Subsequent Anastomosis Research Articles

Nervy Vasculature

HomeArteriosclerosis, Thrombosis, and Vascular BiologyVol. 32, No. 7Nervy Vasculature Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBNervy Vasculature Victoria M. Bedell and Stephen C. Ekker Victoria M. BedellVictoria M. Bedell From the Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN. Search for more papers by this author and Stephen C. EkkerStephen C. Ekker From the Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN. Search for more papers by this author Originally published1 Jul 2012https://doi.org/10.1161/ATVBAHA.112.251272Arteriosclerosis, Thrombosis, and Vascular Biology. 2012;32:1546–1547Blood vessel formation is a critical process during development and in response to normal wound healing. Precocious vasculature formation is associated with a variety of diseases such as cancer. The zebrafish (Danio rerio) has become a powerful model system to illuminate the molecular mechanisms underlying vasculogenesis. Some inherent advantages of the zebrafish include the following: external development that does not require vessel neogenesis for embryo formation, transparent embryos and larva, ready panel of transgenics that use fluorescent proteins for noninvasive imaging, and a full molecular genetic toolbox.See accompanying article on page 1563Recent work has shown that the evolutionary origin of many vascular factors is tied to their biochemical history in nervous system formation.1,2 One mechanism for the deployment of neural patterning genes in blood vessel formation is genome duplication followed by hijacking for use.1,2 In the study by Rissone et al, the authors show a role for more neural players in blood vessel formation, β-neurexin (β-NRXN1a), and neuroligin (NLGN1). NRXNs are cell adhesion molecules that play a role in synaptic activity, whereas NLGNs interact with NRXNs in synapse biology.3–5 The role of NLGNs in vessel formation has not been previously studied.Rissone et al focused on the vascular structure called the caudal plexus (CP). In fish embryos, this region undergoes angiogenesis with subsequent anastomosis and later remodeling.6,7 The present article carefully documents this progression through embryonic development and defines β-NRXN1a and NLGN1 expression in the CP during normal development. In β-NRXN1a knockdown animals, vascular remodeling fails, with a dramatic looping phenotype observed in the blood vessels.Using the strength of their model organism, the authors used morpholino oligonucleotides to coknockdown several known angiogenic genes to look for genetic interactions. Specifically, the authors explore the connection between NRXN signaling and the extracellular matrix (ECM). Prior work demonstrates that ECM interacting forms of vascular endothelial growth factor A are critical for vessel formation in mammals.8–12 In zebrafish, the ECM-modifying enzyme HS6ST-2 is also critical for CP formation and vascular branching.13 Rissone et al show that β-NRXN1a and NLGN1 genetically interact with vascular endothelial growth factor A, and their noted loss-of-function phenotypes are similar to the loss of HS6ST-2.13 Together, these results implicate the ECM as a critical component in β-NRXN1a and NLGN signaling during vascular formation.Rissone et al14 use the ability of the zebrafish to readily knockdown multiple genes to study interactions that would be difficult in other model organisms. Furthermore, they begin to define how the endothelial cells work together with the ECM to correctly pattern new blood vessels and remodel existing vessels.With this data, we can now think about how the CP can be used as a new model for precocious vascular formation, such as cancer vessels. Because tumor vasculature is a combination of angiogenesis and remodeling (see Nagy et al15 for review), the CP could be an excellent way to study normal vascular remodeling within a time frame that makes gene manipulation relatively simple. Does NRXN/NLGN signaling participate in the progression of cancer or other blood vessel–based disease?The evolutionary relationship between critical components of nervous system and vascular development is intriguing. However, most of the data to date have been finding neural patterning genes play a role in vascular development. Is it possible that the evolution goes both ways? For example, is the role of the ECM, as seen in vascular development, a mechanism that also plays a role in neural plasticity?DisclosuresNone.FootnotesCorrespondence to Stephen C. Ekker, Mayo Clinic, 200 1st St SW, 1342C Guggenheim, Rochester, MN 55905. E-mail [email protected]

Single-incision laparoscopy-assisted surgery for bowel obstruction: Report of three cases

