Dolichocolon revisited: An inborn anatomic variant with redundancies causing constipation and volvulus

Primary anastomosis versus stoma following urgent sigmoidectomy for sigmoid volvulus: 58-year experience in a tertiary referral center

Objectives

Primary anastomosis and stoma are the main options in the restoration of intestinal continuity following urgent sigmoidectomy in sigmoid volvulus (SV). Our purpose was to evaluate the outcomes of both techniques in a 1,083-patient SV series.

Methods

Total 1,083 cases with SV treated in Ataturk University Research Hospital in 58-year period between June 1966 and July 2024 were included in this study. We reviewed the records of 612 patients (56.5%) retrospectively, while the remaining 471 cases (43.5%) were evaluated prospectively. We investigated some preoperative, operative, and postoperative characteristics in non-matched analyses.

Results

Among total 379 patients treated with urgent colectomy, primary anastomosis was used in 173 cases (45.6%), while stoma was required in 206 patients (54.4%). The mean age was significantly lower in primary anastomosis group (P<0.005), while male/female ratios were statistically similar (P>0.05). Mean ASA score (P<0.001) and rates of shock (P<0.001), bowel gangrene (P<0.001), bowel perforation (P<0.01), and risky bowel (P<0.005) were also significantly lower in the primary anastomosis group. When stoma closure was considered, operation time was significantly shorter (P<0.001), additionally, morbidity and mortality rates were significantly lower in the primary anastomosis group (P<0.001, in each). The distributions of reoperation rates were statistically similar in both groups (P>0.05). Conversely, hospitalization time was significantly shorter and cost was significantly lower in the primary anastomosis group (P<0.001, in each).

Conclusion

Primary anastomosis has some advantages in comparison to stoma in the restoration of intestinal continuity following urgent sigmoidectomy in SV. However, stoma is generally preferred in patients with bad health status, old age, and risky bowel. New prospective randomized clinical studies or matched analyses may help to clarify the optimal choice.

Colon Volume by Computed Tomography and Scintigraphic Colonic Transit in Constipated Patients With or Without Redundant Colon

Redundant colon, also referred to as "dolichocolon," is an anatomical variant associated with elongation and redundancy thought to be associated with constipation, abdominal pain, and distention.1,2 Diagnosis requires radiological visualization of the non-dilated colon in situ via barium enema or abdominopelvic computed tomography (CT). Colonic redundancy is based on 3 criteria: sigmoid loop displaced cranially relative to the iliac crests (type 1); transverse colon caudal to the iliac crests (type 2); and redundant loops at the hepatic or splenic flexure (type 3).2 Rarely, dolichocolon may meet all 3 criteria.2.

Double Twist and Shout: An Emergency Caused by Torsion of the Ovary and the Wandering Spleen

Intermittent severe abdominal pain is a medical emergency with multiple possible underlying causes. This case report describes a 30-year-old female experiencing severe pelvic pain alternating between the left and right lower abdomen. The pain was periodic and very intense. She also experienced intermittent, vague pain in the upper abdomen. Clinical examination and imaging suggested torsion and detorsion of an ovarian fibroma or dysgerminoma. Additionally, a distended dolichocolon was seen in the upper abdomen. Laparoscopy revealed a twisted and enlarged right ovary in the pelvis. In the upper abdomen, a distended dolichocolon was observed along with a twisted, black spleen. The blood vessels of the wandering spleen hung over the colon like a rubber band, causing constriction. The ovary was removed and diagnosed as a cellular fibroma after histopathological examination. Attempts to untwist the spleen laparoscopically were unsuccessful, so a mini-laparotomy was performed to manually untwist it. Afterward, the spleen regained its normal position and color. Due to the significantly elongated dolichosigmoid, which could cause further complications, the affected segment was removed and a reanastomosis was performed. At the end of the procedure, the spleen remained stable in its original position with a healthy coloration. In retrospect, this patient experienced intermittent twisting of the ovary and spleen over an 18-month period, causing severe abdominal pain. The key lessons from this case are to take abdominal pain seriously, thoroughly examine all areas during surgery, and avoid stopping the investigation after identifying a single issue. A critical approach is essential to pinpointing the cause of each specific symptom, as one pathology may not always explain all observed symptoms. This comprehensive approach ultimately saved the patient's spleen.

