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Objective: Two experiments were conducted to provide a new approach for evaluating feed nutritional value by metabolizable glucose (MG) in piglet diets with different levels of starch and crude fiber. In Exp 1, a regression equation for MG was generated. In Exp 2, the equation was verified, and the optimal growth performance of piglets under appropriate MG levels was tested.Methods: In Exp 1, 20 weaned piglets (7.74±0.81 kg body weight [BW]) were randomly assigned to 1 of 4 treatments, including the basal diet containing different levels of MG (starch, 25.80%, 31.67%, 45.71%, 49.36%; crude fiber, 1.23%, 1.35%, 1.80%, 1.51%). The piglets were implanted with an ileal fistula, cannulation of the carotid artery, portal vein, and mesenteric artery. The chyme from the ileum fistula and blood samples were collected. In Exp 2, 30 weaned piglets (8.96±0.50 kg BW) were randomly assigned to 1 of 5 treatments, including the experimental diets with different levels of MG (37.6, 132.5, 300.0, 354.3, and 412.5 g/kg). The piglets’ BW, and feed consumption were recorded to calculate growth performance during the 28-d experiment.Results: In Exp 1, the MG levels in 4 diets were 239.62, 280.68, 400.79, and 454.35 g/kg. The regression equation for the MG levels and dietary nutrients was: Y (MG) = 12.13×X1 (starch)+23.18×X2 (crude fiber)−196.44 (R2 = 0.9989, p = 0.033). In Exp 2, treatments with 132.5 and 300.0 g/kg MG significantly (p

Highlights • Ileal diverticulum rarely causes pelvic abscess. • Pelvic abscess rarely causes thigh phlegmon. • Rupture of presacral abscess to extra-pelvic site carries high mortality. • Intrapelvic pathology has to be considered in patients with thigh phlegmon., Introduction Ileal diverticula usually remain asymptomatic. If complicated, they may present as intra-abdominal or pelvic abscess. Abscess formation in the presacral space is very rare. The rupture of abscess and spread of pus to extra-pelvic sites through anatomical structures of the pelvis is extremely rare. It carries high mortality if not diagnosed on time. Case presentation We report a case of 52-year-old woman presented with thigh phlegmon and septic condition. The CT scan revealed free air in the left leg and pelvic presacral fluid collection descending to extra-pelvic direction through the greater sciatic notch. Moreover, ileal fistula to presacral abscess was suspected. Multiple incisions and fasciotomies were urgently performed to treat thigh phlegmon. Subsequently, laparotomy was carried out and ileal fistula was excised. Histological examination of the surgical specimen demonstrated that the fistula to presacral abscess has formed due to perforated ileal diverticulum. 3 years after the surgery the patient remains healthy without recurrence. Discussion Rupture of presacral abscess to extra-pelvic site due to ileal diverticulum fistula is an extremely rare case, to our best knowledge, never reported in literature. Due to a rare occurrence and early septic complications if diagnosed late, this condition carries a high mortality rate. Conclusion Intrapelvic pathology must be considered in patients with thigh phlegmon in order to prevent complications and associated mortality.

Highlights • We experienced a case of appendiceal cancer invading the ileum with a fistula. • This is the first case report of appendiceal cancer with an ileal fistula that successfully treated with laparoscopic resection. • Laparoscopic resection can be a feasible, safe and curative procedure in selected cases of appendiceal cancer with a fistula. • Laparoscopic ileocecal resection can be applied for appendiceal cancers with a fistula by experienced surgeons with careful consideration., Introduction Primary appendiceal cancer with fistula formation is extremely rare. We report a case of a patient with appendiceal cancer invading the ileum who underwent successful laparoscopic ileocecal resection. Presentation of case A 76-year-old man who presented with fever and abdominal pain was diagnosed with acute appendicitis and received antibiotics at a local hospital. After a few days, he was referred to our hospital because of an abnormality found in the colonoscopy, which was an oozing ulcer in the terminal ileum. Laparoscopic ileocecal resection was performed with a preoperative diagnosis of ileal cancer. The tumor adhered to the right internal inguinal ring. We dissected the right spermatic cord involved in the tumor. The resected specimen revealed a fistula between the appendiceal orifice and ileac ulcer. Histopathological examination revealed a well differentiated tubular adenocarcinoma. We made the diagnosis of appendiceal cancer with an ileal fistula because the ileal ulcer was derived from the appendiceal site. Discussion Most cases of appendiceal cancer with a fistula undergo laparotomy, but in selected cases, laparoscopic resection should be considered a feasible, safe, and curative procedure. Our patient underwent laparoscopic ileocecal resection, whereby the tumor and other organs with invasion were resected successfully with a negative surgical margin. Conclusion This is the first case report of appendiceal cancer with an ileal fistula successfully treated with laparoscopic resection. Laparoscopic ileocecal resection can be applied for appendiceal cancers with a fistula by experienced surgeons with careful consideration.

