Colonic Anastomosis Research Articles

S1786 A Rare Case of Bowel Obstruction: Cecal Bascule After Colonoscopy

Introduction: Cecal bascule is an exceedingly rare type of cecal volvulus in which a mobile cecum folds anteriorly and superiorly on to the ascending colon, causing partial obstruction. The following vignette highlights a case of cecal bascule following two unsuccessful colonoscopy attempts. Case Description/Methods: A 68-year-old male with history of advanced adenoma and no prior abdominal surgery was admitted for surveillance colonoscopy after inability to intubate the cecum on outpatient colonoscopy. Repeat double balloon assisted colonoscopy attempt failed to intubate the cecum , raising concern for cecal volvulus. While admitted, the patient complained of abdominal distention and discomfort despite ability to pass gas and stool. Abdominal x-ray showed a significantly dilated colon to 12 centimeters (Figure 1A). Computed tomography (CT) revealed upside down rotated cecum with ileocecal valve pointing laterally, dilatation of ascending colon to 10 centimeters without evidence of perforation, compatible with cecal volvulus (Figure 1B). A multi-disciplinary discussion between gastroenterology, radiology, and surgery resulted in exploratory laparotomy with right hemicolectomy and end ileostomy. Intraoperatively, a redundant colon was observed with severely dilated cecum and cecal bascule. He underwent a right hemicolectomy with ileal colonic anastomosis. The patient did well post-surgery without significant sequelae. Discussion: Cecal volvulus, a rare clinical entity, accounts for 1-2% of all large bowel obstructions. Cecal bascule, where the distended cecum folds anteriorly on the ascending colon without torsion, is the rarest type of cecal volvulus, accounting for 5-20% of all cases. It occurs secondary to congenital or acquired adhesions fixing the anterior wall of the cecum to that of the ascending colon. In our patient, the increased motility related to the colonoscopy preparation may have initiated the rotation of the cecum. The signs and symptoms of a cecal bascule are similar to that of a cecal volvulus. Plain X-ray usually reveals a distended cecum. CT of abdomen confirms the diagnosis in 90% of patients showing upward folding of the cecum, as in our patient. Treatment is primarily surgical. Due to high recurrence after simple reduction, cecopexy or resection and anastomosis are preferred approaches. In patients with recurrent or persistent abdominal pain and distension, cecal bascule should be considered in the differential diagnosis.Figure 1.: Abdominal X-ray and exploratory laparotomy findings.

Early enteral nutrition with L-glutamine improves anastomotic healing in rats administered hyperthermic intraperitoneal chemotherapy with cisplatin and 5-FU

Background/Aim: One of the most significant aspects of intestinal surgery is anastomotic wound healing. After intestinal surgery, the most serious complication is gastrointestinal leakage, which is associated with a high rate of morbidity and mortality. The rate of morbidity and mortality can be reduced by increasing the mechanical resistance of the anastomosis. Glutamine improves impaired wound healing through effects on the healing process. This study investigated the effects of early enteral glutamine supplementation on colonic anastomosis healing in rats treated with hyperthermic intraperitoneal chemotherapy (HIPEC) with cisplatin and fluorouracil (5-FU). Methods: Twenty-four rats were divided into three groups. Group 1 underwent colonic anastomosis and intraabdominal hyperthermic saline administration, Group 2 underwent colonic anastomosis and HIPEC, and Group 3 underwent colonic anastomosis and HIPEC and postoperative administration of glutamine solution via an orogastric tube for 7 days. On day 7, all rats were sacrificed and anastomotic bursting pressure (ABP) was evaluated. Tissue specimens were taken to examine tissue hydroxyproline levels and histopathological changes in the anastomotic line. Results: The ABP was significantly greater in Group 2 than in Groups 1 and 3 (P=0.001 and P=0.046, respectively). The tissue hydroxyproline level was higher in Group 1 and Group 3 than in Group 2 (P=0.001 and P=0.043, respectively). The histopathological findings in Group 3 were better than those in Group 2. The histopathological findings were observed to improve in the early enteral nutrition with Glutamine group. Conclusions: The findings of this study indicate that early enteral glutamine supplementation facilitates colonic anastomosis healing following HIPEC with cisplatin and 5-FU, by increasing the ABP and tissue concentrations of hydroxyproline and decreasing the inflammatory response.