Laparoscopic Sigmoid Colectomy with Natural Orifice Specimen Extraction in Sigmoid Volvulus

Sigmoid volvulus (SV), the twisting of the sigmoid colon around its own base, is a relatively rare colonic obstruction form. Endoscopic detorsion is the first-line management option in uncomplicated patients. However, recurrence risk is as high as 90%, with a risk of mortality up to 35%. Although procedures such as sigmoidopexy, sigmoidomesopexy, sigmoidomesoplasty, extraperitonealization, or percutaneous endoscopic sigmoidopexy may prevent or reduce SV recurrence, laparoscopic sigmoid colectomy with natural orifice specimen extraction appears to be the optimal choice in selected cases. Cite this article as: Atamanalp SS. Laparoscopic sigmoid colectomy with natural orifice specimen extraction in sigmoid volvulus. Eurasian J Med. Published online May 2, 2024. doi:10.5152/ eurasianjmed.2024.24420.

Artificial intelligence-powered early identification of refractory constipation in children

Background

Children experiencing refractory constipation, resistant to conventional pharmacological approaches, develop severe symptoms that persist into adulthood, leading to a substantial decline in their quality of life. Early identification of refractory constipation may improve their management. We aimed to describe the characteristics of colonic anatomy in children with different types of constipation and develop a supervised machine-learning model for early identification.

Methods

In this retrospective study, patient characteristics and standardized colon size (SCS) ratios by barium enema (BE) were studied in patients with functional constipation (n=77), refractory constipation (n=63), and non-constipation (n=65). Statistical analyses were performed and a supervised machine learning (ML) model was developed based on these data for the classification of the three groups.

Results

Significant differences in rectum diameter, sigmoid diameter, descending diameter, transverse diameter, and rectosigmoid length were found in the three groups. A linear support vector machine was utilized to build the early detection model. Using five features (SCS ratios of sigmoid colon, descending colon, transverse colon, rectum, and rectosigmoid), the model demonstrated an accuracy of 81% [95% confidence interval (CI): 79.17% to 83.19%].

Conclusions

The application of using a supervised ML strategy obtained an accuracy of 81% in distinguishing children with refractory constipation. The combination of BE and ML model can be used for practical implications, which is important for guiding management in children with refractory constipation.

Dolichocolon (redundant colon) in a rhesus macaque (Macaca mulatta)

Dolichocolon (redundant colon) is an underdiagnosed cause of severe constipation in humans. The clinical presentation reported here in a rhesus macaque closely resembles that of intestinal adenocarcinoma, the most common neoplasia in macaques. Dolichocolon should be considered in differential diagnosis of macaques with anorexia, weight loss, and constipation.

Spontaneous decompression of sigmoid volvulus

Objectives

Spontaneous decompression is an uncommon outcome of sigmoid volvulus (SV). The aim of this study was to evaluate the clinical presentation, diagnosis, treatment, and follow-up of spontaneously decompressed SV.

Methods

We utilized the data of our 1,063 SV patients, the most comprehensive monocenter SV series in the world. To obtain the worldwide data on the spontaneous decompression of SV, we researched the last 56-years' literature in Web of Science and PubMed databases.

Results

The incidence of the spontaneous decompression was 0.1% (1/1,063) in our SV series, whereas it was 1.5% (8/549) in the worldwide data (Fisher exact test, p = 0.001). By this way, cumulative spontaneous decompression rate was found as 0.6% (9/1,602). In the spontaneously decompressed cases, the main clinical features were abdominal pain/tenderness, distention, and obstipation, which were similar to management-required patients. However, the treatment and follow-up algorithm is still a relatively undefined subject.

Conclusion

Spontaneous decompression of SV is a very rare clinical entity. The clinical presentation and diagnosis of the spontaneously decompressed SV look alike the management-required SV. However, as seen in most management-required patients, SV tends to recur in the spontaneously decompressed cases and a recurrence-reducing procedure is required in selected patients.

Appendicitis mimicry of dolichocolon

Dolichocolon is an under-reported, under-diagnosed etiology of chronic constipation that is often overlooked as being a primary diagnosis. We present a case of an undiagnosed dolichocolon in a young adult female whose initial presentation was concerning of appendicitis. Eventually, the patient underwent a subtotal colectomy as a definitive treatment for chronic constipation. Dolichocolon is an anatomical variant that can have severe lifelong consequences, such as chronic constipation, which greatly affects a patient's quality of life and overall health if undiagnosed. The purpose of this case report is to raise awareness among the surgical community regarding the significance of early dolichocolon diagnosis, prevent misdiagnosis, and ultimately improve patient outcomes, including reducing complications associated with chronic constipation.

