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Rationale: Neuroendocrine neoplasia (NEN) of small bowel (SBNEN) frequently present with metastatic disease. Theranostics (molecular imaging followed by targeting therapy) allow for personalised medicine. Liquid biopsies enable precise identification of residual disease and real-time monitoring of therapeutic response. Our aim was to determine the clinical utility of a combination of surgery, theranostics, and a multigene blood measurement in metastasised SBNEN. Methods: Inclusion criteria were SBNEN, G1/G2 NEN, initial tumour diagnosis, stage IV NEN, positivity on 68Ga somatostatin analogue PET/CT, eligible for surgery, and 177Lu peptide receptor radionuclide therapy (PRRT). Blood samples for NETest were collected longitudinally. Progression-free survival (PFS) and overall survival (OS) were calculated. NETest results were assessed prior to surgery and during clinical follow-up. Results: A surgical cohort of 39 SBNEN patients met eligibility criteria. Thirty-two patients underwent ileal resection and 7 right hemicolectomy. The mean number of 177Lu PRRT cycles was 4. Mortality was nil. Surgical morbidity was 10.3%. Transient grade 1/2 toxicity occurred in 41% (PRRT). NETest scores (n=9 patients) decreased in 100% following treatment and correlated with diminished tumour volume and disease stabilization following surgery and PRRT. Median follow-up: 78 months. Median PFS and OS: 42.7 and 110 months, respectively. Progression-free survival at 1-, 3-, and 5-years was 79.4%, 57.1% and 40.5%, respectively. Overall survival at 1-, 3-, and 5-years was 97.4%, 97.4%, and 94.1%, respectively. Conclusions: Surgery combined with 177Lu PRRT is safe and provides favourable PFS and OS in selected patients with advanced SBNEN. Liquid biopsy (NETest) has the potential to accurately delineate disease status.

Highlights • Angiodysplasias are a frequent cause of gastrointestinal bleeding with a diverse clinical manifestations ranging from symptoms and signs of iron deficiency anemia to occult bleeding and even life-threatening bleeding. This case demonstrates angiodysplasia as an impending source of occult gastrointestinal bleeding. • According to most authors histological diagnosis of angiodysplasia is based on the presence of mucosal vascular ecstasies with associated prominently dilated capillaries penetrating the muscularis mucosae. In this case these criteria are satisfied; however presence of large, thick walled vessels in submucosa is not described in the classic case of angiodysplasia. • In this case report: I am discussing this case and making a comparison with the ususal presentation of angiodysplasia, how to diagnose obsure bleeding. • Role of the radiological as well as triphasic CT scan finding to diagnose the angiodysplasia of the small intestine. • Incidine of the angiodysplasia in the small intestine., Background Angiodysplasia is the second most common vascular abnormality of the GI tract after diverticulosis and is the second principal cause of lower GI bleeding over 60 years. Case report A 68-year-old male patient presented to our institute in the outpatient clinic with pallor of gradual onset and progressive course since 6 months. Detailed history revealed hematochezia, sometimes melena. Physical examination revealed signs of iron deficiency anemia which was confirmed by laboratory results and hemoccult positive stool. The patient refused the colonoscopy. A bdominal CT with contrast was then performed which revealed an evidence of abnormal subtle mural contrast flocculation within the small bowel loop with luminal extravasations of contrast at small segment of distal ileum few centimeters from ileocaecal valve with mildly dilated and early filling of its drained vein, this abnormal contrast extravasations and flocculation increased through dynamic study. In addition, evidence of contrast mural flocculation within the left lateral wall of distal few centimeters of rectum was also observed. This abnormal mural contrast flocculation within the wall of solitary segment terminal ileum and distal rectum suggest the evidence of venous ectasia or angiodysplasia. Surgical resection was done with end to end anastomosis of the small intestine without any complication in the postoperative progress. Conclusion This case also emphasizes the critical significance of a mutual multidisciplinary approach to occult gastrointestinal bleeding. The management of angiodysplasia is considered as multidisciplinary team work that would consist of expertise from different departments as in endoscopy, angiography, and gastrointestinal surgery.

