Interintestinal Anastomoses Research Articles

Undifferentiated dysplasia of connective tissue in patients with insufficiency of anastomotic sutures of the gut hollow organs

Objective. Improvement of results of treatment in patients, suffering insufficiency of anastomotic sutures in the gut hollow organs, using determination of role for the connective tissue undifferentiated dysplasia (CTUD) in development of this complication, estimation of the phenomena spreading and elaboration of informative criteria for the CTUD diagnosis.
 Маterials and methods. Retro- and prospective trial was based on data about 42 patients, suffering insufficiency of anastomotic sutures, who were treated in the National Institute of Surgery and Transplantology named after О. О. Shalimov of NAMS of Ukraine, and 20 practically healthy persons (the comparison group), comparable for age and gender with the investigated patients. The procalcitonin of the blood serum and C-reactive protein analysis were used for special laboratory investigation. The status of the connective tissue metabolism was estimated in accordance to content of free oxyprolene in the blood serum and the level of glycosaminoglycans in urine.
 Results. There was revealed, that the most informative phenotypical markers of CTUD in patients, suffering insufficiency of anastomotic sutures of the gut hollow organs, are visceral (78.6%), vascular (73.8%) and arythmical (54.7%) syndromes. There was established, that direct correlation between the level of biochemical markers of the collagen biodegradation and the CTUD degree may be applied for prognostication of development and course of complications in patients, suffering insufficiency of the anastomotic sutures of the gut hollow organs. Severe degree of CTUD in the patients, suffering insufficiency of interintestinal anastomoses, complicated by extended peritonitis, constitutes unfavorable prognostic sign and enhances the mortality by 87.5%.
 Conclusion. The presence of CTUD in the patients, suffering insufficiency of anastomotic sutures of the gut hollow organs constitutes the unfavorable factor of comorbidity, which must be taken into account, choosing the adequate surgical tactics and complex pathogenetically substantiated treatment.

HugeNon-Organ Retroperitoneal Tumor inCombination with aCystoma of Uterine Appendages

The article describes the experience of successful diagnostics and treatment of giant non-organ extraperitoneal tumor combined with a cystoma of uterine appendages.Patient P., 43 years old, was hospitalized in the oncology department, diagnosed with “Abdominal tumor, right ovary?” The state was satisfactory, after palpation of the abdomen, a lumpy formation of a densely elastic consistency, from the womb to the epigastric region, was found. An ultrasound revealed a homogeneous tumor formation 30×28 cm from the border of the uterus to the liver. When performing median laparotomy, a dumbbell-shaped tumor (36×26×20 cm) was found in the retroperitoneal space with involvement of the mesentery of the small intestine, lower horizontal portion of the duodenum, mesentery of the transverse colon, superior mesenteric vessels, aorta and jejunum. In the right appendages, a cystoma 12–15 cm in diameter was found, with inversion and necrosis. Adnexectomy was performed. An express lymph node biopsy revealed cells suspicious for malignancy. The tumor was mobilized and removed as a single unit with retroperitoneal tissue, lymph nodes in combination with resection of 70 cm of the jejunum and fenestrated resection of the duodenum. The resulting gut defect 9×7 cm was sutured with a precision single-row suture. Inter-intestinal anastomosis “endto-end” was formed. Nasointestinal intubation was performed. The abdominal cavity was sutured, and two tubular drainages were installed. The postoperative period was uneventful. The histological conclusion: fibrous histiocytoma of the mesentery of the intestine with malignancy in the center of the node, in the ovary – total hemorrhagic infiltration of all layers, edema. The tumor conference consultation was recommended. After 1.5 years, the patient was admitted with the same clinical picture. During laparotomy, a tumor recurrence was discovered, the nodes of which were located in the retroperitoneal space, in the abdominal cavity with invasion to organs and large vessels. The case was recognized as inoperable, the laparotomic wound was closed completely. Sixteen days after surgery the patient was discharged.

