Laparoscopically assisted bowel surgery for inflammatory bowel disease

Background: Laparoscopic bowel surgery was evaluated in 44 consecutive patients who underwent surgery for inflammatory bowel disease (IBD). We studied feasibility, results, and final outcome. Methods: At two academic institutes, 44 laparoscopically assisted colectomies and laparoscopic ileostomies or colostomies were attempted. All patients had histologically proven IBD and no prior surgery for IBD. Loop ileostomy (n= 4), end colostomy (n= 1), ileocecal resection (n= 26) and (procto)colectomy (n= 13) were performed. All resections were laparoscopically assisted with extracorporal resection and anastomosis. Results: Only in two patients (ileocecal resection in both) was conversion to open surgery necessary. Two patients with laparoscopic ileocolic resection had intra-abdominal abscesses, which were drained percutaneously in both. One patient in the laparoscopically assisted colectomy group had a subphrenic abscess that was drained percutaneously, and one patient had a generalized candidiasis. Conclusions: Laparoscopically assisted colectomies can be performed safely in treating IBD. The laparoscopic method with use of a small vertical umbilical or Pfannenstiel's incision seems acceptable with regard to operating time and overall costs, also allowing superior cosmesis to be maintained. Received: 12 August 1998/Accepted: 13 January 1999     

Isoperistaltic bowel lengthening for short bowel syndrome in children

BACKGROUND: Short bowel syndrome, secondary to a variety of causes, can be lethal in infancy and childhood. Isoperistaltic bowel lengthening, performed by longitudinal division of dilated small bowel with end-to-end anastomosis, has shown early promise but long-term outcome is unknown. METHODS: Sixteen infants and children (aged 3 months to 14 years) had short bowel syndrome from necrotizing enterocolitis (8), gastroschisis (4), atresia (2), and volvulus (2). All of these patients were partially or totally dependent on parenteral nutrition and have undergone isoperistaltic bowel lengthening for short bowel syndrome (length <100 cm). Bowel length was increased by 22% to 85% (mean 42%) with the procedure. Studies of intestinal function were performed preoperatively and postoperatively. RESULTS: Isoperistaltic bowel lengthening resulted in significant improvement in stool counts, intestinal transmit time, intestinal clearance of barium, D-xylose absorption, and fat absorption at 6 months and 12 months postoperatively. Fourteen of 16 patients (88%) have been weaned from parenteral nutrition. CONCLUSIONS: These data show that isoperistaltic bowel lengthening can be an effective operation for short bowel syndrome in children, improving absorption and motility, and allowing weaning from parenteral nutrition.     

Smoking in inflammatory bowel disease and the irritable bowel syndrome

The smoking habits of 145 patients with irritable bowel syndrome (IBS) were compared with those of 63 patients with ulcerative colitis and 25 patients with Crohn's disease. Patients with IBS and ulcerative colitis smoked significantly less than those with Crohn's disease. There was no significant difference in the smoking prevalence between ulcerative colitis and IBS patients. There were significantly more ex-smokers in the ulcerative colitis group and two-thirds of these patients developed their colitis within a year of stopping smoking. It is suggested that any protective role postulated for smoking in the pathogenesis of ulcerative colitis should also be considered for IBS.     

Massive small bowel resection during pregnancy causing short bowel syndrome

Massive small bowel infarction in pregnancy is rare but has devastating complications. Diagnosis is difficult because pregnancy masks the symptoms. Our aim was to assess risk factors and outcomes of massive resection associated with pregnancy. We conducted a review of nine patients with short bowel syndrome (SBS) secondary to massive bowel resection during pregnancy. The most common cause of bowel resection was midgut volvulus in seven patients. Four of these also had malrotation. Three others had previous abdominal operations, including gastric bypass. The two remaining patients had vascular insufficiency. Five of the nine patients presented after a cesarean delivery. There were three fetal deaths. Resulting small bowel length was less than 60 cm in all but one patient. All patients required parenteral nutrition (PN). Seven patients developed significant complications related to SBS and long-term PN. Four patients underwent transplantation. Massive small bowel resection during pregnancy is a devastating complication, which requires a high degree of suspicion to diagnose. Most patients have risk factors, which include previous surgery, congenital malrotation, and a hypercoagulable state. Surviving patients usually need long-term PN or transplantation.     

