Bowel Cleansing Before Bowel Surgery: Major Discordance Between Evidence and Practice

Mechanical bowel cleansing (preparation) before colorectal surgery is commonly practiced, and medical care guidelines consent to this regimen. This has been an incontestable routine for surgeons for more than 100 years. However, during the last years, several randomized control trials and three meta-analyses led to the accumulation of enough evidence to conclude that no significant benefit is derived from this practice and thus, elective colorectal surgery can be safely done without mechanical bowel cleansing. Furthermore, several complications are attributed to mechanical bowel cleansing including anastomotic leakage, wound infections, and septic and non-septic complications that sometimes lead to the need for reoperation. Surgeons around the world may have to seriously reconsider the common practice of preoperative mechanical bowel cleansing. Despite the unquestionable practical value of mechanical bowel cleansing for bowel handling during anastomotic confection, we believe that current literature provides strong evidence that passed the line where this time-honored tradition may be finally called into question.     

The effect of tissue adhesive, octyl-cyanoacrylate, on the healing of experimental high-risk and normal colonic anastomoses

BACKGROUND: Tissue adhesives may be advantageous over sutures in colonic anastomoses because they do not result in potentially dangerous tight tissue approximation. METHODS: Ninety male Wistar-albino rats were used in the study. Excluding the 10 animals that constituted the control, the rest of the animals were divided in two groups: normal (N) and high-risk (HR). Only resection and anastomosis were done on half of the animals in each group. Octyl-cyanoacrylate was applied on the anastomosis of the other half of the groups. Anastomotic assessment was done at the third and seventh postoperative days. Gross anastomotic healing, mechanical strength, hydroxyproline deposition, and histopathological healing indices were used for the assessment. RESULTS: There was no difference in the third day and the seventh day groups regarding the gross healing parameters and hydroxyproline concentration. Similarly there was no difference between the third day groups in terms of mechanical healing (P = 0.669). However, the mechanical strength of the anastomosis assessed the seventh postoperative day was lower in groups in which octyl-cyanoacrylate was applied (P <0.001). Furthermore, inflammatory reaction, presence of necrosis, peritonitis, and exudate was pronounced in groups in which octyl-cyanoacrylate was applied. CONCLUSIONS: Application of octyl-cyanoacrylate to both normal and high-risk colonic anastomosis does not provide any benefit over conventional suturing at the early phase of the healing. However, octyl-cyanoacrylate seems to be detrimental at the late phase of the healing probably due to the ongoing intense inflammatory reaction.     

Scanning electron microscopy in different techniques of microvascular anastomoses: categorization and factors affecting. A descriptive work

Many researchers have investigated microvascular anastomoses by scanning electron microscope (SEM); however, there are neither reports on classifying these anastomotic types according to the SEM results nor about studying the factors that affect these results. Sixty rat femoral arteries were anastomosed using four different techniques: simple interrupted, continuous, sleeve, and autogenous arterial cuff. The anastomotic sites of each group and other two intact femoral arteries were examined by SEM. Intimal disruption and rebuilding of the blood vessel endothelium after microvascular anastomoses depend upon anastomotic time; suture placement, either intra-luminal or extra-luminal; and mechanical factors. Accordingly, the simple interrupted suture technique has the highest degree of intimal disruption and the lowest degree of regeneration, the continuous and cuff anastomoses have better rebuilding with partial neo-endothelial coverage of the cut ends, whereas the sleeve anastomosis has the best regeneration with complete coverage of the cut ends by the new endothelial cells. Presented in the Fifth Congress of the World Society of Reconstructive Microsurgery (WSRM), Athens, Greece, June 2007.     