We present a rare image where an acutely inflammed appendix entered and perforated the terminal ileum. This became a presentable rare image after we converted a laparoscopic attempt to do appendisectomy in this patient in an open surgery. The patient was managed by simple appendisectomy without burying the stump and closing the ileal perforation after freshening the margins in two layers using 3-0 Polyglactin.

Background Endo-sponge treatment is a novel approach to manage selected patients with anastomotic leakage following colorectal surgery. However, the available data are still scanty. Aims To evaluate the efficacy and safety of the endo-sponge therapy in a large series, and to perform a review of the current evidence concerning such a treatment. Methods Consecutive patients diagnosed with partial colonic anastomotic leakage managed with endo-sponge placement were enrolled. The endo-sponge system was changed every 48–72 h as outpatient, until to cavity closure. Literature review was performed for pooled-data analysis. Results Twenty-five patients were enrolled, including 13 (52%) with diverting ileostomy. Following endo-sponge applications (median sessions: 9, range: 1–39; median treatment duration: 4 weeks, range: 1–32), a complete healing was achieved in 22 (88%) patients. Three (12%) patients developed a major complication (1 uretheric fistula, 1 ileal fistula, and 1 pararectal abscess), all successfully treated by surgery. Ileostomy closure was achieved in 11 (84.6%) patients. No mortality related to the procedure was observed. Overall, 174 patients treated with endo-sponge were reported in literature. By considering data of the larger 7 studies, a complete healing of presacral cavity was achieved in 131 (94.3%) out of 149 patients. Conclusions Our relatively large series of patients confirmed the efficacy, tolerability, and an acceptably low complication rate of endo-sponge therapy for colorectal anastomosis leakage treatment.

Introduction Enterocutaneous fistula is considered one of the most serious complications in general surgery and is associated with high morbidity and mortality. Although various treatments are reported to have varying success, high-output enterocutaneous fistulas (output over 500 ml/day) continue to be associated with high mortality, and few papers on this topic exist in the literature. The aim of this study is to describe an effective multidisciplinary treatment method for postoperative high-output enterocutaneous fistula and discuss the clinical development of the therapeutic strategy. Patient concerns Three patients suffered high-output enterocutaneous fistulas, in which case 1 presented with duodenal fistula, case 2 with ileal fistula, and case 3 with small bowel fistula. Diagnosis All 3 cases were diagnosed with high-output enterocutaneous fistulas by drainage of intestinal contents. Interventions With the exception of routine treatment including fluid resuscitation, correction of the electrolyte balance, control of infection, and optimal nutrition, all the cases accepted continuous irrigation and suction with triple-cavity drainage tubes in combination with sequential somatostatin-somatotropin administration were given. With regard to establishing effective drainage, the triple-cavity tube placement was performed by insertion through the initial drainage channel in case 1, percutaneous puncture with dilation by graduated dilators in case 2, and tract reconstruction in case 3. The technical details of the approach are described and clinical characteristics including fistula location, defect size, output volume, approach of triple-cavity tube placement, length of fistula tract, somatostatin and somatotropin administration time, and fistula healing time were recorded and compared. In addition, other various techniques reported in the literature are reviewed and discussed. Outcomes All the patients were cured by the multidisciplinary treatments and were followed up without fistula recurrence and other relevant complications at 1 week, 1 month, and 3 months after the treatments. Conclusion The strategy involving continuous irrigation and suction with a triple-cavity drainage tube in combination with sequential somatostatin-somatotropin administration may be a safe and effective alternative treatment for postoperative high-output enterocutaneous fistula and a more practical method that is easy to execute to manage this problem. Long-term studies, involving more patients, are still necessary to confirm this suggestion.