Highlights • Small bowel perforation by an ingested foreign body (FB) is a rare abdominal emergency. • Computed tomography scan is most effective but imperfect for diagnosis. • Inquiring about FB ingestion and a high index of suspicion are very important. • Laparoscopic surgery is effective even in this rare abdominal emergency. • Extracorporeal handling of the affected small bowel is useful in this condition., Introduction Presently, the advantage of laparoscopic surgery is widely recognized and it is gaining popularity not only in elective abdominal surgeries but also in various kinds of emergent abdominal surgeries. This report describes two patients diagnosed with ileal perforation due to an ingested foreign body (FB)—a rare abdominal emergency—who were treated laparoscopically. Presentation of case Both patients were brought in by an ambulance to our hospital, with complaints of increasing lower abdominal pain. Computed tomography scan revealed a small bowel perforation due to an ingested FB in both patients, and laparoscopy-assisted partial ileal resection was immediately performed. Their postoperative recoveries were uneventful. Discussion Both patients with this rare abdominal emergency were successfully treated with laparoscopic surgery. Its feasible diagnostic and therapeutic abilities and decreased invasiveness contributed to their uneventful and fast recoveries. Extracorporeal handling of the affected small bowel via mini-laparotomy was useful in this setting as it was safe, fast, and cost-effective. Conclusion Laparoscopic surgery is effective, even for this rare abdominal emergency. Moreover, laparoscopy-assisted surgery accompanying mini-laparotomy is a rational treatment approach, especially for this condition.

Background: Despite reductions in surgical rates that have been observed with earlier use of biological therapy, surgery still constitutes an important tool in the therapeutic armamentarium in Crohn’s disease (CD), particularly in patients with stenotic and penetrating phenotypes. In these scenarios, early surgical intervention is recommended, as bowel damage is present and irreversible, leading to lower efficacy with biologics. Summary: The concept of early surgery in CD supposes the possible advantages of better surgical outcomes in luminal CD after initial resection. Optimal timing of surgical intervention is associated with better postoperative outcomes, whilst delays can lead to more technically difficult and extensive procedures, which may result in an increase in postoperative complication rates and higher rates of stoma formation. Furthermore, data from the LIR!C trial have demonstrated that early surgery in luminal localized inflammatory ileocecal CD is an adequate alternative to medical therapy, with lower societal costs in the long term. In this review, we discuss the position of early resection in ileocecal CD by critically reviewing available data, describing the ideal patients to be considered for early surgery, and weighing the potential advantages and disadvantages of an early surgery paradigm. Key Messages: While early surgery may not be the right choice for every patient, the ultimate decision regarding whether surgical or medical therapy should come first in the treatment paradigm must be individualized for each patient based on the disease characteristics, phenotype, risk factors, and personal preference. This highlights the importance of the multidisciplinary team, which remains a key pillar in deciding the overall management plan for patients with CD.

ObjectiveFollowing ileal resection for Crohn’s disease (CD), recurrence is very frequent. Although several clinical risk factors of recurrence have been identified, predicting relapse remains challenging. Performing an ileocolonoscopy within the first year after surgery is currently recommended to assess endoscopic recurrence and to adjust the treatment. We took advantage of a large prospective multicentric cohort to investigate the role of the ileal mucosa-associated microbiota in postoperative endoscopic recurrence.Patients and methodsIleal mucosa-associated microbiota was analysed by 16S sequencing at the time of surgery and/or of endoscopic evaluation in 201 patients (288 samples in total) prospectively recruited in France.ResultsIleal mucosa-associated microbiota exhibits profound changes following surgery in CD. Compared with non-recurrence setting, endoscopic recurrence is associated with strong changes in ileal mucosa-associated microbiota that are highly reminiscent of those observed generally in ileal CD compared with healthy subjects with a reduction in alpha diversity, an increase in several members of the Proteobacteria phylum and a decrease in several members of the Lachnospiraceae and the Ruminococcaceae families within the Firmicutes phylum. At the time of surgery, we identified several bacterial taxa associated with endoscopic recurrence and that can better predict relapse than usual clinical risk factors.ConclusionSurgery has an important impact on ileal mucosa-associated microbiota. Postoperative endoscopic recurrence is associated with changes in microbiota composition and alpha diversity. The gut microbiota has the potential to predict postoperative evolution and recurrence.