Comparative surgical and colonoscopic appearance of colon anastomoses constructed with sutures,staples, and the biofragmentable anastomotic ring

Summary The following animal study was undertaken to compare and assess the endoscopic gross appearance and histology of colonic anastomoses constructed with sutures, staples, and the biofragmentable anastomotic ring (BAR).Methods: Three anastomoses—1 BAR, 1 stapled, and 1 sutured—were placed in each of 48 dogs and colonoscopy and anastomotic evaluation were done.Results: No leaks were found by air insufflation at surgery. Grossly, the BAR had serosal hematomas in 27/48 anatomoses vs 7/48 for stapled and 1/48 for sutured (BAR vs stapledP<0.0005 and sutured vs stapledP=0.07). Adhesions were significantly greater for BAR (35/36) and sutured (34/36) compared to stapled (26/36) (BAR vs stapledP=0.01 and sutured vs. stapledP=0.04). Colonoscopic exams at days 3, 7, and 28 showed no significant difference among groups with respect to bleeding, ulceration, necrosis, granulation, or contour. Sutured anastomoses were more stenotic (24/31) than stapled (4/31) or BAR (3/31) ones (BAR vs sutured and sutured vs stapledP<0.005). At 28 days, 10/10 sutured vs 2/10 stapled vs 3/10 BAR were stenotic (BAR vs suturedP=0.02, sutured vs stapledP=0.01). Inflammation on histologic exam at 28 days was not significantly different: sutured (12/12), stapled (12/12), or BAR (9/12). Fibrosis was more prominent in sutured (12/12) than in stapled (5/12) or BAR (4/12) anastomoses (BAR vs suturedP=0.001, sutured vs stapledP=0.004, and BAR vs stapledP=1.00). All anastomoses healed primarily without necrosis or obstruction.Conclusions: (1) Colonoscopy to evaluate anastomoses can be done safely even in the early postoperative period. (2) The BAR anastomoses had the most serosal hematomas; BAR and sutured had more adhesions than stapled anastomoses; and sutured anastomoses had the most stenosis and fibrosis. None of these differences was of clinical significance.     

Effects of a static magnetic field on wound healing: results in experimental rat colon anastomoses

BACKGROUND: Research has shown that pulsed electromagnetic fields (EMFs) promote wound healing in experimental colonic anastomosis; however, the effects of static EMFs in this setting have not been investigated to date. METHODS: Fifty male Wistar rats were used. Ten served as controls for mechanical strength testing, and the other 40 underwent descending colon resection and anastomosis. Twenty of these 40 animals (M group) had NeFeB magnets placed in contact with the anastomosis site (magnetic field strength at the site 390 to 420 G). The other 20 animals (sham [S] group) had non-magnetized NeFeB bars of the same dimensions and weight implanted. Half of the animals in each group were killed and assessed for healing parameters on postoperative day 3 (M3 and S3 groups) and the other half on postoperative day 7 (M7 and S7 groups). Four types of assessment were done: gross healing, mechanical strength, hydroxyproline deposition, and histopathology. RESULTS: There were no differences between the M and S animals with respect to gross healing parameters. The mechanical strength was also not different between groups (23.8 +/- 12.7 and 24.7 +/- 9.6 mm Hg for M3 and S3, respectively; P = .863 and 91.3 +/- 65.4 and 94.8 +/- 55.9 mm Hg for M7 and S7, respectively; P = .902). Similarly, hydroxyproline deposition was not different between groups on postoperative day 3 or day 7. On postoperative day 3, the M group had significantly higher scores than the S group for fibroblast infiltration (2.4 +/- 0.7 vs 1.4 +/- 0.7, respectively; P = .008) and capillary formation (2.5 +/- 0.7 vs 0.9 +/- 0.4, respectively; P <.001). However, these effects were reversed and did not endure by day 7. CONCLUSIONS: The study results suggest that static EMF has no effect on experimental colonic wound healing in the rat.     

Death after Bowel Resection: Patient Disease, Not Surgeon Error

Introduction  Although bowel resection is associated with a significant mortality rate, little is known about the demographics of the patients and how often surgical error is the primary cause of death. We sought to use a rigorous prospective quality database incorporating standardized peer review, to define how often patients die from provider-related causes. Materials and Methods  All patients undergoing bowel resection with anastomosis at a university hospital from July 2003 to June 2006 were entered into a prospectively maintained quality database. Patients were seen daily with house staff by a specially trained nurse practitioner who recorded demographics and complications. Clinical case reviews were conducted monthly. Five hundred sixty-six patients underwent bowel resection with anastomosis during the study period. Discussion  One hundred ninety-three patients suffered at least one complication (34.1%) and there were 20 deaths (3.5%). In 17 cases, death was deemed unavoidable due to patient disease; most occurred in patients who developed ischemic bowel while hospitalized for a serious concomitant illness. In only one case did death appear clearly related to a surgical complication (0.17%). Death after bowel resection typically reflects the need for urgent surgery in extreme circumstances and not surgeon error. Postoperative mortality rate in this population appears to be poor indicator of surgical quality. Podium presentation at the American Society of Colon and Rectal Surgeons Annual Meeting, Boston, MA, June 2008.     

