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Biopsy of the anastomotic ulcer of patient 2, showing ulcer bed with granulation tissue formation, mild inflammation with hyperemia, microscopic hemorrhage and absence of features of rejection in the remaining glands. There is no abnormal increase in apoptotic bodies, lymphoid infiltrates into the glandular crypt cells, ischemia or viral-associated cytopathic changes (Hematoxylin & Eosin, ×20 magnification).
Source publication
We describe, for the first time, anastomotic ulcers (AU) following bowel transplantation at the Hospital for Sick Children. Two children presented with rectal bleeding, 6 and 9 months, following the transplantation. Isolated ulcers were identified at the ileo-colonic and the colo-colonic anastomosis site. The ulcers resolved, but recurred 6 and 7 m...
Citations
... SBS patients with extreme short bowel syndrome, liver disease, recurrent sepsis and intestinal failure with high morbidity may meet criteria for intestinal transplant [3,8]. Intestinal transplant patients also have an increased risk of AU due to the need for complex resection and reconstruction of the bowel [3,7,8]. We anticipate that due to a rise in the SBS and intestinal transplant population complications of anastomotic ulcerations may become more prevalent within pediatrics as the literature grows. ...
Purpose of review:
Anastomotic ulceration following intestinal resection is an under- recognized problem in pediatrics. We discuss the relevant literature regarding this condition.
Recent findings:
Anastomotic Ulceration following intestinal resection is a potentially life threatening cause of refractory anemia. Evaluation should include correction of micronutrient deficiencies and endoscopic evaluation by upper and lower endoscopy and small intestinal endoscopy if necessary. Initial treatment by medical therapy may consist of anti-inflammatory agents as well as antibiotics to treat small intestinal bacterial overgrowth. Surgical resection should be considered if refractory to treatment. Anastomotic ulcers in pediatric patients with small bowel resection should be considered as a cause of refractory iron deficiency anemia. Endoscopic evaluation should be undertaken to look for evidence of anastomotic ulcers. Surgical resection should be considered if medical therapy fails.
... When used as an adjunct to morphologic examination, either method may help definitively identify adenovirus infection in tissue sections, improving the sensitivity of detection, while also localizing disease and providing evidence for causality (55,93). Since adenoviral enteritis may mimic rejection, the use of these methods is of particular value in situations such as small-bowel transplantation (52,53,(96)(97)(98)(99)(100)(101)(102)(103)(104). ...
Adenovirus, Page 1 of 2
Abstract
Adenoviruses are non-enveloped, double-stranded deoxyribonucleic acid (DNA) viruses associated with a wide range of clinical syndromes in humans ( 1 , 2 ). To date, 67 immunologically distinct serotypes of adenoviruses have been described and further classified into one of seven (A–G) species based on hemagglutinin properties, DNA homology, oncogenic potential in rodents, and clinical disease (see Table 1 )( 1 , 3 – 6 ). Diagnostic Microbiology of the Immunocompromised Host, Second Edition
... We performed a literature review by the interrogation of the Pubmed database, using the following key words: ileocolonic/ perianastomotic/postsurgical ulcerations/ulcers. Thirteen papers reporting a total of 27 cases were retrieved and analyzed [1][2][3][4][5][6][7][8][9][10][11][12][13] . ...
Background and aims
Digestive perianastomotic ulcerations (DPAU) have been occasionally reported as late complications of neonatal or childhood surgery.
Methods
We report here a series of 14 new cases.
Results
Cases were revealed by severe anemia, diarrhea, abdominal pain and growth failure in average 11.5 years after surgery. Ulcerations were most often multiple (n = 11), located on the upper part of ileocolonic anastomoses (n = 12) and difficult to treat. No granulomas were seen but lymphoid follicles were frequent. In addition, either ASCA or ANCA were positive in 4/9 tested patients and 8/11 genotyped patients exhibited a NOD2 mutation (P < 0.0002 when compared to French healthy controls).
Conclusion
Altogether, these findings argue for common physiopathological features between DPAU and Crohn's disease and for a prospective follow-up of selected operated children to explore the early events involved in gut inflammatory lesions.
... We have undertaken 2 cases of small intestine transplantation since 1999 and all of them had developed anemia in the early period after operation [1] . The etiology is quite complex and the perioperative treatment may contribute to it. ...
... The proximal end of the graft was end-to-end anastomosed with the recipient's proximal end of jejunum while the distal end side-to-end anastomosed with the recipient's distal end of jejunum. A 10cm-sized stoma functioned as observing window was made in the distal end of the graft [1] . Case 2, male, 15 years old, suffered from internal hernia of the small intestine, underwent the operation of hernia brisement and enterectomy of the necrosed bowel in August, 1998 and ensued short bowel syndrome occurred. ...
