any age. Performing an ultrasound scan at the slightest clinical suspicion contributes to early diagnosis and therapeutic management. Objective: To show the relevance of ultrasound in the therapeutic management of the child’s intussusception through a correlation between the ultrasound diagnosis and the clinical and/or per operative diagnosis. Patients and Methods: It was a retrospective study of 24 cases from July 2017 to September 2020 (30 months) in the Medical Imaging and Paediatric Surgery departments of Teaching Hospital of Bouaké. We included only patients from 0 to 15 years old who had digestive symptoms, an abdominal ultrasound scan. These patients were eligible for surgery. Data analysis was performed with Epi info 7 software. Results: Median age was 17.2 months [02 - 120]. Male gender predominated (83.3%). Clinico-biological data were dominated by abdominal pain (79.2%), vomiting (75%) and rectorragies (33.3%), with Ombredanne’s triad in 33.3% and hyperleukocytosis (70.8%). Ultrasonography showed invaginated coves (95.8%) sitting in the right angl iliac fossa, peri-umbilical and right flank in 73.9%. Cockade image coupled with the sandwich image accounted for 95.6%. Superficial adenopathies (45.8%) and peri-lesional fluid effusion (20.8%) were associated with it. An occlusive syndrome complicating intussusception was observed in 41.67% associated with intra-peritoneal effusion of fluid (25%). There was a significant diagnostic agreement between the clinic, ultrasound and surgery according to the Fisher’s exact test (p = 0.002). That between ultrasound and surgery was calculated at 95.4%. Conclusion: This study allowed us to show a good clinical-echo-surgical concordance. Ultrasound is therefore an undeniable diagnostic, prognostic and therapeutic tool in the exploration of intussusception, hence the interest of its prescription in the shortest possible time by the clinician.

Meckel Diverticulum Carcinoid Tumor Complicated by Ileal Invagination. About One Case at Vichy Hospital

Meckel’s diverticulum is a common pathology in children and rare in adults. We present a case of a 79-year-old patient in which a significant gastrointestinal bleeding, whose paraclinical explorations confirmed a fatty tumor of the terminal ileum. The exploratory coelioscopy revealed a tumor of the Meckel diverticulum complicated of intestinal invagination, resected at the same time with resection and extracorporeal anastomosis by mini coelio-guided laparotomy. Histology confirmed the presence of heterotopical tissue of the duodenal mucosa with Brunner cells and a carcinoid tumor. In conclusion, this clinical case shows that coelioscopy can be considered a very important diagnostic and therapeutic tool in this pathology especially in the elderly.

Duct-to-mucosa versus invagination pancreaticojejunostomy after pancreaticoduodenectomy： a meta-analysis

Background Postoperative pancreatic fistula remains one of the most common and troublesome complications following pancreaticoduodenectomy. No consensus exists regarding the optimal pancreaticojejunostomy reconstruction technique to reduce this complication. We aimed to perform a systematic review comparing two commonly used techniques of pancreaticojejunostomy reconstruction （duct-to-mucosa versus invagination）, by meta-analysis and assessment of evidence quality. Methods Databases searched including The Cochrane Library, Medline, PubMed, Embase, etc. Randomized controlled trials （RCTs） comparing duct-to-mucosa and invagination pancreaticojejunostomy were included. Outcomes of interest were pancreatic fistula rate, mortality, morbidity, reoperation and hospital stay. Pooled estimates were expressed as risk ratio （RR） or mean difference. Results From 321 identified abstracts, four RCTs （467 patients; duct-to-mucosa： 232; invagination： 235） were included. Pancreatic fistula rate （RR, 0.74; 95% confidence interval （C/）： 0.24-2.28; P=0.60）, mortality （RR, 1.18; 95% CI： 0.39- 3.54; P=0.77）, morbidity （RR, 0.91; 95% CI： 0.69-1.21; P=0.53）, reoperation （RR, 1.09; 95% CI： 0.54-2.22; P=-0.81） and hospital stay （mean difference, -1.78; 95% CI： -4.60-1.04; P=0.22） were similar between techniques. Conclusions Duct-to-mucosa and invagination pancreaticojejunostomy are comparable with regards to assessed parameters. High-quality, large-volume, multi-center RCTs with standard outcome definitions are required.

Ileo-ileal invagination caused by lymphoma

To the editor： Intestinal invagination is uncommon in adults, and neoplasm is the main cause. Ileo-ileal invagination due to lymphoma in adults has been rarely reported in the literature.