We applied single-incision laparoscopy-assisted surgery for several different types of bowel obstruction in selected patients. Before the operation, a long nasal tube was inserted for intestinal decompression and assessment of a stenotic lesion. A specially-designed instrument for single-incision laparoscopic surgery, the SILS Port, was introduced at the umbilicus or proposed ileostomy site. After intracorporeal procedures, extracorporeal resection and reconstruction of the intestine was performed as needed. Three patients with bowel obstruction due to jejunal carcinoma, colonic stenosis, and adhesion underwent single-incision laparoscopy-assisted surgery. The port site was used for subsequent extracorporeal resection and anastomosis of the jejunum in two patients, and for ileostomy in the remaining patient. All of the procedures were completed safely, and there were no postoperative complications. Single-incision laparoscopy can therefore be applied for selected patients with bowel obstruction. In such cases, the preoperative insertion of a long nasal tube for decompression of intestinal contents and assessment of the stenotic lesion is necessary.

A natural orifice transrectal approach for oncologic resection of the rectosigmoid: an experimental study and comparison with conventional laparoscopy

A transrectal (TR) approach for natural orifice translumenal endoscopic surgery (NOTES) makes sense for colorectal surgery because the colotomy can be incorporated into subsequent anastomosis. Because cancer is a primary indication for left-sided colon resection, oncologic standards will have to be met by a NOTES procedure. This study aimed to assess whether pure TR rectosigmoidectomy can be performed with strict adherence to oncologic principles compared with a conventional laparoscopically assisted approach (LAP). Human male cadavers were allocated to either TR (n = 4) or LAP (n = 2). A simulated sigmoid lesion was created at 25 cm. Transrectal retrograde mobilization of the rectosigmoid was performed using conventional transanal endoscopic microsurgery (TEM) instrumentation. After ligation of the superior hemorrhoidal artery and further mobilization, the specimen was delivered transanally and divided extracorporeally. Using a circular stapler, NOTES colorectal anastomosis was performed. Lymph node yield, adequate resection margins, and operative time were compared with LAP. Transrectal retrograde rectosigmoid dissection was achieved in all attempts (4/4) and showed numbers of lymph nodes (median, 5; range, 3-6) similar to the LAP group (median, 4.5; range, 2-7). One pure TR approach failed to resect the lesion. Three TR procedures required additional mobilization via an abdominal approach to provide adequate margins. The mean length of TR specimens was 16 ± 4 cm compared with 31 ± 9 cm achieved by LAP (p < 0.01). The TR operative time was significantly longer (247 ± 15 vs 110 ± 14 min). Lymph node yield during TR rectosigmoidectomy was similar to that achieved by the LAP approach. However, conventional TEM instrumentation alone did not permit adequate colon mobilization. This indicates a need for flexible instrumentation or other technical solutions to perform true NOTES colectomies.

Intussuscepção tipo colíco em bovino provocada por corpo estranho: relato de caso

This report aims to describe a case of colic intussusception, type one, in a crossbreed cow. The clinical findings included dehydration, anorexia, apathy and ruminal hypomotility, besides a swelling in the right flank. On rectal palpation was not observed intestinal distension or presence of liquid, but the animal presented significant discomfort. The feces were blackened, with a putrid odor and presence of mucus. The complete blood count showed only a small increase in segmented neutrophils, without evidence of hemoconcentration or alterations in erythrocytes and leukocytes count. After clinical examination it was decided perform an exploratory laparotomy, where it was possible to observe the presence of fibrin and rupture of intestine. The corrective surgery was performed through bowel resection and subsequent anastomosis. Due to the severity of the case, the animal died one day after surgery. The diagnosis was based on clinical, laboratory and exploratory laparotomy. Keywords: Digestive disorders, intestinal obstruction, exploratory laparotomy.

Kolon-Triplikatur assoziiert mit einer Ileum-Atresie bei Laparoschisis

The present paper reports the unusual and rare case of a colon triplication associated with other findings never reported before, including the diagnostic and therapeutic management with consideration of the relevant, but rare scientific references in the medical literature. In the basic finding of an ileum atresia with laparoschisis, a colon triplication was incidentally found. The surgical procedure performed after the primarily planned Caesarean section within the 34(th) week of gravidity consisted of a bowel-preserving resection of the triplication including the ileum atresia and a subsequent Santulli anastomosis followed by a later excision of the ileostoma. Interestingly, this is the 9(th) reported case in the accessible English medical literature but, however, the first and only one with an associated ileum atresia and laparoschisis, which was successfully treated with a surgical intervention.