Objective To discuss the etiology and practical, efficient therapeutic methods of anemia following living transplantation of small intestine in two cases. Methods Two cases of living intestinal transplantation were studied. After the operation, several measures were adopted, including blood transfusion, hemostasia, adjustment of the dosage of some drugs, providing raw material for hematopoietic system and necessary nutrition support, to treat the patients. Results 4 weeks later, both patients' condition improved rapidly. The index of hemoglobin was increased remarkably, to the normal level of 100-120g/L. Conclusion Anemia is one of the common symptoms accompanied with living intestinal transplantation. The correction of anemia is very crucial in treating such patients.
Intestinal transplantation (ITx) is the treatment of choice for patients with intestinal failure who have developed life‐threatening complications related to long‐term parenteral nutrition. Patients may also undergo ITx as part of a combined liver‐intestine or multi‐visceral transplant for a variety of indications, most commonly intestinal failure‐associated liver disease or porto‐mesenteric thrombosis. Endoscopy plays a critical role in the post‐transplant management of these patients, most commonly in the diagnosis and management of rejection, which occurs in up to 30‐40% of patients within the first year post‐transplant. With a lack of noninvasive biomarkers to identify the presence of rejection, endoscopy and biopsy remain the gold‐standard for its diagnosis. Endoscopic evaluation of the graft is also important in the identification of other complications post‐ITx, including post‐transplant lymphoproliferative disorder, graft‐versus‐host disease, and enteric infections. Each patient’s post‐transplant anatomy may be slightly different, making endoscopy sometimes technically challenging and necessitating clear and frequent communication with the surgical team in order to help identify the highest‐yield approach. Herein, we review the most common pathologies found endoscopically in the post‐ITx patient and describe some of the unique challenges the endoscopist faces when evaluating these complex patients.
Evaluation of the many potential complications in intestinal and multivisceral transplantation is often based on the pathological changes expressed in biopsied tissue from the allograft or native organs. The field of transplant pathology has evolved and now incorporates routine staining of tissue with highly specialized ancillary immunohistochemical and molecular techniques. Moreover, new biomarkers complement these sophisticated histocompatibility evaluations affording the transplant pathologist additional tools to specifically identify one or more complications occurring in grafted gastrointestinal tissue.
The published evidence is scant to guide the endoscopist when faced with a postsurgical intraluminal hemorrhage. Although less common than bleeding peptic ulcers, the endoscopist should be familiar with some issues which are peculiar to bleeding from the anastomotic site. As usual the management of bleeding is team effort with attention to resuscitation and stabilization of the patient followed by a prompt endoscopy
aiming to (1) identify the source of hemorrhage, (2) stop the bleeding, (3) assess the risk of rebreeding, and (4) outline a strategy of how the case should be managed if bleeding cannot be stopped or recurs. As the small bowel anastomosis is thin, the endoscopist should be careful in the use of thermal therapies. There is evidence that the use of clips is preferable over thermal therapy at this location.
Endoscopic follow-up (FU) after colorectal surgery is indicated mainly for patients operated on for cancer who are at risk for metachronous adenomas and/or recurrent cancer. Despite published guidelines, there is both overuse and underuse of endoscopic surveillance, and many institutions continue to have their own follow-up regimens. Therefore, endoscopic FU of colorectal cancer (CRC) survivors remains controversial, and there are several open issues regarding its appropriateness, timing, duration, and cost-effectiveness. Endoscopic FU should allow diagnosis of early anastomotic recurrences and metachronous adenomas and/or cancer in CRC patients after curative surgery. While endoscopic surveillance of the colonic anastomosis does not have any proven benefit, patients with prior rectal cancer should undergo flexible sigmoidoscopy∈±∈endoscopic ultrasound at 3-6-month intervals for the first 3 years after resection, if not treated with neoadjuvant chemoradiation and mesorectal excision. All CRC survivors should undergo lifelong endoscopic FU to prevent metachronous CRCs, with surveillance colonoscopies at 1, 3, and 5 years after surgery and then every 5 years until the benefit is outweighed by comorbidity. Recently, it has been proposed that endoscopic FU should be tailored according to the personal risk of the individual CRC survivor, based on the presence or absence of synchronous adenomas at perioperative colonoscopy, the diagnosis of metachronous lesions during surveillance, and the features of both synchronous and metachronous adenomas. This strategy has been shown to be cost-effective, with a clear survival benefit for CRC survivors.