Laparoscopic harvesting of small bowel graft for small bowel transplantation

Background: Small bowel transplantation represents a valid therapeutic option for patients with intestinal failure, obviating the need for long-term total parenteral nutrition. Recently, reports have shown the feasibility of performing living related intestinal transplantation using segmental small bowel grafts. The limitations of this technique include inadequate harvested small bowel lengths, as compared with the lengths obtained in cadaveric small bowel harvests, and large incisions for the donor. In this pilot study, we evaluated the feasibility of laparoscopically harvesting long segments of proximal jejunum for small bowel transplantation using a porcine model. The results can be used to evaluate the potential for applying this technique in human cases. Methods: For this study 10 yorkshire pigs were used. Under general anesthesia, each pig underwent laparoscopic segmental resection of 200 cm of proximal jejunum on a vascular pedicle. The harvested graft then was autoreimplanted using an open technique by anastomosing the vascular pedicle to the superior mesenteric vessels. Success was determined 2 hours after anastomosis by visually identifying a pink graft with viable-appearing mucosa, an artery with a strong thrill, and palpable venous flow. The animals were then sacrificed. Results: The mean operation time required to laparoscopically harvest the small bowel graft was 80 min (range, 35–120 min), and the mean length of harvested graft was 220 cm (range, 200–260 cm). The mean length of the graft's vascular pedicle was 4.5 cm (range, 4–5 cm). All 10 grafts were successfully harvested laparoscopically and then reimplanted using an open technique. All the grafts maintained good vascular flow, and showed no evidence of mucosal necrosis at necropsy. Obviously, further studies would be required to examine the long-term results of reimplanting a laparoscopically harvested small bowel graft, but proposals for such studies is beyond the scope of this report. Conclusion: Minimally invasive techniques can be used to harvest proximal small bowel grafts for living related small bowel transplantation.     

Bevacizumab-induced bowel perforation

Bevacizumab has shown efficacy in many different malignancies and is approved by the US Food and Drug Administration for advanced colon and lung cancers. As bevacizumab use is expanding, the number of reports of serious adverse effects from the drug are growing. Bowel perforation is a rare but often fatal event that leads the list of dangerous adverse effects. It has been frequently reported in ovarian cancer trials, with early closure of some trials because of the high incidence of bowel perforation. Physicians should be familiar with not only the presentation of bowel perforation, but also with the risk factors, considerations for surgery, and management of perforation in selected patient populations. The authors review the current knowledge on bevacizumab-induced bowel perforation.     

Malignant bowel obstructions

Malignant large bowel obstructions (LBO) present a unique and often challenging problem that requires thoughtful consideration of both short and long-term outcomes. Presentations can vary, but the patient will often need urgent or emergent intervention. Primary colorectal cancer accounts for the majority of malignant LBOs making this topic particularly important for the colon and rectal surgeon. Currently there are 3 main treatment strategies for potentially curable disease: Fecal diversion, primary resection with or without diversion, or colonic stent placement followed by elective resection. Stenting is also being used in palliative circumstances. The following chapter outlines the latest literature in malignant LBOs and provides algorithms for both emergent and elective cases.     

Small bowel imaging

There is a variety of options available to image the small bowel depending on the clinical scenario. This article describes multiple imaging options and focuses on several clinical scenarios common to general surgeons.     

Chemically induced bowel denervation improves survival in short bowel syndrome

This study evaluates the effect of chemically induced bowel denervation on survival, weight gain or loss, transit time, and d-xylose absorption in rats following 80% small bowel resection. Forty-three male Sprague-Dawley rats (150 g) underwent 80% midsmall bowel resection and anastomosis. Twenty rats were short bowel controls (group I). In 23 rats (group II), a 2.0 cm segment of jejunum proximal to the anastomosis was denervated by application of 0.1% benzalkonium chloride (BK) for 30 minutes. Ten additional rats underwent sham laparotomy without bowel resection. Five remained untreated (group III) and in 5 (BK) denervation was added (group IV). Bowel denervation was confirmed by histologic study in all (BK) rats. Weight and daily food and water intake were measured for 30 days and the groups compared. Weight in group I was 43.8 +/- 52.9 g, group II 95.0 +/- 50.1, (P less than .005), group III 177 g, and group IV 175 g. Food intake was greater in group I than II (P less than .05) and was similar to groups III and IV. Water intake calculated as animal weight (g)/mL H2O ingested was lowest in group I (P less than .05). Mortality was 30% in group I (6/20) and only 8.6% in group II (2/23). No deaths were observed in unresected controls (III and IV). Twenty-four additional rats were evaluated for d-xylose absorption and transit time by bringing out a loop enterostomy 10.0 cm from the Ligament of Treitz. Twelve rats were ostomy controls (group V).(ABSTRACT TRUNCATED AT 250 WORDS)     

