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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1250_Библиотеки_им_академика_М_И_Перельмана.pdf
The Mesenteric
Organ in Health
and Disease
Eli D. Ehrenpreis
John C. Alverdy
Steven D. Wexner
Editors
123
The Mesenteric Organ in Health and Disease
Eli D. Ehrenpreis John C. Alverdy
Steven D. Wexner
Editors
The Mesenteric Organ
in Health and Disease
123
Editors
Eli D. Ehrenpreis
Department of Medicine
Advocate Lutheran General Hospital
Park Ridge, IL, USA
Steven D. Wexner
Department of Colon and Rectal Surgery
Cleveland Clinic Florida
Weston, FL, USA
John C. Alverdy
Department of Surgery
University of Chicago Medicine
Chicago, IL, USA
ISBN 978-3-030-71962-3 ISBN 978-3-030-71963-0 (eBook)
https://doi.org/10.1007/978-3-030-71963-0
© Springer Nature Switzerland AG 2021
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part
of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations,
recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission
or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar
methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are exempt from
the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this
book are believed to be true and accurate at the date of publication. Neither the publisher nor the
authors or the editors give a warranty, expressed or implied, with respect to the material contained
herein or for any errors or omissions that may have been made. The publisher remains neutral with regard
to jurisdictional claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
This book is dedicated with love to my wife
Ana and my children Benjamin, Jamie, and
Joseph; all creative scholars dedicated to
making the world a better place.
EDE
All surgeons have the unique privilege of the
opportunity to help patients by improving the
quality of and/or prolonging their lives.
Academic surgeons are also blessed by being
able to share our knowledge and skills with
others allowing the multifold multiplication
of their practices to countless other patients
who we will never meet. The desire to teach
can be fulfilled locally by training residents,
fellows, and students and globally through
research and education. I have been
incredibly fortunate during the last 33 years
to have been able to avail myself of teaching
trainees at Cleveland Clinic Florida. The
common denominator among these endeavors
has been the commitment of my philanthropic
friends who have supported my research and
educational endeavors at Cleveland Clinic
Florida since 1988. Although none of these
magnanimous altruistic friends are surgeons,
their gifts mean that by sharing my vision,
they have also made a global impact on the
health of countless patients, perhaps in every
country. Accordingly, it is with immense
pleasure and eternal gratitude that I express
my deepest appreciation to my friends by
dedicating this textbook to them:
Nick Caporella
Ellen Cates-Smith and Sandford Smith
Aliko Dangote
Dr. Danny Dosoretz and Chely Dosoretz
Itchko Ezratti and Diana Morrisson
Theo and Connie Folz
Bernard and Juliette Klepach
Bill Livek
Bernie Marcus
Earl and Nancy Stewart
Herbert and Doreen Wigwe.
SDW
Foreword
The conventional model of abdominal anatomy described multiple and separate
mesenteries. Recent advancements in our understanding of the mesenteric organ
demonstrate that there is one mesentery and that all abdominal digestive organs are
in direct connection with the single mesenteric organ. These advances prompted a
re-appraisal of human mesenteric embryology that in turn led to the discovery that
abdominal digestive organs develop within and remain in close association with the
mesenteric frame. This has major implications for human biology in general. For
example, it means the abdomen is anatomically organized into two principle
compartments; the mesenteric and non-mesenteric compartment (i.e., the mesenteric model). The mesenteric model of human abdominal anatomy overcomes
problems associated with the peritoneal-based model and in so doing reconciles
embryological, anatomical, surgical, and radiological approaches to the abdomen as
a group.
The centrally positioned mesenteric continuum is of far greater importance in
human biology than was previously thought. It follows that it is of considerable
importance to pathological derangements of human biology, i.e., diseases. The
following is the foundation text on mesenteric diseases and is thus timely. Written
by established expert scientists and clinicians it is carefully designed to provide
information in an accessible format but also to offer a platform for use for reference
purposes. The editors and assembled authors should be congratulated on compiling
the first reference text on mesenteric diseases. It is an invaluable resource that will
become part of teaching curricula in medical, radiological, pathological, and surgical training programs. Most importantly, this will translate into substantial clinical
benefits for patients with abdominal and systematic diseases.
Limerick, Ireland JC Coffey
vii
Preface
Almost two decades ago, a fifty-one-year-old male who was a local politician came
to see me for a cluster of concerning symptoms. The patient complained of pain
across his lower abdomen that was worse with activity. Furthermore, although a
large man, he had a poor appetite and had lost a significant amount of weight in the
prior two months. He was alarmed by another symptom: awakening with sweats
that soaked his pajamas and bedsheets. A physical examination revealed an obvious
abdominal mass that was firm and tender to the touch. The mass enveloped a
substantial portion of the right lumbar, umbilical, and hypogastric regions of the
abdomen. Anticipating a diagnosis of sarcoma, and a dismal prognosis, I ordered
imaging of the abdomen with computerized tomography. As expected, a large
abdominal mass was found. However, a subsequent biopsy demonstrated chronic
inflammation and fat necrosis consistent with the diagnosis of mesenteric panniculitis. After finding virtually no clinical resources to assist in managing this
condition, I embarked on a journey to try to treat my new patient and to offer
innovative approaches to the disease. With the help of an enthusiastic group of
medical residents and gastroenterology fellows, my group began publishing a
variety of observational studies based on a gathering number of patients with
mesenteric panniculitis that were coming to the office. These included a new
method to score the severity of symptoms for future pharmaceutical studies called
the Mesenteric Panniculitis Symptom Assessment Score (MPSAS). Understanding
nuances of the clinical care of patients with mesenteric panniculitis followed,
allowing for the solidification of diagnostic and therapeutic approaches of mesenteric panniculitis. Many questions arose when caring for patients with a rare disease
that had fewer than 300 hundred cases described in the medical literature. For
example, what happens if patients fail or are intolerant to the few initial therapies
that are recommended? What is the synergy that occurs between the physical and
psychological components of a benign disease that nobody knows how to treat?
