Healing of experimental colonic anastomoses. I. Bursting strength of the colon after left colon resection and anastomosis.

Mechanical strength of the left colon with anastomosis and the intact transverse colon was studied by the bursting strength technic from four to fourteen days after standardized left colon resection in the rat. Two different single layer inverting suture technics were used, continuous suture and interrupted sutures. Bursting strength was tested by determinations of both bursting pressure and bursting wall tension, both of which provided the same information concerning mechanical strength of the colon. The bursting strength test measures the anastomotic strength only during the early stages of healing, since more than 90 per cent of the left colon segments ruptured outside the anastomosis as early as day 7. The two different suture technics resulted in the same bursting strength of the left colon segment with anastomosis. Both types of anastomoses showed a moderate narrowing at the anastomotic line upon inflation. This was due to the fact that the anastomosis constituted a relatively firm fibrotic ring from day 7, and both types of anastomoses had an equal inner diameter at that time. By supporting the colonic wall above and below the anastomosis, it could be calculated that the anastomosis on day 7 withstood at least 50 per cent higher circular wall tension than the surrounding colonic wall.There was no correlation between collagen concentration of the colonic wall and bursting strength of the colon either in unoperated controls or after resection and anastomosis. When interrupted sutures were used for anastomosis of the left colon, bursting strength of the intact transverse colon was significantly higher on day 7 than when continuous suture was used. It actually exceeded that of the transverse colon in unoperated controls by almost 50 per cent on the seventh postoperative day, although the collagen concentration in the transverse colon was within normal range. This finding indicated changes in the proximal colonic wall after left colon resection, which are probably related to changes in the structure or arrangement of collagen.     

Healing of experimental colonic anastomoses: III. Collagen metabolism in the colon after left colon resection

In a previous study it was shown that resection and anastomosis of the left colon is accompanied by a marked reduction of collagen concentration in the colon. These changes were not confined to the immediate vicinity of the anastomosis but extended a considerable distance along the bowel and were more marked proximally than distally. Whether the decrease in collagen concentration is due to decreased synthesis or increased breakdown of collagen was studied in the present work by measuring the rate of collagen synthesis and comparing the observations with changes in net amounts of collagen.Synthesis of collagen was studied using pulse labeling with ³H-proline. Studies on the time course of incorporation showed a biphasic pattern with maximal specific activities of collagen 4 and 24 hours after injection of the precursor. The maximal labeling occurred after 24 hours. At that time 75 to 90 percent of the label was present in insoluble collagen, indicating a high rate of turnover. Comparison of net amounts with the rate of synthesis indicates an increased breakdown of collagen. The reaction was clearly most pronounced proximal to the anastomosis. During the first 4 postoperative days breakdown (lysis) dominated. On the 7th day increased net amounts of collagen indicate that synthesis had begun to outbalance processes that break down collagen. The results indicate that the entire colon reacts to the trauma of resection and anastomosis and that in healing of the colon a delicate balance exists between the synthesis and breakdown of collagen.     

Healing of experimental colonic anastomoses. The effect of suture technic on collagen concentration in the colonic wall.

The present experimental study in rats has demonstrated a marked difference in the healing process of anastomoses in the left colon following two different suture technics: continuous and interrupted sutures. Rats having anastomoses constructed of continuous suture showed a high incidence of complications and a marked decrease of collagen concentration in the anastomosis and in the colonic wall proximal to the anastomosis during the first week of healing. In animals with anastomoses made of interrupted sutures there were fewer complications, the decrease in collagen concentration was confined to the anastomotic region, and the recovery of collagen concentration occurred earlier. The findings indicate that the interrupted suture technic is preferable for anastomosis in the left colon.     

Breaking strength of small intestinal anastomoses

The breaking strength of standardized small bowel anastomoses at different times after surgery was studied in the rat. The anastomotic strength with sutures in place successively decreased during the first 3 postoperative days to approximately 15 percent of the immediate postoperative value. This indicates a rapid decrease in the suture holding capacity of the gut wall in the early postoperative course. From the fourth day onward a rapid increase in strength was recorded. This could be due not only to deposition of collagen in the tissue bridging the anastomosis but also to the regained capacity of the gut wall to withstand tearing forces. After 14 days the strength of the anastomosis was due mainly to healing, and the relative contribution from the sutures was negligible. It may be that tearing of sutures through the tissue is more important than defective healing for anastomotic complications.     

Effect of diverting colostomy on breaking strength of anastomoses after resection of the left side of the colon. Studies in the rat

In the present investigation, the effect of a proximal diverting colostomy on suture holding capacity and on anastomotic strength of the excluded left colon was studied. Suture holding capacity was increased 7 days after fecal diversion. Anastomotic strength development, however, was significantly delayed. These differences were accompanied by a diminished collagen response in the anastomotic region after fecal diversion. This might suggest impairment of healing in the excluded colon. The gross appearance of the anastomoses would, however, indicate that increased collagen formation and greater strength development in animals without colostomy is a result of more complicated healing.     