Small bowel volvulus leading to gangrene and short bowel syndrome

A young man was operated for acute abdomen. Laparotomy revealed small bowel diverticulosis with very short mesentery leading to volvulus of near total small bowel. Resection and end to end anastomosis was performed. Patient ended up with short bowel syndrome.     

Small bowel transplantation

Small intestinal transplantation has had several clinical attempts based on extensive experimental work during the past two decades. Several models, such as auxiliary (heterotopic) or orthotopic models, have been developed in regard to problems with graft immunology and function. The question of mesenteric-portal or mesenteric-caval graft drainage was raised, and the answer seems to be open. Concerning lipid absorption, interest was directed to the reconstitution of lymphatic vessels, because orally administered cyclosporine A is absorbed by the lipid mechanism. Carbohydrate digestion and absorption are used for determination of graft function and for monitoring graft rejection. This article summarizes these problems and deals with the surgical procedure of small bowel transplantation in the rat.     

Small bowel neomucosa

The growth of small bowel mucosa onto enteric segments, denuded of mucosa, and onto prosthetic material was studied under light and electron microscopy. Mongrel dogs were divided into seven experimental groups. In Group I, 10-cm-long mucosally denuded colonic segments were inserted into the jejunum by end-to-end anastomosis. In Group II, similar segments were prepared and immediately cut into serial sections. In Group III, similar segments were prepared as blind colostomies. In Group IV, techniques to remove residual colon epithelium were applied to the colonic segments. In Group V, 85% of the small bowel was resected in addition to performing anastomosis of the denuded colonic segment to the remaining bowel. In Group VI, tubular polytetrafluoroethylene (Gore-Tex) prostheses were placed in continuity in the jejunum. In Group VII, 10-cm mucosally denuded jejunal segments were attached by end-to-end anastomosis in the jejunum. Biopsies were taken of the mucosa in all segments at various intervals. Mucosal regrowth onto denuded colonic segments (Groups I, III, IV, V) was complete by 13 weeks. Nests of residual colonic cells had reepithelized the segments with mucosa compatible in appearance with colonic mucosa. Small bowel epithelium had grown 5 mm across the anastomosis. Attempts at removing residual colonic cells or stimulating additional growth of jejunal mucosa were unsuccessful (Groups IV and V). Mucosal growth onto one Gore-Tex graft extended 5 mm across the anastomosis (Group VI). Jejunal epithelium grew 1 cm onto denuded jejunal segments (Group VII). The primary obstacle to growing small bowel neomucosa is the lack of intrinsic potential for extended lateral growth.     

Small bowel transplantation

Many patients die each year lacking only a functional small bowel to survive. The minimum amount of small intestinal absorptive surface required to sustain life varies from patient to patient. Prolonged survival with oral alimentation alone has been reported in a few patients with an intact duodenum and as little as 15-45 cm of residual jejunum. However, without long-term total parenteral nutrition (TPN), prolonged patient survival is the exception rather than the rule. Chronic parenteral nutrition is associated with complications, including sepsis, venous thrombosis, metabolic disorders and liver dysfunction. From studies of patients currently on long-term TPN, it would appear that there are between two and three patients per million of population per year who develop irreversible small bowel failure. It is estimated that 20 new patients/year in the UK receiving home TPN would be potential candidates for small bowel transplantation.     