Video Abstracts

Purpose/Background: It is well recognised that patients following long course chemoradiotherapy can have a complete clinical response. This offers the possibility for organ preservation. However these patients require intense surveillance which commonly involves frequent MRI scans and flexible sigmoidoscopy. LumenEye is a state of the art endoscopic kit, which allows a convenient, comfortable and efficient way of visualising the ano-rectal area in OPD with high quality images avoiding the need for a formal endoscopic procedure. Methods/Interventions: The device includes (a) LumenEye X1 endoscope (b) Tablet display with full HD screen (c) Intuitive CHiP software and (d) Portable case with workstation. The kit displays full HD images and can capture videos. Results/Outcomes: We have used the LumenEye X1 endoscope to survey patients following a complete clinical response who have opted for organ preservation. It avoids the need for an endoscopy and detailed images and videos can be shared with specialist centres. This has been of particular benefit during the Covid 19 pandemic where there has been a limited endoscopy resource. The technology also has other applications such as the intraoperative assessment of left sided colonic anastomosis. Conclusion/Discussion: LumenEye X1 endoscope offers an alternative to the use of endoscopy in the surveillance of patients with a complete clinical response. It also has the potential to free up valuable endoscopy resources.

The effect of carbon monoxide releasing molecule-2 (CORM-2) on healing of ischemic colon anastomosis in rats

Background/aimIschemia on the colon wall negatively affects healing of anastomosis. We were aimed to evaluate the effects of carbon monoxide releasing molecule-2 (CORM-2) on the healing of anastomosis in a rat model of the ischemic colon. Materials and methodsIn this prospective study a total of 60 rats were randomly divided into three groups as colon transection and end-to-end anastomosis (Group I), colon transection, and end-to-end anastomosis following the induction of ischemia (Group II), and colon transection and end-to-end anastomosis following the induction of ischemia and treated with daily intraperitoneal administration of CORM-2 (Group III). Each group was also divided into two equal subgroups as postoperative 3rd and 7th day. Postoperative healing of anastomoses was evaluated by anastomosis burst pressure (ABP), tissue biomarkers including hydroxyproline (HP), malondialdehyde (MDA), glutathione (GSH), and histopathological findings.ResultsIn the ischemic group treated with CORM-2, lower MDA and higher HP levels were observed in comparison to the untreated ischemic group on the 3rdday. GSH and HP levels were higher and MDA levels was lower in the ischemic rats treated with CORM-2 than in the ischemic untreated rats on the 7th day. In the ischemic group treated with CORM-2, the mucosal epithelial score decreased and the neoangiogenesis score increased compared to the untreated rats on the 7th day.ConclusionIn ischemic colon anastomosis, reduces cell destruction by suppressing the oxidative reaction, and strengthening the antioxidative mechanisms of the cells. It also increases collagen formation, epithelial development, and neoangiogenesis.

Surgical Techniques and Outcomes of Colorectal Anastomosis after Left Hemicolectomy with Low Anterior Rectal Resection for Advanced Ovarian Cancer.