Background Objective Intestinal absorption of bile acids is mediated by the apical sodium-dependent bile acid transporter (ASBT). Fecal bile acid dysmetabolism has been reported in dogs with chronic inflammatory enteropathy (CIE). Characterization of ASBT distribution along the intestinal tract of control dogs and comparison to dogs with CIE. Animals Methods Twenty-four dogs with CIE and 11 control dogs. The ASBT mRNA and protein expression were assessed using RNA in situ hybridization and immunohistochemistry, respectively. The concentrations of fecal bile acids were measured by gas chromatography-mass spectrometry. The fecal microbiota dysbiosis index was assessed with a quantitative polymerase chain reaction panel. Results Conclusions and Clinical Importance In control dogs, ASBT mRNA expression was observed in enterocytes in all analyzed intestinal segments, with highest expression in the ileum. The ASBT protein expression was restricted to enterocytes in the ileum, cecum, and colon. Dogs with CIE had significantly decreased expression of ASBT protein in the ileum (P = .001), which was negatively correlated with histopathological score (rho = -0.40; P-corr = .049). Additionally, dogs with CIE had a significantly increased percentage of primary bile acids in feces compared to controls (P = .04). The fecal dysbiosis index was significantly higher in dogs with CIE than in control dogs (P = .01). These findings indicate that ileal protein expression of ASBT is downregulated in dogs with CIE. This change may be linked to the inflammatory process, intestinal dysbiosis, and fecal bile acid dysmetabolism observed in these patients.

Aims: To determine the value of 75SeHCAT retention in determining bile acid diarrhoea (BAD), treatment response and predictors of a positive result.Methods: Retrospective casenote review of consecutive patients undergoing 75SeHCAT from 2008 to 2014, including gender, age, history, clinical, and laboratory parameters. This included diseases associated with Type 1 BAD (ileal resection, Crohn’s disease) and Type 3 BAD. Chi-squared test and logistic regression determined factors predictive of BAD. Subjective response to treatment with bile acid sequestrants (BAS) was analysed with respect to the 75SeHCAT result.Results: Of 387 patients, 154 (39.7%) were male and average age was 50 years. Ninety-five patients (24.5%) were investigated for Type 1 BAD, 86 (22.2%) for Type 3, and 206 patients (53.2%) for Type 2 or idiopathic BAD. There was a large increase in the number performed with time but no difference in percentage positive tests. One hundred and seventy-nine patients (46.2%) had BAD. Positive resul...

Background and Aims Patients with Crohn’s disease (CD) may require small bowel resections. Unfortunately, some of these patients may develop post-operative small bowel obstructions (SBO). Many clinicians perceive ileal resections dramatically increase the risk of developing SBO in the future, but the incidence and risk factors to developing SBO are poorly described. The primary aim of this study is to document the incidence and factors associated with the development of SBO not related to recurrence of disease in CD patients that undergo ileal resection. We also sought to assess long-term outcomes of this complication. Methods We performed a retrospective cohort study including patients aged 18 years or older with CD, who have had ileocecal resection with ileocolonic anastomosis or segmental small bowel resection. Data abstracted included demographics, phenotype and therapies of CD, disease recurrence post-ileal resection and multiple surgical variables. The primary outcome was the development of SBO within 5 years post-surgery not including obstructions secondary to recurrence of CD. Results 92 total patients were included in the analysis. All had a colonoscopy within a year of the surgery. The mean Rutgeerts score was 0 (interquartile range [IQR] 0 to 2) and the mean short endoscopic score was 0 (IQR 0 to 4). The remainder of baseline characteristics are shown in Table 1. At 6 months, 1 year, and 5 years, the rate of SBO was 4/92 (4%), 6/92 (6.5%), and 15/92 (16%), respectively. Throughout follow-up, only 5 patients had an SBO attributed to intra-abdominal adhesions and only 2 patients required surgical lysis of adhesions. Patients that were found to have histologic inflammation in the margins of the resected bowel specimen had a significantly higher chance of developing an SBO within 5 years of the initial surgery (OR: 4.5 [95%CI: 1.3–15.3], p=0.02 - Table 2). Conversely, patients with either active endoscopic and/or radiologic inflammation on post surgical surveillance colonoscopy did not have a higher risk of developing an SBO within 5 years of the initial surgery (p=0.37). Finally the length of bowel resected at the index surgery was not associated with the development of an SBO (AUC: 0.62, p=0.18). Conclusions The incidence of SBO after ileal resection in CD is low and resolves with medical management on most cases. Inflammation in the margins of the resected bowel and previous bowel resections were associated with new SBO within 5 years. These results must take into account the study population were monitored and cannot be extrapolated to those patients that lost follow-up.

