Primary Anastomosis Group Research Articles

Temporary rapid bowel ligation as a damage control adjunct improves survival in a hypothermic traumatic shock swine model with multiple bowel perforations

BackgroundPrimary intestinal anastomosis is not the right choice for multiple bowel perforations under hemodynamically stable conditions. Our group has employed temporary rapid bowel ligation as a damage control procedure in a hypothermic traumatic shock swine model with multiple bowel perforations and hypothesized that damage control treatment would improve survival in the setting of a damage control surgery. Materials and methodsThe abdomen was shot one time with an experimental modified gun while pigs were hemorrhaged to a mean arterial pressure of 40 mm Hg and maintained in shock for 40 min. Cold lactated Ringer solution was gradually infused to induce hypothermia. Animals were randomized to control (no resuscitation), primary anastomosis (PA), or temporary rapid bowel ligation (damage control group, DC). Animals were resuscitated for 12 h with the shed blood and lactated Ringer solution. Delayed anastomosis was performed in DC animals after resuscitation. Surviving animals were humanely killed 24 h after operation. Systemic hemodynamic parameters were recorded and blood samples were obtained for biochemical assays. The lung and ileum was harvested at the end of the experiment for pathologic evaluation and test of wet/dry weight ratio, TNF-α level, and nuclear factor-κB activations. ResultsAll animals suffered extreme physiologic conditions: hypothermia, severe acidosis, hypotension, and depressed cardiac output. Control animals suffered 100% mortality. Compared with the PA group, DC animals required less resuscitation fluid, normalized lactate levels faster, had lower serum creatine kinase, aspartate amino transferase levels and tissue TNF-α level and nuclear factor-κB activations, suffered less severe histopathology, had greater early survival. ConclusionsMultiple bowel perforations under hemodynamically stable conditions seem better managed with DC than with PA. Temporary rapid bowel ligation as a damage control adjunct is important to rapid control of multiple bowel perforations instead of a prolonged operative time.

Long-term Neurodevelopmental Impairment in Neonates Surgically Treated for Necrotizing Enterocolitis: Enterostomy Associated with a Worse Outcome

Necrotizing enterocolitis (NEC) patients often have neurodevelopmental impairment, but the long-term follow-up data is limited. We determined whether surgical factors were of prognostic value for long-term neurodevelopment in children surviving surgery for NEC (SNEC). SNEC patients born between 1996 and 2002 were tested for verbal (VIQ), performance (PIQ) and total (TIQ) intelligence using Wechsler's Intelligence Scale for Children, Third Edition, Dutch Version, and motor skills using the Movement Assessment Battery for Children (M-ABC). Neonatal and surgical data were obtained retrospectively to assess prognostic factors. 19 patients (12 boys), median age 9.9 years (range 6.2-13.1), gestational age 31.0 weeks (range 25.2-40), birth weight 1 250 g (range 780-3 175) were evaluated. Infants with an enterostomy (n=14) scored lower on intelligence than children with a primary anastomosis (n=5): VIQ 85 ± 12 vs. 101 ± 15, p=0.04; PIQ 79 ± 13 vs. 92 ± 11, p=0.06; TIQ 82 ± 11 vs. 97 ± 13, p=0.04. Motor skills were either suspect or clinically impaired in 74%. Clinical classification of results suggest more children in the enterostomy group had a performance rated as clinically impaired compared to the primary anastomosis group, although no statistical difference in M-ABC score was found. There were no differences between primary anastomosis and enterostomy patients with regard to gestational age, birth weight, comorbidities, preoperative Bell stage, residual small and large bowel lengths, inotropic medication, duration of ventilatory support, NICU and hospital stay, and physical exam data on follow-up. However, a selection bias could not be ruled out. The results suggest that an enterostomy in SNEC patients could be associated with worse neurodevelopmental outcomes by the age of 6-13 years compared to a primary anastomosis, although the severity of illness was comparable between both groups. Further studies are needed to prevent selection bias and to elucidate the impact of abdominal surgical factors on neurodevelopmental outcome and the underlying pathophysiology.