Failure of Colorectal Anastomosis: Risk Factors, Prevention, Diagnosis, Therapeutic Tactics

Aim. To analyse and generalize available literature data on the problem of colorectal anastomotic leakage after rectal resection. Key findings. Over the last decade, there has been an increasing trend towards sphincter-preserving operations in modern colorectal surgery. The widespread use of suturing devices of various diameters allows the formation of ultra-low anastomoses (at the level of the pelvic floor). One of the menacing complications after rectal resection is anastomotic leakage, which frequency can reach 21%. The mortality from anastomotic leakage can reach 40%. The analysed literature sources discuss a variety of risk factors, both preoperative and intraoperative, affecting the healing of the inter-intestinal anastomosis. In almost all studies, the height of the tumour and the anastomosis from the anus, preoperative radiotherapy and male sex are independent risk factors for the development of colorectal anastomotic leakage. Concerning other factors, there are conflicting opinions. The timely use of preventive measures and early diagnosis of colorectal anastomotic leakage can reduce the number and severity of postoperative complications.Conclusion. Individual consideration of risk factors and their adequate assessment in terms of possible complications are decisive in the choice of the extent of surgical intervention, which will undoubtedly improve the immediate and long-term results of the surgical treatment of colorectal cancer.

A Device for Studying Hemocirculation in Suture Bands in Interintestinal Anastomoses

A device for investigating blood pressure in the intramural vessels of hollow organs and determining arterial blood hemoglobin oxygen saturation was developed; the device consists of two chambers, one containing LED lamps and the second, an emitter for determining blood oxygen saturation.

Formation and evaluation of bilio-digestive and interintestinal anastomoses by the method of high-frequency electric welding of tissues in experiment

Objective. To develop a new method of the anastomoses formation, that would allow to form bilio-digestive and entero-entero anastomoses both on unchanged and inflamed tissues.
 Маterials and methods. In experimental on 50 laboratory rabbits the single-layer everting cholecysto-entero and entero-entero anastomoses on the Roux-defunctionalized loop of small intestine was created by the method of a high-frequency electric welding. The welding anastomoses were formed both on non-inflamed tissues and in the setting of biliary peritonitis. Patency, hermeticity, strength, macroscopic and microscopic pictures of the obtained joints were evaluated at different postoperative periods.
 Results. All anastomoses, formed by the method of a high-frequency electric welding, were not only patent and hermetic, but also sufficiently strong (40 – 100 mm Hg). The tissues were joined using thermo-adhesion; a coagulation scar was rather narrow, its complete epithelization was accomplished in 3 mo, and a scar maturation completed – in 6 mo.
 Conclusion. The method of a high-frequency electric welding permits to form both, bilio-digestive and inter-intestinal, anastomoses of equal reliability in the settings of non-inflamed and inflamed tissues.

Physico-mechanical features of barrier bicomponent membranes in abdominal surgery.

Revelance. Adhesive disease is one of the terrible complications with a pronounced symptom complex of the dysfunctions of the organs of the gastrointestinal tract. The frequency of this pathology in the early postoperative period with operations on the abdominal organs reaches 11% among 19-25% of all complications. Until now, it remains relevant to search for and develop methods and tools of strengthening the seam line and improve the tightness of interintestinal anastomoses. Therefore, the prospects of using the polymers and the development of such a scientific direction as implantology in medical practice are unlimited.
 Purpose. Studying the physico-mechanical features of polymer samples under the experimental conditions in vitro, in a comparative aspect.
 The materials. Bicomponent resorbable film implants based on cellulose polymers.
 The methods. Microphotography of polymeric film implants was taken with a laboratory microscope Levenhuk D320L with an increase of × 80. The thickness of the experimental samples was measured with the electronic micrometer iGaging 0-1 "/0.00005,. Membranes 10 × 10 mm were weighed with the laboratory scales. The volume and density of samples 10 × 10 mm were calculated. Determination of elasticity was carried out by fixing the angle at the moment of the integrity of the sample of the polymeric film implant in the native state.
 The results. It was revealed that an important feature of these implants is their bilateral structure, which ensures its more tight fixation to the damaged area and at the same time sufficient separation with the surrounding tissue. Thus, we selected samples No. 6, No. 1, which can be used for further in vivo studies.
 The conclusion. The use of polymeric implants is possible due to the variety of membranes in their properties and functions, which will affect the necessity and significance of the application of selected samples in experimental and clinical implantology.