Background: Crohn's disease displays heterogeneity in terms of disease location, progression and response to treatment. Most patients require an intestinal resection due to complicated disease, and a majority of them will experience disease recurrence. We aimed to characterize biological pathways driving postoperative recurrence and to identify predictors which could guide therapeutic management. Methods: In this multicentre prospective study, we conducted transcriptome analysis on ileal mucosa of CD patients undergoing ileocolonic resection. Samples were collected from the most inflamed part of the ileum (n=200), from the ileal resection margin (n=149) and in the neo-terminal ileum 6 months after surgery (n=122). The primary endpoint was postoperative endoscopic recurrence at month 6. We applied a regression model to identify gene signatures predicting for endoscopic recurrence. Findings: Molecular patterns of early endoscopic recurrence significantly differed from those observed in chronic inflammation. Gene expression analysis of the inflamed area of the surgical specimens identified clusters of CD patients. However, pathway gene signatures at the ileal margin were superior to those of the inflamed area to predict postoperative outcome. Several pathways, including JAK/STAT signalling, cell adhesion molecules and extracellular matrix protein were associated with a higher risk of endoscopic recurrence. JAK/STAT pathway activation at the ileal margin predicted early postoperative endoscopic recurrence (AUC of 0*74) and was associated with a higher of clinical relapse on the long term. A significant increase of p-STAT3 levels at the ileal margin was associated with severe endoscopic recurrence (i3, i4) compared to no recurrence (i0) (p=0*02) and moderate recurrence (i1, i2) (p=0*04). Interpretation: Gene expression analysis at the ileal margin of the surgical specimen may strongly predict postoperative outcome. The inflammatory processes associated with postoperative recurrence differ from those engaged in chronic inflammation. Activation of JAK/STAT signalling at the ileal margin of the surgical specimen is predictive of postoperative recurrence and should be specifically targeted. Trial Registration: ClinicalTrials.gov (NCT03458195). Funding Statement: This work was supported by Helmsley Charitable Trust and the Institut national de sante et de la recherche biomedical (INSERM). Declaration of Interests: SN received honoraria from MSD, Abbvie, Takeda, Janssen, HAC Pharma, Tillots, Ferring, and Novartis. BP received honoraria from AbbVie, MSD, Takeda, Janssen, Bioagaran, and Ferring. AB received honoraria from MSD, Abbvie, Ferring, Takeda, Vifor Pharma, Sanofi-Aventis, Hospira, and Janssen. XT received honoraria from Abbvie, MSD, Takeda, Ferring, Norgine, and Janssen. MF received honoraria from AbbVie, MSD, Takeda, Janssen, Pfizer, Ferring, and Boehringer. PS received honoraria from Takeda, MSD, Biocodex, Ferring and Abbvie and financial support from Takeda. MA received honoraria from Janssen, Takeda, Pfizer, MSD, Abbvie, Ferring, Amgen, Biogen, Celgene, and Genentech/Roche. All other authors have no conflict of interest regarding this study. Ethics Approval Statement: All patients provided an informed written consent. The study was approved by AFFSAPS (IDRCB: 2009-A00205-52) and the French Ethic Committee (CPP 2009/17).

The absence of residual disease remains the strongest predictor for disease free and overall survival in patients with advanced stage or relapsed ovarian cancer. However in most cases this desiderates is achieved after performing multiple visceral resections. Extended pelvic disease usually involves the surrounding pelvic viscera and leads to the necessity of digestive resections such as rectosigmoidectomy. In other cases other digestive resections such as right ileocolectomy might be needed. We present the case of a 64 year old patient in which an R0 resection was feasible after association of rectosigmoidectomy, right ileocolectomy and segmental ileal resection.