Co-morbidity and postsurgical outcome in patients with perforated sigmoid diverticulitis

It was previously reported that in patients with acute perforated diverticulitis with Hinchey categories I to III sigmoidectomy with primary anastomosis (PA) is superior to Hartmann's procedure (HP) as later closure of colostomy involves substantial morbidity. We evaluated our experience with PA for patients with perforated diverticulitis over a 10-year period and aimed to investigate whether Hinchey category or co-morbidity are more relevant for postoperative outcome. Records of all patients treated at our institution for sigmoid diverticulitis between 1996 and 2006 were retrieved from an in-hospital database (N = 787, median age 66 years, range 30 to 94, female:male ratio 1.3:1); 73 patients who underwent immediate emergency surgery for perforated diverticulitis were included in this study. American Society of Anesthesiology (ASA) classification to gauge co-morbidity and Hinchey category for intraoperative extent of inflammation were evaluated as regards their relevance for postoperative mortality and major complications. 47 patients (64%) underwent sigmoid colectomy and PA, which was combined with loop ileostomy in 11 patients (15%). Sigmoid colectomy and HP was performed in 26 patients (36%). Major postoperative complications occurred in 26 patients (36%). In the PA group, 10 of 47 patients (21%) had anastomotic leakage. Three leakages occurred despite a loop ileostomy. Anastomotic leakage was independent of Hinchey category (Hinchey I: three patients, Hinchey II: four patients, Hinchey III: three patients, n.s.), but associated with co-morbidity (one patient ASA II, six patients ASA III, three patients ASA IV, P < 0.05). Total mortality was 12%. Seven patients died after HP and two patients after PA. No mortality was observed in PA patients with loop ileostomy. Emergency surgery for perforated sigmoid diverticulitis is associated with high morbidity and mortality rates. Anastomotic leakage was associated with patient co-morbidity rather than with intraoperative Hinchey category, suggesting that the decision to perform PA should better be based on patient's general condition rather than on intraoperative extent of inflammation.

Use of severity classification systems in the surgical decision-making process in emergency laparotomy for perforated diverticulitis

Hartman's procedure (HP) or primary anastomosis (PA) are the two surgical techniques used in patients undergoing emergency colectomy for perforated diverticulitis. There are no objective criteria to guide the surgeon's choice of procedure. This study assesses whether classification and scoring systems can be used in the decision-making process. One hundred eleven patients undergoing emergency laparotomy for perforated diverticulitis were analyzed. Logistic regression and interaction models were used to determine the predictive value in the two settings. Sixty five patients underwent HP and 46 patients underwent PA. Patients with HP had significantly higher scores, median age, and were more often on immunosuppressive medication. Mortality and surgical morbidity did not differ between the groups. The clinical anastomotic leak rate was 28.3% in the PA group. In the univariate logistic regression for in-hospital death, all scores showed a significant influence. The multivariate logistic regression analysis showed that only Charlson comorbidity index (CCI) and American Society of Anesthesiologists score had a significant influence on mortality. Each score was analyzed for its predictive value regarding mortality and morbidity with respect to type of operative procedure. Only CCI revealed a trend towards statistical significance. The risk of death increases with increasing CCI when PA is performed compared to HP. None of the tested scores can be used to help the surgeon decide whether a PA or HP is appropriate in a specific patient. Comorbidity, represented as CCI in this study, might be more important than the locoregional situation.

The healing effects of tissue glues and healing agent locally applied on esophageal anastomoses

Objective This study aimed to investigate the effects of cyanoacrylate (C), fibrin glue (FG), and natrium hyaluronate (NH) on the healing of esophageal anastomosis (EA). Methods Twenty-four rabbits were divided equally into 4 groups: primary anastomosis (PA), C, FG, and NH. A 1-cm-length of the cervical esophagus was resected through a cervical incision and then anastomosis was performed. C, FG, and NH were instilled into anastomosis lines in the respective groups. The animals were fed orally on postoperative day 7 on the condition that there was no esophageal leakage. The rabbits were sacrificed 8 weeks later to evaluate bursting pressure (BP), tissue hydroxyproline (HP) levels and wound healing scores (WHSs) in the anastomosis lines. Results BP was significantly higher in the C group than in the PA, FG, and NH groups, and HP was significantly lower than in the other groups. WHSs in the PA and NH groups were lower than in the C and FG groups. Conclusions C and NH appear to be beneficial in EA healing with respect to increased BP and decreased HP when they are used simultaneously with PA prophylactically to prevent esophageal leakages and stricture.

