Intestinal anastomoses prior to 1882; a legacy of ingenuity, persistence, and research form a foundation for modern gastrointestinal surgery

Diagnosis of Anastomotic Leak

Anastomotic leaks after colorectal surgery is associated with increased morbidity and mortality. Understanding the impact of anastomotic leaks and their risk factors can help the surgeon avoid any modifiable pitfalls. The diagnosis of an anastomotic leak can be elusive but can be discerned by the patient's global clinical assessment, adjunctive laboratory data and radiological assessment. The use of inflammatory markers such as C-Reactive Protein and Procalcitonin have recently gained traction as harbingers for a leak. A CT scan and/or a water soluble contrast study can further elucidate the location and severity of a leak. Further intervention is then individualized on the spectrum of simple observation with resolution or surgical intervention.

Biomaterial-Assisted Anastomotic Healing: Serosal Adhesion of Pectin Films

Anastomotic leakage is a frequent complication of intestinal surgery and a major source of surgical morbidity. The timing of anastomotic failures suggests that leaks are the result of inadequate mechanical support during the vulnerable phase of wound healing. To identify a biomaterial with physical and mechanical properties appropriate for assisted anastomotic healing, we studied the adhesive properties of the plant-derived structural heteropolysaccharide called pectin. Specifically, we examined high methoxyl citrus pectin films at water contents between 17-24% for their adhesivity to ex vivo porcine small bowel serosa. In assays of tensile adhesion strength, pectin demonstrated significantly greater adhesivity to the serosa than either nanocellulose fiber (NCF) films or pressure sensitive adhesives (PSA) (p < 0.001). Similarly, in assays of shear resistance, pectin demonstrated significantly greater adhesivity to the serosa than either NCF films or PSA (p < 0.001). Finally, the pectin films were capable of effectively sealing linear enterotomies in a bowel simulacrum as well as an ex vivo bowel segment. We conclude that pectin is a biomaterial with physical and adhesive properties capable of facilitating anastomotic healing after intestinal surgery.

The effect of three different surgical techniques for colon anastomosis on regional postoperative microperfusion: Laser Doppler Flowmetry study in pigs

BACKGROUND

The optimal surgical approach to reconnecting bowel ends safely after resection is of great importance.

OBJECTIVES

This project is focused on assessment of the perianastomotic microcirculation quality in the short postoperative period when using three different anastomosis techniques in experimental animal.

METHODS

The experimental study involved 27 young female domestic pigs divided into three subgroups of 9 animals according to each surgical method of anastomosis construction in the sigmoid colon region: by manual suture, by stapler, or by gluing. Blood microcirculation in the anastomosis region was monitored using Laser Doppler Flowmetry (LDF). Anastomosis healing was evaluated by macroscopic and histological examination.

RESULTS

Evaluation of the microcirculation in the anastomosis region showed the smallest decrease in perfusion values in animals reconstructed by suturing (Δ= -38.01%). A significantly more profound drop was observed postoperatively after stapling or gluing (Δ= -52.42% and Δ= -59.53%, respectively). All performed anastomoses healed without any signs of tissue and function pathology.

CONCLUSIONS

Sewing, stapling, and gluing techniques for bowel anastomosis each have a different effect on regional microcirculation during 120 min. postoperatively. Nevertheless, the final results of anastomosis healing were found without of any pathology in all experimental animals managed by above mentioned anastomotic techniques.

Management of Colorectal Anastomotic Leak

The aim of this article is to present strategies for preventing and managing the failure of the surgical restoration of intestinal continuity. Despite improvements in surgical technique and perioperative care, anastomotic leaks still occur, and with them occur increased morbidity, mortality, length of stay, and costs. Due to the devastating consequences for patients with failed anastomoses, there have been a myriad of materials and techniques used by surgeons to create better intestinal anastomoses. We will also discuss the management strategies for anastomotic leak when they do inevitably occur.

Staple line/anastomotic reinforcement and other adjuncts: do they make a difference?

Since the development of the stapled intestinal anastomosis, efforts have been aimed at reducing complications and standardizing methods. The main complications associated with stapled anastomoses include bleeding, device failure, and anastomotic failure (leaks and strictures). These complications are associated with increased cost of care, increase in cancer recurrence, decreased overall survival, poor quality of life, and in some cases the need for further procedures including a diverting ostomy. Reducing these complications therefore has important implications. To this end, techniques to reduce the incidence of anastomotic complications have been the focus of many investigators. In this review, we summarize the current staple line reinforcement technology as well as other adjunctive measures, and specifically discuss the role of biologic materials in this realm.

