A solitary Peutz-Jeghers type polyp in the jejunum of a 19 year-old male

A 19-year old male presented with melena and anemia. A duodenoscopy revealed no abnormalities, but a small bowel X-ray series demonstrated a large jejunal polyp. This 4 cm large polyp was visualised during peroperative small bowel endoscopy and was subsequently surgically removed. The polyp had the characteristic histologic appearance of a Peutz-Jeghers type polyp, but the patient had no other signs of Peutz-Jeghers syndrome, such as the characteristic mucocutaneous pigmentation, the presence of multiple polyps or a positive family history. After removal of the polyp, melena did not recur and his hemoglobin concentration normalized. Altogether, the patient does not fulfill the diagnostic criteria for Peutz-Jeghers syndrome and appears to have a solitary jejunal Peutz-Jeghers type polyp. All previously reported patients with such polyps were older than this patient

Influência do ácido ascórbico em anastomoses e alças jejunais íntegras de rato Influence of ascorbic acid on anastomotic and jejunal resistance in rat

Racional - O efeito do ácido ascórbico sobre os processos cicatriciais anastomóticos apresenta resultados conflitantes na literatura. Objetivo - Comparar a resistência cicatricial de anastomoses e de segmentos íntegros jejunais de ratos submetidos a administração de vitamina C, em distintos períodos pós-operatórios. Método - Foram estudados 50 ratos Wistar, submetidos a secção e subseqüente anastomose término-terminal de segmento jejunal, a 10 cm da flexura duodenojejunal. Os animais foram divididos em dois grupos (n = 25): Grupo I - controle; Grupo II - administração de vitamina C oral, 100 mg/kg. Avaliaram-se as pressões de ruptura anastomótica e do segmento íntegro jejunal nos 3º, 5º, 7º, 21º e 28º dias pós-operatórios. Resultados - Os ratos que receberam vitamina C apresentaram uma pressão de ruptura anastomótica maior nos 5º, 7º e 28º dias pós-operatórios. O mesmo ocorreu com as pressões de ruptura do segmento íntegro jejunal dos ratos. Conclusões - A vitamina C aumentou a resistência das anastomoses jejunais dos ratos, tanto no pós-operatório imediato, quanto no tardio. Além disso, a resistência final dos segmentos jejunais íntegros dos ratos submetidos a administração de vitamina C foi significativamente maior do que no Grupo Controle.<br>Backgroud - The effects of vitamin C on anastomotic healing process are controversial. Objective - To compare the jejunal anastomotic tension and in the upright segment in different postoperative periods. Method - Fifty male rats weighing 250 to 400 grams were submitted to laparotomy. The jejunum was transversally cut 10 cm from the duodenojejunal flexure, and subsequently anastomosed. The rats were divided into two groups (n = 25). Group I - control, Group II - oral administration of vitamin C (100 mg/kg). The anastomotic and the upright segment resistance was determined by using bursting pressure test on the 3rd, 5th , 7th , 21st and 28th postoperative days. Results - The rats submitted to oral administration of ascorbic acid show higher bursting pressure on the 5th, 7th and 28th postoperative days. The bursting resistances of the upright segment was higher on the rats submitted to vitamin C ingestion. Conclusions - Vitamin C enhances the anastomotic and jejunal resistances. Moreover, the final resistance on the upright jejunal segment was significant higher than in the control group

Hartmann's procedure versus sigmoidectomy with primary anastomosis for perforated diverticulitis with purulent or faecal peritonitis (LADIES): a multicentre, parallel-group, randomised, open-label, superiority trial

BACKGROUND: Previous studies have suggested that sigmoidectomy with primary anastomosis is superior to Hartmann's procedure. The likelihood of stoma reversal after primary anastomosis has been reported to be higher and reversal seems to be associated with lower morbidity and mortality. Although promising, results from these previous studies remain uncertain because of potential selection bias. Therefore, this study aimed to assess outcomes after Hartmann's procedure versus sigmoidectomy with primary anastomosis, with or without defunctioning ileostomy, for perforated diverticulitis with purulent or faecal peritonitis (Hinchey III or IV disease) in a randomised trial. METHODS: A multicentre, randomised, open-label, superiority trial was done in eight academic hospitals and 34 teaching hospitals in Belgium, Italy, and the Netherlands. Patients aged between 18 and 85 years who presented with clinical signs of general peritonitis and suspected perforated diverticulitis were eligible for inclusion if plain abdominal radiography or CT scan showed diffuse free air or fluid. Patients with Hinchey I or II diverticulitis were not eligible for inclusion. Patients were allocated (1:1) to Hartmann's procedure or sigmoidectomy with primary anastomosis, with or without defunctioning ileostomy. Patients were enrolled by the surgeon or surgical resident involved, and secure online randomisation software was used in the operating room or by the trial coordinator on the phone. Random and concealed block sizes of two, four, or six were used, and randomisation was stratified by age (<60 and ≥60 years). The primary endpoint was 12-month stoma-free survival. Patients were analysed according to a modified intention-to-treat principle. The trial is registered with the Netherlands Trial Register, number NTR2037, and ClinicalTrials.gov, number NCT01317485. FINDINGS: Between July 1, 2010, and Feb 22, 2013, and June 9, 2013, and trial termination on June 3, 2016, 133 patients (93 with Hinchey III disease and 40 with Hinchey IV disease) were randomly assigned to Hartmann's procedure (68 patients) or primary anastomosis (65 patients). Two patients in the Hartmann's group were excluded, as was one in the primary anastomosis group; the modified intention-to-treat population therefore consisted of 66 patients in the Hartmann's procedure group (46 with Hinchey III disease, 20 with Hinchey IV disease) and 64 in the primary anastomosis group (46 with Hinchey III disease, 18 with Hinchey IV disease). In 17 (27%) of 64 patients assigned to primary anastomosis, no stoma was constructed. 12-month stoma-free survival was significantly better for patients undergoing primary anastomosis compared with Hartmann's procedure (94·6% [95% CI 88·7-100] vs 71·7% [95% CI 60·1-83·3], hazard ratio 2·79 [95% CI 1·86-4·18]; log-rank p<0·0001). There were no significant differences in short-term morbidity and mortality after the index procedure for Hartmann's procedure compared with primary anastomosis (morbidity: 29 [44%] of 66 patients vs 25 [39%] of 64, p=0·60; mortality: two [3%] vs four [6%], p=0·44). INTERPRETATION: In haemodynamically stable, immunocompetent patients younger than 85 years, primary anastomosis is preferable to Hartmann's procedure as a treatment for perforated diverticulitis (Hinchey III or Hinchey IV disease). FUNDING: Netherlands Organisation for Health Research and Development.status: publishe