Altered motility and bacterial flora after functional end-to-end anastomosis

The functional end-to-end technique with a gastrointestinal stapler is commonly used for small-bowel anastomosis, but the effects of this anatomically side-to-side anastomosis on motility are unknown. Fasting small-bowel myoelectric activity and culture results were compared in six animals undergoing handsewn end-to-end and functional end-to-end anastomoses. Serosal electrodes were placed at 10 cm intervals, and the small bowel was divided 25 and 55 cm from the ligament of Treitz. The functional end-to-end and end-to-end techniques were performed in each animal in random order. Fasting myoelectric recordings were obtained at weekly intervals for up to 20 weeks after operation. New electrodes were placed, and additional recordings were obtained from 29 to 39 weeks, 51 to 63 weeks, and 108 to 112 weeks after operation. The recordings were visually inspected for passage of phase 3 of the migrating myoelectric complex (MMC). By 12 to 20 weeks after operation, 91% of MMCs crossed the end-to-end anastomoses versus 22% across the functional end-to-end anastomosis (p less than 0.001). Even 2 years after surgery only 56% of MMCs crossed the functional end-to-end anastomosis. Quantitative bacterial cultures suggested a trend toward bacterial overgrowth in the functional end-to-end anastomosis. These results demonstrate that the functional end-to-end anastomosis alters small-bowel motility to a greater degree than an end-to-end anastomosis and may predispose to bacterial overgrowth.     

Cortical vein end-to-end anastomosis after removal of a parasagittal meningioma

A simple technique is described that facilitates a proper procedure of venous end-to-end anastomosis during neurosurgical procedures. This technique, which consists of insertion of a Venflon tube in the vein during anastomosis, results in easier handling and proper apposition of the vein, resulting in an improved quality of the anastomosis. The technique was successfully applied in a patient after parasagittal meningioma resection, and the patency of the cortical vein was confirmed postoperatively on magnetic resonance venography.     

Unusually early recoarctation after extended end-to-end anastomosis in a neonate

A seven-day-old neonate with aortic coarctation and hypoplastic aortic arch underwent extended end-to-end repair with no residual gradient. Eleven hours after repair, femoral pulses were not palpable and recoarctation was confirmed by echocardiography. After failure of prostaglandin E2 infusion, a radically extended end-to-end anastomosis was performed eight days after initial repair. No recoarctation was evident 10 months after the second repair. The unusually early recoarctation was presumably due to residual and active duct tissue in the repair margins.     

Giant peripheral aneurysm of the posterior inferior cerebellar artery treated with excision and end-to-end anastomosis

A patient with a giant aneurysm arising from the tonsillomedullary segment of the posterior inferior cerebellar artery (PICA) presented with clinical and computed tomography findings suggestive of spontaneous cerebellar hemorrhage. Magnetic resonance imaging led to arteriography and the correct diagnosis. Lack of a clippable neck on the aneurysm and its location proximal to the choroidal point prompted treatment by excision of the aneurysm and end-to-end anastomosis of the PICA. No neurological deficit resulted from the procedure.     

Degeneration and regrowth of adrenergic nerves after microvascular anastomosis. A fluorescence histochemical study on end-to-end anastomoses of femoral vessels in the rat

The normal femoral artery and its branches were found to be innervated with a dense network of adrenergic nerves. The nerve plexus around the vein was sparse. Adventitial stripping of the femoral vessels, with or without division and reanastomosis, caused local disappearance of catecholamine fluorescence in the stripped area. The distal adrenergic innervation remained normal if the femoral nerve was left intact. Division of the femoral nerve, alone or in combination with blood vessel division and reanastomosis, caused total disappearance of catecholamine fluorescence from the adrenergic nerves of the entire distal neurovascular tree examined. At the end of the observation period of 36 weeks from the time of division of the nerve, artery and vein with subsequent microvascular anastomosis, numerous adrenergic nerves were observed to have crossed the suture line. The vascular nerve plexus around the femoral vessels was dense in places, but in other places sparse or absent. It seems that the reinnervation occurs not only over the suture line, but also together with other regenerating nerves from the adjacent tissues and by collateral sprouting from adjacent adrenergically normally innervated areas.     

