Artificial sphincters as surgical treatment for experimental massive resection of small intestine

Long-Term Results of Serial Transverse Enteroplasty with Neovalve Creation for Extreme Short Bowel Syndrome: Report of Two Cases

Objective

The aim of this article was to determine whether serial transverse enteroplasty (STEP) and the creation of a new ileocecal valve in extreme short bowel syndrome (SBS) cases (<45 cm) is effective in intestinal adaptation and improvement of nutritional parameters and serum citrulline levels.

Patients and Methods

We present 2 cases of SBS treated with STEP. Enterectomy was performed for massive intestinal ischemia secondary to a gastrointestinal stromal tumor in the first case and to catastrophic antiphospholipid syndrome in the second. After enterectomy, the short residual bowel measured 34 cm in the first patient and 45 cm in the second. In both cases STEP, cholecystectomy, and gastrostomy were performed. In the first case a Brooke neovalve was created, and in the other the ileocecal valve was preserved.

Results

Both patients could finally be weaned off total parenteral nutrition (TPN) and gastrostomy feeding, maintaining a good nutritional status 1 year after surgery.

Conclusions

In extreme SBS, a minimum length of 80–90 cm of functioning small bowel and an intact ileocecal valve are necessary. We plead for the use of STEP with preservation of the ileocecal valve or creation of a neovalve using the Brooke technique in order to achieve the ultimate goal, which is to wean patients off TPN. After a critical review of different surgical techniques, a treatment algorithm is proposed.

Spontaneous cerebrospinal fluid leak from an anomalous thoracic nerve root: case report

The authors report the case of a 28-year-old woman with a spontaneous cerebrospinal fluid leak from the sleeve of a redundant thoracic nerve root. She presented with postural headaches and orthostatic symptoms indicative of intracranial hypotension. CT myelography revealed that the lesion was located at the T-11 nerve root. After failure of conservative management, including blood patches and thrombin glue injections, the patient was successfully treated with surgical decompression and ligation of the duplicate nerve, resulting in full resolution of her orthostatic symptoms.

Radiological anatomical consideration of conjoined nerve root with a case review

Nerve root anomalies are frequently underrecognized regardless of the advances in imaging studies; they are also underappreciated and underreported when encountered surgically. The classification of conjoined nerve roots is based on whether the nerve root emerges at an abnormal level or from an anastomotic branch. In the present report, we describe case with a conjoined nerve root that emerged at a more caudal level than that normally observed that was an undiagnosed on preoperative imaging studies. We also discuss the atypical imaging features obtained through preoperative imaging studies. As observed in the present case, preoperative recognition and diagnosis of such anomalies offer the best opportunity of performing a successful procedure and preventing inadvertent damage to nerve roots intraoperatively.

Nerve root anomalies: implications for transforaminal lumbar interbody fusion surgery and a review of the Neidre and Macnab classification system

Lumbar nerve root anomalies are uncommon phenomena that must be recognized to avoid neural injury during surgery. The authors describe 2 cases of nerve root anomalies encountered during mini-open transforaminal lumbar interbody fusion (TLIF) surgery. One anomaly was a confluent variant not previously classified; the authors suggest that this variant be reflected in an amendment to the Neidre and Macnab classification system. They also propose strategies for identifying these anomalies and avoiding injury to anomalous nerve roots during TLIF surgery. Case 1 involved a 68-year-old woman with a 2-year history of neurogenic claudication. An MR image demonstrated L4–5 stenosis and spondylolisthesis and an L-4 nerve root that appeared unusually low in the neural foramen. During a mini-open TLIF procedure, a nerve root anomaly was seen. Six months after surgery this patient was free of neurogenic claudication. Case 2 involved a 60-year-old woman with a 1-year history of left L-4 radicular pain. Both MR and CT images demonstrated severe left L-4 foraminal stenosis and focal scoliosis. Before surgery, a nerve root anomaly was not detected, but during a unilateral mini-open TLIF procedure, a confluent nerve root was identified. Two years after surgery, this patient was free of radicular pain.