Comparisons of Three Surgical Procedures on Intestine Ischemia Reperfusion Injury in a Superior Mesenteric Artery Injury Model

Temporary ligation, primary anastomosis, and temporary shunt have been reported to deal with superior mesenteric artery (SMA) injuries. We aimed to investigate which brought minimal ischemia reperfusion injury in a hypothermic traumatic shock swine model. SMA was completely clamped while pigs were hemorrhaged to a mean arterial pressure (MAP) of 40 mm Hg. Animals were then randomized into temporary ligation (A, n=8), primary anastomosis (B, n=8), temporary shunt (C, n=8), and control groups (n=4). Animals in group A remained SMA interrupted for additional 1h while the other groups underwent the corresponding procedures immediately. Intestine injury was assessed by histologic examination and measurement of lipid peroxidations at the end of ischemia and experiment. Overall mortality rate was 50%, 25%, and 0% in groups A, B, and C, respectively (P<0.05). The total intestine ischemia time was predominantly shorter in group C in the other groups. Remarkable elevations of malonaldehyde (MDA) in small intestine were noted after reperfusion in group A. Animals in other groups, however, did not exacerbate during the 6-h reperfusion (resuscitation period). Group C showed the lowest MDA level at the end of experiment. Myeloperoxidase (MPO) levels showed no significant elevations during the ischemia or early reperfusion period; nevertheless, it reached approximately 3- to 6-fold in groups A and B (compared with baseline, P<0.01), and remained unchanged in group C at the end of experiment. Our study suggests that temporary shunt insertion might be preferred as it shortens ischemia time, alleviates intestinal ischemia/reperfusion injury, and thus decreases early mortality in this animal model.

Temporary intravascular shunting improves survival in a hypothermic traumatic shock swine model with superior mesenteric artery injuries

Repairs of superior mesenteric artery (SMA) injuries are difficult and often result in high mortality. Our group has employed temporary intravascular shunts (TIVS) as a damage control procedure in a SMA transection model and hypothesized that TIVS would improve survival when compared with primary vascular anastomosis in the setting of a damage control surgery. The SMA was clamped and completely transected while pigs were hemorrhaged to a mean arterial pressure of 40 mmHg and maintained in shock for 30 minutes. Cold lactated Ringer's solution was gradually infused while the abdomen was open to induce hypothermia. Animals were randomized to control (no resuscitation), primary anastomosis (PA), or temporary shunting (TS) of the SMA. Animals were resuscitated for 6 hours with the shed blood and lactated Ringer's solution. Delayed anastomosis was performed in TS animals after resuscitation. Surviving animals were humanely killed 2 days after operation. Systemic hemodynamic parameters were recorded hourly. The ileum was harvested at the end of resuscitation and experiment for pathologic evaluation. All animals suffered extreme physiologic conditions: hypothermia, severe acidosis, hypotension, and depressed cardiac output and oxygen delivery. Control animals suffered 100% mortality. Compared with the PA group, TS animals required less resuscitation fluid, retained higher SMA flow rates, normalized lactate levels faster, suffered less severe intestine histopathology, and had greater early survival. Damage control surgery in the setting of SMA transection seems better managed with TS than with PA. Further validation of this model is required before generalization to human applications.

Primary resection and anastomosis without intraoperative colonic irrigation in left colonic cancer with complete obstruction