食管胃套接术与器械吻合术治疗食管、贲门癌的对比研究

目的对比食管胃套接术与器械吻合术的临床治疗效果,以减少食管、贲门癌根治术后并发症的发生率. 方法将285例诊断明确的食管、贲门癌住院患者按入院顺序随机分为两组,食管胃套接组(套接组)134例,采用食管癌切除食管瓣片成形-食管胃套接术;器械吻合组(吻合组)151例,采用食管癌切除器械吻合术.术后观察吻合口瘘、吻合口狭窄和胃食管反流并发症的发生率,并随访观察3年. 结果套接组术后吻合口瘘、吻合口狭窄和胃食管反流的发生率分别为0%、2.2%和1.5%,而吻合组为1.3%、13.9%和21.2%(P<0.01). 结论食管瓣片成形-食管胃套接术术后并发症少、操作简单,较器械吻合具有一定的优越性.     

The effects of local and sustained release of fibroblast growth factor on wound healing in esophageal anastomoses

Background/Purpose

Postsurgical complications, such as anastomotic leaks in patients with esophageal atresia, have remained unchanged during the last 3 decades. Growth factors enhance healing in several wound-healing models. Therefore, an experimental study was used to evaluate the effects of local and sustained release of basic fibroblast growth factor (FGF) on wound healing in esophageal anastomoses.

Materials and Methods

Twenty-four male Wistar albino rats, which were subjected to a 1-cm segmental resection of the abdominal esophagus followed by end-to-end anastomosis, were allocated into 3 groups. Group I, the control group, had no gelatin film applied to the anastomosis. In group II (gelatin film without FGF) and group III (gelatin film with FGF), anastomoses were covered with unloaded and 2.55 μg FGF-loaded gelatin films, respectively. On postoperative day 7, bursting pressures, histopathologic collagen deposition, and tissue hydroxyproline concentrations of the anastomoses were then analyzed and compared.

Results

Mean bursting pressures, mean submucosal and muscular collagen deposition scores, and mean tissue hydroxyproline concentrations differed significantly between groups. Mean bursting pressures were 22.5 ± 3.1 mm Hg in group I, 29 ± 1.6 mm Hg in group II, and 63.2 ± 6.8 mm Hg in group III (P < .001). Mean submucosal collagen deposition scores (group I: 0.7 ± 0.2, group II: 0.7 ± 0.1, group III: 1.5 ± 0.2; P = .02) and mean muscular collagen deposition scores (group I: 0.8 ± 0.2, group II: 0.8 ± 0.1, group III: 1.8 ± 0.1; P = .01) were significantly higher in FGF animals than the other in the other 2 groups. Mean tissue hydroxyproline concentrations were 2.4 ± 0.5 μg/mg in group I, 3.9 ± 0.4 μg/mg in group II, and 6.0 ± 1.0 μg/mg in group III (P = .007).

Conclusion

Local and sustained release of FGF enhanced wound healing in esophageal anastomoses in this animal model.     