Simple SummaryWe tried to minimize the number anastomoses, restore intestinal continuity, and avoid stoma creation for 295 patients with stage III/IV ovarian cancer who underwent low anterior rectal resection (LAR) with or without colon resection during cytoreductive surgery. When remaining colon cannot reach the rectal stump after left hemicolectomy with LAR, we used the following three techniques for tension-free anastomosis: right colonic transposition, retro-ileal anastomosis through an ileal mesenteric defect, or additional colic artery division. The rate of stoma creation and rectal anastomotic was 3% (9/295) and 6.6% (19/286), respectively. Among 21 patients in whom the remaining colon did not reach the rectal stump after left hemicolectomy with LAR, 20 underwent tension-free anastomosis, including eight, six, and six patients undergoing right colonic transposition, retro-ileal anastomosis through an ileal mesenteric defect, and an additional colic artery division, respectively. Colorectal anastomosis is feasible in patients with extended colonic resection.Extended colon resection is often performed in advanced ovarian cancer. Restoring intestinal continuity and avoiding stoma creation improve patients’ quality of life postoperatively. We tried to minimize the number of anastomoses, restore intestinal continuity, and avoid stoma creation for 295 patients with stage III/IV ovarian cancer who underwent low anterior rectal resection (LAR) with or without colon resection during cytoreductive surgery. When the remaining colon could not reach the rectal stump after left hemicolectomy with LAR, we used the following techniques for tension-free anastomosis: right colonic transposition, retro-ileal anastomosis through an ileal mesenteric defect, or an additional colic artery division. Rates of stoma creation and rectal anastomotic were 3% (9/295) and 6.6% (19/286), respectively. Among 21 patients in whom the remaining colon did not reach the rectal stump after left hemicolectomy with LAR, 20 underwent tension-free anastomosis, including eight, six, and six patients undergoing right colonic transposition, retro-ileal anastomosis through an ileal mesenteric defect, and an additional colic artery division, respectively. Colorectal anastomosis is feasible for patients with extended colonic resection. Low anastomotic leakage and stoma rates can be achieved with careful attention to colonic mobilization and tension-free anastomosis.

Ex vivo comparison ofhand‐suturedversus circular stapled anastomosis in canine large intestine

To compare leakage pressures of colonic anastomoses performed with circular staplers to conventional hand-sewn techniques in dogs. Ex-vivo study. Colon from 11 canine cadavers. Thirty-two colonic anastomoses were performed. Four segments from each colon were randomly assigned to one of four techniques: hand-sewn colonic anastomoses performed with 4-0 glycomer 631 (G) and 4-0 barbed glycomer 631 (BG), and circular stapled colonic anastomoses using 4.8 mm End-to-End Anastomosis (EEA C4.8mm) and 3.5 mm End-to-End Anastomosis (EEA C3.5mm), 21 mm diameter circular staples in cadaveric canine colon. Leakage pressure was defined as the pressure at which dye-containing solution was first observed to leak from the anastomosis site. Leakage pressures were 49.5 mmHg (range:16-72) in group G, 45.5 mmHg (range:19-80) in group BG, 5.3 mmHg (range:0-31) in group C3.5mm, and 29.5 mmHg (range:23-50.3) in group C4.8mm. Anastomoses leaked at lower pressures when stapled rather than hand-sewn (C4.8mm-G p=.0313, C4.8mm-BG p=.0131, C3.5mm-G p=.0469, C3.5mm-BG p=.0313). Two of the C3.5mm constructs leaked immediately after saline infusion with 4/6 leaking at <5.3 mmHg. End-to-end colonic anastomoses closed with circular stapler leaked at lower pressures than hand-sutured anastomoses. Use of the EEA stapler with a staple height of 3.5 mm did not result in safe colonic anastomoses. These results provide evidence to support hand-suturing colonic anatomoses with G and BG in dogs. The 4.8 mm staples may be considered in anatomical locations difficult to reach.

Effect of additional strengthening of colonic anastomosis on abdominal contamination severity