Small bowel obstruction

Background: This is a retrospective review of our experience using a laparoscopic approach in the treatment of acute and chronic small bowel obstruction (SBO). Materials and methods: Of 136 patients hospitalized in our institutions for acute (94 cases: 69.1%) and chronic (42 cases: 30.8%) SBO, from January 1994 to March 1998, 63 (46.3%) were approached laparoscopically. The etiology was accurately diagnosed in 58 cases (92%), and it was possible to treat it laparoscopically in 82.5% (52 of 63 cases). In the remaining 11 cases (17.4%), a formal laparotomy was needed for bowel resection, due to an ischemic small bowel or for malignant disease. Results: Overall, 82.5% of our cases were successfully treated laparoscopically. Conclusions: We conclude that, in experienced hands, laparoscopy is an excellent diagnostic and, in the majority of cases, a therapeutic surgical approach in selected patients with acute or chronic SBO. Received: 30 June 1998/Accepted: 12 February 1999     

Short bowel syndrome

The short bowel syndrome (SBS) is a state of malabsorption following intestinal resection where there is less than 200 cm of intestinal length. The management of short bowel syndrome can be challenging and is best managed by a specialised multidisciplinary team. A good understanding of the pathophysiological consequences of resection of different portions of the small intestine is necessary to anticipate and prevent, where possible, consequences of SBS. Nutrient absorption and fluid and electrolyte management in the initial stages are critical to stabilisation of the patient and to facilitate the process of adaptation. Pharmacological adjuncts to promote adaptation are in the early stages of development. Primary restoration of bowel continuity, if possible, is the principle mode of surgical treatment. Surgical procedures to increase the surface area of the small intestine or improve its function may be of benefit in experienced hands, particularly in the paediatric population. Intestinal transplant is indicated at present for patients who have failed to tolerate long-term parenteral nutrition but with increasing experience, there may be a potentially expanded role for its use in the future.     

Small bowel injuries

Small bowel injuries are becoming more commonplace. Difficult to diagnose and treacherous when missed, small bowel injuries should be searched for assiduously in all patients at risk. Use of DPL or CT scanning, coupled with a low threshold for exploration, improves the diagnosis and treatment of small bowel injuries. A delayed diagnosis results in a progressive septic insult and markedly increased mortality. Early diagnosis is the key. After addressing life-threatening problems, the operation should include a thorough and systematic exploration to identify all injuries. Sound surgical technique includes debridement of nonviable tissue, restoration of small bowel continuity, generous irrigation, and placement of enteral feeding catheters. By adhering to the preceding principles and by exercising meticulous postoperative care and maintaining a low threshold to reoperate, catastrophic complications can be avoided.     

Neonatal bowel obstruction

Newborn intestinal obstructions are a common reason for admission to neonatal ICUs. The incidence is estimated to be approximately 1 in 2000 live births. There are 4 cardinal signs of intestinal obstruction in newborns: (1) maternal polyhydramnios, (2) bilious emesis, (3) failure to pass meconium in the first day of life, and (4) abdominal distention. The presentation may vary from subtle and easily overlooked findings on physical examination to massive abdominal distention with respiratory distress and cardiovascular collapse. A careful history and physical examination often identify the diagnosis. Concomitant resuscitation (volume, gastric decompression, and ventilatory support) may be necessary.     

Small bowel fistulas

Most external small bowel fistulas follow surgical operation, but a few develop spontaneously. Seventy percent will close with conservative treatment including vigorous nutritional support and elimination of sepsis. Internal fistulas involving the small bowel always result from extension of disease in the bowel or in adjacent viscera, and they virtually never close spontaneously. Our 11-year experience of 71 Crohn's fistulas confirms 2 types. Type 1 (n=49) results from spontaneous extension of active bowel disease, while type 2 (n=22) follows leakage of an anastomosis. The former virtually always requires surgical closure, which can usually be achieved without mortality and with minimal complications. Most type 2 fistulas will close with parenteral nutrition, but staged surgery with exteriorization of bowel ends may be required. Our 4 deaths were all among type 2 cases. High-output fistulas with severe associated sepsis should be managed in specialized intestinal failure units. In just under 4 years, 51 patients with complicated intestinal fistulas have been treated in this department, with a 23.5% mortality rate.