Problems of diagnostics and treatment of gastrointestinal perforations in patients with acute intestinal infections

The results of treatment of 97 patients with perforations of the hollow organs of the gastrointestinal tract were analyzed, 31 acute intestinal infections of which were verified. Clinical features of perforation of hollow organs on the background of acute intestinal infection have been revealed. A comparative analysis of clinical and instrumental methods for diagnosing perforations in patients with intestinal infections and without them was carried out. The most sensitive in identifying perforations of hollow organs in patients with acute intestinal infections instrumental methods of investigation were diagnostic laparoscopy (100%) and radiography of abdominal organs (80%). It was established that the combination of the two diseases contributes to the growth of diagnostic errors, increase in the number of common forms of peritonitis and development of the syndrome of mutual aggravation. Analysis of surgical interventions showed that in patients with confirmed diagnosis of acute intestinal infection the primary surgical interventions in most patients resulted in the formation of laparostoma with programmed relaparotomy, in connection with the presence of contraindications for the formation of a primary interintestinal anastomosis. Postoperative complications in the study groups developed in 61,3; 41.7 and 23,8% of cases, respectively. In patients with confirmed diagnosis of acute intestinal infection, lethality was 32,3%, in patients with atypical flow of perforations of hollow organs, simulating the symptoms of acute intestinal infection - 16,7 and 14,3% - in patients with perforations of hollow organs without concomitant acute intestinal infection. The results of the research testify to the relevance of the problem under study and the need to optimize therapeutic-diagnostic algorithm for this category of patients.

Compression anastomoses with nikelid-titanium rings in peritonitis

To introduce into clinical practice compression anastomosis with nikelid-titanium rings (NTR) with shape memory in advanced peritonitis patients who need for intestinal resections. Seventy-six procedures of interintestinal anastomoses with NTR (Günter-Ziganshin implant) have been analyzed for the period 2011-2017. Interventions were carried out for widespread peritonitis. In all cases a unified technique of anastomosis was used by applying an implant in the form of a 'clerical clip'. There were following procedures: gastroenterostomy resection for its failure - 5; small intestine resection followed by interntestinal anastomosis - 36; ileotransverso- or colocolostomy - 35. Mean time of enteroenterostomy was 2.6±0.98 min. If elective re-laparomy was supposed, laparostomy was formed followed by sanation within 48 hours. In 55% of patients 3-5-fold elective sanations were performed. Adequacy of compression anastomoses was assessed clinically according to the nature of drainage output and visually during redo surgery. There were 11 (14.5%) deaths: 9 (12%) patients had APACHE-II score over 20. Macro- and microscopic analysis of intestinal specimens and interintestinal anastomoses with nikelid-titanium rings showed complete impermeability and no visual defects. Microscopically neutrophilic leukocyte infiltration and increased number of fibroblasts were observed as the evidence of regenerative processes activation. Implant rejection time was 7.8±1.4 days. The use of compression anastomoses in case of advanced peritonitis reduces the risk of anastomosis failure to 3% and decreases time of surgery that reduces intraoperative aggression and improves outcomes in patients with prognostically unfavorable outcomes.

