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PURPOSE Colorectal cancer is globally the third most common cancer. Anastomotic complications remain to be an important issue for colorectal surgery. The aim of this study was to investigate the protective effects of thymoquinone (TQ) on the healing process of left colonic anastomosis in an experimental model. METHODS Thirty-two male rats were divided into two groups, as the TQ group and the control group. TQ was administered to the TQ group, whereas the control group was given a standard feed and water for 2 wk. Following the creation of a left colonic anastomosis, subjects in both groups were sacrificed on the postoperative (PO) third and seventh days. Anastomotic burst pressures were measured mechanically. Immunohistochemical stainings for proliferating cell nuclear antigen, cluster of differentiation (CD) 31, CD45 were performed, and the matrix metalloproteinase-2 levels were measured. Histologic total scores were calculated according to Ehrlich-Hunt model. A value of P

The risk of complications and mortality are high after enteroenterostomy in severe peritonitic conditions. Magnetic compression anastomosis (MCA) is a sutureless technique of high efficacy and safety. The purpose of this study was to compare the efficacy of MCA for enteroenterostomy with stapled and hand-sewn techniques under peritonitic conditions.The peritonitic conditions were created by puncturing the colon with a circular blade in 27 mongrel dogs. Eight hours later, the peritoneal cavity was washed with warm, sterilized normal saline solution. The animals were then randomly divided into three groups and underwent colonic anastomosis with MCA, stapled, or hand-sewn techniques, respectively. Animals were euthanized at 1, 2, and 4 w after the operation; anastomoses were compared on the basis of gross appearance and histology.All magnetic devices formed patent anastomoses without a leak. However, one stapled anastomosis and three hand-sewn anastomoses resulted in leaks. The anastomosis time was significantly less in the MCA group than that of the other two groups (P 0.05). All magnetic devices were expelled naturally. The pathologic observation showed that the healing of anastomoses for MCA was smoother than that of the other two groups.MCA is a feasible, safe, and effective alternative for enteroenterostomy under peritonitic conditions in the canine model.

BackgroundWe sought to investigate contemporary management of anastomosis leakage (AL) after colonic anastomosis.MethodsThe American College of Surgeons National Surgical Quality Improvement Program database 2012 to 2013 was used to identify patients with AL. Multivariate regression analysis was performed to find predictors of the need for surgical intervention in management of AL.ResultsA total of 32,280 patients underwent colon resection surgery with 1,240 (3.8%) developing AL. Overall, 43.9% of patients with AL did not require reoperation. Colorectal anastomosis had significantly higher risk of AL compared with ileocolonic anastomosis (adjusted odds ratio [AOR], 1.20; P = .04). However, the rate of need for reoperation was higher for AL in colocolonic anastomosis compared with ileocolonic anastomosis (AOR, 1.48; P = .04). White blood cell count (AOR, 1.07; P < .01), the presence of intra-abdominal infection with leakage (AOR, 1.47; P = .01), and protective stoma (AOR, .43, P = .02) were associated with reoperation after AL.ConclusionsNonoperative treatment is possible in almost half of the patients with colonic AL. The anatomic location of the anastomosis impacts the risk of AL. Severity of leakage, the presence of a stoma, and general condition of patients determine the need for reoperation.

AIMS To assess accuracy of multidetector computed tomography (MDCT) and individual radiological signs in the diagnosis of anastomotic leaks. MATERIALS AND METHODS Patients undergoing anterior resection with a stapled anastomosis over a 2 year period were identified. Electronic and clinical records of these patients were reviewed. Unenhanced and/or enhanced MDCT was performed with intravenous and/or per-rectal contrast medium and read by a radiologist blinded to the patients' clinical details to determine the sensitivity and specificity of specific findings at MDCT for identifying leaks. RESULTS Seventeen percent (30/170) of the anterior resections were suspected to have an anastomotic leak. Ninety-three percent (28/30) of patients underwent MDCT. Seven point six percent (11+2/170) had a confirmed leak. Two patients underwent surgery without MDCT. A leak was confirmed by MDCT in 91% (10/11) of patients. The sensitivity, specificity, and positive and negative predictive values of MDCT in diagnosing a leak was 0.91, 1, 1, and 0.95, respectively. The sensitivity of peri-anastomotic air, peri-anastomotic collection, extravasation of rectal contrast medium, and staple line integrity was 0.81, 0.63, 0.54, and 0.72, respectively. Use of rectal contrast medium (8/11 cases) increased the subjective ease of diagnosis and was the only sign in one patient. CONCLUSIONS Presence of peri-anastomotic air is a reliable marker of anastomotic leaks at MDCT. Leakage of rectal contrast medium is highly accurate and increases confidence of diagnosis. The appearance of the staple line itself is not accurate in assessing anastomotic integrity.