Intestinal obstruction caused by a congenital ileo-ileal internal fistula Background: Among congenital malformations of the digestive tract, internal congenital fistulas tend to be associated with multiple malformations. case report: We report a previously healthy 32 years old male consulting for abdominal pain and vomiting lasting 48 hours. A plain abdominal film show small bowel dilatation and air-fluid levels. The patient was operated with the diagnosis of bowel obstruction. During the operation dilated bowel loops trapped in a congenital ileo-ileal fistula were found. no biopsies were obtained. The patient had an uneventful postoperative evolution.

The etiology of Cronkhite-Canada syndrome (CCS) remains unknown and many cases are refractory to treatment. Therefore, new therapies are urgently needed. Furthermore, a number of CCS cases with gastrointestinal carcinoma have been reported. Our patient had rapid onset of CCS and early development of colon carcinoma associated with adenomas. High anterior resection of the sigmoid colon and ileostomy were performed, and her symptoms and endoscopic and histological findings improved. Helicobacter pylori eradication was carried out 2 years later, surgical closure of an ileal fistula the following year. After 4 months, upper gastrointestinal endoscopy and colonoscopy showed that the CCS lesions had completely disappeared, and biopsies confirmed a normal stomach, duodenum, ileum and colon histologically. The patient has maintained remission for 2 years. The clinical course of this case, showing complete regression of CCS lesions following abdominal colectomy and H. pylori eradication, suggests the significance of H. pylori infection in the treatment of CCS.

DUODENAL – ILEAL FISTULA, RARE VARIANT OF PENETRATING OF DUODENAL ULCER, ASSOCIATED WITH SIGMOID CANCER (Abstract): Duodeno-ileal fistula has benign (penetration of the duodenal ulcer) or malignant etiology. We present the case of a 73 years old woman, with history of right colectomy; she was admitted in our surgical unit for abdominal pain, fecaloid vomiting, fetid halitosis, bloody diarrhea, weight loss and impaired general condition. A moderate anemia and several electrolytic disorders have been revealed by the laboratory exams. The upper digestive endoscopy revealed a penetrating duodenal ulcer with duodeno-ileal fistula and colonoscopy a stenosant tumor at 25 cm of the anal edge. After the correction of anemia and electrolytic disorders an exploratory laparotomy was performed The exploration noted a tumor mass which included duodenum and gastric antrum, gallbladder, ileum, sigmoid loop and the great omentum. The careful dissection confirmed the sigmoid cancer invading the antropyloric region and the double duodenal ulcer with pancreatic penetration and duodeno-ileal fistula. Multiple organs resection were performed: anterograde cholecystectomy; segmental enterectomy; 3⁄4 distal gastric resection with precolic gastro-jejunal anastomosis (Leger type); sigmoid resection with end-to-end colo-colic anastomosis. The postoperative course was uneventful. Several data from the literature were discussed. CONCLUSIONS: Duodeno-ileal fistula is an accidental variety of ulcer penetration caused by particular morphopathological conditions. Surgical treatment of gastro-digestive fistulas should be applied early with a correct balancing of the patient. Operation is complex and often atypical and implies multiple organs resections. In this particular case, the sigmoid cancer which invaded the distal part of the stomach complicated much more the surgical procedure.

Introducción: Las malformaciones congénitas del aparato digestivo pueden ser muy variadas. En caso de presentar síntomas, suelen aparecer en las primeras etapas de la vida con un amplio abanico de manifestaciones clínicas dependiendo del segmento al que afecte y de la complejidad de las malformaciones. Sin embargo, hay muy pocas fístulas internas congénitas recogidas en la literatura médica y la mayoría suelen estar relacionadas con malformaciones múltiples. Caso clínico: Presentamos un situación muy poco frecuente. Se trata de un caso de fístula interna congénita que debutó con un cuadro obstructivo agudo como único síntoma en un adulto. Background: Among congenital malformations of the digestive tract, internal congenital fistulas tend to be associated with multiple malformations. Case report: We report a previously healthy 32 years old male consulting for abdominal pain and vomiting lasting 48 hours. A plain abdominal film show small bowel dilatation and air-fluid levels. The patient was operated with the diagnosis of bowel obstruction. During the operation dilated bowel loops trapped in a congenital ileo-ileal fistula were found. No biopsies were obtained. The patient had an uneventful postoperative evolution.

