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Abstract

Systematic study of the mesentery is now possible because of clarification of its structure. Although this area of science is in an early phase, important advances have already been made and opportunities uncovered. For example, distinctive anatomical and functional features have been revealed that justify designation of the mesentery as an organ. Accordingly, the mesentery should be subjected to the same investigatory focus that is applied to other organs and systems. In this Review, we summarise the findings of scientific investigations of the mesentery so far and explore its role in human disease. We aim to provide a platform from which to direct future scientific investigation of the human mesentery in health and disease.

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... The mesentery is a complex, contiguous, membranous peritoneal fold, which starts at the level of the aortic origin of the superior mesenteric artery (known as the root of the mesentery) and then extends in a fan-like fashion toward its insertion at the intestinal border, thus connecting the intestine (from the level of the duodenojejunal junction to the rectum) to the posterior abdominal wall [1]. Several pathologies can affect the mesentery, which could be benign or malignant, solid or cystic, and primary (originating within the mesentery) or secondary. ...
... Several pathologies can affect the mesentery, which could be benign or malignant, solid or cystic, and primary (originating within the mesentery) or secondary. In many cases, the definite diagnosis requires obtaining biopsies or even surgical exploration [1,2]. Many benign mesenteric pathologies (mesenteropathies) present as a mass on imaging, making it difficult to distinguish benign from malignant mesenteropathies [3][4][5][6][7][8]. ...
... The mesentery is one of the forgotten abdominal structures. The clinical, pathophysiological, and immunological functions of the mesentery as a distinct organ have been discussed increasingly in many recent reviews [1,31]. The clinical manifestation of mesenteropathies is variable [1,3]. ...
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Purpose: To evaluate the diagnostic performance of ultrasound point shear wave elastography (pSWE) using acoustic radiation force impulse (ARFI) technology in different benign and malignant mesenteric masses (MMs). Methods: A total of 69 patients with MMs diagnosed from September 2018 to November 2021 were included retrospectively in the study. The inclusion criteria were (1) an MM over 1 cm; (2) valid ARFI measurements; and (3) confirmation of the diagnosis of an MM by histological examination and/or clinical and radiological follow-up. To examine the mean ARFI velocities (MAVs) for potential cut-off values between benign and malignant MMs, a receiver operating characteristics analysis was implemented. Results: In total, 37/69 of the MMs were benign (53.6%) and 32/69 malignant (46.4%). Benign MMs demonstrated significantly lower MAVs than mMMs (1.59 ± 0.93 vs. 2.76 ± 1.01 m/s; p < 0.001). Selecting 2.05 m/s as a cut-off value yielded a sensitivity and specificity of 75.0% and 70.3%, respectively, in diagnosing malignant MMs (area under the curve = 0.802, 95% confidence interval 0.699-0.904). Conclusion: ARFI elastography may represent an additional non-invasive tool for differentiating benign from malignant MMs. However, to validate the results of this study, further prospective randomized studies are required.
... The peritoneum is defined as the serous membrane lining the inner surface of the abdomen. Contemporary findings demonstrated that the mesentery below the duodenum is continuous and the small and large intestine are connected to it [1][2][3] . Whilst there are suggestions these properties apply above the duodenum, direct evidence is lacking 4 . ...
... To identify key changes in mesenteric morphology, we compared shape at successive time points. A mid-region fold emerged early subdividing the mesentery into upper (pre-fold), mid and lower (post-fold) regions ( Fig. 1c-o, Supplementary Note 2 (sections [1][2][3][4][5]). This format of regionalisation was apparent at all subsequent stages (and in the adult (see below)). ...
... This organisation was also apparent in the adult setting (see below). Detailed descriptions of the morphology of the developing upper, mid and lower regions of the mesentery are included in Supplementary Note 2 (sections [1][2][3][4][5]. ...
Article
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The position of abdominal organs, and mechanisms by which these are centrally connected, are currently described in peritoneal terms. As part of the peritoneal model of abdominal anatomy, there are multiple mesenteries. Recent findings point to an alternative model in which digestive organs are connected to a single mesentery. Given that direct evidence of this is currently lacking, we investigated the development and shape of the entire mesentery. Here we confirm that, within the abdomen, there is one mesentery in which all abdominal digestive organs develop and remain connected to. We show that all abdominopelvic organs are organised into two, discrete anatomical domains, the mesenteric and non-mesenteric domain. A similar organisation occurs across a range of animal species. The findings clarify the anatomical foundation of the abdomen; at the foundation level, the abdomen comprises a visceral (i.e. mesenteric) and somatic (i.e. musculoskeletal) frame. The organisation at that level is a fundamental order that explains the positional anatomy of all abdominopelvic organs, vasculature and peritoneum. Collectively, the findings provide a novel start point from which to systemically characterise the abdomen and its contents. Byrnes et al. reconstruct the developing mesentery from digitized embryonic datasets and human and animal cadavers using 3D digital and printed models. They confirm the mesentery remains a continuous organ in and on which all abdominal digestive organs develop and that at the foundation level, the abdomen comprises a mesenteric and non-mesenteric domain.
... The mesentery is a fan-shaped organ composed of dense connective tissue, blood and lymph vessels, adipose tissue, and nerves. It helps support the intestine in the abdominal cavity [35]. It is common in fish for the pancreas to be very close to the liver and, in the case of zebrafish, in the mesentery [35]. ...
... It helps support the intestine in the abdominal cavity [35]. It is common in fish for the pancreas to be very close to the liver and, in the case of zebrafish, in the mesentery [35]. With the use of Cg, a greater number of mononuclear cells in the connective tissue was observed. ...
... With the use of Cg, a greater number of mononuclear cells in the connective tissue was observed. It is reported in the literature that mesenteric lymph nodes regulate the migration of leukocytes such as B, T, NK (natural killer) and dendritic cells close to the intestinal mucosa through stimuli, although these mechanisms have not yet been fully elucidated [35]. This could be a hypothesis to justify the increase in mononuclear cells with the injection of the phlogogenic agent Cg. ...
Article
This study aims to demonstrate the applicability and importance of zebrafish (Danio rerio) model to study acute and chronic inflammatory responses induced by different stimuli: carrageenan phlogogen (nonimmune); acute infection by bacteria (immune); foreign body reaction (chronic inflammation by round glass coverslip implantation); reaction induced by xenotransplantation. In addition to the advantages of presenting low breeding cost, high prolificity, transparent embryos, high number of individuals belonging to the same spawning and high genetic similarity that favor translational responses to vertebrate organisms like humans, zebrafish proved to be an excellent tool, allowing the evaluation of edema formation, accumulation of inflammatory cells in the exudate, mediators, signaling pathways, gene expression and production of specific proteins. Our studies demonstrated the versatility of fish models to investigate the inflammatory response and its pathophysiology, essential for the successful development of studies to discover innovative pharmacological strategies.
... Mesenteric adipose tissue (MAT) is a contiguous set of adipose tissue that attaches around the different segments of the intestines and serves as a gate for the intestines to communicate with other systems of the whole body (14). Because of the multilevel contiguity between the MAT and intestines, the MAT provides not only a structural platform to maintain the homeostasis of intestines but also enacts as a diplomatic mediator for various intestinal diseases (14)(15)(16). ...
... Mesenteric adipose tissue (MAT) is a contiguous set of adipose tissue that attaches around the different segments of the intestines and serves as a gate for the intestines to communicate with other systems of the whole body (14). Because of the multilevel contiguity between the MAT and intestines, the MAT provides not only a structural platform to maintain the homeostasis of intestines but also enacts as a diplomatic mediator for various intestinal diseases (14)(15)(16). For example, MAT plays a role in regulating intestinal permeability. ...
... MAT is considered a fascinating "new organ" involved in many bowel diseases by acting as a gate for the intestine to communicate with other organs (14,33,34). MAT associated with the small and large intestines is a long and contiguous tissue. ...
Article
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Background: Mesenteric adipose tissue (MAT) plays a critical role in the intestinal physiological ecosystems. Small and large intestines have evidently intrinsic and distinct characteristics. However, whether there exist any mesenteric differences adjacent to the small and large intestines (SMAT and LMAT) has not been properly characterized. We studied the important facets of these differences, such as morphology, gene expression, cell components and immune regulation of MATs, to characterize the mesenteric differences. Methods: The SMAT and LMAT of mice were utilized for comparison of tissue morphology. Paired mesenteric samples were analyzed by RNA-seq to clarify gene expression profiles. MAT partial excision models were constructed to illustrate the immune regulation roles of MATs, and 16S-seq was applied to detect the subsequent effect on microbiota. Results: Our data show that different segments of mesenteries have different morphological structures. SMAT not only has smaller adipocytes but also contains more fat-associated lymphoid clusters than LMAT. The gene expression profile is also discrepant between these two MATs in mice. B-cell markers were abundantly expressed in SMAT, while development-related genes were highly expressed in LMAT. Adipose-derived stem cells of LMAT exhibited higher adipogenic potential and lower proliferation rates than those of SMAT. In addition, SMAT and LMAT play different roles in immune regulation and subsequently affect microbiota components. Finally, our data clarified the described differences between SMAT and LMAT in humans. Conclusions: There were significant differences in cell morphology, gene expression profiles, cell components, biological characteristics, and immune and microbiota regulation roles between regional MATs.
... Connective tissue contiguity could explain the development of musculoskeletal, ocular, and cutaneous abnormalities in intestinal diseases, such as ulcerative colitis and Crohn's disease, and might also account for so far unexplained patterns of pathogen and disease spread. Armed with this knowledge, the diagnosis and assessment of a wide range of common intra-abdominal diseases becomes straightforward [17][18][19][20][21][22]. All these concepts are also reinforced by the fact that since 2016, the mesentery has acquired the dignity of organ, with therefore specific and unique features and functions [17]. ...
... Armed with this knowledge, the diagnosis and assessment of a wide range of common intra-abdominal diseases becomes straightforward [17][18][19][20][21][22]. All these concepts are also reinforced by the fact that since 2016, the mesentery has acquired the dignity of organ, with therefore specific and unique features and functions [17]. ...
Chapter
“It’s all in the gut” says Manu Malbrain. In light of this aphorism, the acknowledgment and the understanding of mechanisms of gastrointestinal pathophysiology has led to the codification of the concept of gastrointestinal failure and the definition of Acute Gastrointestinal Injury (AGI). Undoubtedly, the intestine plays an important role in the development of sepsis syndrome and MOF. Modification of the gut barrier seems to occur clinically and to be responsible for the increased prevalence of infectious complications in critically ill patients. The term “Acute Gastrointestinal Injury” (AGI) has been proposed to address GI dysfunction as part of the multiple organ dysfunction syndrome in critically ill patients, whether or not they have primary abdominal pathology.
... The medial margin is occasionally also described as a retroperitoneal or uncinate margin, defined as the part of the pancreatic head that lies inferior to the transection margin, between the anterior surface and the posterior resection margin including the SMV groove and superior mesenteric artery. [21][22][23][24][25][26][27][28][29][30][31][32][33][34][35] Crippa et al. [36], separately analyzing the superior mesenteric vein (SMV) groove and SMA margin (medial margin), observed that positive margin status (R1 direct and R1 ≤ 1 mm) was an important prognostic factor for recurrence and survival (p<0.0001). R1 ≤ mm was an independent predictor of overall recurrence. ...
... The term mesopancreas has been used by other authors in the literature [21, 23-25, 28, 42]. However, the term mesopancreas is not universally accepted because of the absence of precise anatomic borders [32][33][34][35]. Japan Pancreas Society [29] defines this area as the pancreatic head plexus I (PL phI), located behind the pancreatic head and celiac plexus and the pancreatic head plexus II (PL phII), including the area behind the uncinate process, SMA, and inferior pancreatoduodenal artery (IPDA) [29] (Fig. 3). ...