Purpose of the study. To investigate the effect of additional strengthening of the colonic anastomosis (CA) using modern adhesive materials on the severity of abdominal contamination in patients with insulin resistance (IR).&#x0D; Materials and methods. The study involved 80 patients with IR, who underwent surgery with the CA imposition (median age of the patients – 64 (57; 71) years). All patients were divided into 2 groups, depending on the method of strengthening the CA suture: 1 group – 40 patients who underwent the application of a onerow continuous suture (OCS) of the CA (median age of patients – 65 (57; 75) years, 2 group – 40 patients to whom OCS CA was applied, and in order to seal and strengthen the anastomosis zone a modern Nbutylcyanoacrylate tissue adhesive was added (median age of patients – 63,5 (58,5; 70,5) years. The spectrum of microbial flora of secretions from drains near the anastomosis was determined.&#x0D; Results. The additional use of modern Nbutylcyanoacrylate tissue adhesive to strengthen the area of CA with the imposition of a OCS in patients with IR contributes to a reliable reduction of number of patients with associations consisting of two types of microorganisms compared to the patients without additional strengthening (2 (5,0%) versus 9 (22,5%) of patients, respectively) (χ2 = 5,17, df = 1; р &lt; 0,05), the greater number of patients with no growth of microorganisms in crops from the anastomotic zone ((11 (27,5%) of patients versus 3 (7, 5%) of patients, respectively), as well as fewer cases of high degree of anastomosis zone contamination (3,48 times (χ2 = 7,68, df = 1; р &lt; 0,05)), with prevalence of mild contamination (3, 35 times (χ2 = 15,24, df = 1; р &lt; 0,05)).&#x0D; Conclusion. The additional use of modern Nbutylcyanoacrylate tissue adhesive to strengthen the area of CA with the imposition of a onerow continuous suture in patients with IR contributes to a reliable reduction of contamination of the area around the anastomosis compared to the patients without additional strengthening.

Effect of Adipose-Derived Stem Cells on Colonic Anastomosis in Rats Immunosuppressed With Everolimus: An Experimental Study.

Immunosuppressed patients sometimes require colorectal surgery. We investigated whether adipose tissue-derived stem cells contributed to anastomosis healing in rats immunosuppressed with the mTOR inhibitor everolimus. Sixty male Sprague-Dawley rats were randomly divided into 4 groups of 14 each, with all groups undergoing descending colon anastomosis; the 4 remaining rats were used for stem cell retrieval. Group 1 (control) underwent surgery only, group 2 received stem cell injection, group 3 received everolimus only, and group 4 received everolimus plus stem cell injection. After treatment, each group was randomly divided into 2 equal subgroups according to the day of euthanasia (posttreatment day 4 or day 7). We measured anastomosis bursting pressure and tissue hydroxyproline level and performed histopathological evaluation. At both posttreatment days 4 and 7, median weight loss in group 3 was higher than in group 1, group 3 had higher severity of intraabdominal adhesion than group 4, and group 2 had mean hydroxyproline level higher than the other groups. At posttreatment day 4, mean bursting pressure was significantly different in group 1 versus groups 2 and 4 (P = .002) and group 2 versus groups 3 and 4 (P < .001). No significant differences were shown in pathological analysis except for vascular proliferation on day 7 (P = .003). Injection of adipose tissue-derived stem cells in the anastomosis site prevented anastomosis leakage by contributing to healing. Injection of adipose tissue-derived stem cells in the anastomosis region, especially in the early period after solid-organ transplant in recipients and after gastrointestinal surgery in immunosuppressed patients, may help reduce mortality and morbidity.

Evaluation of short-term risk factors associated with dehiscence and death following full-thickness incisions of the large intestine in cats: 84 cases (1993-2015).

To evaluate short-term risk factors associated with dehiscence and death in cats undergoing full-thickness large intestinal incisions. 84 client-owned cats that had undergone full-thickness large intestinal incisions and for which information regarding outcome through postoperative day 7 was available. Medical records from 4 veterinary teaching hospitals were reviewed. For cats that met the inclusion criteria, signalment, history, laboratory test results, surgical and medical procedures, perioperative complications, and outcome were analyzed. A Fisher exact or Wilcoxon rank sum test was used to identify individual variables associated with dehiscence of intestinal incisions or patient nonsurvival to hospital discharge or both. 84 cats met the inclusion criteria. The overall dehiscence and survival to hospital discharge rates were 8.3% (7/84 cats) and 94% (79/84 cats), respectively. Factors associated with dehiscence and nonsurvival to hospital discharge included presence of band neutrophils, performance of partial colectomy with colonic resection and anastomosis, administration of blood products, postoperative cardiopulmonary arrest, and incisional inflammation or infection. Factors associated with nonsurvival to hospital discharge only included low serum globulin concentration, repair of colonic trauma or dehiscence, and postoperative colonic dehiscence. Factors associated with dehiscence only included hypoalbuminemia, renal dysfunction, administration of blood products or > 2 classes of antimicrobials, and intra-abdominal fecal contamination. Results indicated that intestinal dehiscence and mortality rates associated with large intestinal incisions in cats may be higher than previously proposed, although the risk of either outcome was still low. Factors suggestive of systemic illness were associated with colonic dehiscence or death, and focused prospective studies of risk factors are warranted.