Surgical treatment of congenital basilar invagination with different pathological characteristics: Report of 139 cases

Objective: To describe the different pathological characteristics of congenital basilar invaginations and discuss the surgical treatment of such cases. Methods: A total of 139 patients diagnosed with basilar invaginations underwent surgical treatment from 2008 to 2015. Based on Atul Goel's classification and simultaneous consideration of atlantoaxial dislocation or syringomyelia,the cases were subdivided into four groups. Individualized posterior surgical decompression and/or atlantoaxial reset procedures were performed to correct atlantoaxial dislocation,decompress the brain stem,or resolve syringomyelia. The indications and critical points of each procedure were documented. Results: All 139 patients were surgically treated; 27 patients(19.4%) had underwent at least one decompression surgery previously. On an average,there was gratifying clinical improvement based on the Japanese Orthopaedic Association score analysis.One patient exhibited severe post-operative infection,and the fusion instrument was removed. One patient experienced fracture of internal fixation. Two patients exhibited persistent respiratory symptoms at early stages after the surgery. Four patients felt worse at the latest follow-up. There was no surgical mortality. The poor outcome/morbidity in this series was 5.8%(8/139). Conclusion: The different pathological image characteristics of congenital basilar invaginations based on the presence or absence of syringomyelia and/or atlantoaxial dislocation,reflected the pathological features of complicated basilar invaginations more accurately. Based on these features,different posterior decompression and/or reset procedures,combined with occipitocervical fusion and C1-2 fusion,could be tailored to different patients. These individualized surgeries could reduce surgical complications,decrease morbidity and mortality,and further promote positive outcomes.

Intussusception of the bowel in adults:A review

Intussusception of the bowel is defined as the telescop-ing of a proximal segment of the gastrointestinal tract within the lumen of the adjacent segment.This condi-tion is frequent in children and presents with the classic triad of cramping abdominal pain,bloody diarrhea and a palpable tender mass.However,bowel intussusception in adults is considered a rare condition,accounting for 5% of all cases of intussusceptions and almost 1%-5%of bowel obstruction.Eight to twenty percent of cases are idiopathic,without a lead point lesion.Secondary intus-susception is caused by organic lesions,such as inflam-matory bowel disease,postoperative adhesions,Meckel's diverticulum,benign and malignant lesions,metastatic neoplasms or even iatrogenically,due to the presence of intestinal tubes,jejunostomy feeding tubes or after gas-tric surgery.Computed tomography is the most sensitive diagnostic modality and can distinguish between intus-susceptions with and without a lead point.Surgery is the definitive treatment of adult intussusceptions.Formal bowel resection with oncological principles is followed for every case where a malignancy is suspected.Reduction of the intussuscepted bowel is considered safe for benign lesions in order to limit the extent of resection or to avoid the short bowel syndrome in certain circumstances.

Jejunal small ectopic pancreas developing into jejunojejunal intussusception:A rare cause of ileus

Intussusception is rare in adults. We describe a 62-year-old man with jejunal ectopic pancreas that led to jejunojejunal intussusception and ileus. The patient was admitted to our hospital because of intermittent abdominal pain. Plain abdominal radiography showed some intestinal gas and fluid levels. Abdominal CT scan demonstrated a target sign suggesting bowel intussusception. Jejunography using a naso-jejunal tube showed an oval-shaped mass about 15 mm in diameter with a smooth surface in the jejunum, which suggested a submucosal tumor (SMT), and edematous mucosa around the mass. Partial jejunal resection was carried out and the resected oval-shaped tumor, 14 mm×11 mm in size, was found to be covered with normal jejunal mucosa. The tumor was histologically diagnosed as type ectopic pancreas according to the classification proposed by Heinrich.Abdominal pain resolved postoperatively.This case reminds us that jejunal ectopic pancreas should be included in the differential diagnosis of intussusception caused by an SMT in the intestine.

Role of dynamic computed tomography scans in patients with congenital craniovertebral junction malformations

AIM To evaluate the role of dynamic computed tomography(CT)scan imaging in diagnosing craniovertebral junction(CVJ)instability in patients with congenital CVJ malformations.METHODS Patients with symptomatic congenital CVJ malformations who underwent posterior fossa decompression and had a preoperative dynamic CT scan in flexion and extended position were included in this study.Measurements of the following craniometrical parameters were taken in flexed and extended neck position:Atlanto-dental interval(ADI),distance of the odontoid tip to the Chamberlain’s line,and the clivus-canal angle(CCA).Assessment of the facet joints congruence was also performed in both positions.Comparison of the values obtained in flexion and extension were compared using a paired Student’s t-test.RESULTS A total of ten patients with a mean age of 37.9 years were included.In flexion imaging,the mean ADI was1.76 mm,the mean CCA was 125.4°and the mean distance of the odontoid tip to the Chamberlain’s line was+9.62 mm.In extension,the mean ADI was1.46 mm(P=0.29),the mean CCA was 142.2°(P<0.01)and the mean distance of the odontoid tip to the Chamberlain’s line was+7.11 mm(P<0.05).Four patients(40%)had facetary subluxation demonstrated in dynamic imaging,two of them with mobile subluxation(both underwent CVJ fixation).The other two patients with a fixed subluxation were not initially fixed.One patient with atlantoaxial assimilation and C23 fusion without initial facet subluxation developed a latter CVJ instability diagnosed with a dynamic CT scan.Patients with basilar invagination had a lower CCA variation compared to the whole group.CONCLUSION Craniometrical parameters,as well as the visualization of the facets location,may change significantly according to the neck position.Dynamic imaging can provide additional useful information to the diagnosis of CVJ instability.Future studies addressing the relationship between craniometrical changes and neck position are necessary.