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Resumen La mayoría de las fistulas del intestino delgado son consecuencia de operaciones quirÚrgicas, pero algunas se desarrollan en forma espontánea. Setenta por ciento de las fístulas cicatrizan bajo tratamiento conservador que incluye soporte nutricional y la eliminación de la sepsis. Las fístulas internas que afectan al intestino delgado siempre resultan de la extensión de enfermedad del propio intestino o de vísceras adyacentes, y ellas virtualmente nunca cierran espontáneamente. Nuestra experiencia de 11 años con 71 fístulas por enfermedad de Crohn confirma los dos tipos. El tipo 1 (n=49) resulta de la extensión espontánea de enfermedad intestinal activa, mientras el tipo 2 (n= 22) resulta del escape anastomótico de contenido intestinal. El tipo 1 virtualmente siempre requiere cierre quirÚrgico, el cual puede ser logrado sin mortalidad y con mínimas complicaciones. La mayoría de las fístulas tipo 2 cicatrizan con la nutrición parenteral, pero en algunos casos puede ser necesario realizar cirugía en etapas, con exteriorización de los cabos intestinales. Nuestras 4 muertes ocurrieron todas en pacientes con el tipo 2. Fístulas de alto volumen con severa sepsis asociada deben ser manejadas in unidades especiales para el cuidado de pacientes con falla intestinal. En apenas algo menos de 4 años, 51 pacientes con fístulas intestinales complicadas han sido admitidos a este Departamento, con una tasa de mortalidad de 23.5%.

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Résumé Les fistules externes de l'intestin grÊle peuvent se développer spontanément mais le plus souvent elles succèdent à une intervention chirurgicale. Soixante-dix pour cent cicatrisent grâce à l'hyperalimentation et à l'élimination de l'infection. En revanche les fistules externes qui résultent de l'extension d'une affection spécifique du grÊle à un viscère adjacent ne se ferment jamais spontanément. Notre expérience de 11 ans confirme ces faits. Les fistules internes (n=49) nécessitent presque toujours une intervention chirurgicale dénuée de mortalité et au prix d'une morbidité peu importante. La majorité des fistules externes (n=22) cicatrisent spontanément sous l'influence de l'hyperalimentation mais dans de rares cas il est nécessaire d'avoir recours à une chirurgie en plusieurs temps en extériorisant les deux extrémités du grÊle. La mortalité postopératoire a concerné 4 malades opérés de fistules externes. Les fistules du grÊle a grand débit compliquée d'infection grave doivent Être traitées dans des unités spécialisées. En moins de 4 ans, 51 cas de fistule du grÊle ont été admises dans un département de ce type avec une mortalité de 23.5%.

     

Small bowel transplantation

Small bowel transplantation may offer a future alternative to patients with short bowel syndrome. However, currently available immunosuppressive regimens are not adequate to prevent rejection of small bowel allografts. Recent experimental studies using cyclosporine have provided improved results, especially in rats; but there are relatively few long-term survivors in large animal models. Graft-versushost disease may result from lymphoid tissue in the small bowel transplant but is less troublesome than rejection. Seven patients have undergone small bowel transplantation; the longest survivor died at 6 months. Clinical application of small bowel transplantation must await further refinements in immunosuppression.

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Resumen El transplante de intestino delgado puede ofrecer una alternativa futura a pacientes con el síndrome de intestino corto. Sinembargo, en la actualidad los regimenes inmunosupresivos disponibles no son adecuados para prevenir el rechazo de los transplantes de intestino delgado. Estudios experimentales recientes con el uso de la ciclosporina han presentado mejores resultados, especialmente en ratas, pero se han logrado relativamente pocos sobrevivientes a largo plazo en experimentos con animales mayores. La enfermedad transplante-contra-huésped puede resultar de la presencia de tejido linfoide en el transplante de intestino delgado, pero es menos problemática que el rechazo. Siete pacientes han recibido transplante de intestino delgado; el paciente de más larga supervivencia sucumbió a los 6 meses. La aplicación clínica del transplante de intestino delgado deberá esperar al mayor refinamiento de las técnicas de inmunosupresión.

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Résumé La transplantation de l'intestin grÊle est une méthode thérapeutique susceptible de traiter les malades qui présentent le syndrome dit de l'intestin court. Cependant les agents imunosuppresseurs actuellement disponibles ne permettent pas d'éviter le rejet des allogreffes. Chez le rat des études expérimentales récentes utilisant la cyclosporine ont montré que l'emploi de cet agent médicamenteux entraÎnait une amélioration des résultats, mais le nombre des survivants à long terme a été des plus réduits. La réaction de la greffe contre l'hôte semble Être le fait du tissu lymphoÏde contenu dans le greffon mais elle est moins gÊnante que le rejet. Sept malades ont subi une transplantation de l'intestin. La plus longue survie n'a pas dépassé 6 mois. La pratique de la transplantation de l'intestin ne saurait s'étendre avant que d'avoir amélioré le traitement immunosuppresseur.

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Supported by NIH grants no. AM33040 and no. AM35929.