Abnormal Advanced Hemorrhoidal Disease: The Need of a Staged Resection

We present an unusual case of advanced hemorrhoidal disease in an 57-year-old man presenting with anemia, persistent bleeding, anal protrusion. Conventional hemorrhoidectomy was not feasible because of the risk of a massive hemorrhage caused by hypertrophic protruded vascular anal cushions. A two-stage resection was then undertaken. The aim of the first procedure was to reduce the vascularization of the protruded mucosa by a circular series of interrupted mass stitches. This approach was successful and an important reduction of vascularization was obtained. The operation was then completed two weeks later, requiring a radical circular removal of the giant anal cushions and anal canal epithelium with subsequent mucocutaneous anastomosis. A careful submucosal dissection was performed to identify and preserve the anal sphincters. No normal perianal skin was available to preserve bridges between the resected cushions. At the end of the operation, an ectopic mucosa was apparent but gradual reduction was observed in subsequent postoperative days along with recovery of anal sphincter function, and the patient was uneventfully discharged on the seventh postoperative day. On the 30th postoperative day a normal anal canal closure was observed with no ectopic mucosa. Normal continence with no functional disorder was reported and digital examination demonstrated the presence of a mild asymptomatic stenosis. (See Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A1).

Intracorporeal esophagojejunal anastomosis after laparoscopic total gastrectomy for patients with gastric cancer

To facilitate acceptance of laparoscopic total gastrectomy (LTG) for patients with upper gastric cancer, a simple, secure technique of reconstruction is necessary. The authors developed a new technique for intracorporeal esophagojejunal anastomosis that does not require hand sewing. From September 2006 to January 2008, 16 patients (11 men and 5 women) with gastric cancer underwent LTG at the authors' institution. Laparoscopic esophagojejunal anastomosis using the following method was attempted for all patients. The esophagus was transected while being rotated by about 45 degrees counterclockwise to make the subsequent anastomosis easier. After the Y-anastomosis was created, an endoscopic linear stapler was applied to create a side-to-side anastomosis between the left dorsal side of the esophagus and the jejunal limb. The entry hole was first closed roughly with hernia staplers. Subsequently, an endoscopic linear stapler was applied so that all hernia staplers could be removed and the closure completed. Laparoscopic esophagojejunal anastomosis was successfully performed for 15 patients. Intracorporeal anastomosis failed for one patient because a nasogastric tube was caught between the jaws of an endostapler, which resulted in a conversion to open procedure. No postoperative anastomotic complications occurred. Using the new technique, intracorporeal linear-stapled esophagojejunal anastomosis can be performed easily and securely. This technique could become one of the standard methods for reconstruction after LTG, facilitating the acceptance of LTG as a surgical option for patients with upper gastric cancer.

The Use of Dacron Graft for Cavo-Cavostomy in Orthotopic Liver Transplantation

The end-to-end "interposition" technique and end-to-side "piggyback" technique are standard approaches to in situ anastomosis during orthotopic liver transplantation. We demonstrate that anastomosis of liver allograft to a Dacron vena cava graft can be a feasible solution if traditional anastomoses cannot be used. A 55-year-old man with end-stage liver failure from alcoholic cirrhosis underwent orthotopic liver transplantation; however, an intraoperative complication during recipient hepatectomy rendered the native vena cava unsalvageable. In addition, the donor vena cava was too short to bridge the caval defect for interposition. We therefore used Dacron for an in situ graft to span the gap, with subsequent anastomosis of the allograft to the prosthetic graft in piggyback fashion. The patient did well postoperatively; his only major complication was late anastomotic stenosis, which was treated successfully with balloon dilatation. Unfortunately the patient became recidivous and expired ten months posttransplant, despite indications of satisfactory allograft function.