Intraoperative conjoined lumbosacral nerve roots associated with spondylolisthesis

Lumbosacral nerve roots anomalies may produce low back pain. These anomalies are reported to be a cause for failed back surgery. They are usually left undiagnosed, especially in endoscopic discectomy techniques. Any surgery for entrapment disorders, performed on a patient with undiagnosed lumbosacral nerve roots anomaly, may lead to serious neural injuries because of an improper surgical technique or decompression. In this report, we describe our experience with a case of L5-S1 spondylolisthesis and associated congenital lumbosacral nerve root anomalies discovered during the surgical intervention, and the difficulties raised by such a discovery. Careful examination of coronal and axial views obtained through high-quality Magnetic Resonance Imaging may lead to a proper diagnosis of this condition leading to an adequate surgical planning, minimizing the intraoperatory complications.

Congenital absence of lumbosacral articular facet joint associated with conjoined nerve root: a case report

We report a rare case of congenital absence of the L5-S1 facet joint, which was associated with a conjoined nerve root. Combination of these two anomalies has been quite rarely reported in the literature. A 39-year-old man presented with acute low back pain and right leg radiating pain. Muscle weakness and sensory disturbance of the right leg were also apparent in the region innervated by L5 and S1 nerve roots. Preoperative multidetector three-dimensional computed tomography (3D-CT) showed complete absence of the right S1 superior articular process. Magnetic resonance (MR) images showed lumbar disc herniation at right L5-S1 level that migrated cranially. Intraoperative findings revealed that the right L5 nerve root and S1 nerve root were conjoined, and the conjoined nerve root was compressed by L5-S1 disc herniation, which led to impairment of the conjoined nerve root by a single-level lumbar disc herniation. After removal of the disc herniation, his right leg pain immediately subsided, however muscle weakness and sensory disturbance persisted. Surgeons should be aware of this nerve root anomaly when examining a patient who shows an unusual clinical presentation and/or congenital osseous anomaly.

Dermatomyotomal supply in patients with variations in the number of lumbar vertebrae

OBJECT

Variation in the number of lumbar vertebrae occurs in a small portion of the population. Either the fifth lumbar vertebra shows assimilation to the sacrum or the first sacral vertebra shows a lumbar configuration, resulting in 4 or 6 lumbar vertebrae, respectively. Etiologically, lumbar nerve root syndrome is diagnosed by comparing the anatomical level of the disc herniation to the compressed nerve root and to the pattern of the peripheral sensory and motor deficit. In case of a variation in the number of lumbar vertebrae, defining the lumbar nerve roots becomes difficult. Variations in the number of lumbar vertebrae make the landmarks (the twelfth rib and the first sacral vertebra) unreliable clues to define the nerve roots. The allocation of the clinically damaged segment to the spinal disorder seen in imaging studies is essential for differential diagnosis and spine surgery.

METHODS

A retrospective study was conducted of clinical, electrophysiological, and imaging data among inpatients over a period of 21 months. Eight patients who had isolated monosegmental discogenic nerve root compression and a variation in the number of lumbar vertebrae were selected.

RESULTS

Seven patients presented with 6 lumbar vertebrae, and 1 patient presented with 4 lumbar vertebrae and disc herniation on 1 of the 2 caudal levels. Compression of the second-to-last nerve root in patients with 6 lumbar vertebrae resulted either in clinical L-5 or S-1 syndrome, or a combination of both. Compression of the last caudal nerve root resulted in a clinical S-1 nerve root syndrome.

CONCLUSIONS

The findings suggest that the dermatomyotomal supply of the lumbosacral nerve roots can vary in patients with a variation in the number of lumbar vertebrae, and a meticulous clinical, radiological, and electrophysiological examination is essential.