Rationale: Intraluminal migration of a retained surgical sponge causing intestinal obstruction and fistula is extremely rare occurrence. Patient concerns: A case of a 35-year-old male, who complaining a diffuse abdominal pain beginning three days earlier. He also complained of occasional vomiting, nonspecific abdominal pain, and an unintentional 15 kg weight loss during the past 2 years. However, there were no clear findings in previous laboratory work. He had received an open appendectomy approximately 4 years earlier. Diagnoses: Retained surgical sponge. Interventions: A contrast-enhanced CT of the abdomen showed a clear invagination of the small intestine. However, intraoperatively, we could not find an intestinal segment with intussusception. After the adhesive intestine was detached, a jejunal−ileal cross-linked fistula was found. More surprisingly, a retained surgical sponge was found inside the ileal fistula when the cross-linked fistula was detached. Outcomes: The patient was discharged 7 days after surgery. Lessons: This is the first report showing an atypical image of a complete transmural migration of a retained surgical sponge mimicking intussusception.

Background and aim Fistulae are one of the most frequent complications of Crohn's disease (CD) and occur in 30–40% of patients. Conversely, free perforation is a rare complication and is one of the indications for emergency surgery of CD because of secondary peritonitis. We report a case of a spontaneous fistula rupture secondary to a road traffic accident. Methods Case report. Results A 22 year-old man, with no personal significant medical history, was admitted in the emergency room after a road traffic accident. He underwent abdominal CT, which revealed pelvis fractures, abnormal bowel wall of the terminal ileum (wall thickening and mucosal enhancement), peritoneal effusion within the pelvis, mesenteric nodes and extra-luminal gas within an area of mesenteric inflammation: these features were suggestive of ileum perforation associated with inflammatory bowel disease, most likely CD. Laparoscopic assessment was decided and an ileocaecal resection with ileocolonic anastomosis was performed. Histological analysis revealed terminal ileitis with ulcers, non caseating granulomas and submucosal fibrosis, a transparietal fistula and a caecoappendicular inflammation, confirming CD. Post surgical outcome was uneventful and the patient was discharged at day 9. Conclusion Our patient presented this rare complication revealing CD. The involvement of the terminal ileum and fistulae were characteristics of CD. Rupture of the fistula was favored by the trauma and responsible for the peritonitis. A resection with primary anastomosis was possible. To our knowledge, it is the first case described for the rupture of an ileal fistula secondary to traumatism in a patient with CD.

OZET Appendico-ileal fistula is a rare condition with acute ileus. We report a case of appendico-ileal fistule in a 46-year-old man patient who has undergone laparatomy for intestinal mechanical obstruction. Intraoperatively, an appendix with a lumen was found with a fistula to the terminal ileum. It has been observed that proximal ileal and jejunal intestinal anses were distended. Appendectomy, segmental ileum resection and end-to-end anastomoses were performed as a surgical procedure. This case describes an elderly man with acute ileus presenting with small bowel obstruction. We conclude that, appendico-ileal fistula should be kept in mind in cases with acute ileus presenting with small bowel obstruction.

This report describes a young woman with cystic fibrosis presenting with small bowel obstruction. Intraoperatively, an appendix with a wide lumen was found with a fistula to the distal ileum.

Most patients experience a high stool frequency immediately following the closure of the temporary ileostomy after total colectomy and ileoanal pouch reconstruction. Adaptation occurs within the ensuing weeks to reach a plateau in about three months. Increasing volumes of liquid nutrients were injected, twice daily for two months, into the pelvic pouch through a mucous ileal fistula proximal to the pouch before closing the temporary ileostomy. With this method the number of evacuations per 24 hours was significantly reduced during the first few weeks following the reestablishment of intestinal continuity, compared with a control group (average, 8.5 vs. 18.2, respectively). Patients also had better continence and less urgency to defecate. We suggest this technique in patients undergoing pelvic ileal reconstruction with temporary ileostomy.