Healing of colonic anastomosis in rats under obstructive ileus conditions.

Background: The anastomosis leak in colon resections is a crucial post-operative complication with significant morbidity and mortality. Methods: Forty (40) Wistar rats were allocated in two groups. In SHAM group only anastomosis was performed. In ILEUS group anastomosis was performed following one day of ileus. Animals in both groups were subdivided in two groups according to the day they were sacrificed, 4th or 8th post-operative day. A number of variables between the groups were estimated. Results: Body weight loss was higher following obstructive ileus on both days. Adhesion score in 4th and 8th post-operative day was higher in ILEUS1, ILEUS2 groups compared to SHAM1, SHAM2 groups respectively (p<0.001 for both). Neovascularization decreased following obstructive ileus compared to control on the 4th day (ILEUS1 vs. SHAM1, p=0.038). Bursting pressure was lower in ILEUS2 group than SHAM2 group (p<0.001). The number of fibroblasts decreased following obstructive ileus compared to control on the 4th and 8th day (ILEUS1 vs. SHAM1, p=0.001, ILEUS2 vs SHAM2, p=0.016). Hydroxyproline concentration was decreased in ILEUS2 group compared to SHAM2 group (p<0.001). Conclusions: The balance of collagenolysis and collagenogenesis plays a decisive role in the healing of anastomoses following bowel obstruction. Under those circumstances, anastomosis’ bursting pressure is reduced owning to decreased neovascularization, reduced fibroblast presence and lower hydroxyproline concertation. In our study, local inflammation, neocollagen concentration and collagenase activity were not associated with this adverse effect. However, further research should delineate the mechanisms of healing of colonic anastomoses and identify those factors that can improve our outcomes.

Impact of Gentamicin-Impregnated Collagen on the Intra-Abdominal Adhesions and Integrity of Colonic Anastomosis: An Experimental Study.

BackgroundWe investigated the impact of collagen usage in colo-colonic anastomoses on intra-abdominal adhesion and anastomosis safety.Material/MethodsA total of 30 adult albino Wistar rats (aged 6–8 months) weighing 180–230 g in the laboratory setting were used in this study. Rats were divided into the 3 groups, consisting of 10 rats in each group: treated with gentamicin-impregnated collagen, treated with only collagen, and the control group. After 7 days, rats were sacrificed to evaluate adhesion scores and anastomosis bursting pressures. The Evans scoring system was used to rate adhesion levels. Bursting pressures were measured using a handheld tension device, and the scores obtained at the moment of tissue dissection were determined as the bursting pressure.ResultsThe mean adhesion scores were 2.86±0.37 in the control group, 1.80±0.91 in the collagen group, and 1.78±0.83 in the gentamicin-impregnated collagen group, with the control group showing significantly higher scores than the other groups (p=0.010 and p=0.011, respectively). The mean bursting pressure levels were 174.29±44.68 mmHg in the control group, 223±38.6 mmHg in collagen group, and 223.33±42 mmHg in the gentamicin-impregnated collagen group, showing that the mean bursting pressure levels were significantly lower in the control group than the other groups (p=0.027 and p=0.029, respectively).ConclusionsThis study suggests that colo-colonic anastomosis coverage using materials incorporating collagen alone or gentamicin-impregnated collagen increases the safety of anastomosis and reduces intra-abdominal adhesions.

