Small Intestinal Anastomosis Research Articles

Effects of chronic corticosteroids and vitamin a on the healing of intestinal anastomoses

The ability of vitamin A to reverse the inhibitory effects of chronic corticosteroids on cutaneous and fascial wound healing is well established. To investigate this in the unique low-collagen environment of the intestinal anastomosis, 35 rabbits received twice-daily injections of either saline (control), dexamethasone (0.1 mg/kg/day), dexamethasone plus low-dose vitamin A (1,000 IU/kg/day), or dexamethasone plus high-dose vitamin A (10,000 IU/kg/day) for a 2-week period. Animals then underwent creation of single-layer, inverting small and large intestine anastomoses. All injections were continued postoperatively. A fifth group received only dexamethasone preoperatively and dexamethasone plus high-dose vitamin A postoperatively. On postoperative day 7, animals underwent in situ assessment of anastomotic bursting pressure and subsequent histologic examination using a modified Ehrlich/Hunt scale. Corticosteroids significantly unpaired the healing of small and large intestine anastomoses, with decreased bursting pressures and histologic parameters at 1 week. Only high-dose vitamin A significantly reversed this inhibitory effect, whether given preoperatively or only postoperatively.

Survival after small intestine resection and anastomosis in horses.

The authors examined factors influencing survival in 140 horses that recovered from anesthesia after small intestinal resection between 1968 and 1986, using Kaplan-Meier estimated survival curves and the Cox proportional hazards regression model. Seventy-two horses (51%) died during the initial postoperative period, 19 horses (14%) died after discharge from the hospital, 33 horses (24%) were alive, and 16 horses (11%) were classified as censored. Mean age at surgery was 8 years. Horses 15 years of age or older, Arabians and Stallions, were overrepresented in the hospital population. The most common reason for resection was strangulation of bowel through a mesenteric rent. The mean and 50% median survival times were 1540 and 27 days, respectively. Horses admitted after January 1, 1980, had a significantly longer survival than those admitted before that time. Survival was longer after anastomosis of two small intestinal segments than after anastomosis of a small intestinal segment to the cecum; however, the length of bowel resected and the method of anastomosis had no demonstrable influence on survival. Of the variables studied, the heart rates at presentation and 24 hours after surgery were the most accurate predictors of survival.

Collagen metabolism in small intestinal anastomosis

Collagen metabolism in the small intestinal wall during the first week of anastomotic healing in operated and nonoperated rats was studied. During this period, marked changes in anastomotic strength have been observed. A general and marked increase of collagen synthesis was found throughout the intestine already on the second day. This resulted in increased collagen content. Collagen concentration remained relatively unchanged despite an increase in collagen content as a result of concomitant increase of noncollagenous substances. The previously reported loss of anastomotic strength in the early phase of healing could not be explained by changes in collagen content or metabolism in this study. Cutting of sutures seems to be due to a local process. After 4 days, collagen content increased predominantly in the anastomotic region. It correlated well to the previously observed increase of anastomotic strength.

Resection and anastomosis of small intestine: current methods applicable to the horse.

Intraoperative techniques for assessing the viability of ischaemic bowel are discussed. Intravenous administration of sodium fluorescein appears useful but further investigation of the method is required. Methods of resection and anastomosis of small intestine are described and illustrated, including the use of automatic stapling instruments.

The effect of antineoplastic agents on the healing of small intestinal anastomoses in the rat

The influence of an intravenous 5-day combined chemotherapy with bleomycin (2 mg/kg/d), 5-fluorouracil (10 mg/kg/d) and cis-diamminedichloroplatinum (0.35 mg/kg/d) on the healing of ileal anastomoses was investigated in rats. Ninety-six male Wistar rats were used, divided into four groups. The rats in the control group had surgery without administration of cytostatic agents. The other rats were operated either 2 days after, 2 days before, or during the 5-day chemotherapy course. In each group, rats were killed after 3, 7, and 21 days. Anastomotic healing was assessed by measurement of bursting pressures and hydroxyproline levels. Intestinal healing appeared to be impaired most if the operation was performed in the middle of the antineoplastic chemotherapy course. The effects were most pronounced on the seventh postoperative day. Surgery on the second day after the chemotherapy course led to a slight and early delay in wound healing as measured by the hydroxyproline content. Seven days postoperatively, concentrations had returned to preoperative values. Surgery 2 days before chemotherapy induced only minor differences with respect to the control group. In all groups, bursting pressure and hydroxyproline content at 21 days were similar. Thus, antineoplastic agents retard but do not prevent healing of intestinal anastomoses. The effects are most pronounced when surgery is performed during chemotherapy. If possible, surgery should be performed prior to chemotherapy. Increasing the time interval between surgery and chemotherapy may decrease the delay in intestinal woundhealing.