Article
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Background Pancreatoduodenectomy is the only treatment with a promise of cure for patients with pancreatic head adenocarcinoma, and a negative resection margin is an important factor related to overall survival. Complete clearance of the medial margin with removal of the so-called mesopancreas may decrease the recurrence rate after pancreatic resection. Here, we present some important information about the mesopancreas, total mesopancreas excision, and technical aspects to achieve negative resection margins. The area named mesopancreas is defined as the tissue located between the head of the pancreas and the superior mesenteric vessels and the celiac axis and consists of the nerve plexus, lymphatic tissue, and connective tissue. The superior mesenteric and celiac arteries define the border of the mesopancreas. En bloc resection of anterior and posterior pancreatoduodenal nodes, hepatoduodenal nodes, along the superior mesenteric artery nodes, pyloric nodes, and nodes along the common hepatic artery is necessary.Conclusions Improved knowledge of the surgical anatomy of the region and technical refinements of excision of the mesopancreas along with standardized pathological examination are important to increase and to determine radical resection of pancreatic head cancer.
... The mesentery is a double layer of peritoneum that suspends the small and large bowel from the posterior abdominal wall, preventing these organs from collapsing into the pelvis (15). The mesentery, which contains vessels, nerves, lymphoid tissue, adipose tissue, fibrous tissue and macrophages (16), supplies the intestinal tract with nutrients and is involved in immune defence. These anatomical and functional features suggest that the mesentery acts as an organ (16). ...
... The mesentery, which contains vessels, nerves, lymphoid tissue, adipose tissue, fibrous tissue and macrophages (16), supplies the intestinal tract with nutrients and is involved in immune defence. These anatomical and functional features suggest that the mesentery acts as an organ (16). Furthermore, mesenteric abnormalities have been indicated to be involved in numerous diseases. ...
Article
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Amyloidosis, a systemic disease characterized by the deposition of misfolded protein, is difficult to rapidly diagnose due to its wide range of symptoms. The present study reported on a case of primary amyloidosis (AL) with involvement of the gastrointestinal tract, mesentery and omentum in a 66-year-old male presenting with recurrent diarrhoea and abdominal distension. Oesophagogastroduodenoscopy and enteroscopy revealed multiple gastric ulcers and multiple protuberant lesions in the colon. Laparotomy indicated multiple nodules in the mesentery of the small intestine. Contrast-enhanced CT revealed dilation of the small bowel with pneumatosis intestinalis and positive Congo red staining of gastric mucosa and mesentery biopsy specimens confirmed amyloid deposition. Therefore, the patient was diagnosed with AL. In this case, the clinical manifestation of mesentery amyloidosis was multiple nodules and extensive peritoneal adhesions, which, to the best of our knowledge, has not been reported by any previous study.
... Previous studies of CD mainly focused on inflammatory processes in the intestinal mucosa and submucosa. More recently, there has been an increasing focus on the mesentery and the possibility this may have a pathobiological role in CD (19,29). ...
... Emerging findings suggest that mesenchymal abnormalities in the mesentery extend from this directly into the adjoining intestine (35). If these suggestions are borne out, they support the hypothesis that CD is a primary mesenteropathy (29) or at least bidirectional in terms of how it progresses at a tissue-based level (12). Therefore, it is reasonable to propose that resection of the inflamed mesenteric tissue during surgery for CD may provide improved postoperative outcomes. ...
Article
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Introduction: The mesentery is involved in Crohn's disease. The impact of the extent of mesenteric resection on postoperative disease progression in Crohn's disease remains unconfirmed. This study aimed to determine the association between resection of the mesentery and postoperative outcomes in patients with Crohn's colitis (CC) undergoing colorectal surgery. Methods: Patients with CC who underwent colorectal resection between January 2000 and December 2018 were reviewed, and the data were gathered from a prospectively maintained database. Patients were divided into 2 groups according to the extent of mesenteric resection, the extensive mesenteric excision (EME) group and the limited mesenteric excision (LME) group. Outcomes including early postoperative morbidities and surgical recurrence were compared between the 2 groups. Results: Of the 126 patients included, 60 were in the LME group and 66 in the EME group. There was no significant difference between the 2 groups in early postsurgical outcomes except the intraoperative blood loss was increased in the LME group (P = 0.002). Patients in the EME group had a longer postoperative surgical recurrence-free survival time when compared with those in the LME group (P = 0.01). LME was an independent predictor of postoperative surgical recurrence (hazard ratio 2.67, 95% confidence interval 1.04-6.85, P = 0.04). This was further confirmed in the subgroup analysis of patients undergoing colorectal resection and anastomosis (hazard ratio 2.83, 95% confidence interval 1.01-7.96, P = 0.048). Discussion: In patients undergoing surgery for CC, inclusion of the mesentery is associated with similar short-term outcomes and improved long-term outcomes compared with those seen when the mesentery is retained.
... Currently, the mesentery is classified as an organ that contains not only adipocytes but also blood vessels, lymphatics, nerve tissues, immune cells, and connective tissue matrix (13). Reportedly, mesenteric immune cells play a significant role in the pathogenesis and disease progression of intestinal diseases, particularly Crohn's disease (14)(15)(16)(17). ...
... Following latest research in this field, the mesentery is currently classified as a distinct organ (13) that is histologically characterized by surface mesothelium, the connective tissue lattice, and adipocytes dispersed within the interstices of the lattice (13). However, the immune landscape of the mesentery remains unclear. ...
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Objective The mesentery is a potential site of residual tumor in patients with colorectal cancer (CRC). However, the mesenteric immune microenvironment remains unclear. In this study, we investigated the immune landscape of the mesentery, particularly the role of lymphocytes and its association with the clinicopathological characteristics of CRC. Methods Flow cytometry was used to detect lymphocytes in the paired mesenteric tissue specimens adjacent to the colorectal tumors and normal mesenteric tissue specimens 10 cm away from the colorectal tumor edge and preoperative peripheral blood samples obtained from patients with CRC who underwent surgery. T-distributed stochastic neighbor embedding was utilized to analyze multiparameter flow cytometry data. Multiplex immunohistochemistry was performed to evaluate T cells subsets in the paired mesentery adjacent to the colorectal tumors and normal mesentery. The Fisher’s exact test and non-parametric Wilcoxon’s matched-pairs tests were used for statistical analysis. The non-parametric Mann-Whitney U test was used to determine associations between percentage data and clinical parameters of patients with CRC. Results We found that immune cells in the normal mesentery were mainly of lymphoid lineage. Compared with peripheral blood, the normal mesentery showed decreased NK cells and the CD4/CD8 ratio and increased CD3 ⁺ CD56 ⁺ , memory CD4 ⁺ T, memory CD8 ⁺ T, CD4 ⁺ tissue-resident memory T (TRM), and CD8 ⁺ TRM cells. Compared with the normal mesentery, the mesentery adjacent to the colorectal tumor showed increased B and regulatory T cells and decreased NK, CD3 ⁺ CD56 ⁺ , CD4 ⁺ TRM, and CD8 ⁺ TRM cells. Moreover, memory CD8 ⁺ T cells and plasmablasts are negatively correlated with the depth of invasion of CRC. Increased memory CD4 ⁺ T cells are associated with distant metastasis of CRC and high preoperative serum carcinoembryonic antigen levels. Conclusion The mesentery shows a specific immune microenvironment, which differs from that observed in peripheral blood. CRC can alter the mesenteric immune response to promote tumor progression.
... Notwithstanding, since during surgery a pathologic mesentery could heavily bleed when divided, the attitude of most surgeons has been to retain it. Some authors recently suggested that the mesentery is not only part of the pathologic events that lead to bowel damage typical of CD, but also has prognostic implications during and after surgical treatment [9][10][11][12][13][14]. On the contrary, a large, retrospective analysis on the prevalence and significance of mesentery thickening and lymph node enlargement did not show any effect on long-term recurrence, and in the 2020 guidelines of the Italian Society of Colorectal Surgery (SICCR), mesentery removal during intestinal resection for CD was not recommended [15,16]. ...
... The group from Limerick has the merit of carrying out a thorough study on mesentery anatomy, demonstrating that mesenteric abnormalities strongly relate to mucosal and mural abnormalities of CD, but substantial drawbacks were present in their study, such as the small number of patients included (with the consequent impossibility to perform a multivariate analysis), an historical cohort too heterogeneous in terms of patients' characteristics and medical treatment, and a proposed mesenteric activity index that is very intriguing, but not yet validated. In particular, the huge difference between the two cohorts could be explained with a different postoperative medical treatment, especially considering the positive effect showed by immunosuppressive and biological adjuvant therapy in the REMEDY [9,11,12]. In addition to the REMEDY results, and in contrast with Coffey's, another unclear element is represented by the mesentery behavior in the site of a strictureplasty, where the surgeons leave the mesentery untouched. ...
Article
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Some evidence suggests a reduction in clinical and surgical recurrence after mesenteric resection in Crohn’s Disease (CD). The aim of the REsection of the MEsentery StuDY (Remedy) was to assess whether mesenteric removal during surgery for ileocolic CD has an impact in terms of postoperative complications, endoscopic and ultrasonographic recurrences, and long-term surgical recurrence. Among the 326 patients undergoing primary resection between 2009 and 2019 in two referral centers, in 204 (62%) the mesentery was resected (Group A) and in 122 (38%) it was retained (Group B). Median follow-up was 4.7 ± 3 years. Groups were similar in the peri-operative course. Endoscopic and ultrasonographic recurrences were 44.6% and 40.4% in Group A, and 46.7% and 41.2% in Group B, respectively, without statistically significant differences. The five-year time-to-event estimates, compared with the Log-rank test, were 3% and 4% for normal or thickened mesentery (p = 0.6), 2.8% and 4% for resection or sparing of the mesentery (p = 0.6), and 1.7% and 5.4% in patients treated with biological or immunosuppressants versus other adjuvant therapy (p = 0.02). In Cox’s model, perforating behavior was a risk factor, and biological or immunosuppressant adjuvant therapy protective for surgical recurrence. The resection of the mesentery does not seem to reduce endoscopic and ultrasonographic recurrences, and the five-year recurrence rate.
... The intestinal tissue's macroscopic structure is well preserved after OPT sample processing and details can be observed after volumetric reconstruction. At the centimeter scale, we are able to resolve the mesenteryassociated vasculature, which surrounds and supports the gastrointestinal tract ( Fig. 3(a)) [59]. In the autofluorescence channel (shown in cyan), individual villi appear as an evenly distributed speckled pattern, as shown in Fig. 3(b). ...
Article
Optical projection tomography (OPT) is a powerful tool for three-dimensional imaging of mesoscopic biological samples with great use for biomedical phenotyping studies. We present a fluorescent OPT platform that enables direct visualization of biological specimens and processes at a centimeter scale with high spatial resolution, as well as fast data throughput and reconstruction. We demonstrate nearly isotropic sub-28 µm resolution over more than 60 mm3 after reconstruction of a single acquisition. Our setup is optimized for imaging the mouse gut at multiple wavelengths. Thanks to a new sample preparation protocol specifically developed for gut specimens, we can observe the spatial arrangement of the intestinal villi and the vasculature network of a 3-cm long healthy mouse gut. Besides the blood vessel network surrounding the gastrointestinal tract, we observe traces of vasculature at the villi ends close to the lumen. The combination of rapid acquisition and a large field of view with high spatial resolution in 3D mesoscopic imaging holds an invaluable potential for gastrointestinal pathology research.
... In obese individuals, excess fat deposition leads to adipocyte hypertrophy and secretion of proinflammatory cytokines (TNF-α, and IL-6), chemokines, and complement factors causing low-grade inflammation. Accumulating studies showed a link between altered mesenteric fat (aka creeping fat) and IBD, mainly in CD [182,183]. Low-grade inflammation, on the other hand, can cause an imbalance between leptin/adiponectin ratio and increase intestinal permeability, bacterial translocation, and T-cell infiltration, thus, predisposing an obese individual to IBD [184], as depicted in Figure 7. Karmiris et al. showed that downregulation of leptin expression in mesenteric fat may be due to the inflammatory milieu in IBD patients due to increased production of TNF-α [185]. However, other conflicting studies have shown that leptin levels increased or remained unchanged in IBD [186,187]. ...