Inflammatory cap polyp of the sigmoid colon: a case report

BackgroundInflammatory cap polyp is a very rare benign entity of the distal left colon, characterized by inflammatory polyp with a “cap” of fibrinopurulent exudates. They are usually multiple and commonly present with bleeding per rectum or mucoid discharge. Solitary polyp presenting with intermittent intussusceptions is rare.Case presentationWe report the case of a 45-year-old Nepalese male with a solitary inflammatory sigmoid colon polyp. The patient presented with a 1-month history of rectal bleeding, mucoid discharge, and severe colicky abdominal pain due to intussusceptions. On colonoscopy, there was an exophytic mass with surface exudates. Colonic resection and anastomosis were performed, due to recurring partial intestinal obstruction. At a 6-month follow-up, the patient was asymptomatic.ConclusionInflammatory cap polyp is a benign entity, and it should be kept in mind as an important differential diagnosis of exophytic colonic mass with surface exudates.

Comparison of the efficacy of growth factor collagen and antibiotic collagen on colon anastomosis in experimental animals with peritonitis.

In spite of advances in surgical techniques, the significance of anastomosis leak continues in colorectal surgery. There is no ideal method in spite of all studies and technical advances in this field. Our aim ofthis study was to use fibroblast growth factor collagen (FGF-C) and antibiotic collagen (AB-C) to increase the rate of anastomosis healing in experimental animals withperitonitis. This animal experimental study received ethics committee approval. Theanimals were dividedinto three groupsof seven animalseach; the first group was control, the second group was the fibroblast growth factor collagen group, and the third group was the antibiotic collagen group. Under anesthesia, more than 50% of the colonic lumen was opened 4-5cm distal tothe ileocecal junction to create a defect. Twenty-four hours later, primary anastomosis was performed. The second group had the anastomosis line covered with a cover containing FGF-C. The third group had the anastomosis line covered by material containing AB-C. The experiment was concluded on the postoperative 7th day, and the anastomosis burst pressure, tissue hydroxyproline level, and histopathological assessment were performed. Though the burst pressure was higher in the experimental groups, it was not statistically significant. In the second and third groups, vascular proliferation and fibroblastic activity appeared to be better than in the control group. Hydroxyproline values were statistically significant in the experimental groups compared to the control group. FGF-C and AB-C may have potential utility in anastomosis healing, especially in those susceptible to infection due to anastomosis leak.

Does Platelet-Rich Plasma (PRP) Improve Colonic Anastomotic Healing in Rats Undergoing Cisplatin-Paclitaxel-Based HIPEC?

Hyperthermic intraperitoneal chemotherapy (HIPEC) causes delays in wound healing. Platelet-rich plasma (PRP) gel has been shown to be effective in facilitating wound healing. We examined the effect of PRP gel on the healing of colonic anastomosis in rats that received HIPEC. Twenty-four rats were subdivided into three groups. In group 1, the rats only underwent colonic anastomosis. In group 2, the rats underwent colonic anastomosis and cisplatin-paclitaxel-based HIPEC. In group 3, the rats underwent colonic anastomosis and cisplatin-paclitaxel-based HIPEC. Afterwards, PRP gel was administered to the colonic anastomosis region. The rats were sacrificed on the 7th postoperative day, the anastomotic bursting pressure (ABP) was recorded, and tissue samples were taken from the anastomotic line. Compared to that in group 2, ABP was higher in group 1 and group 3 (p= 0.002 and 0.048, respectively). Tissue hydroxyproline levels were higher in group 1 (p= 0.001) and group 3 (p = 0.043) than in group 2. Histopathological evaluation revealed a significant decrease in fibroblast activity in group 2 compared to that in group 1 (p= 0.006), with no significant difference between group 3 and group 1 (p= 0.585). Collagen accumulation was significantly lower in group 2 than in group 1 and group 3 (p= 0.001 and p= 0.019, respectively). PRP gel application may aid wound healing by increasing colon ABP, tissue fibroblast activity and collagen accumulation; therefore, its use may reduce the cytotoxic effects of HIPEC and facilitate the anastomotic wound healing process.