Objective To assess the value of primary resection and anastomosis without intraoperative irrigation in the patients with obstructive left colonic cancer. Method Between January 2000 and January 2008, 93patients underwent primary resection and anastomosis for colonic cancers were analyzed retrospectively. Primary resection and anastomosis without intraoperative colonic irrigation (decompression by manual defecation) was performed in 43 patients with obstructive left colonic caner and traditional left-sided colectomy in 50 cases without obstruction. Both groups of patients were comparable in terms of gender, nutritional status, underlaying disease, tumor location and stage, etc ( P = 0.83,0.13,0.29,0.51,0.38). The average age of the patients with colonic obstruction was significant older than that of the cases without obstruction (61.2 ± 8.6 vs. 58.1 ±7.8, P =0.010).The operative results were compared between patients with obstructive colonic cancer and cases without obstruction.Results The mean hospital stay of the primary anastomosis group and traditional left-sided colectomy group were (16.6±7.8) d and (12.4±5.4) d respectively, and the former was significant longer than the latter (P =0.002). The costs of hospitalization in the two groups were (50192.8 ± 39727.4) RMB and (46489.3 ±29543.1)RMB respectively (P = 0.04) . The morbidity and mortality in the two groups were 25.6% (11/43) vs. 18%(9/50) (P =0.375) and 2.3% (1/43) vs. 2.0% (1/50) (P =0.714) respectively, and there were no significant difference between the two groups. Conclusions Primary resection and anastomosis without intraoperative colonic irrigation (decompression by manual defecation) compares favorably with traditional left-sided colectomy in safety and efficiency for left colonic cancer with obstruction. Key words: Colonic carcinoma; Intestinal obstruction; Treatment

Evaluation of the Risk of a Nonrestorative Resection for the Treatment of Diverticular Disease: The Cleveland Clinic Diverticular Disease Propensity Score

The choice of operation for diverticular disease is a contentious issue, particularly in patients with acute symptoms. This study compares early outcomes between primary resection and anastomosis and Hartmann's resection and describes a propensity score for the selection of patients for nonrestorative procedures. Data were collected from 731 patients undergoing primary resection and anastomosis (Group 1) and 123 patients undergoing primary Hartmann's resection (Group 2) for diverticular disease in a single tertiary referral center from January 1981 to May 2003. Multifactorial logistic regression was used to develop a propensity score for estimating the likelihood of performing a nonrestorative procedure. Operative 30-day mortality and surgical or medical complications were 0.7 percent, 26.0 percent, and 4.8 percent for primary resection and anastomosis and 12 percent, 43.9 percent, and 14.6 percent for Hartmann's resection, respectively (P < 0.001). There was no difference in the readmission rates between primary resection and anastomosis and Hartmann's resection (7.6 percent vs. 9.9 percent, P = 0.428). Laparoscopy was used for 32.7 percent of primary resection and anastomosis vs. 1.6 percent for Hartmann's resection (P < 0.001). Independent predictors in favor for Hartmann's resection were body mass index > or = 30 kg/m2 (odd's ratio = 2.32), Mannheim peritonitis index >10 (odd's ratio = 6.75), operative urgency (emergency, urgent vs. elective surgery, odd's ratio = 16.08 vs. 13.32), and Hinchey stage > II (odd's ratio = 27.82). The area under the receiver operating characteristic curve for the choice of operative procedure was 93.9 percent. Although Hartmann's resection was associated with a higher incidence of postoperative adverse events, the choice of operation was dependent on the patient presentation and intra-abdominal contamination, which can be quantified in the preoperative setting by the Cleveland Clinic diverticulitis propensity score.

Hartmann's Reversal Is Associated With High Postoperative Adverse Events

The aim of this study was to ascertain the preva lence and pattern of surgical and medical adverse events in patients undergoing Hartmann's reversal for diverticular dis ease. A comparison of postoperative outcomes is made be tween Hartmann's reversal and primary resection and anas tomosis. Data were collected from patients who underwent successful Hartmann's reversal (Group 1 n=121) and primary resection and anastomosis (Group 2 n=731) for diverticular disease in a single center from January 1981 to May 2003. Multivariate logistic regression was used to compare early postoperative mortality, medical and surgical complications and readmission rates between the two groups. Hartmann's reversal was associ ated with a higher prevalence of surgical or medical com plications compared with primary resection and anastomo sis (43.8 percent and 9.1 percent for Hartmann's reversal vs. 26.0 percent and 4.8 percent for primary resection and anastomosis). There was no difference in the readmissior rates (7.2 percent vs. 7.6 percent, respectively, P = 0.88) or early postoperative mortality (1.7 percent vs. 0.7 percent, P = 0.25) between Hartmann's reversal and primary resection and anastomosis. The need for reoperation, prolonged ileus respiratory tract infections, and renal failure were more common adverse events in the Hartmann's reversal group (P < 0.01). Having controlled for the number of comorbid conditions, extent of diverticular disease, severity of peri toneal contamination (Mannheim Peritonitis Index), and op erative urgency, patients who underwent Hartmann's rever sal were 2.1 times more likely to have adverse surgical events during their postoperative period (95 percent confidence interval for odds ratio = 1.3-3.3). Hartmann's reversal is a complex surgical procedure that is associated with a high prevalence of postoperative adverse events in comparison with primary resection and anastomosis. To minimize the prevalence of such adverse events, patients who undergo Hartmann's reversal need careful preoperative evaluation and close monitoring in their postoperative period.