Multimodal therapy in treatment of rectal cancer is associated with improved survival and reduced local recurrence - a retrospective analysis over two decades

Background

The management of rectal cancer (RC) has substantially changed over the last decades with the implementation of neoadjuvant chemoradiotherapy, adjuvant therapy and improved surgery such as total mesorectal excision (TME). It remains unclear in which way these approaches overall influenced the rate of local recurrence and overall survival.

Methods

Clinical, histological and survival data of 658 out of 662 consecutive patients with RC were analyzed for treatment and prognostic factors from a prospectively expanded single-institutional database. Findings were then stratified according to time of diagnosis in patient groups treated between 1993 and 2001 and 2002 and 2010.

Results

The study population included 658 consecutive patients with rectal cancer between 1993 and 2010. Follow up data was available for 99.6% of all 662 treated patients. During the time period between 2002 and 2010 significantly more patients underwent neoadjuvant chemoradiotherapy (17.6% vs. 60%) and adjuvant chemotherapy (37.9% vs. 58.4%). Also, the rate of reported TME during surgery increased. The rate of local or distant metastasis decreased over time, and tumor related 5-year survival increased significantly with from 60% to 79%.

Conclusion

In our study population, the implementation of treatment changes over the last decade improved the patient’s outcome significantly. Improvements were most evident for UICC stage III rectal cancer.

[Ludwig von Riediger (Ludwik Rydygier). A great surgeon forgotten in Germany]

Riediger was born in West Prussia and studied medicine in Greifswald under Carl Hueter. Having accomplished his surgical training in Gdańsk, Greifswald and Jena in 1879 he built an outstanding private hospital in Chełmno where he wrote important publications in the Polish language. In 1887 he polonized his name to Rydygier to obtain Bavarian citizenship and succeeded Johann von Mikulicz as the chair of surgery at the Jagiellonian University. In 1897 he was given the chair in surgery at the University of Lviv and in 1901/02 he became rector. In World War I he served in the Austrian and Polish Armies. In the Polish-Soviet War (1920) he played an active role against the invading Bolshevic (Soviet) army as head of the medical service for the Polish army in Pomerania. After 23 years in Lviv he became professor emeritus. Before returning to West Prussia he lost his fortune due to the stock market crash in 1920 and died at 70 years old. Riediger founded the Polish Society of Surgeons and was cofounder of the German Association of Urology. His descendents formed a dynasty of surgeons in Brazil.

Endoscopic gastrojejunostomy with a natural orifice transluminal endoscopic surgery technique

AIM: To determine the technical feasibility and safety of an endoscopic gastrojejunostomy with a pure natural orifice transluminal endoscopic surgery (NOTES) technique using a T-anchoring device in a porcine survival model.

METHODS: An endoscopic gastrojejunostomy with a pure NOTES technique using a T-anchoring device was performed on 10 healthy female minipigs weighing approximately 40 kg each under general anesthesia. All procedures were performed with a transgastric approach using a 2-channel therapeutic endoscope.

RESULTS: The transgastric gastrojejunostomy was technically successful in all cases. A total of four to six stitched pairs of a T-anchoring device were used to secure the anastomosis. The median time required to enter the peritoneal cavity and pull the small bowel into the stomach was 34 min (range: 19-41 min); the median time required to suture the anastomosis was 67 min (range: 44-78 min). An obstruction of the efferent limb occurred in one case, and a rupture of the anastomosis site occurred in another case. As a result, the functional success rate was 80% (8/10). Small bowel adhesion to the stomach and liver occurred in one case, but the anastomosis was intact without leakage or obstruction.

CONCLUSION: A transgastric gastrojejunostomy with a T-anchoring device may be safe and technically feasible. A T-anchoring device may provide a simple and effective endoscopic suturing method.