Clinical features of conjoined lumbosacral nerve roots versus lumbar intervertebral disc herniations

Unidentified nerve root anomalies, conjoined nerve root (CNR) being the most common, may account for some failed spinal surgical procedures as well as intraoperative neural injury. Previous studies have failed to clinically discern CNR from herniated discs and found their surgical outcomes as being inferior. A comparative study of CNR and disc herniations was undertaken. Between 2002 and 2008, 16 consecutive patients were diagnosed intraoperatively with CNR. These patients were matched 1:2 with 32 patients diagnosed with intervertebral disc herniations. Matching was done according to age (within 5 years), gender and level of pathology. Surgery for patients with CNR or disc herniations consisted of routine microsurgical techniques with microdiscectomy, hemilaminotomy, hemilaminectomy and foraminotomy as indicated. Outcomes were measured using the Oswestry Disability Index and the Short Form-36 Questionnaire. Clinical presentation, imaging studies and surgical outcomes were compared between the groups. Conjoined nerve root's incidence in this study was 5.8% of microdiscectomies performed. The S1 nerve root was mainly involved (69%), followed by L5 (31%). Patients with CNR tended to present with nerve root claudication (44%) compared to the radiculopathy accompanying disc herniations (75%). Neurologic deficit was less prevalent among patients with CNR. Nerve root tension tests were not helpful in distinguishing between the etiologies. Radiologist's suspicion threshold for nerve root anomalies was low (0%) and no coronal reconstructions were obtained. The surgeon's clinical suspicion accurately predicted 40% of the CNRs. Surgical outcomes did not differ between the cohorts regarding the rate of postoperative improvement, but CNR patients showed a trend toward having mildly worse long-term outcomes. Suspecting CNRs preoperatively is beneficial for appropriate treatment and avoiding the risk of intraoperative neural injury. With nerve root claudication and imaging suggestive of a "disc herniation", the surgeon should be alert to the differential diagnosis of a CNR. Treatment is directed at obtaining adequate decompression by laminectomy and foraminotomy to relieve the lateral recess stenosis. Outcomes can be expected to be similar to routine disc herniations.

Influência de válvulas artificiais sobre a morfometria intestinal de ratos

OBJETIVO: Avaliar o papel de válvulas artificiais constituídas por seromiotomias circunferenciais duplas no comprimento dos vilos, no diâmetro do intestino delgado e no peso de ratos. MÉTODO: Foram utilizados 40 ratos, distribuídos em quatro grupos. Os animais do Grupo R foram submetidos à ressecção de 50% do intestino delgado, sem criação de válvulas. No Grupo RV associaram duas válvulas à ressecção intestinal. No Grupo V foram criadas duas válvulas, sem ressecção intestinal. O Grupo C forneceu a altura normal dos vilos. A eutanásia deu-se entre o décimo e o 14º dia pós-operatórios. RESULTADOS: Houve aumento no comprimento dos vilos nos grupos R, RV e V. Comparado ao Grupo R, o comprimento dos vilos nos grupos RV e V foi semelhante nos segmentos proximal e distal. No Grupo RV, os vilos do segmento proximal tiveram comprimento superior ao do distal. No Grupo V, o comprimento dos vilos do segmento proximal foi menor que do distal. A alça intestinal teve diâmetro maior que no pré-operatório no Grupo R e nos segmentos proximal à primeira válvula e distal à segunda, dos grupos RV e V. A ressecção intestinal levou à perda ponderal nos grupos R e RV, sem diferença entre os grupos. No Grupo V houve ganho de peso, significativo quando comparado aos grupos R e RV. Apesar de não impedirem a perda ponderal em animais submetidos à ressecção, as válvulas não determinaram perda superior à da ressecção isolada. CONCLUSÃO: Essas válvulas parecem influenciar positivamente a adaptação intestinal e podem ser incluídas entre as técnicas de reabilitação intestinal cirúrgica, isoladamente ou precedendo intervenções de alongamento do intestino.