Effects of tension on local blood flow in experimental intestinal anastomoses

In intestinal anastomoses, local blood flow is one of the most important factors contributing to the success of the healing process. While submucosal local blood flow is maintained better in the colon than in the small intestine, the incidence of anastomotic leakage is higher in the former than in the latter. To resolve this conflict, we have examined differences in the reactivity of the intestinal segments toward the application of tension. Anastomosis was performed with a stapler on the jejunum, ileum, and colon of experimental dogs. The anastomotic sites were subjected to tensile loads applied in incremental steps to measure and compare local blood flow, measured by the hydrogen clearance method, in the submucosal layers of the anastomoses in these intestinal segments. The results of these comparative evaluations indicate that, at a tensile stress level of more than 4 g/mm 2, local blood flow in the colon is significantly smaller than that in the jejunum and ileum. These findings were corroborated by microangiographical observations carried out during stress application. The microangiographical data suggest that the rate of filling of the contrast medium is lower with colonic anastomosis than with jejunal and ileal anastomoses. In addition, the intraluminal pressure of the colon was higher than that of the small intestine during the induced peristalsis. The different sensitivity of the local microcirculation systems of the intestinal segments to tension may thus be considered one of the factors accounting for the higher incidence of clinical suture failure in colonic than in small intestinal anastomoses.

Changes in collagen content of the small intestinal wall after anastomosis

Collagen content of small intestinal anastomosis in the rat was investigated in relation to previously reported changes in suture-holding capacity. The decrease in suture-holding capacity during the first 3 days previously observed, the inflammatory phase, did not correlate with collagen content during this period. However, the increase in suture-holding capacity from the third to the seventh days, the phase of fibroplasia, correlated well with an increased collagen content in the intestinal wall in both the ileum and jejunum. Anastomotic strength and collagen content correlated well after the third day. Deposition of collagen, not only in the wound but also in the intestinal wall and within the loop of the suture during the phase of fibroplasia, is the likely explanation for the rapid increase of suture-holding capacity during this period.

Peritoneal cell responses to acute gastro-intestinal inflammation.

Cell changes in the peritoneal exudate induced by an acute localised inflammation due to a small intestinal anastomosis have been studied. The maximum response occurs on the second day. The neutrophil polymorphonuclear leucocyte output on the second is seven times greater in the peritoneal exudate than in the effluent lymph from the gastro-intestinal tract. The fate of the inflammatory cell response of the peritoneal exudate has been studied using thymidine-labelled cell transfer experiments. Some neutrophil polymorphonuclear leucocytes and eosinophils are phagocytosed by monocyte/macrophage cells in the peritoneal cavity. The majority of the neutrophil polymorphonuclear leucocytes and eosinophils migrate through diaphragmatic "stomata" to the parathymic lymph glands via the mediastinal lymphatics.

Early postoperative results with EEA stapler.

This study of 106 patients who had end-to-end anastomoses (EEA) performed by 26 surgeons in 11 hospitals reports the operative and postoperative complications of using the EEA stapling device. The complications are probably exaggerated, because this study involves the initial experiences of many surgeons. The 106 patients included 78 patients with colon anastomoses, 3 with small intestinal anastomoses, and 25 with gastric anastomoses. The mortality rate included two patients (1.9%) with low rectal anastomoses who died of problems associated with the EEA stapler. The anastomotic morbidity rate included 9 operative complications (9%), which were corrected at operation, and 12 postoperative complications (11%), which included leaks (4), fistula (4), and stenosis (4). Intra-abdominal abscess occurred in 3 and wound infections in 19 patients (18%). The EEA stapler requires practice and specific skills for its safe use. The EEA stapler makes a reliable, inverted anastomosis and can be used successfully throughout the gastrointestinal tract.

Study of acute localised inflammation of the gastrointestinal tract: the effluent lymph.

The effect of localised acute inflammation, produced by a small intestinal anastomosis on the effluent lymph of the gastrointestinal tract and on the efferent lymph of the mesenteric lymph glands has been studied in rats. There is a progressive increase in the output of lymph from the gastrointestinal tract in rats with an intact anastomosis, but a decreased output in animals with a disrupted anastomosis causing either generalised peritonitis or a localised para-anastomotic abscess. The total white cell output is increased on the second day after constructing an intact intestinal anastomosis and this increase is principally due to neutrophil polymorphonuclear leucocytes. The neutrophil polymorphonuclear leucocyte response is prolonged, but has returned to normal values at four weeks. Although the output of cells of the mononuclear phagocytic series which are esterase positive is increased it is not statistically significant. An intact anastomosis does not produce any alteration in the lymphocyte output. The neutrophil polymorphonuclear leucocyte response to an intestinal anastomosis is decreased by a factor of two and the non-lymphocytic non-specific esterase positive cell response is decreased by a factor of six by the mesenteric lymph glands which may be functioning in a 'filtering' capacity dealing with agents originating at the anastomosis and noxious to the body,