Sigmoid volvulus and diabetes mellitus

Objectives

Diabetes mellitus (DM) complicates about 15.7% of sigmoid volvulus (SV) cases. However, the pathophysiology of this relation is still unclear. Our objective was to evaluate the association of DM and SV.

Methods

The clinical data of 1,051 patients treated in Ataturk University Faculty of Medicine during 56 years between June 1966 and July 2022 were considered. The records of 612 cases (58.2%) were evaluated retrospectively till June 1986, while 439 (41.8%) were investigated prospectively thereafter. To obtain the worldwide data, an electronic search of the last 56-years' literature (from 1967 to date) was performed in Web of Science and PubMed databases.

Results

DM was statistically higher in SV patients than of general population (15.7% vs. 8.3%, p<0.001). Conversely, SV and DM co-occurrence was statistically lower in our series than of world-wide data (2.9% vs. 15.7%, p<0.001). In our series, SV and DM comorbidity was statistically higher in elders that that of children (3.9% vs. 0.0%, p<0.05). Although sigmoid gangrene was more common in DM patients when compared with that of total, the difference was not statistically significant (42.9% vs. 27.4%, p>0.05). Conversely, the mortality rate was statistically higher in DM cases than that of no diabetics in SV (28.6% vs. 7.8%, p<0.001).

Conclusion

Although the pathophysiology of SV and DM comorbidity is still relatively unexplainable, our study suggests that DM worsens the prognosis of SV. For this reason, early diagnosis and proper treatment have great importance in such patients.

Isolated diffuse intestinal ganglioneuromatosis presented as a redundant sigmoid colon: a case report

Diffuse intestinal ganglioneuromtosis is a benign tumor of the enteric nervous system, that almost always occurs in children with systemic syndromes. Whereas isolated cases in adults are exceedingly rare.

Case Presentation

A 38-year-old man presented with refractory chronic constipation. An abdominal computed tomography scan revealed a redundant sigmoid colon, then he underwent a sigmoid colectomy. Histopathologic examination showed diffuse ganglioneuromatosis. However, the patient was in good health 18 months after surgery.

Clinical Discussion

Intestinal ganglioneuromas commonly occur in children with systemic syndromes such as multiple endocrine neoplasia type 2B and neurofibromatosis type 1. The most frequent symptoms are abdominal discomfort, constipation, ileus, weight loss, appendicitis, and obstruction in more severe cases. surgical resection is the standard management in diffuse ganglioneuromatosis.

Conclusion

Although diffuse ganglioneuromatosis is uncommon, it should be considered in patients with refractory constipation.

Acute colonic flexures: the basis for developing an artificial intelligence-based tool for predicting the course of colonoscopy

Tortuosity of the colon is an important parameter for predicting the course of colonoscopy. Computed tomography scans of the abdominal cavity were performed in 224 (94 female, 130 male) adult subjects. The number of acute (angle not exceeding 90°) bends between adjacent colonic segments was noted and analyzed. Data were analyzed for correlation with gender, age, height and weight. An artificial intelligence algorithm was proposed to predict the course of colonoscopy. We determined the number of acute flexions in females to be 9.74 ± 2.5 (min-max: 4-15) and in males to be 8.7 ± 2.75 (min-max: 4-20). In addition, more acute flexions were found in women than in men and in older women (after 60 years) and men (after 80 years) than in younger ones. We found the greatest variability in the number of acute flexures in the sigmoid colon (0-9), but no correlation was found between the number of acute flexures and age, gender, height or BMI. In the transverse colon, older and female subjects had more flexures than younger and male subjects, respectively. Older subjects had more acute flexures in the descending colon than younger subjects. There are opportunities to use the number of acute flexures (4-7, 8-12, more than 12 flexures) to classify patients into appropriate risk categories for future incomplete colonoscopy. On this basis, we predicted troublesome colonoscopies in 14.9% female and in 6.1% male subjects.

Factors affecting recurrence in sigmoid volvulus

Objectives

Recurrence is a relatively common outcome following endoscopic decompression in sigmoid volvulus (SV). This study aims to evaluate the factors affecting recurrence in SV.