Article
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The gut microbiota is a complex community of microorganisms that has become a new focus of attention due to its association with numerous human diseases. Research over the last few decades has shown that the gut microbiota plays a considerable role in regulating intestinal homeostasis, and disruption to the microbial community has been linked to chronic disease conditions such as inflammatory bowel disease (IBD), colorectal cancer (CRC), and obesity. Obesity has become a global pandemic, and its prevalence is increasing worldwide mostly in Western countries due to a sedentary lifestyle and consumption of high-fat/high-sugar diets. Obesity-mediated gut microbiota alterations have been associated with the development of IBD and IBD-induced CRC. This review highlights how obesity-associated dysbiosis can lead to the pathogenesis of IBD and CRC with a special focus on mechanisms of altered absorption of short-chain fatty acids (SCFAs)
... As our understanding of the anatomy and physiology of the mesentery becomes clearer, the role of the mesentery in health and disease is beginning to unfold (94,95). In particular the part played by the mesentery in the setting of Crohn's disease is becoming more apparent (96)(97)(98)(99)(100). ...
Article
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Postoperative recurrence after ileocaecal resection for fibrostenotic terminal ileal Crohn's disease is a significant issue for patients as it can result in symptom recurrence and requirement for further surgery. There are very few modifiable factors, aside from smoking cessation, that can reduce the risk of postoperative recurrence. Until relatively recently, the surgical technique used for resection and anastomosis had little or no impact on postoperative recurrence rates. Novel surgical techniques such as the Kono-S anastomosis and extended mesenteric excision have shown promise as ways to reduce postoperative recurrence rates. This manuscript will review and discuss the evidence regarding a range of surgical techniques and their potential role in reducing disease recurrence. Some of the techniques have been shown to be associated with significant benefits for patients and have already been integrated into the routine clinical practice of some surgeons, while other techniques remain under investigation. Current techniques such as resection of the mesentery close to the intestine and stapled side to side anastomosis are being challenged. It is looking more likely that surgeons will have a major role to play when it comes to reducing recurrence rates for patients undergoing ileocaecal resection for Crohn's disease.
... Five years ago, in a paper published in a medical journal, Coffey and O'Leary (2016) proposed that the mesentery is an organ of the human body and, as such, should be added to the traditional list of human organs, as item No. 79. In a timely review of that article, Neumann (2017) remarked that "no two anatomists are likely to compile identical lists of the organs of the human body, " largely because of the vague current notions of organ, "commonly defined in medical dictionaries as a (somewhat independent) part of the body that performs a (vital or special) function." ...
Article
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Contrasting definitions of organs based either on function or on strictly morphological criteria are the legacy of a tradition starting with Aristotle. This floating characterization of organs in terms of both form and function extends also to organ systems. The first section of this review outlines the notions of organ and body part as defined, explicitly or implicitly, in representative works of nineteenth century’s comparative morphology. The lack of a clear distinction between the two notions led to problems in Owen’s approach to the comparative method (definition of homolog vs. nature of the vertebrate archetype) and to a paradoxical formulation, by Anton Dohrn, of the principle of functional change. Starting from the second half of the twentieth century, with the extensive use of morphological data in phylogenetic analyses, both terms – organ and body part – have been often set aside, to leave room for a comparison between variously characterized attributes (character states) of the taxa to be compared. Throughout the last two centuries, there have been also efforts to characterize organs or body parts in terms of the underlying developmental dynamics, both in the context of classical descriptive embryology and according to models suggested by developmental genetics. Functionally defined organ are occasionally co-extensive with morphologically defined body parts, nevertheless a clear distinction between the former and the latter is a necessary prerequisite to a study of their evolution: this issue is discussed here on the example of the evolution of hermaphroditism and gonad structure and function.
... The mesenteric artery then extends radially to the intestinal margin. 33 Therefore, in this study, mesenteric vessels were selected to be the feeding and draining vessels. While using the chamber to repair the defect, it can restore the local normal anatomy. ...
Article
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Purpose: Successful intestinal tissue engineering requires specialized biocompatible scaffolds and a vibrant vascularization microenvironment. A pre-vascularized chamber can provide both in vivo, but there is little report on using it to improve intestinal regeneration. Besides, researchers have found that gelatin is highly biocompatible and graphene oxide (GO) can be used to improve mechanical properties. Thus, applying a pre-vascularized chamber fabricated gelatin and GO into intestinal tissue engineering is worth a try. Materials and methods: In this study, an investigation into the physicochemical and mechanical properties as well as biocompatibility of the electrospun graphene oxide-gelatin (GO-Gel) scaffolds were conducted in vitro. Meanwhile, a pre-vascularized GO-Gel (V-GO-Gel) chamber model was built by implanting the scaffold around the mesenteric vessels in rat. After vascularization process, the chamber was used to repair the perforation and then assessed by histology and immunofluorescence analyses. Results: These porous scaffolds were mechanical improved with GO incorporated into gelatin. Further, the cell adherence, viability and morphology on the scaffolds were maintained. The V-GO-Gel chamber model was successfully built and effective enhanced the repair of the intestinal wall than the other group without recurrence or complications. Conclusion: The V-GO-Gel chamber shows promising therapeutic potential in the repair of intestinal wall defects.
... Just like the recent discovery of the mesentery as the body's 79 th organ by J. Calvin Coffey [16] as recently in 2017 and subsequent endorsements including in anatomy textbooks like Gray's Anatomy, this potential 'organ 80' may be endorsed later by the medical community [17]. Some researchers challenged the status of the newly described tubarial glands by citing the long history of known minor salivary glands in the nasopharynx. ...
Chapter
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There are about 500-1000 minor salivary glands in the body, and most of them are located in the oral cavity or oropharynx. They are small and embedded in the aero-digestive tract entrance of the head and neck region. Minor salivary glands located in the nasopharynx are relatively less in number and the major pathologies associated with these glands are rare. Tubarial gland or tubarial salivary gland is recently reported as a pair of macroscopic salivary glands in the nasopharynx. The remote location of the glands, the rarity of major pathologies involved, and non-recognized functional significance might have made them elusive before. A brief review of minor salivary glands and tubarial glands is attempted. It is an evolving field in medicine, pathology, and characterization of diseases of the nasopharynx especially the diseases of salivary gland origin have gained renewed interest recently.
... This complex tissue consists of compartmentalized blood vessels, lymphatic vessels, and nerves in a spiderweb-like structure, whereby bundles of these routes connect each gut segment with the central arteries and veins, its draining LNs or the nervous system, respectively, and are surrounded by mesenteric adipose tissue (MAT). 91 This mesenteric web also attaches the intestine to the abdominal wall, providing support to maintain proper positioning of the intestine for digestion. Sub-regions of the mesentery can be defined based on the associated intestinal segment, but functional differences according to sub-region are currently unknown. ...
Article
The emerging concept of tissue specific immunity has opened the gates to new inquiries into what factors drive immune cell niche adaptation and the implications on immune homeostasis, organ specific immune diseases, and therapeutic efficacy. These issues are particularly complicated at barrier sites, which are directly exposed to an ever-changing environment. In particular, the gastrointestinal (GI) tract faces even further challenges given the profound functional and structural differences along its length, raising the possibility that it may even have to be treated as multiple organs when seeking to answer these questions. In this review, we evaluate what is known about the tissue intrinsic and extrinsic factors shaping immune compartments in the intestine. We then discuss the physiological and pathological consequences of a regionally distinct immune system in a single organ, but also discuss where our insight into the role of the compartment for disease development is still very limited. Finally, we discuss the technological and therapeutic implications this compartmentalization has. While the gut is perhaps one of the most intensely studied systems, many of these aspects apply to understanding tissue specific immunity of other organs, most notably other barrier sites such as skin, lung, and the urogenital tract.
... Ein bekanntes Beispiel ist der 1996 beschriebene Musculus sphenomandibularis [35], ein angeblich neuer Kaumuskel, der allerdings bereits von Zenker als medialer Anteil des Musculus temporalis erschöpfend beschrieben wurde [36]. Ebenso erzeugen Berichte über »neu entdeckte« Organe und Strukturen wie das Mesenterium [37], das Interstitium [38] oder das anterolaterale Ligament des Knies [39] bei Anatomen meist nicht mehr als ein ungläubiges Kopfschütteln [40,41]. Der Austausch mit einem Anatomen kann also verhindern, Zeit und Arbeit in Fallbeschreibungen zu investieren, die sich nachträglich als redundant erweisen. ...
Article
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An intimate contact between surgeons and clinical anatomists is beneficial for both specialities and can foster medical education, clinical training and research.
... The mesothelium is one of the fundamental histological structures that composes the mesentery [33]. Mesentery´s fat is abnormally expanded in Crohn's Disease, leading to the formation of creeping fat around the intestinal damaged area. ...
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Our understanding of the interplay between human adipose tissue and the immune system is limited. The mesothelium, an immunologically active structure, emerged as a source of visceral adipose tissue. After investigating the mesothelial properties of human visceral and subcutaneous adipose tissue and their progenitors, we explored whether the dysfunctional obese and Crohn’s disease environments influence the mesothelial/mesenchymal properties of their adipocyte precursors, as well as their ability to mount an immune response. Using a tandem transcriptomic/proteomic approach, we evaluated the mesothelial and mesenchymal expression profiles in adipose tissue, both in subjects covering a wide range of body-mass indexes and in Crohn’s disease patients. We also isolated adipose tissue precursors (adipose-derived stem cells, ASCs) to assess their mesothelial/mesenchymal properties, as well as their antigen-presenting features. Human visceral tissue presented a mesothelial phenotype not detected in the subcutaneous fat. Only ASCs from mesenteric adipose tissue, named creeping fat, had a significantly higher expression of the hallmark mesothelial genes mesothelin (MSLN) and Wilms' tumor suppressor gene 1 (WT1), supporting a mesothelial nature of these cells. Both lean and Crohn’s disease visceral ASCs expressed equivalent surface percentages of the antigen-presenting molecules human leucocyte antigen – DR isotype (HLA-DR) and CD86. However, lean-derived ASCs were predominantly HLA-DR dim, whereas in Crohn’s disease, the HLA-DR bright subpopulation was increased 3.2-fold. Importantly, the mesothelial-enriched Crohn’s disease precursors activated CD4+ T-lymphocytes. Our study evidences a mesothelial signature in the creeping fat of Crohn’s disease patients and its progenitor cells, the latter being able to present antigens and orchestrate an immune response.
... They hypothesized that the primary pathology in small bowel CD initiates from the mesentery. Therefore, removal of the mesentery was proposed to prevent disease recurrence (37). However, others who hypothesize that the confounding factor is resection margin involvement rather than the mesenteric excision have challenged their results (38). ...
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Crohn's disease in the small bowel could present itself as an inflammatory stricture, a fibrotic stricture as penetrating disease or a combination of both. It is pertinent to differentiate the disease process as well as its extent to effectively manage the disease. Currently, a combination of medical and surgical therapies forms part of the treatment plan while the debate of which therapy is better continues. In managing the strictures, identification of the disease process through imaging plays a pivotal role as inflammatory strictures respond to anti-tumor necrosis factor (TNF) and biological agents, while fibrotic strictures require endoscopic or surgical intervention. Recent evidence suggests a larger role for surgical excision, particularly in ileocolic disease, while achieving a balance between disease clearance and bowel preservation. Several adaptations to the surgical technique, such as wide mesenteric excision, side to side or Kono-S anastomosis, and long-term metronidazole therapy, are being undertaken even though their absolute benefit is yet to be determined. Penetrating disease requires a broader multidisciplinary approach with a particular focus on nutrition, skincare, and intestinal failure management. The current guidance directs toward early surgical intervention for penetrating disease when feasible. Accurate preoperative imaging, medical management of active diseases, and surgical decision-making based on experience and evidence play a key role in success.
... Moreover, there has been a growing body of evidence that CD might be a primary mesenteropathy in recent years [67][68][69][70][71]. In line with the principle of CD originating from the mesentery, Coffey et al. demonstrated that the inclusion of the mesentery during ICR results in significantly reduced rates of reoperation compared to conventional ICR (40% versus 2.9%, p = 0.007) [72]. ...
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Crohn’s disease (CD) represents a heterogeneous and complex disease with no curative therapeutic option available to date. Current therapy is mainly antibody-based focusing on the immune system while other treatment alternatives such as surgery are considered to be “last options”. However, medical therapy for CD results in mild to severe side effects in a relevant amount of patients and some patients do not respond to the medication. Following that, quality of life is often significantly reduced in this patient cohort, thus, therapeutic alternatives are urgently needed. Updated evidence has revealed that surgery such as ileocecal resection (ICR) might be a potential therapeutic option in case of localized terminal ileitis since resection at early time points improves quality of life and significantly reduces the postoperative need for immunosuppressive medication with low rates of morbidity. In addition, new surgical approaches such as Kono-S anastomosis or inclusion of the mesentery result in significantly reduced rates of disease recurrence and reoperation. Based on the new evidence, the goal of this review is to provide an update on the role of surgery as a reasonable alternative to medical therapy in the interdisciplinary treatment of patients with CD.