Effect of diverting colostomy on collagen metabolism in the colonic wall. Studies in the rat

The effect of total bowel rest by colostomy on collagen metabolism was studied. Fecal diversion led to a marked decrease of collagen and protein synthesis in the excluded colon. These changes were accompanied by a decrease in the amount of collagen and noncollagenous components. In the colonic part proximal to the colostomy site, a less marked decrease in collagen content was observed. It was concluded that stimulation of intraluminal bulk might be important as a regulating factor for collagen turnover. It remains to be determined if the observed changes in collagen metabolism affect colonic healing.     

Surgical treatment of thyroid carcinoma in a defined population: 1960 to 1977. Evaluation of the results after a conservative surgical approach

Ninety patients from a demographically well-defined area of, on an average, 243,000 inhabitants were surgically treated for thyroid carcinoma during an 18 year period. Sixty-five of the patients had papillary carcinoma, 20 follicular carcinoma, 4 medullary carcinoma, and 1 anaplastic carcinoma. Seventy-eight patients were operated on for cure, and among them, 23 had total thyroidectomy and 55 partial thyroidectomy. Additional therapy with thyroxine was given to all patients postoperatively. None of the patients treated for cure died from thyroid carcinoma at follow-up 2 to 20 years after diagnosis. One of 42 patients (2.4 percent) primarily treated for cure with lobectomy for papillary carcinoma had local recurrence in the thyroid bed which was excised successfully. No patient treated for cure of follicular carcinoma had local recurrence. All verified recurrences except one were diagnosed within 5 years of primary operation. We conclude that local recurrence after procedures less than total thyroidectomy that are considered to be curative is unusual provided that thyroxine is given postoperatively. Thus it seems that the reported high rates of microscopic carcinoma in the contralateral lobe in patients with unilateral cancer have little clinical significance. A conservative approach in most patients with localized thyroid carcinoma is indicated because it reduces the risk of postoperative complications.     

Effects of lysine-vasopressin on blood loss and haemodynamics after early excision in burned pigs

EARLY excision of deep dermal burns changes the pathophysiological events and may shorten healing time provided the wounds can be covered with grafts (Haynes, 1969; Jan?ekovi?, 1970; Mac Millan, 1971; Burke et al., 1976). Major blood loss is difficult to avoid and makes excision difficult or impossible. Vasopressin, a powerful peripheral vasoconstrictor, has been found to increase cardiac output and to improve the perfusion of vital organs under hypovolemic conditions (Ericsson, 1971; Wetterlin et al., 1977). Such effects may prove favourable during early excision of burns. In order to study the effects of lysine-vasopressin (LVP) on bleeding and haemodynamics, pigs were burned and submitted to acute excision with and without LVP-treatment.     

Osteochondritis dissecans and brachymesophalangia: a hereditary syndrome

A kindred with an unusual congenital hand and foot anomaly is presented. It is an autosomal dominant hereditary disorder characterized by brachymesophalangia, slight clinodactyly, deformed metacarpal heads, osteochondritis dissecans in metacarpophalangeal joints, absence or hypoplasia of the ulnar styloid processes, and brachyhypophalangia in the feet.     

Single-layer anastomosis of the colon. A review of 165 cases.

One hundred sixty-five patients undergoing elective colorectal or colonic anastomoses with a one-layer technic are presented. One death from suture line dehiscence was noted, and the overall mortality was 2.4 per cent. The usual technic for esophagogastrointestinal suturing in French surgical centers is described and the importance of suture technic in the etiology of anastomotic leaks is discussed.     

Late precancerous changes and carcinoma of the gastric stump after Billroth I resection

Carcinoma of the gastric remnant after resection for benign ulcers is regarded as a rare complication after Billroth I resection. In seventy-four patients reexamined by gastroscopy and multiple biopsies ten to twenty-two years after gastric resection four cases of cancer of the gastric stump were diagnosed and the patients operated on. Another eight patients had regenerative polyps and one patient had a tubular adenoma. The histologic findings in gastroscopic biopsy specimens from the gastric stoma and fundus are compared. Possible precancerous changes and etiologic aspects are discussed briefly. Repeated gastroscopy is recommended starting about ten years after gastric resection for benign ulcers.     

Avulsion fracture of the lateral malleolus in children

Five girls under the age of 13 years with recurrent symptoms after ankle injuries were found on radiography to have a bony fragment close to the tip of the fibula. At operation it was found that the fragment was attached to the proximal end of the anterior talofibular ligament except in one case in which the fragment had no ligamentous attachment. In the latter case a rupture of the anterior talofibular ligament itself was also found. There was no sign of ankle instability. Removal of the fragments relieved the symptoms in each girl and it is suggested that the symptoms in such cases are due to the bony fragment rather than to ligamentous injury.     

Deficient collagen formation by obese mice in a standard wound model.

Poor healing was demonstrated in two different experimental models of diabetes mellitus. In one model, there was an absolute lack of insulin and in the other, a resistance to insulin. A review of the history of the results of surgery in diabetic patients shows that in the clinical situation, wound failure is associated with both a lack of insulin and a resistance to insulin. Thus, the causes of wound failure in diabetic patients include a failure of insulin to perform its normal role in healing. This does not exclude other causes such as "small vessel disease" as etiologic factors, but it does suggest that control of metabolic derangements is beneficial to healing in diabetic patients who undergo operation.     