Influence of the type of anastomosis: end-to-side anastomosis versus end-to-end.

The by-pass technique of arterial reconstruction has some theoretical disadvantages, particularly, unnecessary abandoning of useful main arteries, undesirable flow patterns and the possible descent of debris from the by-passed portion of artery. An oblique end-to-end technique can avoid these undesirable features and also avoid the creation of an over-sized vessel at the site of end-to-side anastomosis. It is suggested that the least procedure compatible with success should be used in arterial reconstruction in the lower limb and an ascending range of options open to the surgeon is given.     

Growth of the hypoplastic aortic arch after simple coarctation resection and end-to-end anastomosis.

Surgical treatment of a hypoplastic aortic arch associated with an aortic coarctation is controversial. The controversy concerns the claimed need to surgically enlarge the diameter of the hypoplastic arch, in addition to resection and end-to-end anastomosis. The purpose of this prospective study is to determine the fate of the hypoplastic aortic arch after resection of the aortic coarctation and end-to-end anastomosis. Between July 1, 1988, and January 1, 1990, 15 consecutive infants less than 3 months of age with an aortic coarctation were evaluated echocardiographically. A Z-value was calculated, being the number of standard deviations the aortic arch differs from the expected value, derived from a control group. Eight of these 15 infants had a hypoplastic aortic arch with a mean Z-value of -7.14 +/- 1.39. The other seven infants had a "normal" aortic arch with a mean Z-value of -1.85 +/- 1.08. All 15 infants underwent simple coarctation resection and end-to-end anastomosis. Six months after operation the mean Z-value increased significantly in those with a hypoplastic arch to -1.08 +/- 0.69 (p less than 0.0001) and in those with a "normal" aortic arch to 0.106 +/- 0.99 (p = 0.004). No infant died in our series (0%; CL 0% to 12%) and a recoarctation developed once (12.5%; CL 2% to 36%). Therefore we believe that simple resection and end-to-end anastomosis is the operation of choice for aortic coarctation associated with a hypoplastic aortic arch despite the presence of a ventricular septal defect and that enlargement of the hypoplastic aortic arch is not necessary.     

Microvascular carotid end-to-end anastomosis with the Argon laser

A carotid end-to-end anastomosis was performed in 50 Wistar rats (mean weight 260 g) by means of a Coherent 900 Argon laser. A micromanipulator coupled to an operating Zeiss OPMI 1 microscope provided a beam with a focused spot of 150 m in diameter. After 2 stitches were made (180° apart from each other) to obtain good adjustment of the arterial ends, vessel anastomosis was achieved on common carotids (0.7–1.2 mm in diameter) using 19 laser shots of a mean power output of 300 milliwatts (mW) (1,700 W/cm²) for 5 sec. Good vascular flow was confirmed by Doppler spectral analysis and angiography performed on day 0, 3, 10, 20, and so forth up to 7 months. Light and scanning electron microscopy showed that the heating effects of the Argon laser caused collagenous fusion of the media on day 0, while the sealing line became reendothelialized on day 10. The patency rate was 76%. Complications such as thrombosis, disruption, and aneurysm must be attributed to initial technical drawbacks.

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Resumen Se realizó la anastomosis término-terminal de la carótida en 50 ratas (peso promedio 260 g) por medio del laser de Argón Coherent 900. Un micromanipulador conectado a un microscopio operatorio Zeiss OPMI 1 provee un haz con un foco de 150 m de diámetro. Después de colocar 2 suturas (a 180° de separación la una de la otra) para lograr una buena aposición de los extremos vasculares, la anastomosis vascular fue realizada sobre las carótidas primitivas (0.7–1.2 mm de diámetro) utilizando 19 disparos de laser de una potencia promedio de 300 mW (1,700 W/cm²) por 5 segundos. Buen flujo vascular fue confirmado mediante análisis espectral con Doppler y angiografía realizados en los días 0, 3, 10, 20, hasta 7 meses. Microscopía de luz y de tamizaje electrónico mostró que los efectos calorigénicos del láser de Argón causó fusión colagenosa del medio en el día 0, en tanto que la línea de sellamiento apareció re-endotelizada en el día 10. La tasa de permeabilidad fue de 76%. Complicaciones tales como trombosis, ruptura, y formación de aneurisma deben ser atribuidas a problemas con la técnica operatoria.