... We also contend that regardless of whether the above investigation is a mere academic exercise or one potentially ending in changing SS-related clinical practice, the implications may raise a broader scientific question, i.e., should these observations be treated as a discovery or re-discovery? Similarly, other recent discoveries have been made regarding anatomical descriptions and sites that were presented as novel, namely a) the meningeal lymphatic vessels (20); b) the interstitium as a fluid-filling space between cells (21); c) the mesentery as a complete organ instead of fragmented parts (22); d) the discovery of arterial and venous capillaries in long bones (23); e) the presence of atavistic limb muscles in human embryos (24); and, f) the increase in the incidence of the sesamoid bone fabella over the last 150 years (25). Criticisms on the novelty of these findings have been expressed and collectively discussed (26). ...
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Background: Opinions vary on the medial border of D3 lymphadenectomy for right colon cancer. Most surgeons placed the medial border along the left side of superior mesenteric vein, but some considered the left side of superior mesenteric artery as the medial border. Objectives: This study investigated the clinical outcomes of laparoscopic D3 lymphadenectomy for right colon cancer with the medial border along the left side of superior mesenteric artery. Design: This was a retrospective study. Settings: The study was conducted in specialized colorectal cancer department of five tertiary hospitals. Patients: Patients receiving laparoscopic D3 lymphadenectomy for right colon cancer from January 2013 to December 2018 were included. Main outcome measures: After propensity score matching, 307 patients receiving laparoscopic D3 lymphadenectomy along the left side of superior mesenteric artery were assigned to the SMA group and 614 patients were assigned to the SMV group. Univariate, multivariate and Kaplan-Meier analysis were performed to assess the clinical data. Results: The short-term outcomes were similar between the two groups; however, the SMA group had a higher rate of chylous leakage (p<0.001). More lymph nodes were harvested from the SMA group than from the SMV group (p=0.001). The number (p=0.005) of metastatic LNs and the lymph node ratio (p=0.041) in main nodes were both higher in the SMA group. The two groups had similar long-term survival, but the SMA group tended to show better disease-free survival in stage III patients (p=0.056). Limitations: This was a retrospective, non-randomized study. Conclusion: Laparoscopic D3 lymphadenectomy along the left side of superior mesenteric artery, except for a higher rate of chylous leakage, had comparable short-term outcomes with the SMV group. The SMA group tended to achieve better disease-free survival in stage III patients, but further study is required to better elucidate differences in these approaches as risks/benefits do exist.
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Background: Preconception care interventions are directed toward the promotion of women’s health and well-being before pregnancy. Aim: To evaluate an educational preconception program on empowering the Egyptian premarital women with the concept of self-efficacy and locus of control behaviors. Methods: A quasi-experimental, quantitative, (pre/ post one group) research design was used with 84 premarital females recruited conveniently from five primary health care centers located at Port- Said City, Egypt. Data collection: By using 2 main tools which were locus of control scale, and the selfefficacy of diet and physical exercises used to assess self-efficacy of adults for diet (fat, salt) and exercise. Results: Total mean of women age was 23.26 ± 4.2, majority were bachelor’s degree of education, and unemployed. A highly statistically significant difference was reported between pre and post total mean score of internal and external locus of control, self-efficacy of eating healthy foods and motivation behavior related physical exercises at p-value < 0.000. Conclusion: The application of preconception educational intervention had a positive effect on empowering a sense of locus of control and self-efficacy behaviors among studied participants, which evidenced by a statistically significant difference between pre-test and post-test of multidimensional locus of control through improving their self-efficacy regarding eating and exercises. Recommendation: Incorporate of preconception educational programs to be an integral part of the services provided by PMCs and to ensure the dissemination of information related to locus of control behaviors, healthy lifestyles and motivation behavior of regular physical exercises that warrant the improvement of reproductive health and pregnancy outcomes for future Egyptian mothers. Keywords: Education program; locus of control; preconception; self-efficacy of eating
Article
Introduction: The aim of this study was to implement our technique for the initial dissection of the inferior hypogastric plexus and protection of the autonomic nerve supply to the corpora cavernosa in laparoscopic radical cystoprostatectomy with an orthotopic ileal neobladder and report the initial outcomes. Methods: Eleven normally potent patients with preoperative cT2N0 bladder cancer who underwent bilateral nerve-sparing laparoscopic cystoprostatectomy performed by the same surgeon were selected from May 2018 to September 2020. In this procedure, the anterior part of the inferior hypogastric plexus was dissected first between the prehypogastric nerve fascia and rectal proper fascia medial to the distal ureter. Then the Denonvilliers' fascia and the nerves around the prostate were preserved according to current intrafascial principles. The preliminary operative, oncologic, and functional results are presented. Results: The median follow-up duration was 18 months. We observed early and late complications in 5 patients, but none exceeded grade III. Of the 11 patients, ten gained daytime continence (90.9%), and 8 (72.7%) showed nocturnal continence at the last follow-up. Regarding postoperative potency, 10 of the 11 patients (90.9%) remained potent with or without oral medications, excluding one who had partial tumescence but did not follow our recommendations regarding medication use. No local recurrence or positive surgical margins were noted. Conclusion: In addition to emphasizing our cavernosal nerve-sparing procedure, this report on the precise dissection and protection of the inferior hypogastric plexus could be of clinical significance, providing potentially ideal short-term functional results.
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Organ transplantation is the best treatment option for patients with end-stage organ failure. Unfortunately, the availability of donor organs and immune rejection severely limited organ transplantation, which results in a large number of patient deaths. Organ bioengineering could provide new ideas for the global shortage of critical organs. The use of decellularization-recellularization technology of natural tissues and organs has promising results in heart, lung, liver, pancreas, intestine, and kidney engineering. Decellularized whole organ with preserved structures and vasculature can provide a decellularized tissue platform for organ regeneration. Successful decellularization has provided suitable scaffolds to repopulate cells to grow fully transplantable organs ex vivo. Recellularized organs can perform organ-specific functions in a short time, which indicates that engineered organs have potential in future clinical applications. Selecting the best cell type, obtaining the required numbers of cells, delivering the cells to the scaffold, and maturing these cells into functional organs are all steps. Although the decellularization and recellularization of various organs including the heart, liver, lung, kidney, bladder, etc. have yielded exciting results, it is not possible to obtain donor organs for this method from humans. In this review, we focus on the progress of recellularization of whole organs in vivo and highlight future challenges in this field.
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The greater omentum is a highly vascularized anatomical structure in the peritoneal cavity. Its main components are connective, adipose and vascular cells, along with specialized immune cells. The omentum functions as a site for fat accumulation, it has adhesive properties to control traumatized and inflamed tissues, and a function in local hemostasis, immune responses, and revascularization. Other functions include the absorption of fluids, the phagocytosis of particulate matter, and foreign body reaction. The omentum is catalyzing significant interest for its potential as a site for pancreatic islet and cell transplantation. Our knowledge about this structure, its functions, and its potential as a site for transplantation is poised to grow in the coming years.
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Background: Ileocolic resection (ICR) is the most commonly performed operation in Crohn’s disease (CD) patients. The surgical report is a vital tool for accessing information to gauge a patient’s long-term prognosis and guide treatment decisions. Dictated narrative reports are the traditional method for surgical documentation but often lack essential information. Objective: To assess the quality of operative note reporting in CD patients undergoing ICR. Design: Multi-institutional retrospective cohort collaborative study. Settings: Four tertiary inflammatory bowel disease referral centers in the United States and Canada. Patients: Consecutive CD patients undergoing ICR between 2014 - 2020. Interventions(s) if any: n/a Main Outcome Measures: Variability and frequency of 28 critical items in the operative note. Results: Analysis of 400 consecutive operative reports among 4 institutions (n=100/institution) revealed significant variability in almost all variables. Initial surgical approach and wound protector use were the most consistently or frequently reported across all IBD centers, although this figure was not statistically significant. Limitations: Retrospective cohort study with inevitable selection bias. Conclusions: This study highlights the need for synoptic reporting in CD patients undergoing ICR.
Article
Stricturing and penetrating disease are complications of Crohn disease (CD) that significantly affect patient outcomes. Careful evaluation for such complications is critical to the interpretation of magnetic resonance enterography. This manuscript outlines the key findings related to stricturing and penetrating CD and discusses current understanding of the pathophysiology and prognosis of complicated CD based on the literature.
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Nowadays, the mesentery as a new organ was discovered. Mesenteric events may play an important role in the pathophysiology of several diseases. The aim of our study was investigate the synergic effects of ultrasound (US) and laser therapies on mesentery in obese-hyperglycemic rats. The 25 male Wistar rats were randomized into five groups. Obese non-diabetic (OND) group: obese rats without diabetes and no treatment conditions; SHAM group: obese-hyperglycemic rats treated with placebo; US group: obese-hyperglycemic rats treated with US; LASER group: obese-hyperglycemic rats treated with laser and; US+LASER group: obese-hyperglycemic rats treated with US plus laser. An animal model of type 2 diabetes based on a hyperlipidemic diet combined with a low dose of streptozotocin was used in this study. Body mass and biochemical measurements were performed. GOT and GPT level showed a significant reduction in the treated groups than SHAM. The total cholesterol, triglycerides and VLDL levels showed significantly lower values for the US+LASER group. There was also reduced risk of cardiovascular diseases evidenced by Castelli index in the treated groups than SHAM. This study showed that the US and laser treatment on mesentery resulted to an improvement in biochemical measurements of the obese-hyperglycemic rats, especially the total cholesterol, triglycerides and VLDL levels. This article is protected by copyright. All rights reserved.
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The mesenteryMesentery is a single and continuous organ. All abdominal digestive organs are directly connected to the mesenteric frame, which in turn collectively connects the abdominal digestive system to the body. It has a defined arterial inflow (via the coeliac trunk and superior and inferior mesenteric arteries) and venous drainage (at hepatic veins). Once the arterial trunks enter the mesentery they subdivide into major branches that remain intra-mesenteric until target organs are reached. The entirety of the portal venous system is intra-mesenteric in location. Mesenteric continuityContinuity and contiguity with abdominal digestive organs enables us subdivide the abdomenAbdomen into mesenteric and non-mesenteric domains. This modelModel (the mesenteric model) reconciles anatomical, embryological, surgical and radiological approaches to the abdomen. It explains how all abdominal digestive organs are centrally connected and it explains the peritoneal landscape.
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Laparoscopic right hemicolectomy is a procedure that involves removing the cecum, the ascending colon, the hepatic flexure, the first third of the transverse colon, and part of the terminal ileum. Due to anatomic complexity, laparoscopic surgery for right colon cancer, especially hepatic flexure and transverse colon, is not an easy procedure. Some key steps are quite complicated procedures, so we would like to point out and explain the difficult sites of dissection during a right colectomy.
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Background Strictureplasties (SXP) represents an alternative to bowel resection in Crohn’s disease (CD). Over the years, there has been growing interest in the role of non-conventional SXP for the treatment of extensive CD. A systematic review was performed on complications and recurrence of conventional and non-conventional SXP. Methods The available literature was screened according to the PRISMA statement until June 2020. Results were categorized into three groups: studies reporting on conventional SXPs; studies with a mixed cohort of conventional and non-conventional SXPs (% non-conventional SXPs ≤15%), and studies reporting on non-conventional SXPs. Considered endpoints were postoperative complications, and overall and SXP site-specific surgical recurrence. Random effect meta-analysis and meta-regression were used to obtain and compare combined estimates between groups. Results A total of 26 studies for a total of 1839 patients with CD were included. The pooled postoperative complication rate was 15.5% (95% CI 11.2%-20.3%), 7.4% (95% CI 0.2%-22.9%), and 19.2% (95% CI 5-39.6%). The rate of septic complications was 4% (95% CI 2.2%-6.2%), 1.9% (95% CI 0.4%-4.3%), and 4.2% (95% CI 0.9%-9.8%). Cumulative overall surgical recurrence was 27.5% (95% CI 18.5%-37.6%), 13.2% (95% CI 8.6%-18.7%), and 18.1% (95% CI 6.8%-33.3%) and SXP site-specific surgical recurrence was 13.2% (95% CI 6.9%-21.2%), 8.3% (95% CI 1.6-19.3%), and 8.8% (95% CI 2.2%-19%). Formal comparison between the groups revealed no differences. Conclusion Non-conventional SXP did not differ to conventional SXP with respect to safety and long-term recurrence. Consistent heterogeneity was observed and partially limits the conclusion of this study.