Background Intestinal anastomosis is a major technical component of gastrointestinal procedures. We have developed a new procedure of colonic anastomosis with a degradable stent. This article evaluates this procedure. Methods Forty pigs were assigned randomly to a stent group (n = 20) and a control group (n = 20). A colonic anastomosis with a degradable stent was performed in the stent group, and hand-sewn anastomosis was performed in the control group. Pigs of each group were divided evenly into 4 subgroups according to time of death (days 3, 7, and 14, and month 10 postoperatively) to evaluate the healing of anastomosis. Results All procedures were completed successfully. The surgical time of the stent group was significantly less than the control group. No complications occurred in either group. Bursting pressure of the stent group was significantly higher than the control group on postoperative days 3 and 7. No significant difference of hydroxyproline content or microvessel density was found between the 2 groups. Conclusions The procedure of colonic anastomosis with a degradable stent is a simple, feasible, and safe procedure in this porcine model.

Background: Performing a full-thickness intestinal wall resection Of a sessile polyp located on the mesenteric side with a compression clip may lead to compression of mesenteric vessels. The application of such a clip may therefore cause a compromised blood supply in the particular bowel segment, leading to perforation. Objective: To evaluate the performance of a newly developed, nitinol compression clip, called the NiTi clamp, for full-thickness resection of the bowel wall, while the clip is deliberately deployed endoluminally on the mesenteric side. Design: Prospective animal study. Multinational, multidiciplinary; gastroenterology and general surgery, research Cooperation. Setting: Animal research laboratory. Intervention: Six pigs were operated upon and endoscopically evaluated and then killed after 3 weeks. Linear compression closure clips based on nitinol springs were used. Three longitudinal enterotomies were performed: in the cecum, spiral colon, and proximal rectum. Four clips were deployed in each animal. Main Outcome Measurements: A total of 23 clips were deployed. The average expulsion day was 9 days. Results: All but 3 clips were normally expelled. One pig developed bowel ischemia due to intussusception. In endoscopic procedures, no signs of significant segmental mucosal ischemia were found. The macroscopic appearance of the compression closure lines was thin and delicate, but epithelialization was significantly delayed at 5 sites. Limitation: Differences between porcine and human colorectal anatomy. Conclusion: Full-thickness clamping of the bowel with the NiTi clamp, including the local mesenteric vasculature does not significantly impair local healing of the clamp site and gives hope to further development of novel full-thickness endoscopic resection technologies. (Gastrointest Endosc 2009;70:1146-57.)

BACKGROUND: Failure of anastomotic healing is one of the major complications in colorectal surgery. Because histamine plays an important role in immune and inflammatory reactions, we demonstrate the effects of famotidine on the healing of colonic anastomosis in rats. METHODS: Twenty-eight Sprague-Dawley rats were used in the study. Excision and end-to-end anastomosis was performed in the distal colon of the rat. The Famotidine Group received 2 mg/kg/day famotidine; the Control Group received the same amount of saline. Bursting pressure of anastomoses and hydroxyproline content of perianastomotic tissues were evaluated on the third and seventh days following surgery. RESULTS: Bursting pressures and hydroxyproline contents for the Famotidine Group were significantly lower than the equivalent parameters for the Control Group on both the third and seventh days post-surgery. CONCLUSIONS: According to our findings, famotidine exerts detrimental effects on the anastomotic bursting pressure and hydroxyproline content of perianastomotic tissues in the colon of rats.