Use of Flap Based on Anterior Tibial Artery for Free Transfer

Free flap transfer can be a challenge because of the risk of anastomotic failure, especially in microvascular tissue transfers. Free lateral crural flap based on the anterior tibial artery has good vascular condition that results in a low rate of failure. To avoid loss of the anterior tibial artery of the donor, we reconstructed the anterior tibial artery after the flap was harvested with a "half-half" technique in a simple way. Ten patients underwent this type of flap transfer and succedent artery reconstruction. All flaps survived. In no case was a subsequent anastomosis thrombosis operation required. Donor site morbidities were negligible. By contrast, the vessels of the free lateral crural flap were in better condition than that of other flaps. The flap can be used reliably and successfully without loss of the major artery trunk. We believe that the flap has special characteristics that may be useful in selected instances.

Tracheal Resection and Anastomosis in a Mallard Duck (Anas platyrhynchos) with Traumatic Segmental Tracheal Collapse

A male mallard duck (Anas platyrhynchos) presented for examination for acute respiratory distress and lethargy. The duck had experienced recurrent episodes of respiratory distress since being attacked by a raccoon the previous year, resulting in neck lacerations. Diagnostic tests, including a complete blood count, plasma biochemical analysis, radiography, and tracheoscopy, revealed a collapsed trachea. Surgical correction of the collapsed tracheal segment resulted in resection of 9% of the total tracheal length and subsequent anastomosis. Tracheoscopy performed 2 and 3 months after surgery revealed a healthy mucosa, minimal reduction of the tracheal lumen in the area of anastomosis, and minimal suture granuloma formation.

Augmented Anastomotic Urethroplasty

During substitution urethroplasty, if the stricture contains a 1 to 2 cm region that is particularly narrow and/or fibrotic, that portion may be excised with subsequent anastomosis of the dorsal or ventral aspect of the urethra to shorten, widen and optimize the urethral wall onto which an onlay graft is to be placed. This procedure is termed augmented anastomotic urethroplasty. To determine the effectiveness of this approach we reviewed our experience with augmented anastomotic urethroplasty in an 8-year period. We reviewed the records of patients who underwent augmented anastomotic urethroplasty between October 1997 and April 2005. Perioperative characteristics were compared between successes and failures using the Wilcoxon/Kruskal-Wallis and Fisher exact tests. Of 69 patients who underwent augmented anastomotic urethroplasty for recurrent urethral strictures 5 had undergone previous urethroplasty using a genital skin flap or graft. At a median followup of 34 months (range 13 to 103) 62 patients had no evidence of stricture recurrence and required no further intervention for an overall success rate of 90%. Stricture recurrence, defined as the inability to easily pass a standard flexible cystoscope through the area of repair, occurred in 7 patients (10%). Patients with stricture recurrence were significantly older (mean age 52 vs 39 years, p = 0.02) and more likely to experience postoperative urinary tract infection (28% vs 3.2%, p = 0.05) than patients without repeat stricture. Augmented anastomotic urethroplasty is an effective technique that allows the use of a shorter onlay graft. It may optimize overall results due to improvement in the urethral wall and the associated corpus spongiosum.

QRS DURATION FOLLOWING THE NORWOOD PROCEDURE: BLALOCK-TAUSSIG SHUNT VERSUS RIGHT VENTRICLE TO PULMONARY ARTERY SHUNT

Background:To describe the incidence of QRS prolongation, intraventricular conduction delay (IVCD), and presence of ventricular arrhythmias in patients undergoing the Norwood procedure with subsequent superior cavopulmonary anastomosis. Differences between the modified Blalock-Taussig shunt (BTS) and the right ventricle to pulmonary artery shunt (RV-PA) on these variables were investigated. Methods:Eighty-two consecutive patients underwent Norwood palliation with a BTS (n = 41) or a RV-PA (n = 41). Standard 12-lead surface ECGs were retrospectively reviewed at three separate times: (1) prior to the Norwood procedure, (2) immediately post-Norwood procedure, and (3) prior to the superior cavopulmonary anastomosis. Groups were compared at these times for the absolute QRS duration, the change in QRS duration from one time interval to the other, and the number of patients with IVCD. The presence of ventricular rhythm abnormalities requiring treatment at any time was recorded. Results:Immediately after the Norwood procedure, QRS duration was slightly longer and median QRS change slightly larger for the RV-PA than the BTS group (P = 0.04). However, there were no differences in these variables at the time of pre superior cavopulmonary anastomosis. Within both groups, there was a significant increase in median QRS duration over time; from both pre- and post-Norwood to presuperior cavopulmonary anastomosis (P < 0.001). Conclusions:IVCD is common in patients following a Norwood procedure regardless of the type of shunt received. A ventriculotomy had small effects on QRS duration in the short term, but had no effect on the incidence of treatable ventricular rhythm abnormalities.