АНТИБАКТЕРІЙНА СТІЙКІСТЬ ЕЛЕКТРОЗВАРНОГО З’ЄДНАННЯ ЖИВИХ ТКАНИН

Матеріали і методи. Антибактерійна стійкість електрозварного з’єднання (ЕЗ) досліджена в умовах гнійно–некротичного ураження, бактеріального забруднення, параканкрозного запалення або наявності калу у міжкишковому анастомозі (МКА), в судинах діаметром до 10 мм, міхуровій протоці діаметром до 12 мм, анальній нориці діаметром до 5 мм. В експерименті на 17 свинях, маса тіла 45 – 75 кг, та в клініці у 74 хворих віком від 24 до 72 років використовували апарати ЕК–300М1 і ЕКВЗ–300 ПатонмедТМ.
 Результати. У строки спостереження до 30 діб неспроможність ЕЗ у відкритій рані, черевній порожнині, відхіднику не спостерігали. Виявлені E. coli (3 штами), E. faecalis, E. cloacae, C. hofmanii, S. aureus в концентрації до 108, патогенні штами Clostridium у 3 хворих. Відзначене утворення цілісної структури біологічної тканини по всій лінії створення ЕЗ. Вже на 4–ту добу в МКА виявляли новоутворену грануляційну тканину з судинами, продуктивне запалення.
 Висновки. ЕЗ є суцільним, зберігає просторову структуру залучених волокон, не містить вільних клітинних фрагментів, що є тригерами запалення та поживними речовинами, забезпечує первинне загоєння у присутності мікроорганізмів з лізуючими властивостями.

Sutureless Compression Anastomoses Formation with Use of TiNi Device on the Small Gut

A new device made of nickelid titanium and a way of formation of a sutureless compression anastomosis on the small bowel were developed with the purpose of creating a compression interintestinal anastomosis on the small bowel without the manual portion of seams. 28 sutureless compression anastomosis on the small bowel are created during the experiment. They include 10 «side-to–side» anastomoses, 10 «end-to-end»anastomoses and 8 «end-to-side» anastomoses. Mechanical and biological durability of anastomoses, terms of compression devices failure, primary permeability of anastomoses, morphogenesis of a compression seam are studied. No complications connected with the use of the compression device were noted. During the experiment it is proved that all sutureless compression anastomoses created by means of the nickelid titanium device are mechanically and is biologically tight. By the ninth day all the dogs had no compression devices in their abdominal cavities. The histological researches show that the process of neogenesis goes with the minimal symptoms of sclerosis and leads to the full adaptation of all small bowel layers. The new way of the formation of a sutureless compression anastomosis on the small bowel allowed to create a stronger and more reliable anastomosis and thereby to prevent the development of typical complications and to receive more favorable remote results.

PREDICTION OF COLORECTAL ANASTOMOSIS FAILURE

Aim. To study the possibilities of using chemiluminescent blood analysis and determining blood plasma lactate content for prediction of colorectal anastomosis failure. Materials and methods. Chemoluminescent blood analysis was carried out and blood plasma lactate content was determined within the days 1, 4 and 8 after the surgery in 78 patients with colorectal cancer, who had undergone the radical surgical intervention. Blood of 10 donors was used as a control. All patients were divided into 2 groups. Group I included 5 patients with interintestinal anastomosis failure developed, group II included the rest 73 persons. Results. Before the treatment started, a reliable elevation of chemiluminescence intensity was revealed in patients with colorectal cancer. Within the days 1 and 4 after the surgery, chemiluminescence indices were significantly higher in the group of patients with anastomosis failure than in patients of the second group. By the postoperative day 8, patients of group II experienced normalization of chemiluminescence indices, whereas in patients with anastomosis failure these indices remained reliably increased. Within the postoperative days 1 and 4, blood plasma lactate content significantly raised in patients of group I. No changes in lactate level among patients with uncomplicated postoperative course were noted. Conclusions. Chemiluminescent erythrocyte analysis and determination of blood plasma lactate content within the postoperative day 1 can be used to predict colorectal anastomosis failure in patients with malignant neoplasms of the colon.

Эффективность комбинированного лечения колоректального рака у пациентов старческого возраста