Interposition of a jejunal segment as an alternative one-stage operation for acute left colon obstruction.

Much debate surrounds the one-stage surgical management of acute left colon obstruction. Many surgeons are still reluctant to perform primary anastomosis in unprepared bowel fearing the risk of anastomotic dehiscence. Although intraoperative lavage and subtotal colectomy have recently proved effective for preventing fecal loading, both of these procedures have drawbacks and the search for additional alternative surgical procedures continues. We conducted an experimental study to examine a new one-stage operation, consisting of the interposition of a jejunal segment to the resection site of the colon, to manage acute left colon obstruction. The colons of 20 domestic pigs were obstructed, and 2 days later, segmental resection and either primary colo-colonic anastomosis or interposition of a jejunal segment was performed. Autopsies were done 6 weeks after the operations and the anastomotic regions were subjected to bursting pressure analysis. The operating time was longer in the interposition group at 49 +/- 14 vs 38 +/- 12 min ( P < 0.01). There was no mortality or clinical signs of anastomotic dehiscence in either group. A perianastomotic abscess was detected on autopsy in one animal from the primary colo-colonic anastomosis group. The bursting pressures of the jejunocolic anastomoses were significantly higher ( P < 0.001) than those of the primary colo-colonic anastomoses. These experimental results suggest that jejunal interposition may be a feasible alternative to primary colonic anastomosis to create intestinal continuity after resection for acute obstruction of the left colon.

Penetrating colon injuries requiring resection: diversion or primary anastomosis? An AAST prospective multicenter study.

The management of colon injuries that require resection is an unresolved issue because the existing practices are derived mainly from class III evidence. Because of the inability of any single trauma center to accumulate enough cases for meaningful statistical analysis, a multicenter prospective study was performed to compare primary anastomosis with diversion and identify the risk factors for colon-related abdominal complications. This was a prospective study from 19 trauma centers and included patients with colon resection because of penetrating trauma, who survived at least 72 hours. Multivariate logistic regression analysis was used to compare outcomes in patients with primary anastomosis or diversion and identify independent risk factors for the development of abdominal complications. Two hundred ninety-seven patients fulfilled the criteria for inclusion and analysis. Overall, 197 patients (66.3%) were managed by primary anastomosis and 100 (33.7%) by diversion. The overall colon-related mortality was 1.3% (four deaths in the diversion group, no deaths in the primary anastomosis group, p = 0.012). Colon-related abdominal complications occurred in 24% of all patients (primary repair, 22%; diversion, 27%; p = 0.373). Multivariate analysis including all potential risk factors with p values < 0.2 identified three independent risk factors for abdominal complications: severe fecal contamination, transfusion of > or = 4 units of blood within the first 24 hours, and single-agent antibiotic prophylaxis. The type of colon management was not found to be a risk factor. Comparison of primary anastomosis with diversion using multivariate analysis adjusting for the above three identified risk factors or the risk factors previously described in the literature (shock at admission, delay > 6 hours to operating room, penetrating abdominal trauma index > 25, severe fecal contamination, and transfusion of > 6 units blood) showed no statistically significant difference in outcome. Similarly, multivariate analysis and comparison of the two methods of colon management in high-risk patients showed no difference in outcome. The surgical method of colon management after resection for penetrating trauma does not affect the incidence of abdominal complications, irrespective of associated risk factors. Severe fecal contamination, transfusion of > or = 4 units of blood within the first 24 hours, and single-agent antibiotic prophylaxis are independent risk factors for abdominal complications. In view of these findings, the reduced quality of life, and the need for a subsequent operation in colostomy patients, primary anastomosis should be considered in all such patients.