Peptide YY (PYY) is released postprandially into both the circulation and the distal intestinal lumen. While circulating PYY inhibits pancreatic secretion and insulin release, the effects of intraluminal PYY on pancreatic function are unknown. The aim of the present study was to evaluate the effect of exogenous, intraileal luminal PYY on pancreatic exocrine function and fasting glucose levels. Chronic pancreatic and ileal fistulae (50 cm from the ileocecal valve) were created in nine mongrel dogs. The animals were given intravenous infusions of secretin (125 ng/kg/h) and cholecystokinin octapeptide (CCK-8, 50 ng/kg/h) for four hours. At the beginning of the second hour, either normal saline or PYY, at low [physiologic (2 ng/ min)] or high [supraphysiologic (50 ng/min)] levels, was infused antegrade into the ileal fistula for two hours. Pancreatic juice was collected for PYY and glucose levels. Ileal luminal PYY infusions had no effect on pancreatic bicarbonate or protein output. Fasting serum PYY and glucose concentrations were unaffected by either dose of intraluminal PYY. We conclude that ileal luminal PYY does not influence pancreatic exocrine function or fasting glucose levels.

Ten patients with well established ileostomies were studied in a metabolic ward and alterations in ileostomy chemistry occurring when an elemental diet was ingested were measured. After a 4-day control study the patients were given an elemental diet as the sole nutritional source for a 10-day period. For the last 3 days of the study, an additional 2 liters of water were consumed with the diet. The mean daily fecal output for the group during the control period was 570 ± 275 g. During the administration of the elemental diet, the fecal output fell to 441 ± 194 g (P

We encountered a case of Crohn's disease complicated with free perforation of the ileum, fecal fistula of the ileum after appendectomy and contunuity of Crohn's disease to the appendix. We report the outline of the case and discuss the characteristics of these three complications. The patient, a 25-year-old man, was admitted to the hospital with the chief complaint of abdominal pain. A provisional diagnosis of perforative peritonitis was made, and laparotomy was undertaken. As a result, perforation was found in the small intestine, 230cm distal from the ligament of Treitz. A resection about 40cm of the small intestine including the perforated region was, therefore, performed with end-to-end anastomosis. The resected specimen showed a longitudinal ulcer located along the mesenteric border, cobblestone appearance and thickening of the ileal wall. Histologically, findings of transmural inflammatory cell infiltration mostly with lymphocytic aggregations and sarcoid-like, noncaseous granuloma were obtained. Postoperative examination of the large intestine showed longitudinal ulcers, shortening and pseudodiverticular formation in the ascending and transverse colon. Thus, the patient was diagnosed as Crhon's disease. This case is presumed to have been complicated with ileal fistula developing at a relatively high incidence after appendectomy for Crohn's disease involving the appendix, scarce in Japan.

It has been shown in a recent communication (Florey and Harding, 1934) that an alkaline mucin-containing secretion is obtained from fistulæ of that part of the duodenum containing Brunner’s glands in several species of mammals. It is convenient to summarize here the evidence for believing that this secretion is that of Brunner’s glands. In the original communication on the subject (Florey and Harding, 1933) it was noted that an abundant flow of an alkaline mucoid secretion was obtained from a duodenal loop of a rabbit, anæsthetized with urethane, but that no fluid collected in an ileal loop. This observation has now been extended to fistula-bearing animals. Fistulæ of that part of the duodenum containing Brunner’s glands continuously secrete an alkaline mucin-containing fluid (Florey and Harding, 1934). An ileal fistula of a rabbit or cat inserted by the same methods, does not secrete any juice which can be collected. Ileal fistulæ in the dog do not produce a flow of succus entericus unless mechanically or chemically stimulated (Babkin, 1928, p. 770). Fistulas of the proximal part of the duodenum, however, produce spontaneously a flow of mucoid juice amounting to as much as 1 - 5 cc an hour (Ponomarew, 1902; Florey and Harding, 1934). The striking histological difference between the duodenum and the ileum is the presence of Brunner’s glands in the former. It is therefore reason­ able to connect the flow of mucoid juice with these structures. This deduction is further strengthened by the fact that the cells composing Brunner’s glands are of the type recognized as “ mucous.” Bensley (1903), in an extensive histological survey of the glands gives good evidence that they are mucus-producing organs, a view which our own observations support (Florey and Harding, 1934). Analyses of the juice in all species examined show that it contains either a mucin (goat, rabbit, sheep) or a substance very closely allied (cat, dog, pig). The source of this mucin must be either Brunner’s glands or the goblet cells of the villi and crypts of Lieberkühn. The latter source is quite unlikely as it has been shown (Florey, 1930) that fistulæ of the colon in the dog do not secrete fluid but become plugged with inspissated mucus, yet in the colon goblet cells reach their maximal development. It has also been shown histologically (Florey and Harding, 1933) that Brunner’s glands secrete when hydrochloric acid is perfused through the duodenal lumen and that a mucoid substance is added to the perfusing fluid. On the basis of all these observations, it is considered justifiable to conclude that the alkaline mucoid fluid collected from the upper part of the duo­denum is, in fact, the secretion of Brunner’s glands.