Methods

In 434 patients with SV treated between June 1986 and January 2022, probable recurrence-affecting factors including age, age of SV onset, gender, dietary habit, defecation habit, altitude of living area, and SV attack count were analyzed in prospectively collected data.

Results

Of 434 patients, 111 (25.6%) had recurrent SV with mean 1.6 ± 2.3 of volvulus episodes (range: 1-21 attacks). SV recurrence demonstrated a significant linear increase with age (14.3%, 17.1%, 21.5%, and 29.9%, respectively, in young, middle aged, mature, and elderly patients, p < 0.001). Recurrent SV was also significantly higher in male gender (28.5% vs 12.7%, p = 0.004), high-fiber diet habit (32.9% vs 17.7%, p < 0.001), and living at high altitude (26.9% vs 12.5%, p = 0.047). Although SV recurrence was higher in patients with chronic constipation, the difference was not significant (36.7% vs. 20.3%, p = 0.594). When compared with that of the patients with mature onset or elderly onset patients, SV attack count was significantly higher in young-onset cases (1.3 ± 0.9 and 1.1 ± 0.3 vs 4.6 ± 6.9, p < 0.001).

Conclusion

Elderliness, early-onset, maleness, high-fiber diet habit, high altitude, and most likely chronic constipation may be the practical clinical parameters of recurrent SV. These parameters, as well as the presence of previous SV episode history, must be considered in the decision-making process in the elective treatment of SV.

Sigmoid Volvulus and Ileosigmoid Knotting: An Update

Sigmoid volvulus and ileosigmoid knotting are uncommon intestinal obstructions, which generally affect adult males. The etiology is multifactorial. Volvulus triad including abdominal pain/tenderness, distention, and obsti pation/constipation is the common clinical presentation. Although x-ray radiography helps with diagnosis, the current diagnostic procedure is computed tomography or magnetic resonance imaging in addition to flexible endoscopy in sigmoid volvulus. Endoscopic decompression is the primary treatment except for the presence of bowel gangrene and peritonitis in sigmoid volvulus, while such conditions and also ileosigmoid knotting require emergency surgery. The prognosis is relatively poor under these adverse circumstances and in ileosigmoid knotting.

Hypermobile Ehlers-Danlos syndrome and disorders of the gastrointestinal tract: What the gastroenterologist needs to know

BACKGROUND AND AIM

Hypermobile Ehlers-Danlos syndrome (hEDS) and the hypermobility spectrum disorders (HSD) can be challenging to diagnose and manage. Gastrointestinal symptoms and disorders of gut-brain interaction are common in this cohort and multifactorial in origin. The primary aim of this review is to arm the gastroenterologist with a clinically useful understanding of HSD/hEDS, by exploring the association of gastrointestinal disorders with HSD/hEDS, highlighting current pathophysiological understanding and providing a pragmatic approach to managing these patients.

METHODS

Literature relevant to the gastrointestinal system and hypermobile Ehlers-Danlos syndrome was systematically searched, critically appraised, and summarized.

RESULTS

Diagnosis is based upon clinical criteria and a genetic basis is yet to be defined. The prevalence of many gut symptoms, including abdominal pain (69% vs 27%, P < 0.0001), postprandial fullness (34% vs 16%, P = 0.01), constipation (73% vs 16%, P < 0.001), and diarrhea (47% vs 9%, P < 0.001) are significantly higher in HSD/hEDS compared with non-HSD/hEDS individuals. Disorders of gut-brain interaction are also common, particularly functional dyspepsia. The pathophysiology of gut symptoms is poorly understood but may involve effects of connective tissue laxity and its functional consequences, and the influence of autonomic dysfunction, medication and comorbid mental health disorders. Awareness is the key to early diagnosis. Management is limited in evidence-base but ideally should include an integrated multidisciplinary approach.

CONCLUSIONS

HSD/hEDS is a multisystemic disorder in which gastrointestinal symptoms, particularly related to disorders of gut-brain interaction are common. Deficiencies in knowledge regarding the pathophysiological processes limit evidence-based interventions and remain important areas for future research.

Effect of dose splitting of a low-volume bowel preparation macrogol-based solution on CT colonography tagging quality

Purpose

To compare examination quality and acceptability of three different low-volume bowel preparation regimens differing in scheduling of the oral administration of a Macrogol-based solution, in patients undergoing computed tomographic colonography (CTC). The secondary aim was to compare CTC quality according to anatomical and patient variables (dolichocolon, colonic diverticulosis, functional and secondary constipation).