Aim of investigation.To estimate efficacy of combined treatment of colorectal cancer (CRC) in senile patients, to determine risk factors for postsurgical complications and evaluate postoperative mortality. Material and methods. The retrospective and prospective analysis of primary CRC patients, who were operated in The First Sechenov Moscow State Medical University and Petrovsky National Research Center of Surgery in April, 2006 to May, 2014 was carried out. Overall 122 patients with CRC of the II-IV stage of senile age were selected, whose mean age was 79 (75-95) years. Preoperative comorbidity assessment and perioperative complications risk were assessed by Charlson comorbidity index and ASA physical status classification system. Cr-POSSUM scoring system was applied to predict postoperative (30-day) mortality. Overall and cancer-specific survival rate were assessed taking into account comorbidity of patients and prescribed adjuvant therapy. Results. The average Charlson score taking into account age of the patient was 7.6±2.4. Forty seven patients (39%) were classified as ASA≥3. The predicted postoperative motility (Cr-POSSUM) was 13.2%. In 106 (87%) patients colon or rectum resection with formation of primary interintestinal anastomosis and D3 lymph node dissection, at 11 (9%) - abdominal and perineal rectum extirpation is executed, 5 patients had obstructive Hartmann operation. Patients with the IV stage of CRC underwent standard volume surgery with high-grade lymph node dissection due to the high risk of obstruction or tumor bleeding. Achieved 30-day postoperative mortality was 4.9%, overall 5-year survival rate - 67.3±5.6%, cancer-specific survival - 70.1±4.4%. In group of patients with III and IV stages of CRC who received postoperative adjuvant therapy, the tendency to higher total survival was noted, however only cancer-specific survival scores had statistically significant differences in this subgroup. Conclusions. Multidisciplinary approach to CRC treatment provides achievement of satisfactory postoperative mortality in senile patients (4.9% versus predicted 13.2%) along with satisfactory total and cancer-specific 5-year survival rate. Postoperative adjuvant therapy significantly improves treatment results for third stage CRC, however the objective indications for adjuvant therapy are yet to be established. Due to complex drugto-drug interactions specificity of metabolism and biological tumor properties, cross-reactions of concomitant diseases in senile patients each step of combined treatment should be discussed at multidisciplinary consultation.

Predictors for morbidity of radical cystectomy and different types of urine derivation: 20-year experience of a surgery center

Background. Most of serious complications of radical cystectomy (RCE) should be associated with the comorbidity of patients and the interintestinal anastomoses designed with urinary reservoirs rather than with RCE. It is relevant to identify and assess the role of predictors for morbidity of RCE and urine derivation. Objective: to search for risk factors for complications after RCE with different types of urine derivation. Subjects and methods. The immediate and late results of RCE and urine derivation were studied in 350 patients with bladder cancer. Sequential postoperative complications were additionally analyzed in chronological order in all the patients, including non-cancer ones (n = 43). Results. 43.9% of the patients had postoperative complications, if a surgeon had sufficient surgical experience; there was a preponderance of patients with mild-to-moderate complications (Clavien-Dindo grade I-II, 37.8%) unassociated with urine derivation. The patients with severe postoperative complications were 16.3%; mortality was 3.1%, which significantly correlated with surgical experience. Late (3-18 month) postoperative complications were detected in 21.4% of the patients with a preponderance of those with urine derivation-related complications (19.4). The frequency of complications due to extraintestinal versus intestinal urine derivations was significantly higher (68.1 and 49.8% (p < 0.05). During two-step surgical treatment, the patients demonstrated higher morbidity and worse survival. Extraintestinal urine derivations, continuous urinary intestinal diversion determine a less favorable prognosis compared with one-stage ortho- and heterotopic procedures. The type of urine derivation and the experience of a surgeon performing RCE are valid predictors for postoperative morbidity and independent prognostic factors of overall and cancer-specific survival, respectively. 150 operations are needed for achieving optimal surgical experience. Discussion. It is appropriate to increase the time of research reports on the results of urine derivation up to 12-18 months of a postoperative follow-up. In practice, the routine use of two-step RCE and final urine derivation and internal and/or external urine ones should be abandoned; preference should be, when possible, given to single-stage ortho- and/or heterotopic urine derivations rather than to the former. Conclusion. Extraintestinal (percutaneous puncture nephrostomy, ureterocutaneostomy), and internal (ureterosigmoanastomosis, ureterosigmorectoanastomosis, Mainz pouch II) urine derivations, two-step surgical treatment, and a surgeon’s insufficient experience are predictors for high morbidity and poor prognostic factors for survival after RCE and urine derivation.