Background This study assesses the safety outcome of early oral feeding and reports on the factors affecting early postoperative feeding after colorectal procedures. Patients and methods Between June 2005 and April 2008, 120 consecutive patients underwent elective colonic anastomosis and were then randomized into two groups. The early feeding group began fluids on the first postoperative day while the regular feeding group was managed in the traditional way – nothing by mouth until the resolution of ileus. Results The majority of patients (75%) tolerated the early feeding. The times to first passage of flatus (3.3±0.9days vs 4.2±1.2days) and stool (4.1±1.2days vs 4.9±1.2days) were significantly quicker in group 1. Hospital stay was also significantly shorter in the early feeding group (6.2±0.2days vs 6.9±0.5days). Operative time and amount of blood loss had an impact on the tolerability of early feeding while age, gender, type of operation and previous abdominal operation had no such impact. Conclusion Early oral feeding after colorectal surgery is safe and tolerated by the majority of patients. Operative time and amount of blood loss do, however, have an impact on the tolerability of early feeding.

WOS: 000255410000006 PubMed: 18028949 Purpose. To investigate the effect of platelet-rich plasma (PRP) on tissue maturation and wound healing in experimental colonic anastomosis. Materials and methods. Thirty Sprague Dawley rats were divided into three groups of 10 rats each. Group I (control group) was subjected to colon anastomosis only. Group II (PRP group) was subjected to colon anastomosis and topical PRP was applied. Group III (Bioglue group) was subjected to colon anastomosis and topical tissue sealant was applied (Bioglue; Cryo-life, Kennesaw, GA). The rats were sacrificed on postoperative day 7, and the bursting pressure of the anastomosis and tissue hydroxyproline levels were measured; histopathological changes on the anastomosis line were also examined. Results. The bursting pressure was statistically higher in the PRP group than in the control and Bioglue groups (P < 0.05). The hydroxyproline levels were also statistically higher in the PRP group than in the control and Bioglue groups (P < 0.05). Histopathologically, there was less inflammatory cell infiltration, intensive fibroblast development, and rich collagen production in the PRP group. Conclusion. PRP may be used in colon anastomosis, especially in patients with impaired wound healing, to obtain a better anastomotic strength. (c) 2008 Elsevier Inc. All rights reserved.

Preoperative mechanical bowel preparation aims to rid the colon of solid stool, to reduce postoperative infectious complication rate. During the 20th century, this practice became a surgical dogma, and primary colonic anastomosis was considered unsafe in the face of unprepared bowel. More recently, several well-designed single-center randomized trials have suggested that bowel cleansing may have no benefit in reducing postoperative complication rate. None of these studies, however, had the statistical power to draw firm conclusions. Recently, two large multicenter studies with adequate power were published, showing no difference in the rate of anastomotic leak, wound infection, or other complications between patients who had preoperative mechanical bowel preparation, and those who had not. Despite this evidence, it seems that mechanical bowel preparation is still commonly practiced around the globe. A multicenter North American study is needed to change this time-honored surgical practice.

SummaryNoncardiac operations are being increasingly performed on patients with left ventricular assist devices (LVADs). However, little is known on the impact of continuous-flow LVADs on the vascular supply of the colon for anastomoses. In this case, a 67-year-old male supported on an LVAD underwent four successful noncardiac operations including two intestinal anastomoses; left colon and small bowel anastomosis. To the best of our knowledge, no existing literature has reported successful colonic anastomosis on a continuous-flow LVAD. This case illustrates the plausibility of performing colonic anastomoses with appropriately selected patients supported on an LVAD. A 67-year-old male with congestive heart failure underwent LVAD placement for decompensated heart failure while awaiting orthotopic transplantation. During his recovery, he developed a stage IV sacral decubitus ulcer which required a sigmoid loop colostomy placement and a rotational flap. Subsequent stoma closure with partial sigmoid colectomy and stapled anastomosis was performed, and healed without evidence of anastomotic leak. This case illustrates the potential for colonic anastomoses for patients on continuous-flow LVAD support. Although oxygenation is known to be an important aspect of healing, this patient's outcome suggests that intestinal anastomoses can be performed on the induced pulseless environment of an LVAD. Further studies will be needed to further elucidate the success of longer segment resections and appropriate surgical candidates.