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Résumé Les auteurs réalisent sur 50 rats Wistar (poids moyen 260 g) une anastomose carotidienne croisée termino-terminale grâce à un laser argon (Coherent 900). Un micromanipulateur couplé à un microscope opératoire (OPMI 1 Zeiss) permet d'utiliser un faisceau de 150m de diamètre. L'anastomose est effectuée sur la carotide commune (0.7– 1.2 mm de diamètre), les extrémités vasculaires ayant été préalablement rapprochées par 2 fils (à 180° de distance). En moyenne 19 impacts de 300 milliwatts (mW) (1,700 W/cm²) et de 5 sec. sont nécessaires pour obtenir la soudure. La qualité de l'anastomose est confirmée par des controles Doppler et angiographiques réguliers de J₀ à J₂₁₀. La microscopie optique et éléctronique à balayage montre une fusion immédiate du collagène et une ré-endothélialisation dès J₁₀. Le taux de réussite de la série est de 76%. Les complications (thrombose, lâchages anastomotiques ou anevrysmes) sont expliquées par les difficultés techniques de la mise au point initiale.

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Presented at the Société Internationale de Chirurgie in Paris, September 1985.     

Biliary injury after laparoscopic cholecystectomy: end-to-end anastomosis covered with umbilical vein

The management of biliary injuries after laparoscopic surgery presents a surgical challenge. We describe a promising method of biliary reconstruction with umbilical vein covering followed by end-to-end anastomosis. In the patient reported here, the umbilical vein was identified in the pedicled ligamentum teres, transected as if it were a sheet, and sutured, then covered ventrally to the anastomosed bile duct. This procedure may be a promising reinforcement of the reconstructed site which maintains the biliary integrity; however, it can be applied, only in selected situations.     

Purse string placement for staple anastomosis using the end-to-end anastomosis stapling instrument.

There may be technical difficulties in the use of recommended clamp for the insertion of the purse-string suture during the construction of an end-to-end staple anastomosis. Hand sewing the purse string eliminates some of the problems, but unless the suture is positioned within a few millimetres of the cut edge of the bowel, ischaemic tissue may be included in the staple line. In dogs, this leads to anastomotic dehiscence. The anastomosis may, however, be protected by excising the ischaemic tissue and reinforcing the staple line with sutures. An "over and over" purse-string technique is now preferred to minimize the risk of this occurring.     

Restoration of external urethral sphincter function after pudendal nerve end-to-end anastomosis in the male rabbit

PURPOSE: In this study we rehabilitated external urethral sphincter function by pudendal nerve end-to-end anastomosis after experimental pudendal nerve axotomy in male rabbits. MATERIALS AND METHODS: A total of 17 animals were included in this study, including group 1-a control group of 5 (29.4%), group 2-6 (35.3%) and group 3-6 (35.3%). Animals from group 2 underwent bilateral axotomy and group 3 underwent pudendal nerve end-to-end anastomosis. In all groups we performed urodynamic investigations prior to axotomy, after axotomy or anastomosis, and 14, 42 and 90 days after axotomy or nerve anastomosis. RESULTS: In untreated group 1 control sphincter pressure was 28.5 cm H2O. In group 2 average urethral sphincter pressure was 5.6 cm H2O 14 days after axotomy with only a slight increase to 11.05 cm H2O by day 90. In group 3 external urethral pressure increased to 8.26 cm H2O after 14 days and to 21.32 cm H2O by postoperative day 90. CONCLUSIONS: External urethral sphincter deficiency after bilateral pudendal nerve axotomy demonstrates the primacy of the pudendal nerve in the innervation of the external urethral sphincter. We were able to rehabilitate external urethral sphincter function by performing pudendal nerve end-to-end anastomosis.