改良襻式与Roux-en-Y胆肠吻合术对胃肠动力及结构影响的比较

目的 探讨改良襻式与Roux-en-Y胆肠吻合术对肠道蠕动功能与结构的影响.方法 15只新西兰兔分为改良组、R-Y组和对照组,分别检测胆肠吻合术前和术后25 d开腹状态下空腹慢波频率(SWF)、术后21 d再次开腹前的空腹SWF及其在移行性复合运动中的顺行扩布率(MMC%)、餐后峰电位频率(SPF)及其顺行扩布率(SP%),并进行电生理学比较.术后90 d改良组取输入襻缝扎段及输出襻组织,R-Y组取胆汁引流襻上段肠组织分别行HE染色、c-kit标记染色及透射电镜观察.结果 术后改良组SWF较术前减少8.4%,R-Y组减少23.8%(P＜0.05).术后21 d开腹前改良组SWF及SPF较对照组减少(P＜0.05);R-Y组各指标均较其他组减少(P＜0.01).改良组输入襻近端电活动能通过缝扎段顺行扩布;R-Y组胆汁引流襻上段存在异位起搏点并呈逆行扩布.改良组输入襻缝扎段未见复通,其肠腔闭塞伴黏膜层轻度萎缩;免疫组织化学法及透射电镜示内环肌层存有正常Cajal间质细胞(ICCs).R-Y组胆汁引流襻稍扩张,c-kit阳性面积与改良组比较无差异,电镜下ICCs与神经末梢、平滑肌细胞缝隙连接减少.结论 胆肠吻合术后,改良组实验兔肠蠕动轻度减弱,但能维持正常扩布方向;R-Y组术后肠襻动力障碍可能由ICCs与周围细胞连接异常引起.     

A comparison of robotic, laparoscopic, and hand-sewn intestinal sutured anastomoses performed by residents

BACKGROUND: Robotic surgery offers all the advantages of laparoscopy with additional increased accuracy. The use of robotic surgery has increased in the past 5 years. It has proven particularly useful in complex surgical procedures such as intracorporeal intestinal anastomosis. As the prevalence of robotic surgery increases, so will the need for residents to be able to perform surgery using the robotic system. Our goal was to compare hand-sewn, laparoscopic, and robotic suturing techniques performed by midlevel residents using a porcine intestinal model. METHODS: Fifteen residents unfamiliar with the robotic suturing technique participated in performing an initial hand-sewn suture line and then were randomized with cross-over to laparoscopic or robotic suturing. Completion time, leak pressure, number of sutures per cm, and difficulty level were assessed. RESULTS: The mean leak pressure for hand-sewn, laparoscopic, and robotic suturing was 9.5, 3.2, and 11.4 mm Hg, respectively. The laparoscopic group had 6 and the robotic group had 1 suture line that was inadequate for testing. Suture breakage was common in the robotic group. The anastomosis was considered hard by 92% in the laparoscopic group versus 17% in the robotic group. The time it took to complete 1 cm of anastomosis was .9, 8.7, and 8.3 minutes for hand-sewn, laparoscopic, and robotic suturing, respectively. CONCLUSION: The robotic suture line performed by midlevel residents was superior to laparoscopy, although the time for anastomosis was equivalent.     

磷酸钠盐和聚乙二醇电解质口服溶液用于肠道准备的研究

目的评价比较口服磷酸钠和聚乙二醇电解质法对肠道清洁的效果及患者的耐受性和安全性。方法将115例住院需行肠道准备的患者按随机数字表随机分组分别应用磷酸钠盐口服液（NaP,试验组）和聚乙二醇（PEG,对照组）进行肠道清洁,通过患者的主观和客观感受、水电解质检测指标和结肠镜肠道清洁效果的评估,对两种肠道准备方法进行比较。结果试验组患者的耐受性评估为（13．5±0．8）分,明显高于对照组的（8．4±0．7）分（t=4．91,P〈0．05）;试验组未饮完率1．8％,与对照组的8．8％比较,差异有统计学意义（P〈0．05）。试验组有效率96．6％,对照组89．5％,两组比较差异有统计学意义（P〈0．05）。试验组与对照组肠道准备前后血清无机磷、血钾和血钙变化百分比分别为64．49±63．83与0．32±12．41、-8．22±6．52与-2．64±12．38和-3．22±5．10与0．83±2．68,两组差异有统计学意义（P〈0．05）。电解质变化在24h内恢复正常,未发现显著性临床效应。结论与聚乙二醇电解质液相比,口服磷酸钠有较好的耐受性和安全性及肠道清洁有效性。     