Methods

One-hundred-eighty patients were randomized into one of three regimens where PEG was administered, respectively: in a single dose the day prior to (A), or in a fractionated dose 2 (B) and 3 days (C) before the examination. Two experienced radiologists evaluated fecal tagging (FT) density and homogeneity both qualitatively and quantitatively by assessing mean segment density (MSD) and relative standard deviation (RSD). Tolerance to the regimens and patient variables were also recorded.

Results

Compared to B and C, regimen A showed a lower percentage of segments with inadequate FT and a significantly higher median FT density and/or homogeneity scores as well as significantly higher MSD values in some colonic segments. No statistically significant differences were found in tolerance of the preparations. A higher number of inadequate segments were observed in patients with dolichocolon (p < 0.01) and secondary constipation (p < 0.01). Interobserver agreement was high for the assessment of both FT density (k = 0.887) and homogeneity (k = 0.852).

Conclusion

The best examination quality was obtained when PEG was administered the day before CTC in a single session. The presence of dolichocolon and secondary constipation represent a risk factor for the presence of inadequately tagged colonic segments.

Can Infant Dyschezia Be a Suspect of Rectosigmoid Redundancy?

Infant dyschezia is a functional gastrointestinal disorder that occurs in children less than nine months of age. This disorder causes much anxiety among parents who consult different physicians when suspecting major intestinal problems. The aim of this study is to verify whether infant dyschezia involves an anatomic abnormality (redundancy) of the colon. In this retrospective study (48 months) we analyzed all the children younger than 9 months who came to our attention through the suspicion of gastrointestinal abnormality (Hirschsprung’s disease, anorectal malformations, colonic disorders or constipation). They all had a complete medical history, clinical examination and diagnostic tests, such as blood samples, suction rectal biopsy, a study of stool characteristics and, finally, a contrast enema. In cases with infant dyschezia, different colonic sizes and rectosigmoid length were measured, which created a ratio with the diameter of the second lumbar vertebra. These values were compared with those reported in the literature as normal for the age of one year. Of the 24 patients evaluated (mean age 4 months), 9 were excluded for different diagnoses (aganglionic megacolon, hypothyroidism, constipation). The comparison of the ratios obtained in the remaining 15 cases showed a significantly higher rectosigmoid length (redundancy) in children with dyschezia, 18.47 vs. 9.75 (p < 0.001). The rectosigmoid redundancy, a congenital anomaly already reported as a cause of refractory constipation, may be present in children with infant dyschezia.

Bowel habits and gender correlate with colon length measured by CT colonography

PURPOSE

CT colonography enables three-dimensional measurement of colon length. However, previous studies using CT colonography have not examined the association with gender, age, physique, a history of laparotomy and bowel habits, all possible contributory factors to colon length. The aim of this study is to investigate factors associated with colon length.

MATERIALS AND METHODS

We conducted a post hoc analysis based on data obtained from a previous multi-center trial including 321 patients with positive fecal immunochemical tests who underwent CT colonography. Colon length was measured using a computer-generated center line and was divided at the iliac crest level into the distal and proximal colons. Bowel habits were classified into three groups: A-daily; B-once every 2 or 3 days; and C-less than once in 3 days. Statistical comparison was made using one-way ANOVA with Bonferroni's correction.

RESULTS

A total of 295 patients were analyzed. The entire colon length (cm, mean ± standard deviation) of individual patients was 150.3 ± 18.5 cm and ranged from 109.7 to 195.9 cm. The female colon was significantly longer than the male colon (154.3 ± 18.1 cm vs. 147.1 ± 18.3 cm; p = 0.022). Colon length showed trends associated with age (p = 0.18) and a history of laparotomy (p = 0.14). According to bowel habits, the entire colon measured 147.4 ± 17.9 in group A, 154.7 ± 18.5 in group B and 158.6 ± 18.3 in group C, and significant differences were observed for "A vs. C" (p = 0.002) and "A vs. B" (p = 0.014). In subgroup analysis by colon segment, the proximal colon trended similarly to the entire colon while there were no trends for the distal colon.

CONCLUSIONS

This study has clearly demonstrated that bowel habits and gender both correlate with the length of the entire colon measured by CT colonography, and in particular, the proximal colon. Using CT colonography, we measured the colon length in 295 patients. The entire colon length was 150.3 ± 18.5 cm on average. Females and constipated (less frequent defecation) patients have a significantly longer colon, and in particular, the proximal colon. Colon length showed trends associated with age and a history of laparotomy.