PREVENTIVE COLOSTOMY IN PLANNED TREATMENT OF PATIENTS WITH RECTAL CANCER

The article described an original method of forming preventive colostomy, which reduced the rate of incompetence of interintestinal anastomosis in sphinctersaving resection concerning rectal cancer. This also facilitated patient's rehabilitation in early postoperative period.

Interintestinal anastomoses formation using permanent magnet in surgical treatment of children with intestinal stomas

It was analyzed the results of treatment of 48 children aged from 1 month to 14 years. In these observations by the 6th - 7th days after doubleintestinalstoma formation magnetic dies with inductance from 300 to 360 mTl and energy force at least 255 kJ/m3 were introduced into lumen of afferent and efferent intestinal loops. Attractive or compression force between dies was 600 g, i.e. force per 1 cm2 was 200 g according to dies' surface 1.12.83.0 cm. Magnets are not only surgical instruments but also physiotherapeutic devices improving microcirculation and stimulating regeneration in the area of anastomosis. Interintestinal anastomosis has been completely formed for 5-7 days. Thereafter magnetic dies have been removed. Stool was normalized in 45 of 48 observations after surgery (1-3 times daily). Intestinal discharge from ileostomy reduced to minimal amount. In 2 patients irregular bowel movements was observed due to adhesive stenosis of interintestinal anastomosis. Magnetic dies can't be established in 1 case due to adhesive process. Hospital stay was from 10 to 25 days in 41 children. 7 patients were discharged for outpatient treatment later. All children were under observation for the period 2-4 months after discharge. Signs of hypotrophy including body weight deficit within 10% of age norm were diagnosed only in 3 children with prematurity degree I-II. Hereafter children were repeatedly hospitalized; intestinal stomas were surgically removed using conventional technique. Thus complete convalescence was obtained.

MODERN ASPECTS FOR ASSESSING DISTAL STUMP IN PLASTIC COLON SURGERIES

Aim. To improve the results of plastic surgical treatment of stomed patients after obstructive resection of the distal parts of the colon. Results. The results of surgical treatment of 20 patients who underwent operations for restoration of colon continuity after obstructive resections of the distal parts of the colon (Hartman type surgery) were analyzed. The postoperative examination of colonic stump including polyfocal biopsy of mucosa indicated that in 29 cases there were detected the confirmed morphological signs of diverse colitis. Techniques of transanal anastomosis decompression and intraluminal sanation of the zone of interintestinal anastomosis were used for treatment of all patients with moderate and marked endoscopic and morphological symptoms of diverse colitis. Conclusion. Thus, assessment of the distal part of the colon after obstructive resections permits to plan restoration of intestinal canal at early stages and to improve significantly surgical results. Application of the techniques of transcanal decompression and intraluminal sanation of the zone of anastomosis is an effective method for prevention of their failure.

Clinical Experience of Frame Ring Utilization in Applying Interintestinal Anastomoses in Urgent Surgery

The problem of restoration of intestinal integrity preserves its importance as the intestinal suture is a basis for digestive tract surgery. Tightness failure in the intestinal suture during gastrointestinal surgery is a threatening and, unfortunately, frequent complication, and it gets especial importance in emergency patients and those with severe concomitant pathologies. The research is carried out on utilization of a metal frame ring in applying interintestinal anastomoses. Clinical utilization of the method developed was preceded with a series of experiments on animals with morphological researches with the use of the device. Seventy operations were performed with utilization of a frame metal ring during application of interintestinal anastomoses. After performing an operation, intestinal peristalsis restored faster. In the postoperative period, all patients undertook study of abdominal exudates to determine for early diagnostics of development of intestinal suture failure. In clinical practice, utilization of a frame ring is indicated in applying primary interintestinal anastomoses in adverse conditions, namely, peritonitis and intestinal obstruction.

Angiological analysis of interintestinal anastomoses

One of the frequent and usually fatal complications of intestinal resection is suture inconsistency, which is observed with varying frequency in different techniques of interintestinal anastomoses formation. Although there have been speculations about the role of circulatory disorders in the origin of suture inconsistency, we have not found any evidence in the literature.