Selective celiac angiography and surgical exploration for suspected liver cancer: A comparative study of 196 patients

In 196 patients subjected to celiac angiography and exploratory laparotomy for suspected liver tumor, 81 per cent of the tumors were diagnosed by angiography, 26 per cent of patients had false-negative angiograms, and 16 per cent had false-positive angiograms. Diagnosis on laparotomy proved correct except in one patient. Of 22 patients with liver tumors not diagnosed on angiography, 10 could be specifically treated and 3 of them have survived more than one year. This gain is discussed in relation to the rather high number of unnecessary laparotomies.     

Release of acid hydrolases in hemorrhagic shock after pretreatment with hydrocortisone in the pig

An experimental study of the effect of pharmacologic doses of hydrocortisone in hemorrhagic shock in the pig is described. Oligemic hypotension was induced for sixty minutes by maintaining the mean arterial blood pressure at 30 mm Hg. Pretreatment with hydrocortisone (50 mg/kg of body weight) suppressed the plasma activity of the acid hydrolases β-D-glucosidase and β-D-galactosidase compared with that in a control group. In addition, treatment with steroids reduced the degree of metabolic acidosis and hyperpotassemia. After reinfusion of the shed blood the arterial blood pressure was higher in the group treated with steroids.The results of this study indicate that glucocorticoids have a protective effect in hemorrhagic shock in pigs. This action seems to occur primarily at a metabolic level rather than by direct interference with the general circulation.     

A clamp technique for intestinal anastomosis.

A technique of inverting intestinal anastomosis is described. This technique is based on a continuous lockstitch of absorbable material for the inner row aided by strategically placed Allis clamps. Its advantages are mainly greater speed and safety and precise apposition even when marked discrepancies in bowel diameter exist.     

Development of portasystemic shunts after subcutaneous transposition of the spleen in the rat

Transposition of the spleen to the abdominal subcutaneous tissue in rats was performed, and the development of collaterals between the portal and systemic venous vessels was studied. The effects of different modifications in operative technic and of the time lapse after transposition on the development of these anastomoses were examined. The capacity of the collaterals was studied by determining survival after acute portal ligation, by recording portal pressure, and by performing angiography. The clinical significance of the method described is still to be demonstrated.     

Experimental nonsuture colonic anastomoses

A comparative study of sutured colonic anastomoses and anastomoses made by isobutylcyanoacrylate was performed in 60 rats. No difference in the strength of the anastomoses, as expressed by the bursting pressure, was found, and there was no difference in the frequency of adhesions or stenoses, provided the cyanoacrylate was meticulously covered by omentum. Histologic evidence of delayed healing was observed in the cyanoacrylate group; however, this did not seem to reduce the strength of the anastomosis. Provided it is covered with an omental tag, isobutylcyanoacrylate may prove to be a valuable adjunct to conventional suture techniques under special circumstances.     

Relation between early and advanced gastric cancer

Of 75 consecutive inpatients with gastric carcinoma during a 3.5 year period, 40 underwent operation with the intention of cure, 5 had palliative gastric resection and 30 had exploratory celiotomy only. Early gastric cancer was found in 11 cases, that is, 15 percent of patients with gastric carcinoma or 24 percent of patients subjected to gastrectomy. The patients with early gastric cancer were operated on with the intention of cure.Comparison with a previous series from the same geographic area shows that the ratio between early gastric cancer and all gastric cancer increased significantly. This improvement in the management of patients with gastric carcinoma can be ascribed to the use of gastroscopy and biopsy. The survival rates in patients with early gastric cancer are excellent. The prognosis in patients with advanced gastric cancer, on the other hand, is poor and has remained so for the last 30 to 40 years.Twelve of the 75 patients had gastric stump carcinoma; 2 of these were early gastric cancer. Screening of asymptomatic patients for gastric cancer is at present an impossible task in most Western countries, but the risk of cancer after partial gastrectomy for benign lesions makes screening desirable in this selected group of patients.     

Changes in blood clotting and fibrinolysis after liver ischemia in pigs

Ten pigs were subjected to fifteen minutes of liver ischemia and four pigs to sixty minutes of liver ischemia. After fifteen minutes of ischemia three of ten animals showed a significant prolongation in the recalcification time. There was no decrease in clotting factors to explain the prolongation. The increase in fibrinolytic activity was similar in the three pigs with and the seven pigs without a prolonged recalcification time. There were no changes in fibrinogen concentration in any of the animals. Dilution tests for determining the circulating anticoagulants strongly indicated the presence of an anticoagulant in the plasma samples with a prolonged recalcification time.All four animals subjected to sixty minutes of liver ischemia showed a moderate prolongation in the recalcification time of longer duration but not of the same magnitude as that of the animals having fifteen minutes of liver ischemia. The prolongation in the recalcification time in this group was probably a result of a decrease in clotting factors.