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Studies have found associations between mesenteric adiposity and metabolic syndrome. This chapter describes the development of metabolic syndrome, the pathogenetic role of the mesenteryMesentery, how mesenteric adiposity can lead to insulin resistanceInsulin resistance, and ultimately how the mesentery affects central adiposity and an individual’s overall state of health. Changes within mesenteric adiposity are characterized as an increased and prolonged inflammatory state due to central obesity that ultimately leads to dysfunctional and fibrotic adipocytesAdipocyte.
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The gastrointestinal (GI) tract is constantly exposed to potentially harmful microbes. The mesentery helps determine which organisms warrant an immune response, and thus plays an important role in immune homeostasis. Immune homeostasis is defined as the balance between tolerance and over activity and both processes rely on the intricacies of both the innate and adaptive immune system. If the innate immune system identifies a pathogenic organism, it recruits polymorphonuclear neutrophils (PMNs), macrophages, and dendritic cells to mount an initial response. Dendritic cells that populate the mesentery are critical in presenting pathogens to mesenteric lymph nodes. This serves to activate a systemic immune response via the adaptive immune system. The adaptive immune system will then recruit antigen-specific immune cells, such as B and T cells, in order to kill the pathogen and ultimately protect the host. If a benign organism or food protein is incorrectly identified as pathogenic by the innate immune system, the mesenteric lymph nodes will recruit the adaptive immune system, and an inappropriate immune response is initiated. This response results in excessive inflammation from accumulation of immune cells and local tissue destruction. Due to its role in helping to balance these responses of the immune system, the mesentery is an important component of immune homeostasis.
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Traditional teaching has perceived the mesentery as a fragmented structure with complex relationships to surrounding intraabdominal structures. This concept has been indoctrinated into mainstream surgical and anatomical literature for over a century. Recent research and formal appraisal of the mesentery has defined it as a unique organ, continuous from the duodeno-jejunal flexure to the mesorectum. Histological and electron-microscopic studies have expanded on the details of the mesenteric organ, demonstrating it consists of a surface mesothelium and underlying connective tissue throughout. Fibrous septae divide adipocyte lobules within the body of the mesocolon. Where in contact with the retroperitoneum, the mesentery is the mesocolon, and two mesothelial layers are separated by a distinct layer of connective tissue—Toldt’s fascia—separates both. Lymphatic channels are evident both in mesenteric connective tissue and Toldt’s fascia. The new model of the mesentery organ provides us with an opportunity to understand disease states that involve the mesentery. The rich network of lymphatics and close relationship of the mesentery to other intra-abdominal structure, mean the mesentery is prone to a myriad of disease states. When pathological process originate from the mesentery itself, and spread to involve adjacent structures, this is known as a primary mesenteropathy. In contrast secondary mesenteropathies are diseases where the primary abnormality originates outside the mesentery and indirectly involves the mesentery. Neoplasms of the mesentery are rare and usually diagnosed incidentally on radiological imaging. They encompass a heterogenous group of lesions ranging from benign cysts to aggressive malignancies. They can arise from distinct cellular components of the mesenteric organ, including the peritoneal surface, connective tissue, adipocytes, lymph nodes, and blood vessels, with a wide spectrum of surgical management options. In this chapter, we describe the major types of mesenteric neoplasms, indications and contraindications for surgery, and the surgical management for mesenteric neoplasms.
Article
Background In invasive examinations of the colon, e.g. colonoscopy, the tortuosity of the colon is a crucial factor for successful completion of the procedure. If adjacent segments of the colon bend at acute angles (under 90˚), endoscopy may become difficult and troublesome. Methods We retrospectively enrolled 227 individuals (96 female, 131 male) who underwent abdominopelvic computed tomography examination. For inclusion, subjects were required to have a negative history for colonic disease and abdominopelvic surgery. We measured the angle between the descending colon and the proximal part of the sigmoid (in degrees). In addition, the position of the descending-sigmoid flexure was assessed in relation to the left anterior superior iliac spine, the median plane, and anterior aspect of the 5th lumbar vertebra (in mm). The study protocol was reviewed and approved by the local ethics committee. Results We visualised the descending-sigmoid flexure in all 227 subjects. In one third of cases, the flexure formed an angle smaller than/or 90˚. In females, this landmark (mean ± standard deviation) was located 30.2 ± 8.4 mm from the left anterior superior iliac spine, 88.6 ± 14.2 mm from the median plane, and 115.4 ± 21.4 mm from the anterior aspect of the 5th lumbar vertebra. In males, the dimensions were: 32.1 ± 12.8 mm, 97.6 ± 15.8 mm, and 123.9 ± 22.9 mm, respectively. This landmark distance remained constant from the left anterior superior iliac spine regardless of subject age, height and weight. The other measured distances were related to age, height, weight or BMI. Conclusions The descending-sigmoid flexure is an important landmark in large intestine morphology situated approximately width of two fingers (3 cm) from the left anterior superior iliac spine and one hand width (9-10 cm) from the median plane. In approximately one third of the subjects, the flexure formed an angle of less than/or 90˚, which can cause a problem during colonoscopy.
Article
Zusammenfassung Neueste wissenschaftlichen Erkenntnisse über das vegetative Nervensystem werfen unser Denkmodell der Anatomie über den Haufen. Aktuelle Studien zeigen, dass es anscheinend keine parasympathischen Nervenfasern im sakralen Rückenmark gibt. Zudem zählen, neben Sympathikus und Parasympathikus, noch zwei weitere Strukturen zum vegetativen Nervensystem – das enterische Nervensystem und das „little brain on the heart“. Die klinischen Krankheitsbilder der vegetativen Nervensysteme sind längst Gegenstand der osteopathischen Forschung und lassen sich anscheinend positiv beeinflussen.
Article
In the last decade, there has been growing interest in the pathological involvement of hypertrophic mesenteric fat attached to the serosa of the inflamed intestinal segments involved in Crohn's disease, known as creeping fat. In spite of its protective nature, creeping fat harbours an aberrant inflammatory activity which, in an already inflamed intestine, may explain why creeping fat is associated with a greater severity of Crohn’s disease. The transmural inflammation of Crohn’s disease facilitates the interaction of mesenteric fat with translocated intestinal microorganisms, contributing to the activation of the immune response. This may be not the only way in which microorganisms alter the homeostasis of this fatty tissue: intestinal dysbiosis may also impair xenobiotic metabolism. All these Crohn’s disease-related alterations have a functional impact on nuclear receptors such as the farnesoid X receptor or the peroxisome proliferator-activated receptor γ, which are implicated in the regulation of immune response, adipogenesis and the maintenance of barrier function, as well as on the creeping fat production of inflammatory influencers such as adipokines. The dysfunction of creeping fat worsens the inflammatory course of Crohn’s disease and may favour intestinal fibrosis and fistulizing complications. However, our current knowledge of the pathophysiology and pathogenic role of creeping fat is controversial and a better understanding might provide new therapeutic targets for Crohn’s disease. We aim to review and update the key cellular and molecular alterations involved in this inflammatory process that link the pathological components of Crohn’s disease with the development of creeping fat.
Article
Introduction The precaecocolic fascia, previously known as Jackson's membrane, is a variable vascular peritoneal fold between the ascending colon and the right posterolateral abdominal wall. First described in 1913, it was originally thought to be of developmental or inflammatory origin and associated with abdominal pain. This investigation aimed to review its frequency, form and structure and look for evidence of association with malformation of the bowel, or previous inflammation. Materials and Methods Twenty-six dissecting room cadavers were studied to identify the precaecocolic fascia, any malrotation of the colon or signs of previous inflammation: adhesions, surgical scars or absence of the appendix. Its structure was examined histologically and latex injections were used to trace the arteries. Results Membranes comparable with previous descriptions of the precaecocolic fascia occurred in 12 of 26 abdomens. They varied in form and size from long and translucent to short, thick and opaque. In structure, the fascia resembled a fold of peritoneum containing a thickened fibrous lamina. Large thin-walled arteries in the fascia crossed the arteries in the wall of the colon at the point of attachment. No significant association with colonic malrotation or markers of previous inflammation were found. Conclusions Attention should be paid to the definition of the precaecocolic fascia and “membrane” seems a more appropriate term than “fascia”. It is one of a recognised group of peritoneal folds/bands, doubtful in origin but unlikely to be post-inflammatory. It may modify colonic mobility or complicate colonic operations. This article is protected by copyright. All rights reserved.
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The concepts of total mesorectal excision (TME) and circumferential resection margin (CRM) radicalized rectal cancer surgery and translated into an improved local and distal recurrence, along with prolonged overall survival. TME dissection occurs in the areolar plane between the visceral fascia that envelops the rectum and mesorectum and the parietal fascia that envelops the pelvic wall structures. The CRM corresponds to the non‐peritonealized surface of the resection specimen created by the dissection of the subperitoneal aspect of the rectum. In colorectal cancer, high budding correlated with worse overall survival and distal recurrence. In a fashion similar to perineural invasion spread, rectal cancer can utilize these available pathways of least resistance to collectively migrate and invade locoregional lymph nodes. The effects of neoadjuvant treatment on postoperative complications have been explored in a few large cohorts of pelvic exenterations. The largest contained 1184 patients, of which 614 had neoadjuvant chemoradiotherapy.
Article
Background: Mesentery thickening and enlarged lymphnodes are typical findings of Crohn's disease (CD), but their role is unknown. Aim of the present study was to evaluate their prevalence and significance on postoperative complications and long-term surgical recurrence after CD surgery. Methods: 1272 consecutive, unselected patients were retrospectively reviewed, divided into 4 groups based on the presence or absence of a thickened mesentery and enlarged lymphnodes, and stratified for primary or recurrent surgical procedure. In all patients but those treated with strictureplasty the mesentery and lymphnodes were removed. Patients' characteristics, peri-operative findings, and long-term recurrence were compared by univariate and multivariate analysis. Results: Thickened mesentery and enlarged lymphnodes were not present in all cases, were typical of ileal location and penetrating behaviour, had a constant decrease over recurrences, were independent of either pre-operative medical therapy or surgical approach, did not increase the duration of surgery and complications, presented similar 20-years recurrence rate to normal mesentery and lymphnodes. Lymphopathy was associated to a worst nutritional status during disease recurrences. At multivariate analysis, age, location, and behaviour, but not mesenteric characteristics, were related to an increased risk of surgical recurrence. Conclusions: This study provides new information on mesentery and lymphnodes in CD patients. Further studies are needed to clarify the appropriate surgical approach.
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The use of medical imaging technologies, bioimaging, digitized archives of scientific and medical literature, the special mentality of researchers, going beyond the skills of professional education have led to the discovery of new organs of the human body. The aim of the review is to present in the first iteration the basic information about the new organs of the human body and the need for their identification for complete scientific and practical work. Anterolateral ligament of the knee is present in 97.56 % of people. It was first described in 1879, rediscovered in 2013. The juxta-oral organ was first described in 1885, and again in 2015-2020. Description of the lymphatic drainage system of the brain was published in 1787 and 1816, rediscovery and detailing already in the 21st century. It was proposed to identify the interstitium as a special organ that deposits and transports about 20 % of the interstitial fluid in the body. It is assumed that the interstitium can act as a shock absorber and keeps tissue from rupture. The vision of the mesentery as a whole continuous organ will make it possible to modify many operations, reduce their invasiveness, implement full-fledged rehabilitation after surgery, and improve the quality of life of patients.