Estudo morfológico do intestino de ratos após a criação cirúrgica de esfíncteres artificiais

OBJETIVO: Avaliar as alterações morfológicas ocorridas após à confecção de esfíncteres no intestino delgado de ratos. MÉTODO: Foram estudados 30 ratos, Wistar, distribuídos em três grupos de 10 animais. Grupo A, controle, foi retirado um segmento de intestino delgado de 20mm de extensão. Grupo B, foram realizados dois esfíncteres, um a 100mm e outro a 150mm da junção íleo-cecal. Grupo C, um esfíncter à 100mm da junção íleo-ceco-cólica. Entre 10º e 14º dia os animais do Grupo B e C foram re-operados para a ressecção do segmento intestinal envolvendo os esfíncteres com margem de 10mm proximal e distal. As aferições de peso foram feitas no pré-operatório das duas intervenções. O diâmetro das alças foi computado antes e depois da confecção dos esfíncteres. Nas peças ressecadas dos três grupos foram medidas as alturas das vilosidades dos segmentos pré e pós-esfíncter dos Grupos B e C, segmento intermediário do Grupo B e segmento intestinal do Grupo A. Os dados obtidos foram submetidos à análise estatística do programa SPSS. RESULTADO: O peso dos animais aumentou nos dois grupos com significância no grupo B. Aumento do diâmetro das alças e a média das alturas das vilosidades foram significante. CONCLUSÃO: A confecção dos esfíncteres leva a alterações da camada de vilos e dos diâmetros das alças, semelhantes àquelas que ocorrem na fase de adaptação intestinal após ressecções.

Alterações morfométricas da musculatura dos músculos longitudinal e circular de ratos submetidos à criação de piloros no intestino delgado

OBJETIVO: Realizar um estudo morfométrico comparativo da musculatura longitudinal e circular do intestino delgado de ratos submetidos à construção cirúrgica de um e de dois piloros no intestino delgado utilizando-se da técnica de criação de piloros proposta por Rena et al. MÉTODO: Foram utilizados 52 ratos Wistar machos divididos em três grupos. O Grupo A, destacado como controle, composto de 10 animas, cada um forneceu 20mm de segmento de intestino para o estudo. Os animais do Grupo B, composto de 32 animais, foram submetidos à construção de dois piloros, um a 100mm e outro a 150mm da válvula ileocecal e os animais do grupo C, composto de 10 animais, foram submetidos à construção de um piloro a 100mm da mesma. A eutanásia ocorreu no décimo dia. A morfometria das camadas musculares longitudinal e circular acima e abaixo dos piloros foi estudada com utilização do microscópico modelo "Axiostar plus" conectado à câmera "Axioncam Version 5.05.10" com objetiva X5 / 0,12 no o programa "AxioVision 3.1.2.1". RESULTADOS: As alças apresentaram aumento da espessura da camada muscular acima e abaixo do ponto da operação. O estudo morfométrico comparativo das camadas musculares longitudinal e circular mostrou aumento significativo em comparação ao controle, não demonstrando significância entre os grupos B e C. CONCLUSÃO: Os resultados deste estudo revelaram importante aumento de espessura das camadas musculares, porém, menos acentuados que aqueles descritos na literatura quando foram realizados em animais submetidos à estenose fixa. Esses dados indicam que a construção operatória de piloros pela técnica utilizada promove alterações musculares de menor monta, possivelmente, pela função valvular do piloro.

[Ileocecal valve reconstruction in dogs]

PURPOSE

The importance of keeping the ileocecal valve in the intestinal ressections has been reported by several authors. When preserved, the ileocecal valve was related to a longer survival and prevention of the short bowel syndrome, due to its ability to block the colonic content reflux into the ileum and to avoid the rapid empting of the ileal content into the cecum. It was assessed a tecnique of ileocecal valve reconstitution, based on vesicoureteral anti-reflux tecniques.