Improvement of colonic healing and surgical recovery with perioperative supplementation of inulin and galacto-oligosaccharides

Anastomotic leak (AL) is a major complication in colorectal surgery. Recent evidence suggests that the gut microbiota may affect healing and may cause or prevent AL. Butyrate is a beneficial short-chain fatty acid (SCFA) that is produced as a result of bacterial fermentation of dietary oligosaccharides and has been described as beneficial in the maintenance of colonic health. To assess the impact of oligosaccharides on colonic anastomotic healing in mice, we propose to modulate the microbiota with oligosaccharides to increase butyrate production via enhancement of butyrate-producing bacteria and, consequently, improve anastomotic healing in mice. Animal experiments were conducted in mice that were subjected to diets supplemented with inulin, galacto-oligosaccharides (GOS) or cellulose, as a control, for two weeks before undergoing a surgical colonic anastomosis. Macroscopic and histological assessment of the anastomosis was performed. Extent of epithelial proliferation was assessed by Ki-67 immunohistochemistry. Gelatin zymography was used to evaluate the extent of matrix metalloproteinase (MMP) hydrolytic activity. Inulin and GOS diets were associated with increased butyrate production and better anastomotic healing. Histological analysis revealed an enhanced mucosal continuity, and this was associated with an increased re-epithelialization of the wound as determined by increased epithelial proliferation. Collagen concentration in peri-anastomotic tissue was higher with inulin and GOS diets and MMP activity, a marker of collagen degradation, was lower with both oligosaccharides. Inulin and GOS diets were further associated with lower bacterial translocation. Dietary supplementation with inulin and GOS may improve anastomotic healing and reinforce the gut barrier in mice.

Human Oral Mucosal Stem Cells Reduce Anastomotic Leak in an Animal Model of Colonic Surgery

Background: Anastomotic leak is regarded as one of the most feared complications of bowel surgery; avoiding leaks is a major priority. Attempts to reduce or eliminate leaks have included alternate anastomotic techniques. Human oral mucosa stem cells (hOMSC) are self-renewing and expandable cells derived from buccal mucosa. Studies have shown that hOMSC can accelerate tissue regeneration and wound healing. The objective of this study was to evaluate whether hOMSC can decrease anastomotic leak rates in a murine model of colon surgery. Methods: Two experiments were performed. In the first study, mice underwent colonic anastomosis using five interrupted sutures. hOMSC (n = 7) or normal saline (NS; n = 17) was injected into the colon wall at the site of the anastomosis. To evaluate whether hOMSC can impact anastomotic healing, the model was stressed by repeating the first experiment, reducing the number of sutures used for the construction of the anastomosis from five to four. Either hOMSC (n = 8) or NS (n = 20) was injected at the anastomosis. All mice that survived were sacrificed on postoperative day 7. Anastomotic leak rate, mortality, daily weight, and daily wellness scores were compared. Results: In the five-suture anastomosis, there were no differences in anastomotic leak rate, mortality, or daily weight. Mice that received hOMSC had significantly higher wellness scores on postoperative day 2 (p < 0.05). In the four-suture anastomosis, there was a significant decrease in leak rate (70% [NS] vs. 25% [hOMSC], p = 0.029) and higher wellness scores in mice that received hOMSC (p < 0.05). Conclusion: Our study suggests that injecting hOMSC at the colonic anastomosis can potentially reduce anastomotic leak and improve postoperative wellness in a murine model of colon surgery.