Temporary Arteriovenous Loop Between the Saphenous Vein and the First Plantar Metatarsal Artery in Toe-to-Hand Transfers

We describe a technique for creating a temporary arteriovenous loop by anastomosing the saphenous vein to the first plantar metatarsal artery to facilitate harvesting and subsequent anastomosis of a great or second toe transfer. This technique has been used in 9 patients: 6 pediatric toe-to-hand transfers for congenital hand differences and 3 adult toe transfers for a thumb amputation. All 9 toe transfers survived. The advantages of this technique are that it allows precise determination of the exact length of the loop to reach the recipient artery, it facilitates palmar positioning of the arterial pedicle, and, if necessary, the saphenous vein can be anastomosed directly to the lateral digital artery of a great toe transfer or the medial digital artery of a second toe transfer rather than the first plantar metatarsal artery itself, thereby minimizing more proximal dissection of the first plantar metatarsal artery, which is more difficult and time consuming.

Poor Feeding and Emesis in a 1-day-old Male

A 1-day-old term male infant presents with poor feeding and emesis. ### Prenatal History: ### Birth History: ### Presentation: Complete blood count, blood culture, and cerebrospinal fluid studies …

Dynamic esophageal lengthening for long gap esophageal atresia: Experience with two cases

This report describes two infants with long gap esophageal atresia managed by dynamic esophageal lengthening. Preliminary traction on the atretic ends of the esophagus permitted subsequent primary anastomosis under significant tension. One patient has done well, while the other developed an anastomotic stricture requiring resection. The esophagus was preserved in both infants.

O fator de crescimento de fibroblasto básico melhora a cicatrização de anastomoses duodenais em ratos

OBJETIVOS: Avaliar as alterações histológicas, e o ganho de resistência em anastomoses duodenais tratadas com fator de crescimento de fibroblasto básico (FGFb). MÉTODOS: Vinte ratos da raça Wistar foram submetidos a secção transversal do duodeno, seguida de anastomose. Os animais foram divididos em 4 grupos de 5 animais cada: A1 e A2 (experimentais), nos quais foi aplicado FCFb sobre a anastomose logo após seu término; e B1 e B2 (controles), nos quais foi administrada solução salina sobre a zona de anastomose. Os roedores foram mortos com superdose de anestésico, sendo A1, B1 no 5º dia e A2, B2 no 7º dia de pós-operatório. Foi feita avaliação quanto à resistência das anastomoses à pressão e análise da densidade média dos achados histopatológicos com auxílio do sistema digitalizado Image proPlus. RESULTADOS: No grupo A1 a pressão suportada pelas anastomoses foi de 52± 14,4 mmHg e no grupo A2 140± 34,8 mmHg. Em B1 a pressão atingiu 33,6± 15,2 mmHg e as anastomoses do grupo B2 suportaram pressão 105± 30,3. No grupo A1 a densidade média dos elementos histopatológicos foi de 93± 9,3 e A2 atingiu 181,8± 27,6. Nos grupos de controle B1 e B2 as densidades médias foram 67,6± 16,7 e 101± 12,9 respectivamente. A análise estatística revelou diferença significante entre nos dados dos grupos experimentais e controles (p&lt;0,05). CONCLUSÃO: a aplicação tópica do FCFb foi capaz de aumentar a resistência das feridas do duodeno suturadas e observadas após 5 e 7 dias de evolução. Estimulou a neovascularização, a formação de fibroblastos e de fibras colágenas, melhorando os escores histológicos em relação ao controle.