METHODS

Fourteen beagles were operated. Seven underwent ileocecal valve reconstitution following the tecnique proposed and in the other seven a simple end-to-end anastomosis was performed. To assess the new valve, it was done the clinical follow up, the microbiologic analysis and the manometric study.

RESULTS

Clinically, during 45 days of follow up, there was no difference between the dogs with and without ileocecal reconstitution. In the aerobic bacteria analysis, the predominant bacterium was Escherichia coli. Quantitatively, the cultures grew in an irregular way, so that it was not able to compare the bacterial growth between the groups with or without ileocecal valve. The new valve had a colo-ileal reflux pressure similar to that of the physiological valve (P > 0.05). However, when compared to the non valve group, the reflux pressures of the physiological valve and new valve were significantly higher, with P < 0.05 and P < 0.001, respectively.

CONCLUSION

In this study, the reconstituted ileocecal valve served as a barrier to the colo-ileal reflux just as the physiological valve does.

Irreversible intestinal failure

Intestinal failure (IF) can be defined as the reduction of functional gut mass below the minimal amount necessary for digestion and absorption adequate to satisfy the nutrient and fluid requirements for maintenance in adults or growth in children. In developed countries, IF mainly includes individuals with the congenital or early onset of conditions requiring protracted or indefinite parenteral nutrition (PN). Short bowel syndrome was the first commonly recognized cause of protracted IF. The normal physiologic process of intestinal adaptation after extensive resection usually allows for recovery of sufficient intestinal function within weeks to months. During this time, patients can be sustained on parenteral nutrition. Only a few children have permanent intestinal insufficiency and life-long dependency on PN. Non-transplant surgery including small bowel tapering and lengthening may allow weaning from PN in some cases. Hormonal therapy with recombinant human growth hormone has produced poor results while therapy with glucagon-like peptide-2 holds promise. Congenital diseases of enterocyte development such as microvillus inclusion disease or intestinal epithelial dysplasia cause permanent IF for which no curative medical treatment is currently available. Severe and extensive motility disorders such as total or subtotal intestinal aganglionosis (long segment Hirschsprung disease) or chronic intestinal pseudo-obstruction syndrome may also cause permanent IF. PN and home-PN remain are the mainstays of therapy regardless of the cause of IF. Some patients develop complications while receiving long-term PN for IF especially catheter related complications (thrombosis, sepsis) and liver disease. These patients may be candidates for intestinal transplantation. This review discusses the causes of irreversible IF and emphasizes the specific medico-surgical strategies for prevention and treatment of these conditions at several stages of IF.

Effects of intestinal muscular wrapping on remnant intestinal motility after massive small bowel resection in conscious canines

We searched the effect of the muscular valve on the management of short bowel syndrome. The motility of the remnant intestine with a special muscular valve after 80% massive distal small bowel resection (MSBR) was evaluated in conscious dogs. The valve (muscular ring) was made by the autointestinal muscle layer holding vascular pedicle. Interdigestive and postprandial bowel motility using bipolar electrodes and/or contractile strain gauge force transducers 2-4 weeks after the surgery, and data of this group (Group I) were compared to the motility in dogs after MSBR without valve construction (Group II) and in controls (Control). Results; Fasting duodenal migrating myoelectric (or motor) complexes (MMCs) in Group I occurred at longer intervals than in Control and almost similarly to those in Group II. MMCs arising from the duodenum were often interrupted before the jejunum above the valve and the anastomosis. The velocity of duodenal MMC propagation was slowed in every intestinal segment including that from the duodenum to the proximal jejunum, and to the jejunum above the anastomosis. Transit time in MSBR group (I and II) from the duodenum to the terminal ileum was extremely shorter than in Control, but there were no differences between in Groups I and II. The duration of the postprandial period without duodenal MMCs in Group I was significantly prolonged than in Control, but was shorter than that in Group II. The muscular valve was frequently activated, and the jejunum covered with the valve was contracted frequently which synchronized with the valve activity. It seemed the valve worked as sphincter. However, intestinal obstruction was not occurred through the jejunum covered by the valve. In conclusion, changes in gut motility after MSBR with the valve construction compensate for the shortened intestine and maintain the bowel content earlier postoperatively in comparison with the MSBR alone, and also contribute to the adaptive increase in the remnant intestinal absorption.