Ileal schwannoma developing into ileocolic intussusception

Intussusception is rare in adults. We describe a 47-year-old man with ileal schwannoma that led to ileocolic intussusception. Abdominal ultrasonography,abdominal CT scan and barium enema confirmed an ileal tumor. Colonoscopy revealed a peduncular submucosal tumor (SMT) 75 mm long with an ulcerated apex at the ascending colon. The provisional diagnosis was a gastrointestinal stromal tumor of the terminal ileum. Ileocecal resection was carried out and the tumor was histologically diagnosed as schwannoma. Abdominal pain resolved postoperatively. This case reminds us that ileal schwannoma should be included in the differential diagnosis of intussusception caused by an SMT in the intestine.

Bowel intussusception in adult:Prevalence,diagnostic tools and therapy

Intussusception is defined as invagination of one segment of the bowel into animmediately adjacent segment. The intussusception refers to the proximalsegment that invaginates into the distal segment, or the intussusception (recipientsegment). Intussusception, more common occur in the small bowel and rarelyinvolve only the large bowel. In direct contrast to pediatric etiologies, adultintussusception is associated with an identifiable cause in almost all thesymptomatic cases while the idiopathic causes are extremely rare. As there aremany common causes of acute abdomen, intussusception should be consideredwhen more frequent etiologies have been ruled out. In this review, we discuss thesymptoms, location, etiology, characteristics, diagnostic methods and treatmentstrategies of this rare and enigmatic clinical entity in adult.

Jejunojejunal Intussusception following Jejunostomy

Intussusception is an invagination of a segment of the gastrointestinal tract into an adjacent one. Jejunojejunal intussusception is a rare complication of jejunostomy tube placement with an incidence of 1%. We are reporting a case of 35-year-old man who was suffering from severe oral, lesions due to Ingestion of acide agents. He received Witzel jejunostomy for early feeding. Ileus developed postoperatively and plain X-ray of the abdomen showed distended small bowel loop. Abdominal computed tomography revealed target sign as well as the feeding tube in a dilated jejunum and intussusception was diagnosed. Exploratory laparotomy was required due to failure of expectant therapy. Reduction of intussusception was done during exploratory laparotomy. The jejunostomy feeding was continued and the postoperative course was uneventful.

Back to basics:A meta-analysis of stump management during open appendicectomy for uncomplicated acute appendicitis

AIM: To compare simple ligation vs stump invagination during open appendicectomy for uncomplicated acute appendicitis on the risk of postoperative complications. METHODS: A meta-analysis was conducted on randomised controlled trials comparing the two stump closure methods in open appendicectomy. Databases searched were Pub Med, EMBASE and Cochrane Library databases. Included were those studies focusing on inflamed and suppurative appendicitis while perforated and gangrenous appendix was excluded. We also excluded retrospective case-control studies, commentaries, historical technical articles, or trials involving laparoscopic appendicectomies. The outcome of the meta-analysis was to find eventual differences in theincidence of postoperative ileus and wound infections between the two techniques of stump invagination. RESULTS: Seven studies were included corresponding to 1468 patients. Postoperative complications consisted in wound infections(7%), ileus(4%), pyrexia(2%), vomiting(1%), obstructions from adhesions(0.1%). No cases of peritonitis, fecal fistulas(stump leaks), abdominal abscesses or wound dehiscences were reported. Postoperative ileus within the first 72 h was four times more frequent with stump invagination compared to simple ligation(OR: 4.06; 95%CI: 2.14-7.70; P < 0.0001). No significant differences were noted for wound infections(OR: 1.24; 95%CI: 0.83-1.87; P = 0.30) while for the remaining complications the incidence was extremely low in both groups. There was a high homogeneity on results(Q value for heterogeneity of postoperative ileus P = 0.17; Q value for heterogeneity of wound infections P = 0.98). CONCLUSION: Stump invagination does not seem to prevent infective complications but is associated with an increased risk of postoperative ileus in uncomplicated cases. Appropriate studies on complicated appendicitis should now evaluate the influence of the two techniques in this higher-risk subgroup.

