Safety of band ligator use in the small bowel and the colon.

BACKGROUND: Endoscopic band ligation for bleeding small-bowel vascular lesions has been reported as safe and efficacious based on small case series. There have been several other published case reports of band ligators used for bleeding lesions, usually Dieulafoy's lesions, in the stomach, the proximal small bowel, and the colon. In addition, this method has been used for postpolypectomy bleeding stalks. There has never been a critical look at the anatomic consequences of banding in the thinner sections of bowel. METHOD: The purpose of this study is to define the anatomic and histologic consequences of applying band ligator devices to the small and the large bowel. Fresh surgical specimens, both large and small bowel, that were excised because of neoplastic lesions were transported to our endoscopy unit where one end of the intact bowel was sutured shut. A standard upper endoscope was passed via the open end, and the bowel was closed tightly with rubber band ties. The bowel then was insufflated, and band ligators were applied to unaffected mucosa by using a standard technique. Photodocumentation from inside and outside the bowel was obtained. Some of the band polyps were cut above the band, and some were cut below the band in the fresh state. Some were fixed in formalin and examined microscopically. Histologic sectioning occurred at the level of the bands. RESULTS: The results were striking in that there were large holes (1 cm) in the fresh ileum specimen. There was gross serosal entrapment manifested by visible puckers on the outer surfaces of the specimens, especially in the small bowel and the right colon. The left colon, anatomically thicker, was less affected. The histologic evaluation revealed inclusion by the band ligator of the muscularis propria and serosa on the small bowel, the muscularis propria in the right colon, and the submucosa in the left colon. CONCLUSIONS: Based on these findings, we conclude that band ligator devices are not safe in the small bowel and the right colon but probably are safe in the thicker left colon.

The meandering mesenteric artery: a historic review and surgical implications.

PURPOSE: The aim of this study was to review the literature regarding collateral mesenteric circulation with emphasis on the mesenteric meandering artery (of Moskowitz). Standard vascular embryology and anatomy are described as are the collateral mesenteric vessels that can develop with arterial stenosis or occlusion. A discussion on the correct usage of terms for describing mesenteric collateral vessels follows. METHODS: We undertook review of the historical literature to discuss the surgical implications of the meandering mesenteric artery. RESULTS: Despite a long history of study by anatomists and surgeons, confusion still persists regarding both the number and correct descriptive terminology of the collateral mesenteric vessels. CONCLUSIONS: The use of the vague historic term "arc of Riolan" should be discarded for the more precise term "meandering mesenteric artery." The meandering mesenteric artery should routinely be preserved in all surgical procedures, to include resection for cancer, given its critical function in providing collateral mesenteric circulation. Further evaluation in the asymptomatic patient, however, is unnecessary.