Descending-sigmoid colon flexure - An important but surprisingly ignored landmark

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 enroled 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.

Dolichocolon Presenting with Bilateral Hydronephrosis in a Neonate

Background

Dolichocolon is an inborn anatomic variant of the colon with redundancies often causing constipation and/or volvulus presenting in childhood, adolescence, or adulthood. To the best of our knowledge, this is the first case of dolichocolon presenting in infancy with constipation and bilateral hydronephrosis. Case Presentation. A nineteen-day-old neonate presented to the emergency department with severe constipation and discomfort. During his admission, he developed pyelonephritis, and subsequent ultrasound of the kidneys and bladder showed bilateral hydroureteronephrosis. A barium enema was performed and it showed a dolichocolon. Enemas and lactulose were initiated with good effect on both the constipation as well as the hydronephrosis.

Conclusions

Dolichocolon in a neonate can cause severe constipation which could also lead to an obstructive nephropathy if untreated. Monitoring of urine flow might be indicated when a neonate presents with severe constipation.

CT colonography evaluation of the relationship between colon anatomy and diverticula

OBJECTIVES

In this study, we aimed at investigating the relationship between diverticula and in vivo colonic features such as total colon length (TCL), using CTC. We also evaluated polyps, neoplastic lesions and the correlation among them.

METHODS

This retrospective study considered a series of patients who underwent CTC in our Hospital from 2010 to 2018. We evaluated TCL, the length of each colon segments and sigmoid colon diameter using dedicated software. We verified the presence of diverticula, polyps and neoplasm and measured the number of diverticula using a five-point class scale, evaluating the colonic segments involved by the disease and the number of diverticula for each segment. A logistic regression model was used to analyse the relationship between diverticula and the patients' age, sigmoid colonic diameter and the length of each colonic segments.

RESULTS

The population finally included 467 patients, 177 males and 290 females (average age of 67 ± 12; range 45-96). The mean TCL was 169 ± 25 cm (range 115-241 cm). Out of the 467, 323 patients (69%) had at least one analyse. The patients with diverticula had a mean TCL significantly shorter than patients without diverticula (164 ± 22 vs 181 ± 27 cm; p = 0.001). Among the different variables, sigmoid colon length, sigmoid colon diameter and patient's age were correlated with diverticula (p < 0.01). Otherwise there is no association among diverticula, polyps and neoplasm.

CONCLUSIONS

The presence of colonic diverticula was significantly inversely correlated with TCL.The TCL was not significantly correlated with polyps and cancers.

ADVANCES IN KNOWLEDGE

The presence of colonic diverticula was significantly inversely correlated with total colon length, and in particular they significantly decreased with increasing colon length; our observation could contribute to the comprehension of diverticula pathogenesis.

Expanding the phenotypic spectrum of lipomatosis of the sciatic nerve: Early-onset colonic diverticular disease

BACKGROUND

Lipomatosis of nerve (LN) is a complex peripheral nerve disorder characterized by fibrofatty nerve enlargement. MRI of this pathology is pathognomonic and obviates a diagnostic biopsy. Mutation in PIK3CA has been associated with LN cases with nerve-territory overgrowth which may occur in some cases. We evaluate an association of LN of the sciatic nerve and early-onset colonic diverticular disease and discuss the potential pathogenesis.

METHODS

Our institutional database was searched for LN cases. Available information of identified cases was reviewed, and cases with a confirmed diagnosis of LN affecting the lumbosacral plexus and/or sciatic nerve; available MRI of the affected nerve(s); and diverticular disease occurring in the area supplied by the nerve(s) affected by LN were further analyzed. PIK3CA mutation testing was performed on available tissue samples.

RESULTS

We identified 10 LN cases of lumbosacral plexus and/or sciatic nerve. Of these, three fulfilled our inclusion criteria. All three patients had concomitant colonic diverticular disease, diagnosed at a relatively young age. MRI studies of these cases showed LN involvement of the sacral nerves innervating the sigmoid colon. All three also had abnormal diagnostic workup including various GI tests and evidence of associated nerve-territory overgrowth. Colonic tissue samples for PIK3CA mutation were negative.