Background The present study was prompted by our previous successful experience with the compression anastomosis clip (CAC) on animals followed by a study on 20 patients scheduled for colonic resection. Methods Sixty patients with colonic cancer were assigned randomly to undergo an anastomosis either with the CAC or a stapler. To perform anastomosis with CAC, the 2 edges of the resected colon are aligned. Two 5-mm incisions are made close to the edges, through which (using a special applier) the CAC, after being cooled in ice water, is introduced in an open position. In response to the body temperature, the clip resumes its original (closed) position, thereby clamping the 2 bowel segments together. At the same time, a small scalpel incorporated in the applier makes a small incision through the clamped walls for the passage of gas and feces. The clip is detached from the applier to be left inside the intestine. The 2 5-mm incisions are sutured. The clip is expelled with the stool within 5 to 7 days, creating a perfect uniform compression anastomosis. Results Neither group had anastomotic complications such as leakage or obstruction. All the other parameters were better in the study group than in the control patients. Conclusions The use of the CAC for colonic surgery is safe, simple, efficient, shortens operation time, and is almost what we call the “no-touch concept” in surgery and may decrease infection.

Resumen Introduccion Se valora el efecto de la octreotida sobre la oclusion experimental del colon y posterior anastomosis. Material y metodo Se realiza una oclusion de colon en dos grupos de ratas Wistar, a uno de los cuales se le administra octreotida. A las 48 h se relaparotomizo a los animales, se valoraron el grado de oclusion y el contenido intestinal y se reseco un fragmento intestinal para estudio histologico, confeccionando una anastomosis termino-terminal. A los 7 dias se reintervino a los animales y se valoraron las complicaciones, determinando la presion de rotura de la anastomosis, la cantidad de colageno que contiene y su histologia. Resultados El grupo tratado con octreotida presento un mayor radio intestinal y peso de las heces en el asa ocluida, asi como de la presion de rotura y tension parietal de rotura, con diferencias estadisticamente significativas. La presencia de dehiscencia, fuga y complicaciones fue similar en ambos grupos. El valor de hidroxiprolina fue mayor en el grupo tratado, sin valor estadisticamente significativo. La ausencia de isquemia en el asa ocluida fue mayor en el grupo tratado y este valor predice una mayor tension parietal de rotura de la posterior cicatriz anastomotica. Conclusiones El tratamiento con octreotida de la oclusion colica experimental mejora la pared intestinal que va a ser sometida a una anastomosis.

Wound strength depends on the balance between collagen synthesis and degradation; however, the role of collagen breakdown in wound healing is still not well understood. We investigated the role of matrix metalloproteinases in wound healing by using BE16627B, a matrix metalloproteinase inhibitor. Identical surgical procedures consisting of a colonic anastomosis (single-layer, inverted) and implantation of an osmotic pump in the back were performed in male Sprague-Dawley rats weighing 270 to 290 grams. The animals were randomly assigned to receive either BE16627B (n = 10) dissolved in dimethylsulfoxide and diluted with ethylene glycol at a dosage of 2.4 mg/rat/day for 3 days or the vehicle solution alone (n = 11). The solutions were administered through the surgically implanted osmotic pumps. The animals were killed 4 days after surgery, and the colonic bursting pressure (mm Hg) and hydroxyproline concentration (μg/mg wet tissue, index of collagen) were measured. The administration of BE16627B enhanced colonic anastomotic healing, as measured by the increase in the colonic bursting pressure (160 ±12 vs. 125 ±7 mm Hg; P