Histopatologia da seromiotomia dupla e sutura seromuscular no cólon descendente de ratos

Realizamos um estudo experimental em ratos com o objetivo de retardar o trânsito intestinal no cólon e verificar as alterações macroscópicas nas fezes e as histopatológicas ocorridas no intestino grosso. Foram operados 15 ratos e 15 ratas num total de trinta, divididos em três grupos denominados 30, 60 e 90 dias, conforme o tempo proposto para relaparotomia. Todos os ratos foram submetidos a duas seromiotomias extramucosas, no cólon descendente, com incisões circunferenciais (360°). Elas se localizavam, uma a 1 cm e a outra a 2 cm acima da reflexão peritoneal. Após as seromiotomias, fez-se a sutura seromuscular circundando todo o perímetro do cólon. Analisaram-se os aspectos clínicos e histopatológicos. Concluiu-se que há formação de um anel fibroso, com elevação da mucosa em direção à luz, do tipo valvular e descontinuidade da musculatura longitudinal e transversal.

Ileocecal valve reconstruction during continent urinary diversion

During construction of an ileocecal reservoir, such as the Mainz or Indiana pouch, the ileocecal valve is lost. Subsequently, the intestinal transit time is shortened and malabsorption as well as diarrhea may result. Patients having undergone previous bowel resection as well as children with myelomeningocele who often already have frequent defecations will be heavily affected by the loss of the ileocecal valve. We have functionally reconstructed the ileocecal valve by embedding ileum into the ascending colon via a submucosal tunnel in analogy to the technique used when creating the continence mechanism during the Mainz pouch procedure using the appendix. Experimental results in 15 dogs demonstrated that the surgically reconstructed valve genuinely mimics the physiological function of the authentic valve and confirmed a marked transit time prolongation without evidence of obstruction. Our first clinical experience in 12 patients using this operative technique is promising. Equally, the morphological appearance of the newly created valve closely resembles the genuine ileocecal valve during barium enema as well as endoscopic investigations.

Sequential intestinal lengthening procedures for refractory short bowel syndrome

Better understanding of the long-term delivery of parenteral nutrition (PN) in neonates and children has increased the survival for patients who have neonatal short bowel syndrome. Most infants with short bowel syndrome experience progressive enteral adaptation and are weaned from PN. This report describes the authors' clinical experience with nine infants and children who had refractory short bowel syndrome; single or sequential procedures were performed to lengthen the small bowel. Gut lengthening procedures used included a small bowel nipple valve constructed distally, to provide temporary partial obstruction and thereby induce dilatation and lengthening of the proximal small intestine (six patients). Bianchi's technique was used in three patients primarily and in six others after the bowel had been dilated and lengthened by the nipple valve. Kimura's gut lengthening technique was used in one patient after the small bowel had spontaneously become dilated subsequent to a Bianchi procedure. In all, 16 lengthening procedures were performed on the nine patients. Preoperatively, the nine patients tolerated less than 10% of their caloric intake enterally, with no evidence of improvement for a minimum of 6 months. Small bowel segments ranged from 6 to 92 cm originally and were increased an average of 2 1/2 times the original length. Two patients have been totally weaned from PN. For the patients whose lengthening procedure was performed more than 1 year ago, the percentage of enteral caloric intake averages 50%. One of the patients was profoundly impaired neurologically and was not resuscitated from an apneic episode. Another patient died in his sleep of unknown causes 1 year after intestinal lengthening.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of the short-bowel syndrome

The patient with short-bowel syndrome after massive small-intestinal resection represents one of the greatest clinical challenges a general surgeon must face. Maintaining optimal nutritional and metabolic support until maximum bowel adaptation can occur is the top priority of therapy. Currently, no operative procedure for adjunctive management of the short-bowel syndrome is sufficiently safe and effective to recommend its routine use. Long-term parenteral nutrition remains the cornerstone of successful management.