Unusual Initial Presentation Of Celiac Disease in Children: Three Case Reports

Background: The togetherness of invagination with celiac disease is an extremely rare condition especially in children. However, invagination may be the presenting symptom of celiac disease. Moreover, recurrent invaginations have been also reported in patients with celiac disease. Aim: To increase the awareness of clinicians about togetherness of these conditions. Case Presentation: Herein, we will discuss three children with diagnosis of celiac disease who presented with invagination and intestinal pseudo-obstruction. Conclusion: Children with pseudo-obstruction and invagination without an underlying etiology should be evaluated for the presence of celiac disease, especially if they have accompanying growth retardation or anemia and if they are at an unusual age for invagination. Further studies are warranted to elucidate the exact relationship of invagination with celiac disease.

Prevention of pancreaticojejunal anastomotic leakage after pancreaticoduodenectomy with separate internal drainage of bile and pancreatic fluid

OBJECTIVE: To introduce a new reconstructional procedure to deerease the complications afterpancreaticoduodenectomy.METHODS: Separate internal drainage of bile and pancreatic fluid in pancreaticiduodenectomy wasperformed in 256 patients. The digestive tract was reconstructed with Child method, with invaginatedpancreaticojejunostomy using a long silastic tube to drain pancreatic fluid internally, an end-to-sidecholedochojejunostomy and an end-to-side duodenojejunostomy or gastrojejunostomy. Gastrostomy drainagewas also performed.RESULTS: No complications of pancreatic leakage were found.CONCLUSION: The separate internal drainage of bile and pancreatic fluid plays an important role inpreventing pancreaticojejunal anastomotic leakage.

Endoscopic endonasal approach to the craniovertebral junction

The surgical approach to lesions of the ventral craniovertebral junction(CVJ)has evolved significantly in the last several years with the advent of endoscopic skull base surgery.Differing pathologies of the CVJ can result in irreducible compression of the cervicomedullary region.The endoscopic endonasal approach lends itself well to this region due to the ventral location,and while there is a steep learning curve,is a safe and effective way to perform decompression of the cervicomedullary region.Herein,we discuss the anatomy of the CVJ,preoperative evaluation and surgical considerations,our surgical approach,complications,and outcomes.

Biodegradable cationic e-poly-L-lysine-conjugated polymeric nanoparticles as a new effective antibacterial agent

Biocompatible and biodegradable ε-poly-L- lysine （EPL）/poly （ε-caprolactone） （PCL） copolymer was designed and synthesized. The amphiphilic EPL-PCL copolymer could easily self-assembled into monodispersed nanoparticles （NPs）, which showed a broad-spectrum antibacterial activity against Escherichia coli, Staphylococcus aureus and Bacillus subtilis. Interestingly, the antibacterial efficacy of the novel NPs is more potent than the cationic peptide EPL. To explore the underlying mechanism of the biodegradable cationic NPs, various possible antibacterial pathways have been validated. The NPs have been found that they can disrupt bacterial walls/ membranes and induce the increasing in reactive oxygen species and alkaline phosphatase levels. More importantly, the self-assembled NPs induced the changes in bacterial osmotic pressure, resulting in cell invagination to form holes and cause the leakage of cytoplasm. Taken together, our results suggest that the EPL-PCL NPs can be further developed to be a promising antimicrobial agent to treat infectious diseases as surfactants and emulsifiers to enhance drug encapsulation efficiency and antimicrobial activity.

Pristine mesoporous carbon hollow spheres as safe adjuvants induce excellent Th2-biased immune response

The development of a safe and effective adjuvant that amplifies the immune response to an antigen is important for vaccine delivery. In this study, we developed pristine mesoporous carbon hollow spheres as high-capacity vaccine protein nanocarriers and safe adjuvants for boosting the immune response. Mono-dispersed invaginated mesostructured hollow carbon spheres （IMHCSs） have an average particle size of -200 nm, large pore size of 15 rim, and high pore volume of 2.85 cmB.g-1. IMHCSs exhibited a very high loading capacity （1,040 ~tg-mg-1） towards ovalbumin （OVA, a model antigen）, controlled OVA release behavior, excellent safety profile to normal cells, and high antigen delivery efficacy towards macrophages. In vivo immunization studies in mice demonstrated that OVA-loaded IMHCSs induced a 3-fold higher IgG response compared to a traditional adjuvant QuilA used in veterinary vaccine research. OVA delivered by IMHCSs induced a higher IgG1 concentration than IgG2a, indicating a T-helper 2 （Th2）-polarized response. Interferon-y and interleukin-4 concentration analysis revealed both T-helper 1 （Thl） and Th2 immune responses induced by OVA- loaded IMHCSs. IMHCSs are safer adjuvants than QuilA. Our study revealed that pure IMHCSs without further functionalization can be used as a safe adjuvant for promoting Th2-biased immune responses for vaccine delivery.