Etiology and surgical management of pediatric acute colon perforation beyond the neonatal stage

PurposeAcute colon perforation is a pediatric surgical emergency. We aimed to analyze the different etiologies and clinical characteristics of acute non-traumatic colon perforation beyond the neonatal period and to identify surgical management and outcomes.MethodsThis retrospective study included 18 patients admitted with acute colon perforation and who received surgical treatment.ResultsAge of patients ranged between 1 month and 15 years. Five patients swallowed foreign objects (two swallowed magnets), two had colon perforation secondary to a malignant tumor (both colorectal adenocarcinoma) and two were iatrogenic (one prior colonoscopy, one air enema for intussusception). There was one perforation due to chemotherapy and Amyand’s hernia respectively. The remaining seven patients had unknown etiologies; five of them were diagnosed with colitis. Fifteen (83.3 %) patients underwent open laparotomy, among which four attempted laparoscopy first. Three (16.7 %) patients underwent laparoscopic surgery. Fourteen (77.8 %) patients received simple suture repairs and four (22.2 %) received colonic resections and anastomosis. Four (22.2 %) patients received a protective diverting colostomy and three (16.7 %) received an ileostomy.ConclusionsThere is a wide range of etiology besides necrotizing enterocolitis and trauma, but a significant portion of children present with unknown etiology. Type of surgery elected should be dependent on the patient’s etiology, disease severity and experience of surgeons.

Effect of Dual Mesh Wrap on The Stability of Colonic Anastomosis

Effect of Dual Mesh Wrap on The Stability of Colonic Anastomosis

Research progress of different bowel reconstructions for postoperative functional protection during low anterior resections of rectal cancer

Straight coloanal anastomosis (SCA), colonic J-pouch anastomosis (CJP), transverse coloplasty pouch anastomosis (TCP), and side-to-end anastomosis (SEA) are the most commonly used procedures of bowel reconstructions in the low anterior resections (LAR) of rectal cancer. Different bowel reconstruction procedures greatly affect postoperative bowel function, urinary function and sexual function. SCA is the most traditional procedure. CJP has been studied extensively and well-developed reconstruction method; however, recent studies have shown that CJP has the highest morbidity of complications, so the clinical application of CJP is limited. SEA is not inferior to CJP and SCA in the short-term and long-term defecation function, urination function, and sexual function, with reliable operational safety, so it is expected to become an alternative to SCA and CJP. The research on TCP is lacking, but there are some related clinical trials currently underway, and the results are worth expecting. The improvement and innovation of bowel reconstructions provide a bright prospect for better functional prognosis in patients with rectal cancer.

Incarcerated Amyand hernia with necrosis of the appendix and cecum

Abstract Introduction Presence of vermiform appendix (inflamed or not) within a hernia sac is called Amyand hernia. It is a rare disease, occurring about 1% of inguinal hernia patients. Commonly the diagnosis occurs intraoperatively. Case report A 7-month-old boy was admitted with abdominal distension, vomiting and non-stooling for the past 3 days. Examination revealed a painful abdomen on palpation, scrotal erythema and irreducible mass on right inguinoscrotal region. A plain abdominal X-ray showed dilated colon and small bowel loops. At surgery, we performed laparotomy and was founded cecum and appendix inside the hernia sac, with signs of necrosis. Due to extension of ischemia, the cecal appendix, cecum, and terminal ileum were resected, and an end-to-end ileo ascending colon anastomosis was performed. The hernia sac was closed with a right inguinotomy. Discussion Amyand hernia is a rare disease, occurring in about 1% of adult herniotomies. In children is much less uncommon, estimated in 0,07–0,28%, and the presence of an inflamed vermiform appendix is related as 0,08%. There are several clinical manifestations of Amyand hernia: reducible or incarcerated hernia within non-inflamed appendix or inflamed appendix to systemic signs of sepsis. Pre-operative imaging studies (such as ultrasonography or computed tomography) can be useful. The diagnosis generally occurs intraoperatively. Appendectomy in Amyand hernia remains controversial. Conclusion AH is usually diagnosed as an incarcerated/strangulated right inguinal hernia and should be considered in the differential diagnosis of incarcerated/strangulated in neonates and infants. Adequate treatment is an urgent surgical exploration of the inguinal region and laparotomy, if necessary. The surgical approach in the presence of suspected ischemia, necrosis, or perforation of the structures placed inside the hernia sac may prevent the need for intestinal resection.