CONCLUSION

While the pathogenesis of the colonic diverticular disease is increasingly recognized as being multifactorial, our observations are consistent with the potential role of autonomic nervous system dysfunction affecting either the pelvic floor musculature, or the colon itself (or both) in a subset of patients with early-onset diverticular disease.

Characterization of gut contractility and microbiota in patients with severe chronic constipation

Chronic constipation (CC) is one of the most common gastrointestinal disorders worldwide. Its pathogenesis, however, remains largely unclear. The purpose of the present work was to gain an insight into the role of contractility and microbiota in the etiology of CC. To this end, we studied spontaneous and evoked contractile activity of descending colon segments from patients that have undergone surgery for refractory forms of CC. The juxta-mucosal microbiota of these colon samples were characterized with culture-based and 16S rRNA sequencing techniques. In patients with CC the spontaneous colonic motility remained unchanged compared to the control group without dysfunction of intestinal motility. Moreover, contractions induced by potassium chloride and carbachol were increased in both circular and longitudinal colonic muscle strips, thus indicating preservation of contractile apparatus and increased sensitivity to cholinergic nerve stimulation in the constipated intestine. In the test group, the gut microbiota composition was assessed as being typically human, with four dominant bacterial phyla, namely Firmicutes, Bacteroidetes, Proteobacteria, and Actinobacteria, as well as usual representation of the most prevalent gut bacterial genera. Yet, significant inter-individual differences were revealed. The phylogenetic diversity of gut microbiota was not affected by age, sex, or colonic anatomy (dolichocolon, megacolon). The abundance of butyrate-producing genera Roseburia, Coprococcus, and Faecalibacterium was low, whereas conventional probiotic genera Lactobacillus and Bifidobacteria were not decreased in the gut microbiomes of the constipated patients. As evidenced by our study, specific microbial biomarkers for constipation state are absent. The results point to a probable role played by the overall gut microbiota at the functional level. To our knowledge, this is the first comprehensive characterization of CC pathogenesis, finding lack of disruption of motor activity of colonic smooth muscle cells and insufficiency of particular members of gut microbiota usually implicated in CC.

Frequency and clinical impact of Dolichocolon in women submitted to surgery for rectosigmoid endometriosis

INTRODUCTION

Rectosigmoid endometriosis and Dolichocolon can both present with a triad of chronic abdominal pain, constipation and bloating. The relationship between these two pathologies is unknown. The present study aims to determine the frequency of DC in women with rectosigmoid endometriosis and its possible impact on pre- and post-operative symptoms.

MATERIAL AND METHODS

We conducted a retrospective cohort study on 113 consecutive patients submitted to magnetic resonance imaging enema and subsequent complete surgical removal for symptomatic rectosigmoid endometriosis between June 2015 to June 2018. Dolichocolon is an anatomic variant characterized by redundancies and lengthening of the colon. We divided our study population according to its presence or absence. The two groups were compared in terms of demographic data, surgical findings and pre- and post-operative clinical variables. Pain symptoms were assessed through numerical rating scale from 0 to 10. Bowel complaints included constipation, bloating and diarrhea.

RESULTS

Thirty-five patients (31 %) presented a dolichocolon at magnetic resonance imaging enema. The two groups were comparable in terms of demographic data, pre-operative clinical variables and surgical findings. At 6-month follow-up, there was a significant improvement of symptoms, except for constipation and bloating in dolichocolon group. In particular, we observed with a statistical difference (p < .05) the persistence of constipation and bloating in dolichocolon group compared to non-dolichocolon group.

CONCLUSIONS

Dolichocolon was observed in one third patients with rectosigmoid endometriosis and could influence surgical outcomes for rectosigmoid endometriosis in terms of relief of bowel symptoms.

Recurrent colonic intussusception due to a lipoma of the transverse colon at the background of congenital dolichocolon and chronic constipation

Colonic intussusception caused by benign tumour in adults is uncommon condition. Lipoma as benign tumour arises from submucosal layer of gastrointestinal tract and derives from mature adypocytes. It is usually small asymptomatic lesion and reveals during colonoscopy, CT, surgery or autopsy accidentally. However, in cases with large size it may cause abdominal pain, constipation, diarrhoea, anaemia, bleeding or intussusceptions. We present a 52-year-old female patient with colonic intussusception caused by lipoma of the transverse colon and with congenital dolichocolon. The patient had several episodes of bowel obstructions which were treated conservatively. We performed elective open extended right hemicolectomy, ileotransversostomy end-to-end.