Bowel endometriosis: Recent insights and unsolved problems

Bowel endometriosis affects between 3.8% and 37% of women with endometriosis.The evaluation of symptoms and clinical examination are inadequate for an accurate diagnosis of intestinal endometriosis.Transvaginal ultrasonography is the first line investigation in patients with suspected bowel endometriosis and allows accurate determination of the presence of the disease.Radiological techniques (such as magnetic resonance imaging and multidetector computerized tomography enteroclysis) are useful for estimating the extent of bowel endometriosis.Hormonal therapies (progestins,gonadotropin releasing hormone analogues and aromatase inhibitors) significantly improve pain and intestinal symptoms in patients with bowel stenosis less than 60% and who do not wish to conceive.However,hormonal therapies may not prevent the progression of bowel endometriosis and,therefore,patients receiving long-term treatment should be periodically monitored.Surgical excision of bowel endometriosis should be offered to symptomatic patients with bowel stenosis greater than 60%.Intestinal endometriotic nodules may be excised by nodulectomy or segmental resection.Both surgical procedures improve pain,intestinal symptoms and fertility.Nodulectomy may be associated with a lower rate of complications.     

Bowel Obstruction in the Postoperative Period of Laparoscopic Inguinal Hernia Repair (TAPP): Review of the Literature

A case is presented of a male patient that presented with intestinal obstruction in the early postoperative period of a transabdominal preperitoneal inguinal repair (TAPP) that was diagnosed and repaired successfully using laparoscopy. Whenever a total extraperitoneal procedure (TEP) cannot be performed, the peritoneal closure of the TAPP should be done water-tight using interrupted stitches of absorbable monofilament sutures.     

Solitary and complicated neurofibroma of small Bowel: A case report

IntroductionNeurofibromatosis is a genetic disorder characterized by tumors and pigmentary changes on the skin, such as spots that color leans to ‘White Coffee’.Neurofibromas of the gastrointestinal tract are commonly associated with neurofibromatosis type I (NF1). Although, digestive involvement can be the single manifestation of the disease and may consequently; represent the only diagnostic element.Presentation of caseWe report here; a case of a patient admitted to the emergency department with a bowel obstruction, for which radiological investigations revealed the presence of intussusception due to an intestinal tumor.The patient underwent a bowel resection with anastomosis, and then, after being examined histologically, the result has identified an intestinal neurofibroma without evidence of malignancy. Then and on the fourth day following the surgery, the patient was discharged with good clinical improvement.DiscussionThe intestinal neurofibroma may be the first and the only manifestation of neurofibromatosis type I. Also, it’s uncommon to present a neurofibroma isolated from the small bowel with an intussusception, which makes the pre-surgical diagnosis very difficult. And until now, only a few case reports of these conditions have been reported.ConclusionWe report this uncommon clinical case of an isolated neurofibroma from the small bowel to raise awareness among the medical team about this exceptional pathology. Nevertheless, its risk of developing serious complications and malignant transformation led us to opt for earlier surgical treatment.Furthermore, it requires a close clinical follow-up to eliminate the neurofibromatosis type I or the multiple endocrine neoplasia type II.     

Double stapled haemorrhoidopexy for haemorrhoidal prolapse: indications,feasibility and safety

Aim Selected patients with haemorrhoidal prolapse undergoing double stapled anopexy with the procedure for prolapse and haemorrhoids (PPH03) were studied. Method Between March 2007 and March 2010, 235 patients referred with haemorrhoids were included in the study. Patients with obstructed defaecation were excluded. At surgery intraoperative evaluation for double stapled anopexy was carried out based on the criteria of prolapse occupying half or more of the anal circumference and redundant prolapsed tissue determined by the circular anal dilator. Patients fulfilling these criteria were submitted for double stapled anopexy with the PPH03 stapler. All clinical and operative data were recorded in a prospectively maintained database. Results Among the 142 patients with haemorrhoidal prolapse having surgery 91 had a single and 51 a double stapled technique. The mean operative time was 34.8 min with no major or minor intraoperative complications. Recurrence at 48 months was 1.9% and the mean satisfaction score was 8.9. Conclusion The double stapled PPH03 technique in selected cases was as safe and effective as a single stapling technique with a lower incidence of recurrence over a medium‐term follow‐up.