NOTES and anastomosis

The history and development for forming anastomoses using natural orifice translumenal endoscopic surgery (NOTES) techniques is described. Sutured gastrojejunostomy, enteroenteral anastomosis, and ileocolonic anastomoses using rigid and circular staplers passed through the rectum and vaginal wall using a transgastric supervising endoscope using a natural orifice translumenal endoscopic surgery hybrid approach. The staplers for this type of approach have to change. They need to be longer, more flexible, and able to change shape (eg, becoming smaller for introduction and then expanding in the peritoneal cavity). Different methods of introduction over guidewires or in combination with flexible gastroscopes are also needed. There is still a requirement for more ingenuity, persistence, and research if the goal of safer effective formation of anastomoses by less invasive means is to be realized.

On the 100th anniversary of sterile catgut kuhn: Franz Kuhn (1866-1929) and the epistemology of catgut sterilization

The long road to effective catgut sterilization began with the work of Lord Joseph Lister (1867) and did not end until 40 years later. At the end of the nineteenth century dozens of different techniques were used to "sterilize" catgut, by immersing the cord in a cold chemical solution, by exposing it to steam, or by a combination of the two techniques, yet none of these approaches offered the ultimate solution. One of the many physicians working on the catgut problem at that time was the German surgeon Franz Kuhn (1866-1929), best known as a pioneer of intubation anesthesia. This review offers a brief biographical sketch of Kuhn's life and career on the occasion of the centenary of Sterile Catgut Kuhn. The goal of the present study is to describe several landmarks in the development of the catgut sterilization method. To explain this process, two approaches are taken: first, an analysis to see whether the character traits of the typical surgeon at that time provided the soil in which innovation could thrive, and second, an epistemological examination of the conceptual models for the attainment of knowledge current at that time. Perspectives for the future are explored in light of the "imperative of responsibility" of Hans Jonas.

Mario Donati and the vertical mattress suture of the skin

Mario Donati (1879-1946) was one of the foremost European surgeons of the early 20th century. During an impressive carrier as surgeon, teacher, and innovator he authored more than 200 scientific works. Already as a young teacher he won the admiration of his colleagues: "His lectures were models of clarity and conviction, his originality and brilliance as a surgeon have well earned [him] a place among the most famous of the clinical masters of surgery of all eras" (Mario Donati. J. Int. Coll. Surg. 1946;9:739). The present review offers a brief biographical sketch of Donati's life and career, presents an eyewitness account of the origin of the Donati stitch, and discusses a possible precursor of this suture technique in the Middle Ages. On the occasion of the 60th anniversary of the end of World War II, the authors would like to pay a special homage to Mario Donati, who due to his Jewish ancestry was removed from his office as Professor of Surgery at the University of Milan in 1938 and died shortly after his return from exile in Switzerland.

Otto W. Madelung and the recognition of Madelung's deformity

Madelung's deformity is an uncommon congenital condition of the wrist usually seen in adolescent girls. It first was documented in the 1800s and is characterized by a shortened radius that curves ulnarly and volarly, a prominent ulna head that projects dorsally from the wrist, and a triangular arrangement of the carpal bones. It is mostly an aesthetic deformity although functional problems and pain may prompt surgeons to undertake a variety of corrective surgical procedures with varying degrees of success. This challenging condition is encountered rarely in a hand surgeon's practice. Even more obscure than the condition is the physician it is named after: Otto Wilhelm Madelung, a distinguished and successful German surgeon who lived at the turn of the century. This article provides a historical perspective on the person and the condition that is still an enigma a century later.

Transgastric anastomosis by using flexible endoscopy in a porcine model (with video)

BACKGROUND

Transgastric flexible endoscopic anastomosis might offer advantages over open and laparoscopic surgery, especially for bariatrics or patients with obstructive malignancy.

OBJECTIVE

To develop methods for performing transgastric anastomosis.

DESIGN/RESULTS

Twelve gastrojejunal anastomoses were formed in pigs weighing 27 kg to 38 kg (6 each in survival and nonsurvival groups) by using a per-oral double-channel gastroscope. The stomach was penetrated with a needle-knife guidewire combination and bow-sphincterotome incision. The small intestine (SI) was grasped with a snare-over-forceps method and pulled into the stomach for suturing. Sutures were placed in pairs through the deep muscle of the stomach and small intestine to join the tissues securely. The SI was incised with a needle-knife to open the anastomosis. Anastomoses were placed close to the cardioesophageal junction for bariatric purposes or in the antrum for pancreatic bypass. Survival studies in 6 pigs showed anastomosis patency at 7 to 10 days.

CONCLUSION

Gastrojejunal anastomosis was accomplished via the transgastric route by using a new double-channel endoscopic method.