Secondary operations for duodenal ulcer

During the past twenty-five years, 141 secondary operations were performed on men aged twenty-four to eighty-four years to correct disabling symptoms after definitive surgery for duodenal ulcer. Recurrent ulceration (81 patients) or its sequelae, gastric outlet obstruction (15) and gastrojejunocolic fistula (10), were the most frequent complications that necessitated a second operation. Abnormalities in the physiologic function of the gastrointestinal tract including reflux gastritis (16 patients), late dumping (11), and postvagotomy diarrhea (2) are being diagnosed more frequently and are amenable to surgical correction. Mechanical disorders including gastrojejunal intussusception (3) and retrogastric hernia (1) as well as carcinoma of the gastric stump (2) are correctable only by surgical intervention. The complications that follow vagotomy with drainage appear early (average, 18 months), whereas those related to gastrectomy are seen somewhat later (average, 8 years) and those after gastroenterostomy the latest (average, 10 years). Recurrent ulcers after gastrectomy respond well to transthoracic vagotomy (30 of 33 patients), but in some this leads to outlet obstruction. Therefore, if there is partial stomal obstruction or a large ulcer, reresection is necessary. Antrectomy gave the best results when primary vagotomy with drainage failed to control ulcer diathesis. All eleven patients who underwent partial gastrectomy and vagotomy when recurrent ulcers followed gastroenterostomy were apparently cured. Stomal obstruction (16) and gastrojejunocolic fistula (10) were corrected by revision of the previous gastric to small intestinal anastomosis and removal of more of the acid-producing stomach. Reflux gastritis in twelve patients responded to biliary diversion using a Roux-en-Y or Henley loop. The former is simpler and therefore the preferred form of therapy. Late dumping (reactive hypoglycemia) was controlled by reversed jejunal segments. Improvement was more apparent when the segment was inserted between the stomach and duodenum than when it was placed distal to the ligament of Treitz. Only one of two patients with postvagotomy diarrhea benefited from a reversed jejunal segment. The three patients with gastrojejunal intussusception and one with retrogastric hernia were all saved with early surgical intervention. Carcinoma, although rare (2 patients), seems to be increasing, and resection is indicated, although the results are poor.

ELECTROPHYSIOLOGICAL STUDIES ON THE PERISTALTIC PROPAGATION IN THE SIDE-TO-SIDE ANASTOMOSED INTESTINAL LOOPS

To study the mode of peristaltic propagation from the oral part to the anal over and across the anastomotic line following side-to-side smallintestinal anastomosis, the action potentials were recorded from the surface of the rabbit's intestine, which was survived by means of a modified Trendelenburg's method.Within one week following the side-to-side anastomosis, spike bursts of varying periods were recorded from electrodes placed above and below the anastomotic line and it was noted that the amplitude was generally low. Within one month after the anastomosis, the spike potentials above the anastomotic line were greater than those of below as in the case of an end-to-end anastomosis. Within two months, however, the action potentials above and below the anastomotic line seem to return to the normal pattern, but the amplitude of spikes recorded from the electrode placed just above or below the anastomotic line was 200μV, and it was lower than those of normal by 30-50μV. In three months after the anastomosis, the patterns of spike bursts were restored from conduction-block to those of the normal, and at this stage it is expected that the effective transport of the intestinal content may take place.

Total Colectomy for Carcinoma of Rectum and Hepatic Flexure, with Anastomosis of Small Intestine to Anus

Total Colectomy for Carcinoma of Rectum and Hepatic Flexure, with Anastomosis of Small Intestine to Anus

End-to-end Anastomosis in the Small Intestine

End-to-end Anastomosis in the Small Intestine

Method of End-to-end Anastomosis in Small Intestine

Method of End-to-end Anastomosis in Small Intestine

INTESTINAL ANASTOMOSIS.

The long-term results of 370 cases of intestinal anastomosis are described. 121 cases were studied in detail. There were 61 duodenal, 43 small intestinal, and 17 colon anastomoses. The follow-up examinations permitted the following conclusions: 1. The long-term results of duodenoduodenostomy and duodenojejunostomy are similar. 2. Resection of a duodenal membrane was often followed by stenosis. 3. End-to-end anastomosis of small intestine and colon give good long-term results, but after side-to-side anastomoses, 24% of the cases will develop a closed loop syndrome.