Article
Over the past 5 years, systematic investigation of the mesenteric organ has expanded and shown that the mesentery is the organ in and on which all abdominal digestive organs develop and remain connected to. In turn, this observation has clarified the anatomical foundation of the abdomen and the fundamental order at that level. Findings related to the shape and development of the mesentery have illuminated its function, advancing our understanding of the pathobiology, diagnosis, and treatment of several abdominal and systemic diseases. Inclusion of the mesentery in surgical resections alters the course of benign and malignant diseases. Mesenteric-based scoring systems can enhance the radiological interpretation of abdominal disease. Emerging findings reconcile observations across scientific and clinical fields and have been assimilated into reference curricula and practice guidelines. This Review summarises the developmental, anatomical, and clinical advances made since the mesentery was redesignated as an organ in 2016.
Article
Crohn's disease (CD) is a complex and relapsing gastrointestinal disease with mesenteric alterations. The mesenteric neural, vascular, and endocrine systems actively take part in the gut dysbiosis-adaptive immunity-mesentery-body axis, and this axis has been proven to be bidirectional. The abnormalities of morphology and function of the mesenteric component are associated with intestinal inflammation and disease progress of CD via responses to afferent signals, neuropeptides, lymphatic drainage, adipokines, and functional cytokines. The hypertrophy of mesenteric adipose tissue plays important roles in the pathogenesis of CD by secreting large amounts of adipokines and representing a rich source of proinflammatory or profibrotic cytokines. The vascular alteration, including angiogenesis and lymphangiogenesis, is concomitant in the disease course of CD. Of note, the enlarged and obstructed lymphatic vessels, which have been described in CD patients, are likely related to the early onset submucosa edema and being a cause of CD. The function of mesenteric lymphatics is influenced by endocrine of mesenteric nerves and adipocytes. Meanwhile, the structure of the mesenteric lymphatic vessels in hypertrophic mesenteric adipose tissue is mispatterned and ruptured, which can lead to lymph leakage. Leaky lymph factors can in turn stimulate adipose tissue to proliferate and effectively elicit an immune response. The identification of the role of mesentery and the crosstalk between mesenteric tissues in intestinal inflammation may shed light on understanding the underlying mechanism of CD and help explore new therapeutic targets.
Article
Background: Complete mesocolic excision (CME) with central vascular ligation (CVL) was proposed by Hohenberger in 2009. The CME principle has gradually become the technical standard for colon cancer surgery. How to achieve CME with CVL in laparoscopic right hemicolectomy (LRH) is controversial, and a unified standard approach is not yet available. In recent years, the authors' team has integrated the theory of membrane anatomy, tried to combine the cephalic approach with the classic medial approach (MA) for technical optimization, and proposed a cranial-medial mixed dominant approach (CMA). Aim: To explore the feasibility of operational approaches for LRH with CME. Methods: In this retrospective cohort study, the clinical data of 57 patients with right-sided colon cancer (TNM stage I, II, or III) who underwent LRH with CME from January 2016 to June 2020 were collected and summarized. There were 31 patients in the traditional MA group and 26 in the CMA group. Results: There were no significant differences in baseline data between the two groups. The operation was shorter and the number of lymph nodes dissected was higher in the CMA group than in the MA group, but there was no significant difference in the number of positive lymph nodes, intraoperative blood loss, postoperative exhaust time, feeding time, postoperative hospital stay or postoperative complication incidence. Conclusion: Our study shows that the CMA is a safe and feasible procedure for LRH with CME and has a unique advantage.
Chapter
Dendritic cells (DCs) are professional antigen presenting cells that play an important role in the induction of T cell responses. Different subsets (cDC1s, cDC2s, pDCs, and moDCs) were described based on the expression of different surface markers and functions. In the context of peritoneum, DCs are also a key population cell orchestrating immune responses against pathogens, malignant cells and tissue-damage. Furthermore, they play an important role in the promotion of an anti-inflammatory microenvironment, which is necessary to maintain tolerance and adipocyte homeostasis. The aim of this review is to summarize the current knowledge of the functional and phenotypic features of peritoneal DCs and shed some light on the importance of these cells within this unique cavity and its associated components: the omentum, the mesentery and gut-associated lymphoid tissue (GALT).
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Ileal pouch-related adenocarcinoma remains a rarity; thus, guidelines on treatment are currently lacking. We present this case of a 54-year-old man who underwent restorative proctocolectomy with stapled ileal pouch–anal anastomosis formation for familial adenomatous polyposis during the 1980s. Despite undergoing annual surveillance endoscopy, the patient was noted to be anaemic and passing fresh blood per anus. Endoscopy and radiological investigation revealed the presence of a pouch-related adenocarcinoma. This was subsequently treated with short-course radiotherapy and pouch excision. The patient remains well until now and will follow six-monthly surveillance protocols with a transition to annual surveillance after 2 years.
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Complete mesocolic excision (CME) for the treatment of colon cancer was first introduced in the West in 2008. The first aim of this procedure is to remove the afflicted colon and its accessory lymphovascular supply by resecting the colon and mesocolon in an intact envelope of visceral peritoneum, which holds potentially involved lymph nodes. The second component of CME is a central vascular tie to remove completely all lymph nodes in the central (vertical) direction. In its original iteration, CME was performed via laparotomy, although many centers preferentially perform laparoscopic surgery, with its associated benefits and similar oncological outcomes, as the standard treatment for colonic cancer. Here, we present the surgical techniques for CME in open and laparoscopic surgery, as well as the surgical, pathological and oncological outcomes of the procedure that are available to date. Because there are no randomized control trials comparing CME to "standard" colon surgery, the principles underlying CME seem anatomical and logical, and the results published from the Far East, reporting an 80% 5-year survival rate for Stage III cancer, should guide us.
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Background: Anatomical knowledge of the variations of Superior mesenteric artery (SMA) and its branches is important to minimize the complications and hence this article will be helpful for the clinicians planning surgery and intervention around the aforementioned vessels. Materials and Methods: In the present study, we studied the pattern of arrangement and distribution of the SMA in twenty cadavers in the gross anatomy dissection room in the department of anatomy, AIIMS, New Delhi. Results and Discussion: On the basis of branching pattern of SMA, the cadavers were divided into three groups I, II, III. Group I consisted of the most usual pattern of arrangement of SMA, in 70% of cases (14 cadavers). In Group II i.e. in 25 % cases (5 cadavers) we observed a common trunk of ileocolic and right colic arteries. Group III consisted of the rarest variation in the branching pattern of SMA, where we got a common trunk of left colic artery with an accessory splenic artery arising from anterior aspect of SMA, instead of Inferior mesenteric artery (IMA) which was seen in 5% cases (1 cadaver).Main splenic artery took origin from coeliac trunk as usual. Conclusions: These uncommon and rare variations in the branching pattern of arteries of the gut are clinically very important for surgeons and radiologists to prevent damage to these vessels which otherwise may lead to severe haemorrhage and other complications. In the present article we discuss about the morphology and development of the SMA along with its variations.
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The human mesentery is now regarded as contiguous from the duodenojejunal (DJ) to anorectal level. This interpretation prompts re-appraisal of computed tomography (CT) images of the mesentery. A digital model and reference atlas of the mesentery were generated using the full-colour data set of the Visible Human Project (VHP). Seventy one normal abdominal CT images were examined to identify mesenteric regions. CT appearances were correlated with cadaveric and histological appearances at corresponding levels. Ascending, descending and sigmoid mesocolons were identifiable in 75 %, 86 % and 88 % of the CTs, respectively. Flexural contiguity was evident in 66 %, 68 %, 71 % and 80 % for the ileocaecal, hepatic, splenic and rectosigmoid flexures, respectively. A posterior mesocolic boundary corresponding to the anterior renal fascia was evident in 40 % and 54 % of cases on the right and left, respectively. The anterior pararenal space (in front of the boundary) corresponded to the mesocolon. Using the VHP, a mesenteric digital model and reference atlas were developed. This enabled re-appraisal of CT images of the mesentery, in which contiguous flexural and non-flexural mesenteric regions were repeatedly identifiable. The anterior pararenal space corresponded to the mesocolon. • The Visible Human Project (VHP) allows direct identification of mesenteric structures. • Correlating CT and VHP allows identification of flexural and non-flexural mesenteric components. • Radiologic appearance of intraperitoneal structures is assessed, starting from a mesenteric platform.
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It is now well established that mesenteric-based colorectal surgery is associated with superior outcomes. Recent anatomic observations have demonstrated that the mesenteric organ is contiguous from the duodenojejunal to the anorectal junction. This led to similar observations in relation to associated peritoneum and fascia. The aim of this review was to demonstrate the relevance of the contiguity principle to resectional colorectal surgery. All literature in relation to mesenteric anatomy was reviewed from 1873 to the present, without language restriction. Mesenteric-based surgery (i.e. complete mesocolic excision, total mesocolic and mesorectal excision) requires division of the peritoneal reflection (i.e. peritonotomy), and mesenteric mobilisation in the mesofascial plane. These are the fundamental technical elements of mesenterectomy. Mesenteric, peritoneal and fascial contiguity mean that in resectional surgery, these technical elements can be reproducibly applied at all levels from the origin at the superior mesenteric root, to the anorectal junction. The goals of complete mesocolic, total mesocolic and mesorectal excision can be universally achieved at any level from duodenojejunal flexure to anorectal junction, by adopting technical elements based on mesenteric, peritoneal and fascial contiguity. © 2015 S. Karger AG, Basel.
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Although promising, the evidence supporting the use of anti-tumor necrosis factor agents (anti-TNFs) in the postoperative Crohn's disease (CD) is still based on limited experience. We aimed to conduct a meta-analysis of prospective studies evaluating the efficacy and safety of anti-TNFs for prevention of postoperative recurrence (POR) in CD. MEDLINE, EMBASE, Web of Science, Cochrane database and conference proceeding abstracts were searched. The primary outcome measure was the number of patients who developed POR as defined by the primary studies. Six prospective studies were included. The rate of endoscopic recurrence (ER) was significantly lower in anti-TNFs (9.2%, 7/76) compared with non-biologicals group (61.5%, 83/135) (odds ratio (OR) 0.05, 95% confidence interval (CI) 0.02-0.13; P<0.001). The rate of severe ER was also lower in the anti-TNFs group (1.6%, 1/64) than that in the non-biologicals group (32.7%, 18/55, OR 0.10; P=0.04). Significantly lower proportion of patients in the anti-TNFs group developed clinical recurrence (3.4%, 2/59) compared with non-biologicals arm (41.1%, 49/119; OR 0.1; P<0.001). More anti-TNFs-treated patients (86.5%, 45/52) were maintained in clinical remission compared with non-biologicals group (58.1%, 43/74, OR 4.05; 95%CI 1.60-10.29, P <0.01). The adverse events were similar between the two groups (anti-TNFs 44.9% (22/49) vs. control 52.5% (42/80), P =0.69). Anti-TNFs are superior to non-biologic agents in preventing endoscopic and clinical recurrence of CD without causing more adverse events. Copyright © 2015 European Crohn’s and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.
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To determine the incidence of appendiceal Crohn's disease (CD) and to summarize the characteristic histologic features of appendiceal CD. We reviewed the pathology files of 2179 appendectomy specimens from January 2007 to May 2013. The computer-assisted retrieval search facility was utilized to collect specimens. We selected those cases that were diagnosed as CD or chronic granulomatous inflammation and defined the final diagnosis according to the histologic findings of CD, including transmural lymphocytic inflammation, non-caseating epithelioid granulomas, thickening of the appendiceal wall secondary to hypertrophy of muscularis mucosa, mucosal ulceration with crypt abscesses, mucosal fissures, and fistula formation. We found 12 cases (7 male and 5 female patients, with an average age of 29.8 years) of appendiceal CD. The incidence of appendiceal CD was 0.55%. The chief complaints were right lower quadrant pain, abdominal pain, lower abdominal pain, and diarrhea. The duration of symptom varied from 2 d to 5 mo. The histologic review revealed appendiceal wall thickening in 11 cases (92%), transmural inflammation in all cases (100%), lymphoid aggregates in all cases (100%), epithelioid granulomas in all cases (100%), mucosal ulceration in 11 cases (92%), crypt abscesses in 5 cases (42%), perforation in 2 cases (17%), muscular hypertrophy in 1 case (8%), neural hyperplasia in 5 cases (42%), and perpendicular serosal fibrosis in 8 cases (67%). A typical and protracted clinical course, unusual gross features of the appendix and the characteristic histologic features are a clue in the diagnosis of appendiceal CD.