BACKGROUND: This study analyzed intestinal anastomoses by manual suture and by compression with biofragmentable ring under delay of cicatrization administering parenteral corticoids. MATERIAL AND METHODS: Twenty dogs were divided into two groups: control and test, the latter submitted to intramuscular administration of hydrocortisone hemisuccinate, 25 to 33 mg/kg/day, on the 30th preoperative and 7th postoperative days. During surgery, each animal underwent two colon sections with anastomosis by manual suture in a single extramucous plane and compression with biofragmentable ring. The animals were sacrificed 7 days after the procedure to evaluate the anastomoses. RESULTS: In the postoperative period, one death occurred in the test group and two in the control group, caused by nonblocked fistula in the anastomoses by ring compression. Statistically, there was a similar incidence of adherences, fistulas, afferent dilatation and obstruction using comparison methods. On microscopy, deficiency in mucous regeneration of the anastomoses by compression was observed. Computerized histological analysis evidenced in the anastomoses by compression, a greater inflammatory reaction, greater edema of the submucous membrane and enlarged scars. CONCLUSIONS: It was concluded that, with the biofragmentable ring, in colonic anastomosis under delay of cicatrization induced by corticoids, similar results to manual suture regarding to postoperative complications incidence were obtained; ring, however, determined worse mucous regeneration and greater cicatricial inflammatory reaction.

Surgical stapling instruments can be used to perform end-to-end anastomoses in the colon and rectum. A new method of colonic anastomosis is described for cats with acquired forms of megacolon. Alternative approaches for performing colonic anastomoses are described in humans and in large dogs which can be used for colonic resections of focal nature as well as for subtotal colectomy. Advantages and disadvantages of surgical stapling instruments in the large intestine are reviewed.

We reviewed our experience with 32 patients who underwent massive intestinal resection to determine when intestinal continuity should be maintained. An enterostomy was created in 21 patients (66 percent) at the initial resection because of questionable bowel viability and an unstable condition or the need for colonic anastomosis. Intestinal continuity was restored in only 20 percent of these patients. In 11 patients (34 percent), intestinal continuity was maintained at the time of resection. Only four of these patients (36 percent) had a satisfactory long-term outcome. Overall, intestinal continuity was maintained in 10 of the 22 patients (45 percent) followed over the long-term. Three quarters of patients with intestinal remnants shorter than 3 feet had an enterostomy. We believe intestinal continuity should be restored at the time of massive resection only in carefully selected patients when bowel viability is ensured, remnant length is greater than 3 feet, and a colonic anastomosis is not required. Maintaining intestinal continuity eliminates the inconvenience of the stoma but may cause dietary restriction and perianal discomfort.

The effect of antibiotic colon preparation on the tensile strength and morphologic appearance of colonic anastomoses has been investigated in dogs. Preparation with preoperative kanamycin did offer a slight benefit over mechanical bowel cleansing. The addition of erythromycin and kanamycin to the preoperative bowel preparation significantly (p less than 0.001) improved the mean tensile strengh of the healing colonic anastomosis. Continuation of erythromycin and kanamycin for one week postoperatively almost doubled the mean tensile strength of the healing anastomosis. Continuation of erythromycin without kanamycin in the postoperative period provided little protection over the preoperative administration of kanamycin and erythromycin. Histologic examination showed that erythromycin and kanamycin given during the pre- and postoperative period changed the mode of healing from that of secondary intention to healing by first intention. The findings support the concept that soilage of the peritoneal cavity at the time of elective colon surgery is not as important as leakage caused by poor anastomotic healing. Antibiotic bowel preparation with kanamycin and erythromycin improves the healing of colonic anastomoses.

This report reviews the experience of pediatric surgeons in seven cities in North American and Western Europe where the Swenson procedure was performed on 880 patients. Information on the diagnosis, treatment, complications, and long-term results was collected by reviewing the hospital records, the treating physicians' office records, and by interviewing the patients in person or by telephone. A follow-up evaluation was obtained on 814 patients. The patients' ages at the time of the resection ranged from four days to 50 years. The length of follow-up averaged 10.3 years, while the longest follow-up was 39.5 years. The overall postoperative mortality was 2.4% during the entire 40 years of the study. The postoperative mortality has decreased to 1.25% for the last 20 years. Significant factors influencing postoperative mortality included Down's syndrome, the patient's age at the time of the operation, and leak of the distal colonic anastomosis. Most of the patients followed for over 5 years have normal bowel habits, report one to three bowel movements per day, and have no soiling. No patient has urinary incontinence or impotence.