Summary and ConclusionsIn a patient with an ileal fistula it was shown that about 25% of ingested creatinine was expelled unabsorbed from the fistula. The amount of creatinine excreted in the urine was equal to the amount absorbed. The evidence suggests that, in oral experiments, no creatinine is absorbed by the large intestine. When injected intravenously, creatinine is virtually all excreted in the urine. These results are at variance with the hypothesis of creatinine transformation in the human body.

Summary Influences of indigestible dietary bulk (kaolin), short chain fatty acids (SCFA), and their interaction on the weight and epithelial cell proliferation rate of digestive organs were studied. Rats with an ileal fistula were fed an elemental diet with or without kaolin (10% w/w). They were given a 3ml SCFA mixture (acetate, propionate, and butyrate; 100, 20, and 60 mM, respectively; pH 6.1) or a 3ml NaCl solution (180 mM; pH 6.1) via the fistula twice a day for 14 days. Kaolin, but not SOFA, increased full and empty body weight by 14% and 13%, respectively. Kaolin increased the tissue weight, but not relative tissue weight (tissue weight/empty body weight), of the forestomach, distal colon, liver and heart by 6-14%. SCFA, independent of the presence of kaolin, increased the weight and the relative weight of the cecum, both by 15%. SCFA, but not kaolin, increased the cryptal cell production rate in colonic segments by 50-140%. These results indicate that (a) SCFA accelerates epithelial cell proliferation, thereby increasing cecal tissue weight, (b) kaolin stimu lates body weight gain which is accompanied by a proportional increase in the tissue weight of some digestive organs, and (c) the actions of these factors are independent of each other.

Ten patients with a well-established ileostomy were studied in a metabolic ward and alterations in ileostomy content of trypsin and bile acids were measured during the ingestion of an elemental diet. After a 4-day control study the patients were given an elemental diet as the sole nutritional source for a 10-day period. For the last 3 days of the study an additional 2 litres of water were consumed with the elemental diet. The mean daily faecal output for the group during the control period was 578 ± 300 ml, and during administration of the elemental diet the fistula output fell to 418 ± 90 ml (P Although the concentration of amylase in the ileal fluid rose, the total output was not altered. Oral administration of an additional 2 litres of water did not alter the concentration of trypsin or bile acids in the ileal fluid. It is concluded that elemental diet ingestion produces changes in ileal fistula output which are of benefit to the patient with an enterocutaneous fistula. Output from the fistula of fluid and electrolyte is less and the corrosive nature of the discharge is reduced.

Although the initial results of arterial homograft replacement have been brilliant, it is apparent that ruptures are becoming more common. Such an occurrence is reported in an aortic bifurcation arterial homograft three years after resection of an abdominal aortic aneurysm.

A report of a case of appendico-ileal fistula presenting as a submucosal mass in the terminal ileum is presented. We have not seen any other patient in whom the lesion presented as a small bowel tumor. This case is also particularly unusual in that the patient had never experienced any symptoms consistent with appendicitis.