Utility of appropriate peritonitis grading in the surgical management of perforated sigmoid diverticulitis

We evaluated the prognostic validity of preoperative risk scores in the surgical management of patients with diverticular perforation and diffuse peritonitis. From 1988 to 1998, 82 patients, mean age 72 ± 15 years, underwent urgent surgery for perforated diverticulitis with generalized peritonitis. They were operated either with the Hartmann technique or with resection and primary anastomosis. ASA Classification and Mannheimer Peritonitis Index (MPI) were documented as risk scores at time of surgery and used as guidelines to decide for one of both procedures. A Hartmann resection (HA) was performed in 62 patients (76%) and resection with primary anastomosis (PA) in 20 (24%). Seventy-one percent of patients in the HA group corresponded to ASA IV/V, compared with 35% in the group with primary anastomosis (P < 0.001). Patients with Hartmann resection had also a higher MPI (23 ± 8) vs those with primary anastomosis (18 ± 7; P < 0.004). However, differences between the HA group and the PA group due to post-operative morbidity (21% vs 35%) and mortality (35% vs 20%) did not reach statistical significance. Nevertheless, multivariate analysis of the whole series revealed a significant relationship between MPI and mortality (P < 0.0043), independent of ASA class, age and operative procedure. Patients assigned to Hartmann procedure had more co-morbidities and more advanced peritonitis as assessed by increased ASA and higher MPI. The Mannheimer Peritonitis Index proved to be an independent prognostic index in estimating mortality with respect to peritonitis extension and septic status of the patient.

Feeding troubles following delayed primary repair of esophageal atresia.

Severe feeding troubles were recorded in five babies with long-gap esophageal atresia who underwent, between 1985 and 1990, a delayed primary anastomosis after spontaneous growth of their esophageal stumps. A comparison with 20 cases of direct esophageal anastomosis, operated on in the same period, was carried out by means of recorded esophagrams, pH monitoring and questionnaires charting the growth pattern and feeding habits of the patients. Bottle feeding, and, later on, the introduction of semi-solid foods was significantly retarded in the group of children with delayed primary anastomosis (labeled as group B) as well as height and weight parameters. Failure to complete feeds, dysphagia, vomiting, coughing, choking and recurrent respiratory symptoms were also significantly more common in this group than in the primary anastomosis group (labeled as group A) even in the absence of stricture. Variable degrees of disordered esophageal motility were present in all patients but pooling of the contrast medium, retrograde flow and delayed clearing of the esophagus were more frequent in group B. No patient was shown to have associated hiatal hernia. A 24 hour pH recording showed severe gastroesophageal reflux in 4 out of 13 cases of group A and in 3 out of 5 cases of group B. Clearing times were significantly delayed in all refluxing children. Our data suggest that the retarded start of oral feeding and swallowing coordination in patients with delayed primary anastomosis add further negative factors to their congenitally impaired esophageal motility, causing protracted dysphagia which represents a major problem for both family and hospital staff.

Primary anastomosis for necrotising enterocolitis: A 12-year experience

Between January 1975 and October 1987, 50 cases of necrotising enterocolitis (NEC) have required surgery. The principle that the best management is resection and exteriorisation of the ends, which was developed in the early 1970s, has been superseded by the realisation that resection and primary anastomosis can be safe in a well-resuscitated infant in whom the bowel ends appear viable. Eight babies had widespread NEC and no procedure was performed. Thirteen babies had resection and exteriorisation with five long-term survivors (39%). Twenty-nine babies had a primary anastomosis irrespective of birth weight, gestational age, length of resection, or the presence of peritonitis--with 22 (76%) long-term survivors. The pre-operative risk factors and length of bowel resected were similar in the two groups. The length of hospital stay, the period of total parenteral nutrition, the time to full feeds, and the time on a ventilator were all shorter in the primary anastomosis group, with no increase in short- or long-term morbidity or mortality. Provided that the bowel ends are viable, primary anastomosis is the procedure of choice for babies with NEC requiring laparotomy.