Anterior commissure carcinoma II: The role of salvage supracricoid laryngectomy

Supracricoid laryngectomy (SCL) was performed for 45 cases of recurrent anterior commissure carcinoma (ACC). The procedure involves excision of the thyroid cartilage with the tumor-bearing mucosa and subsequent anastomosis between the thyroid and cricoid cartilage. It is therefore called cricohyoidopexy, or cricohyoidoepiglottopexy if the epiglottis is also included in the excision. Rate of control of local spread at 2 years was 95.4%. Oncologic and functional results also indicate that SCL is a suitable alternative to total laryngectomy in selected cases of ACC. (Am J Otolaryngol 2002;23:1-3. Copyright © 2002 by W.B. Saunders Company)

Proximalized lateral tunnel for the bypass to the dorsalis pedis artery -- a safe way to go.

Wound complications associated with bypass grafting to the dorsalis pedis artery are frequent, and threaten the viability of the bypass and the limb. The long saphenous vein can be tunneled from its bed down the lateral side of the anterior margin of the tibia for subsequent anastomosis with the dorsalis pedis artery. The proximalized lateral tunnel for the bypass to the dorsalis pedis artery has the advantage of protecting the bypass graft from exposure if the patient develops wound breakdown.

Posterior sagittal abdominoperineal pull-through: A new approach to definitive treatment of Hirschsprung's disease—Initial experience

Purpose : Posterior sagittal abdominoperineal pull-through (PSAPP) was applied for the surgical treatment of Hirschsprung's disease (HD) to decrease the incidence or eliminate the complications related to the major pullthrough procedures. Methods : Ten children with HD underwent the new surgical procedure, PSAPP. The diagnosis of the disease was established under 1 year of age in 7 children and between 2 and 5 years of age in three instances. The length of resected aganglionic segment ranged from 6 to 20 cm (mean, 11.9 cm). The follow-up period was 18 months to 4 years (mean, 2.7 years). Postoperative clinical and manometric results were compared with children after Rehbein procedure and with controls. Results : Postoperative complications were observed in patients operated on first: anastomotic stenosis in three children, enterocolitis in three, constipation in two, anastomotic leak (iatrogenic injury) in one, and dehiscence of colostomy anastomosis in two patients. Improved surgical technique allowed to eliminate the causes of complications, and the last five children of this group who underwent surgery have had an uneventful postoperative outcome. Conclusion : The posterior sagittal approach with the posterior anorectotomy provides an excellent exposure of the operative field, allowing to perform the lowest possible resection and subsequent anastomosis.

2.8 Management of patients with dissection of the descending thoracic aorta — A comparative study between closing and non-closing dissections

This report describes the individualized operative therapy in 75 patients with intestinal atresia or stenosis based on pathological findings (1972–1978). Location of obstruction was duodenal in 30, jejunoileal in 38, and colonic in 7. Duodenal atresia was noted in 23 infants and stenosis in 7. Associated anomalies were observed in 23 patients, prematurity in 11, polyhydramnios in 11, and Down's Syndrome in 10. Operative treatment included duodenoduodenostomy (DD) in 19 patients, duodenotomy and web excision in 9, and side-to-side duodenojejunostomy (DJ) in 2. Both (DJ) cases needed revision to (DD) because of obstruction. A gastrostomy was used in all cases. Jejunoileal atresia occurred in 33 patients and stenosis in 5. Operations included wide proximal resection and endto-end anastomosis in 18 patients with normal bowel length, minimal resection with antimesenteric tapering enteroplasty (using autostaples) and anastomosis in 9 patients with foreshortened bowel, and resection and double barrel enterostomy in 6 with peritonitis or questionable bowel viability. Seventy percent received total parenteral nutrition (TPN). Six patients with colon atresia and one infant with stricture of the rectosigmoid survived initial colostomy and subsequent anastomosis at 3 to 6 mo of age. Survival for duodenal cases was 84%, jejunoileal 90%, and colonic 100%. Individualizing the operative management according to pathologic findings and TPN support when indicated improve operative survival in infants with intestinal atresia.