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Obesity has become one of the main threats to health worldwide and therefore gained increasing clinical and economic significance as well as scientific attention. General adipose-tissue accumulation in obesity is associated with systemically increased pro-inflammatory mediators and humoral and cellular changes within this compartment. These adipose-tissue changes and their systemic consequences led to the concept of obesity as a chronic inflammatory state. A pathognomonic feature of Crohn's disease (CD) is creeping fat (CF), a locally restricted hyperplasia of the mesenteric fat adjacent to the inflamed segments of the intestine. The precise role of this adipose-tissue and its mediators remains controversial, and ongoing work will have to define whether this compartment is protecting from or contributing to disease activity. This review aims to outline specific cellular changes within the adipose-tissue, occurring in either obesity or CF. Hence the potential impact of adipocytes and resident immune cells from the innate and adaptive immune system will be discussed for both diseases. The second part focuses on the impact of generalized adipose-tissue accumulation in obesity, respectively on the locally restricted form in CD, on intestinal inflammation and on the closely related integrity of the mucosal barrier.
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Although total mesorectal excision has now become the ‘gold standard' for the surgical management of rectal cancer, this is not so for colon cancer. Recent data, provided by Hohenberger and West et al. and others, have demonstrated excellent oncological outcomes when mesenterectomy is extensive (as is implicit in the concept of a ‘high tie') and the mesenteric package not violated. Such studies highlight the importance of understanding the basics of the mesenteric organ (including the small intestinal mesentery, mesocolon, mesosigmoid and mesorectum) and of abiding to principles of planar surgery. In this review, we first offer classic descriptions of the mesocolon and then detail contemporary thinking. In so doing, we provide an anatomical basis for safe and effective complete mesocolic excision (CME) in the management of colon cancer. Finally we list opportunities associated with the new anatomical paradigm, demonstrating benefits across multiple disciplines. Perhaps most importantly, we feel that a crystallized view of mesenteric anatomy will overcome factors that have hindered the general uptake of CME.
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Recent developments in colonic surgery generate exciting opportunities for surgeons and trainees. In the first instance, the anatomy of the entire mesenteric organ has been clarified and greatly simplified. No longer is it regarded as fragmented and complex. Rather it is continuous from duodenojejunal flexure to mesorectum, spanning the gastrointestinal tract between. Recent histologic findings have demonstrated that although apposed to the retroperitoneum, the mesenteric organ is separated from this via Toldt’s fascia. These fundamentally important observations underpin the principles of complete mesocolic excision, where the mesocolic package is maintained intact, following extensive mesenterectomy. More importantly, they provide the first opportunity to apply a canonical approach to the development of nomenclature in resectional colonic surgery. In this review, we demonstrate how the resultant nomenclature is entirely anatomic based, and for illustrative purposes, we apply it to the procedure conventionally referred to as right hemicolectomy, or ileocolic resection.
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Persistent ascending or descending mesocolon is an embryological anomaly that occurs during the final process of intestinal development in organogenesis. Specifically, the primitive dorsal mesocolon fails to fuse with the parietal peritoneum in the fifth month of gestation. Herein, we describe a case of ascending colon cancer with persistent ascending and descending mesocolon treated by laparoscopic right hemicolectomy. Preoperative computed tomography imaging of the abdomen demonstrated that the descending colon shifted at the midline of the abdomen and the sigmoid colon was located under the ascending colon. The detailed preoperative imaging examination revealed malpositioning of the large intestine and aided in the procedural planning. Because persistent mesocolon may result in the formation of abnormal adhesions, an accurate preoperative diagnosis is essential. We propose that it is important to consider this anomaly when making the preoperative imaging diagnosis to ensure a safe operation.
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Mesenteric cysts are rare abdominal tumours. They are found in the mesentery of small bowel (66%) and mesentery of large intestine (33%), usually in the right colon. Very few cases have been reported of tumours found in mesentery of descending colon, sigmoid or rectum. Mesenteric cysts do not show classical clinical findings and are detected incidentally during imaging due to absent or non-specific clinical presentation or during management of one of their complications. Ultrasonography (USG)/computed tomography (CT)/ magnetic resonance imaging (MRI) are used in diagnosing mesenteric cyst but they cannot determine the origin of cyst. Laparoscopy not only helps in diagnosing the site and origin of the mesenteric cyst but also has a therapeutic role. Laparoscopic treatment of mesenteric cyst is a safe, preferred method of treatment and is a less-invasive surgical technique. Here, we present an unusual case of mesenteric cyst arising from the sigmoid mesocolon treated by laparoscopic excision.
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Purpose of review: This article assesses the role of the mesentery in Crohn's disease. Recent findings: The mesentery is centrally positioned both anatomically and physiologically. Overlapping mesenteric and submucosal mesenchymal contributions are important in the pathobiology of Crohn's disease. Mesenteric contributions explain the topographic distribution of Crohn's disease in general and mucosal disease in particular. Operative strategies that are mesenteric based (i.e. mesocolic excision) may reduce rates of postoperative recurrence. Summary: The net effect of mesenteric events in Crohn's disease is pathologic. This can be targeted by operative means. VIDEO ABSTRACT: http://links.lww.com/COG/A18.
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A recent paper indicates that intraoperative and postoperative complications associated with complete mesocolic excision are increased when compared with conventional surgery. Variability in complication rates between studies highlights the need for standardization in colorectal surgery. This process should start by addressing factors that have hampered standardization to date.
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Background: Complete mesocolic excision (CME) seems to be associated with improved oncological outcomes compared with 'conventional' surgery, but there is a potential for higher morbidity. Methods: Data for patients after elective resection at the four centres in the Capital Region of Denmark (June 2008 to December 2013) were retrieved from the Danish Colorectal Cancer Group database and medical charts. Approval from a Danish ethics committee was not required (retrospective study). Results: Some 529 patients who underwent CME surgery at one centre were compared with 1701 patients undergoing 'conventional' resection at the other three hospitals. Laparoscopic CME was performed in 258 (48·8 per cent) and laparoscopic 'conventional' resection in 1172 (68·9 per cent). More extended right colectomy procedures were done in the CME group (17·4 versus 3·6 per cent). The 90-day mortality rate in the CME group was 6·2 per cent versus 4·9 per cent in the 'conventional' group (P = 0·219), with a propensity score-adjusted logistic regression odds ratio (OR) of 1·22 (95 per cent c.i. 0·79 to 1·87). Laparoscopic surgery was associated with a lower risk of mortality at 90 days (OR 0·63, 0·42 to 0·95). Intraoperative injury to other organs was more common in CME operations (9·1 per cent versus 3·6 per cent for 'conventional' resection; P < 0·001), including more splenic (3·2 versus 1·2 per cent; P = 0·004) and superior mesenteric vein (1·7 versus 0·2 per cent; P < 0·001) injuries. Rates of sepsis with vasopressor requirement (6·6 versus 3·2 per cent; P = 0·001) and postoperative respiratory failure (8·1 versus 3·4 per cent; P < 0·001) were higher in the CME group. Conclusion: CME is associated with more intraoperative organ injuries and severe non-surgical complications than 'conventional' resection for colonic cancer.
Article
Abnormalities in mesenteric adipose tissue (MAT) have long been recognized; however, the functional changes in the mesenteric adipocytes as well as the underlying mechanisms are not entirely clear. The aim of this study was to analyze the function and morphology of the MAT in patients with Crohn's disease (CD) and the underlying mechanism. The MAT specimens were obtained from areas adjacent to the intestinal wall in patients with CD (n = 33) and without CD (control, n = 23) who underwent intestinal resection. For patients with CD, paired samples were obtained from the macroscopically hypertrophic mesenteric adipose tissue (htMAT), adjacent to the involved ileum, and the macroscopically normal mesenteric adipose tissue (nMAT), contiguous with the healthy segment of the ileum. Morphological and molecular techniques were used to detect the characteristics of the MAT of CD and compare them with the characteristics of the control tissues. Hypoxia was confirmed by a high expression of hypoxia-inducible factor 1α. The function and morphology of the nMAT in patients with CD were similar to those of the control tissues. htMAT of CD was dysfunctional based on the evidence that htMAT exhibited decreased lipid store, fatty acid synthase, and adipose triglyceride lipase, but increased levels of glucose transporter 1, aldolase C, and lactate when compared with those from nMAT and control tissues (P < 0.01). In addition, the structure of htMAT was found to be disorganized and characterized by higher levels of collagen content, interleukin 1β, interleukin 6, tumor necrosis factor α, and MCP-1 when compared with nMAT and control tissues (P < 0.01). htMAT was in a hypoxic condition, based on the findings that htMAT had a higher level of hypoxia-inducible factor 1α and a decreased number of vessels per adipocyte compared with those of nMAT and the control tissues (P < 0.01). The transforming growth factor β/Smad and nuclear factor-kappa B signaling pathways were found to be activated in htMAT, which may be associated with hypoxia. The disorganized structure and dysfunction of mesenteric adipocyte tissue in CD was confirmed, and these alterations may be associated with hypoxia. It is possible that amelioration of mesenteric adipocyte hypoxia may help attenuate CD with underlying MAT inflammation.
Article
The optimal technique for curative resection of colonic cancer includes high ligation of the mesenteric vessels, wide excision of the colonic mesentery and prevention of tumour cell spillage. This article reports results from the authors' institution for patients in whom complete mesocolic excision was performed long before the term was coined. Patients operated on for cure for primary adenocarcinoma of the colon between January 1994 and December 2004 were identified from a prospectively maintained, institutional review board-approved, colorectal cancer registry. Medical records and operation notes were reviewed. The primary outcomes were recurrence (local and distal) and age-adjusted 5-year survival. Some 1013 patients (560 men and 453 women) were identified, with a median age of 69 (range 21-96) years. The most common location of the cancer was the sigmoid colon (32·9 per cent), followed by the caecum (26·7 per cent) and ascending colon (17·0 per cent). Operations were performed laparoscopically in 134 patients (13·2 per cent). Median duration of hospital stay was 7 (range 1-64, mean 8·2) days. Overall morbidity and mortality rates were 13·5 and 2·2 per cent respectively; there were 20 anastomotic leaks (2·0 per cent). Some 282 patients (27·8 per cent) had stage I, 386 (38·1 per cent) stage II and 345 (34·1 per cent) stage III disease. Median lymph node yield was 28·3 (range 0-241, mean 28·3), and 12 or more nodes were examined in 88·1 per cent of patients. Adjuvant chemotherapy was administered to 277 patients (80·3 per cent) with stage III disease. Overall local and distant recurrence rates at 5 years were 5·1 and 17·1 per cent respectively. The 5-year local recurrence rate was 2·2, 5·3 and 7·7 per cent for American Joint Committee on Cancer stages I, II and III respectively. Corresponding distant recurrence rates were 4·0, 14·7 and 30·5 per cent. The 5-year overall cancer-free age-standardized survival rate was 85·3 per cent. Five-year age standardized survival rates for patients with disease stages I, II and III were 97·7, 90·8 and 69·8 per cent respectively. These data define modern results of surgery for colonic cancer with conservative use of chemotherapy. © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd.
Article
Smoking is known to have a deleterious effect on Crohn's disease (CD). The present study addressed the specific impact of smoking on the outcome of surgery for CD. A review of the National Surgical Quality Improvement Program (NSQIP) database (2005-2012) identified 7,631 patients with CD undergoing surgical resection. Patients were stratified based on smoking status and were compared with univariate statistical tests. Generalized linear regression and multiple logistic regressions were used to model the impact of smoking on the surgical outcome (length of stay [LOS], mortality, postoperative complications and readmission). To confirm the validity of the regression models and to evaluate the influence of smoking in comparable patient cohorts, a propensity score match was also performed. There were 2,047 (26.8%) patients with CD identified as current smokers, and 5,584 (74.2%) identified as non or ex-smokers. Smokers were more likely to have a pulmonary comorbidity, pre-operative weight loss and a higher ASA classification. No differences in mortality were observed between smokers and non or ex-smokers in univariate analysis. In multivariate analysis, smoking status was not significantly associated with LOS. Morbidity (OR 1.20, P=0.003), particularly infectious (OR 1.30, P<0.001) and pulmonary (OR 1.87, P<0.001) complications, and readmission (OR 1.58, P=0.004) were significantly associated with smoking status. These findings were validated on propensity score matching analysis. In patients with CD, the detrimental effects of smoking on surgical outcomes are driven by infectious and pulmonary complications, and by increased likelihood of readmission. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
Article
Background: Laparoscopic colectomy has become accepted for resection of colon cancer, and laparoscopic complete mesocolic excision (CME) has proved feasible and safe. We have evaluated the safety, efficacy, and feasibility of laparoscopic CME via reduced port surgery (RPS) in patients with colon cancer. Methods: We prospectively assessed 17 consecutive patients with colon cancer undergoing laparoscopic CME via RPS between February 2012 and January 2014. Video recordings were used to assess the quality of the surgery, including CME completion. We also assessed operative data, complications, pathological findings, visual analog scale (VAS), cosmesis, and the hospital length of stay. Results: All patients underwent en bloc resection of mesocolon with CME completion. The median surgical duration and blood loss were 298 min and 41 ml, respectively. No intraoperative complications occurred in any patient. The median number of lymph nodes retrieved was 20, with lymph node metastasis identified in eight patients. The mean VAS scores for postoperative days 1, 3, and 7 were 3.2, 1.5, and 0, respectively. All patients were satisfied with their cosmesis. The median postoperative hospital stay was 11 days. Conclusions: Laparoscopic CME via RPS for colon cancer is a safe and feasible surgical procedure with cosmetic advantages.