What future risks can be anticipated and what is the appropriate follow up for
patients with mesenteric panniculitis? One can anticipate similar difficulties when
caring for patients with other rare or poorly understood medical conditions. Our
group ultimately developed several new potential treatments for mesenteric panniculitis including thalidomide, enteric coated budesonide (unpublished), and low
dose naltrexone using the MPSAS as a guide to drug response. Because many
ix
x Preface
patients that are first diagnosed with “mesenteric panniculitis” or “misty mesentery”
based solely on CT findings without confirmatory biopsies, we also explored the
relationship between mesenteric panniculitis and malignancy, an important piece
of the mesenteric panniculitis puzzle.
The mesentery, generally viewed as a fragmented group of connective tissues
that functioned to attached the gastrointestinal organs to the abdominal cavity, has
undergone anatomic description for centuries. Of interest, a drawing of the
mesentery by Leonardo Da Vinci from about 1508 that is owned by the Royal
Collection Trust shows his deep understanding of its gross anatomy, most likely
developed from its careful dissection away from adjacent abdominal organs. In Da
Vinci’s view, the mesocolon and mesorectum are shown in contiguity suggesting a
single mesenteric structure whose point of origin appears to be at the mesenteric
root near the small intestine. This view was contrary to the more modern anatomists
who described a fragmented, unorganized version of the mesentery. After a detailed
review of historic anatomic descriptions as well as gross and microscopic examination of cadaveric and surgical resections, J Calvin Coffey, a colorectal surgeon
from Limerick Ireland, and his group published a paper in the Lancet Gastroenterology and Hepatology in 2016 that re-examined the relationship of the mesentery
and its surrounding structures. Their proposal that the mesentery is a distinct organ
in the body first raised a great deal of interest in the scientific and lay press and
subsequently resulted in the acceptance of this concept in the scientific world. In
fact, the mesentery now appears on the list of 79 organs of the human body on
Wikipedia and is classified as a gastrointestinal organ. Aside from the curiosity that
the finding of a “new organ in the body” creates, this concept allows for an
expanded understanding of the role that the mesentery may play in the pathophysiology of diseases affecting other organ systems.
Most medical diseases of the mesentery have not received the degree of attention
as the mesenteric vascular disorders, including ischemic enteropathy and ischemic
colitis. Ischemic enteropathy is among the deadliest medical condition affecting the
mesentery and has been the focus of important work and medical breakthroughs in
the past few decades. Other medical diseases of the mesentery are generally viewed
in the miscellaneous category of gut disorders and have remained releg ated as such.
In the surgical literature, the mesentery has garnered more attention. Inclusion of
mesenteric resection in the management of rectal cancer has resulted in significant
improvement in prognosis in these patients. More recent work has also suggested
that removal of portions of the mesentery with intestinal resections may enhance the
outcomes of these surgeries in patients with Crohn’s disease. Since the time that my
patient walked through the office door, a greater understanding of mesenteric
involvement in local and systemic disease processes has occurred. The single organ
model of the mesentery is a potential catalyst toward understanding the role of the
mesentery in the maintenance of the homeostasis in healthy individuals.
These fresh developments in the field of mesenteric disorders and my prior
experience with mesenteric panniculitis directed me to think about creating a new
book specifically focused on the mesentery. To fully actualize the process, it was
vital to engage surgical colleagues to write and edit major portions of the work.
Preface xi
I was fortunate to receive enthusiastic interest in the book from Dr. John Alverdy, a
talented surgeon and Professor of Surgery at the University of Chicago, whose life
work has focused on the effects of bacterial translocation from the gastrointestinal
tract, the source of which occurs at the interface of the mesentery and the gut. Dr.
Steven Wexner, Chairman of the Department of Colorectal Surgery at Cleveland
Clinic Florida, is an innovator in the field of colorectal surgery who has also
become an eager partner in this endeavor. His work on laparoscopic mesorectal
resections, mesenteric lengthening techniques, and advanced laparoscopic surgeries
for Crohn’s disease has made him an ideal coauthor and coeditor for the project.
In putting together this first book devoted specifically to diseases of the
mesentery, we had several important challenges. Our goal was to create an easy to
read and clinically relevant book. However, since we wished to bring the reader up
to speed on translational aspects of normal and abnormal mesenteric function, a
detailed review of mesenteric anatomy and physiology was also required. To
accomplish these goals , we have enlisted a number of additional authors and
co-authors to create the chapters of this book. All authors were instructed to focus
on clinical features of their subjects. Illustrative examples and succinct tables are
included throughout to assist in the understanding of material that is presented. We
have been very fortunate to have enlisted Dr. Abraham Dachman, Professor of
Radiology from the University of Chicago who created a library of radiographic
images of mesenteric diseases for use in the book.
The structure of the book consists of introductory chapters, followed by a review
of the anatomy, embryology, and physiology of the mesentery. After an overview
of relevant medical procedures, the role of the mesentery in systemic medical
disorders is covered in several chapters. The book is completed with chapters for
specific medical and surgical diseases of the mesentery.
As authors and editors, we respectfully submit our book as the first endeavor to
assemble what is known about the mesentery in a single volume. We hope in turn
that our efforts will enhance the appreciation of the mesentery in normal and disease
states and that this will stimulate further developments that benefit patient care.
Park Ridge, IL, USA Eli D. Ehrenpreis