Adult intussusception is rare and laparotomy is required in most of the cases due to the potential pathologic underlying reasons. Although it is technically challenging, single-incision laparoscopic surgery can work as an alternative to laparotomy. Here we report the case of a 45-year-old man with intermittent right lower quadrant abdominal pain for 1 month. Abdominal enhanced computed tomography (CT) scan was performed and ileo-ileal intussusception was found, with lipoma as a likely leading point. Ileal resection was performed using the single-incision laparoscopic-assisted technique. Multiple trocars in the umbilical incision technique and conventional instruments were used. After identification of the ileo-ileal intussusception, the involved small bowel was extracted from the umbilical incision, and resection and anastomosis were performed extracoporeally. The operation time was 65 min and the post-operative hospital stay was 2 days. The patient recovered uneventfully, with better cosmetic results.

Bile acid malabsorption (BAM) is a common cause of diarrhoea in Crohn’s disease (CD) patients with ileal resection. BAM is usually diagnosed by selenium-labelled homotaurocholic acid test (75SeHCAT) but its availability is limited. Consequently, a large proportion of patients either remain undiagnosed or subject to empirical therapy. There is a paucity of studies examining the correlation between length of ileal resection and severity of BAM, which will be of use to clinicians with no recourse to diagnostic testing for BAM. We tested the correlation between length of resected ileum and percentage retention on 75SeHCAT of all CD patients with a prior surgical resection who underwent 75SeHCAT testing. Response to treatment with bile salt sequestrant and 75SeHCAT retention values was tested using Fisher’s exact test. A total of 91 patients were identified with a median age of 47 (IQR 21-80). The median length of resected ileum was 24 cm (range 15–165 cm) with a median of 1 resection (range 1–4). Overall, 88 patients (97%) had 75SeHCAT retention values of

The authors evaluated the usefulness of intraoperative photodynamic eye (PDE) observation in patients with nonocclusive mesenteric ischemia (NOMI). Between February 2012 and July 2013, 6 patients who had undergone emergency surgery for NOMI were enrolled. Intraoperative PDE observation was performed to decide the adequate length of bowel resection including all skipped dark spots, which could not be detected as ongoing mucosal ischemic changes under visible light observation. All ongoing mucosal ischemic changes were easily detected as dark spots using PDE observation in all 6 patients. The mean length of adequate ileal resection (92 ± 48 cm) was significantly longer than that of ischemic ileum (85 ± 50 cm) (mean ± SD) (P = 0.043). After resection of an adequate length of bowel, all the patients had a good course until discharge without incidents due to residual bowel ischemia, except for 1patient who died. PDE observation is useful for deciding the adequate length of bowel to resect, including ongoing mucosal ischemic changes that cannot be detected under visible light observation. In patients with NOMI, resection of an adequate length of bowel is necessary to prevent postoperative incidents due to residual bowel ischemia.

Objetive: The aim of this study is to announce the outcomes and experiences of our operated incarcerated inguinal hernias. Material and Method: The clinical outcomes and the therapeutical effects of 38 patients whom underwent surgery for incarterated inguinal hernia between January 2005 -January 2010 were evaluated retrospectively. Results: There were 30 male (79%) and 8 female (21%) patients. The averageage of the patients was 45 years (17-85). The hernia seated on the right side in 24 cases (63%) and on the left side in 14 cases (37%). ‘McVay’ procedure was applied for 4 patients with femoral hernias and ‘Bassini’ procedure was applied for 34 patients. Ileal resection was added for 1 case and omental resection for 4 of them. The morbidity rate was 8% (3 cases). Postoperative pain occured in one patient (3%), and seroma occured in 2 patients (5%). The average duration of hospital stay was 3.6 days. Recurrence occured in 3 of 28 patients in the 36 months (8-45) follow up period. Conclusion: In our study, the rate of bowel resection and the rate of the morbidity of surgical treatment is founded low. Incarcerated inguinal hernias must be operated immediately in order to lower the morbidity and motality rates.

Trichobezoar is less common in boys. We are reporting a case of isolated ileal trichobezoars in a 4-year old boy causing intestinal obstruction and gut ischemia with perforation and peritonitis. The case was managed surgically with ileal resection and anastomosis. Postoperative period was uneventful.