Article
To describe the rates of elevated inflammation, obesity, and metabolic syndrome (MetS) within a large cohort of individuals with depression and to examine the interrelationships of inflammation and MetS in depressed individuals. Analyses were conducted on study participants from the 2009-2010 National Health and Nutrition Examination Survey (NHANES) with Patient Health Questionnaire (PHQ-9) depression scores ≥ 10 to (1) examine the relationship of inflammation (C-reactive protein; CRP) with demographic and clinical characteristics and (2) examine the prevalence of MetS criteria within CRP groups. 5,579 participants provided PHQ-9 data; of those, 606 had PHQ-9 scores ≥ 10 and were included in further analysis. Of the 606 depressed participants, 585 participants had valid CRP data; 275 participants (47.01%) had CRP levels ≥ 3.0 mg/L, while 170 (29.06%) had CRP levels ≥ 5.0 mg/L. Elevated inflammation was significantly correlated with body weight, waist circumference, body mass index, insulin, 2-hour glucose tolerance, and self-report general health (P values < .05). 112 subjects (41.18%) met American Heart Association/National Heart, Lung, and Blood Institute criteria for MetS. Those with elevated CRP were more likely to meet criteria for MetS (odds ratios of 2.81 for those with CRP levels ≥ 3.0 mg/L and 1.94 for those with CRP levels ≥ 5.0 mg/L). Over 29% of depressed individuals had elevated levels of CRP, and 41% met criteria for MetS. Individuals with elevated inflammation are more likely to be obese and meet criteria for MetS. These results highlight the significant inflammatory and metabolic burden of individuals with depression. © Copyright 2014 Physicians Postgraduate Press, Inc.
Article
Despite its well-documented relation with visceral adiposity (VAT) and cardiometabolic risk (CMR), whether waist circumference (WC) should be measured in addition to body mass index (BMI) remains debated. This study tested the relevance of adding WC to BMI for the estimation of VAT and CMR. In the International Study of Prediction of Intra-abdominal Adiposity and Its Relationship with Cardiometabolic Risk/Intra-abdominal Adiposity, 297 physicians recruited 4,504 patients (29 countries). Both BMI and WC were measured, whereas VAT and liver fat were assessed by computed tomography. A composite CMR score was calculated. From the 4,109 patients included in the present analyses (20 ≤ BMI < 40 kg/m(2), 47% women), about 30% displayed discordant values for WC and BMI quintiles, despite a strong correlation between the 2 anthropometric variables (r = 0.87 and r = 0.84 for men and women, respectively, p <0.001). Within each single BMI unit, VAT and WC showed substantial variability between subjects (mean difference between 90th and 10th percentiles: 175 cm(2)/16 cm and 137 cm(2)/18 cm for VAT/WC in men and women, respectively). Within each BMI category, increasing gender-specific WC tertiles were associated with significantly higher VAT, liver fat, and with a more adverse CMR profile. In conclusion, this large international cardiometabolic study highlights the frequent discordance between BMI and WC, driven by the substantial variability in VAT for a given BMI. Within each BMI category, WC was cross-sectionally associated with VAT, liver fat, and CMR factors. Thus, WC allows a further refinement of the CMR related to any given BMI. Copyright © 2014 Elsevier Inc. All rights reserved.
Article
AimsTo examine the associations between endogenous sex steroid hormones (oestradiol, testosterone and sex hormone-binding globulin) with diabetes risk in a South-Asian population living in the USA.Methods We used data from the Metabolic Syndrome and Atherosclerosis in South-Asians Living in America pilot study. The analytical sample included 60 women and 45 men of Asian Indian origin living in the San Francisco Bay Area, who were free from diabetes and cardiovascular disease and did not use exogenous sex steroids. Sex steroid hormone levels were assessed by validated conventional radioimmunoassays, and visceral and hepatic adiposity were assessed by computed tomography. We used multivariable regression to examine the association between endogenous sex steroid hormone levels (log-transformed) and fasting glucose and 2-h glucose levels in a series of sex-stratified models adjusted for age, waist circumference, visceral and hepatic adiposity, and insulin resistance.ResultsIn age-adjusted models, lower levels of sex hormone-binding globulin (β=-0.18, 95% CI -0.30, -0.06) and higher levels of free testosterone (β=0.14, 95% CI 0.02, 0.26) were associated with elevated fasting glucose levels in South-Asian women, whereas lower levels of sex hormone-binding globulin (β=0.14, 95% CI -0.26, -0.02) and lower levels of total testosterone (β=-0.12, 95% CI -0.24, 0.00) were associated with elevated fasting glucose levels in South-Asian men. Adjustment for waist circumference, visceral adiposity and insulin resistance attenuated most of these associations, while adjustment for hepatic adiposity strengthened some of the observed associations. Similar results were found for 2-h glucose levels.Conclusions Results were consistent with previous research, which suggests that endogenous sex steroid hormones are a risk factor for diabetes across multiple race/ethnic groups. Additional studies are needed to determine whether visceral fat is a mediator or confounder of associations between sex steroid hormone and glucose levels.This article is protected by copyright. All rights reserved.
Article
Aim To analyze our experience in translating the concept of total mesorectal excision to “no-touch” complete removal of an intact mesocolonic envelope (complete mesocolic excision), along with central vascular ligation and apical node dissection, in the surgical treatment of right-sided colonic cancers, comparing “mesocolic” to less radical “non-mesocolic” planes of surgery in respect to quality of the surgical specimen and long-term oncologic outcome. Method A total of 115 patients with right-sided colonic cancers were retrospectively enrolled from 2008 to 2013 and operated on following the intent of minimally invasive complete mesocolic excision with central vascular ligation. Results Morbidity and mortality were 22.6% and 1.7%, respectively. Mesocolic, intramesocolic, and muscularis propria planes of resection were achieved in 65.2%, 21.7%, and 13% of cases, respectively, with significant impact for mesenteric plane of surgery on R0 resection rate (97.3%), circumferential resection margin <1 mm (2.6%), and consequent survival advantage (82.6% at 5 years) when compared to muscularis propria plane of surgery, with R0 resection rate and overall survival falling to 72% and 60%, respectively, and with circumferential resection margin <1 mm raising to 33.3%, all being statistically significant. Stratifying patients for stage of disease, laparoscopic complete mesocolic excision with central vascular ligation significantly impacted survival in patients with stage II, IIIA/B, and in a subgroup of IIIC patients with negative apical nodes. Conclusion In our experience, minimally invasive complete mesocolic excision with central vascular ligation allows for both safety and higher quality of surgical specimens when compared to less radical intramesocolic or muscularis propria planes of “standard” surgery, significantly impacting loco-regional control and thus overall survival.
Article
Inadequate resection of the adjoining mesentery is associated with adverse outcome for colon cancer. Disruption of the integrity of the mesenteric lymphatic package has been implicated in this, though not proven. Recent studies have determined mesenteric anatomy and histology and now provide an opportunity to determine accurately the distribution of lymphatic vessels. The aim of this study was to characterise the distribution of the lymphatic vessels (LV) within the small intestinal and colonic mesentery, and in Toldt's fascia, which lies between the mesocolon and underlying retroperitoneum. Mesenteric samples were harvested from 12 human cadavers. Samples were taken from the small bowel mesentery, ascending, transverse, descending mesocolon and from both apposed and non-apposed portions of the mesosigmoid. Serial sections were stained immunohistochemically with monoclonal antibody D2-40 (podoplanin), and Masson's Trichrome. Lymphatic vessel (LV) density and radius of diffusion were determined using a stereological approach. A lymphatic network was embedded within the mesenteric connective tissue lattice throughout each mesenteric region. LV were identifiable within the submesothelial connective tissue where they measured 10.2 ± 4.1 μm in diameter and had an average radius of diffusion of 174.72 ± 97.68 μm. Unexpectedly, LV were identified in Toldt's fascia, where they measured 4.3 ± 3.1 μm in diameter and had a radius of diffusion of 165.12 ± 66.26 μm. This is the first study systematically to determine and quantify the distribution of lymphatic vessels within the mesenteric organ and to demonstrate the presence of such vessels within Toldt's fascia. A rich lymphatic network occupies all levels of the mesenteric connective tissue lattice. Within the latter, they are found within 0.1 mm of peritonealised mesenteric surfaces and are separated by an average distance of 0.17 mm and may be particularly vulnerable during surgery.
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The peritoneum is commonly encountered in abdominal surgery. The development and rotation of the primitive gut tube leads to the normal adult arrangement of the peritoneal cavity, which forms bloodless planes allowing the retroperitoneal portions of the bowel to be safely mobilised. The arrangement of the peritoneum also forms spaces in which infected fluid or pus can collect. The microcirculation of peritoneal fluid is now well understood, and the large absorptive surface of the peritoneum can be exploited in peritoneal dialysis. The absorption of gas by the peritoneum following abdominal surgery is faster in neonates than in older children, and understanding this process contributes to the interpretation of postoperative radiographs.
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Background Association of C-reactive protein (CRP) and body mass index (BMI) with diabetic retinopathy (DR) has conflicting reports. Method Sixty diabetes patients each with DR (Group A), no DR (Group B) and 60 healthy volunteers (control, group C) were studied. CRP was measured. BMI was calculated. Result Significant difference in CRP was observed between groups A & B (p = 0.000) and A & C (p = 0.007). No significant difference in BMI was observed. Central macular thickness correlated positively with CRP and negatively with BMI. Conclusion We observed strong association of CRP with DR and no significant relationship between DR and BMI.
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: Crohn's disease is complicated by the development of fibrosis and stricture in approximately 30% to 50% of patients over time. The pathogenesis of fibrostenotic disease is multifactorial involving the activation of mesenchymal cells by cytokines, growth factors, and other mediators released by immune cells, epithelial cells, and mesenchymal cells. Transforming growth factor β, a key activator of mesenchymal cells, is central to the process of fibrosis and regulates numerous genes involved in the disordered wound healing including collagens, and other extracellular matrix proteins, connective tissue growth factor, and insulin-like growth factors. The activated mesenchymal compartment is expanded by recruitment of new mesenchymal cells through epithelial to mesenchymal transition, endothelial to mesenchymal transition, and invasion of circulating fibrocytes. Cellular hyperplasia and increased extracellular matrix production, particularly collagens, from fibroblasts, myofibroblasts, and smooth muscle cells add to the disturbed architecture and scarring on the intestine. Extracellular matrix homeostasis is further disrupted by alterations in the expression of matrix metalloproteinases and tissue inhibitors of metalloproteinase in the gut. Among the 163 susceptibility genes identified that contribute to susceptibility in inflammatory bowel disease mutations in NOD2/CARD15, innate immune system components and autophagy jointly contribute to the activation of mesenchymal cells and pathogenesis of fibrosis in this polygenic disorder. Numerous growth factors cytokines and other mediators also contribute to development of fibrosis in the susceptible patient. This review focuses on the molecular mechanisms that regulate mesenchymal cell function, particularly smooth muscle cells, the largest compartment of mesenchyme in the intestine, that lead to fibrosis in Crohn's disease.