The value of intestinal myotomy and myectomy in improving the reservoir capacity of the endorectal pull-through

In laboratory models of massive small bowel resection and colectomy, intestinal myotomy has been shown to decrease stool frequency and malabsorption. Using physiologic and anatomic parameters of gastrointestinal function, we assessed the ability of three types of ileal myotomies to improve outcome after total abdominal colectomy, mucosal proctectomy, and endorectal pull-through (ERPT) without an enteric reservoir. Twenty puppies underwent ERPT. These dogs were randomly assigned to three experimental groups or a control group consisting of animals without a myotomy. The myotomies were performed by excising the serosa and muscularis propria of the ileal wall in three different patterns. There was no difference between any of the groups with respect to general health, postoperative weight gain, stool frequency, intestinal transit time, water absorption, electrolyte absorption, barium enemas, neorectal capacity and dimensions, and histology.

Intestinal transit time is delayed by artificial sphincters after massive enterectomy in dogs

Artificial sphincters were created in three groups of dogs after the resection of 87.5 percent of the intestine in each animal. Intestinal transit time was measured after 6 weeks by observing the passage of a radiopaque medium through the animals' intestinal tracts. No statistically significant differences were found between the intestinal transit times of dogs with one artificial sphincter and control animals. In dogs with two artificial sphincters there was a delay in the radiologically monitored intestinal transit time that was statistically significant compared with that of the control group.

A muscle ablation sphincter to prevent diarrhea after total colectomy in puppies: a preliminary report

Many adjunctive surgical techniques have been proposed to decrease diarrhea following total colectomy with an ileoanal anastomosis. A previously proposed method of longitudinal muscle ablation in canine small intestine to produce an "artificial sphincter" and increase transit time after massive small bowel resections has been applied to puppies who have had a total abdominal colectomy and ileoproctostomy. Total abdominal colectomy with ileoproctostomy at the level of the peritoneal reflection was performed in 6 mongrel puppies, aged 6-8 weeks. Two control puppies died within 2 weeks of the procedure with overwhelming diarrhea. Four experimental animals had "sphincters" (circumferential excision of a 1 cm length of longitudinal muscle) placed 5 cm proximal to the ileoproctostomy anastomosis. The puppies with colectomy plus sphincter were followed from 14 months to two years postoperatively and had intestinal transit times of 3-4 1/2 hours comparable to unoperated littermates. Intermittent postoperative barium enemas were performed and gross and histologic examination of the sphincters were carried out at necropsy. This muscle ablation technique when used in puppies with total abdominal colectomy and ileoproctostomy controls diarrhea, allows survival with normal growth and does not result in proximal small bowel enteritis.

Surgical therapy for the short bowel syndrome

The introduction of total parenteral nutrition has resulted in more patients surviving massive intestinal resection. Long-term parenteral nutrition is expensive, has potential complications, and causes inconvenience for the patient. Therefore, interest persists in surgical therapy for the short bowel syndrome. The goals of surgical therapy in the short bowel syndrome are to slow intestinal transit, increase the area of absorption, and reduce gastric hyperacidity. Patients with sufficient absorptive area, but rapid intestinal transit, benefit from antiperistaltic segments or colon interposition. Intestinal valves yield inconsistent results. Recirculating loops are associated with prohibitive morbidity and mortality. Experience with intestinal pacing is limited. Patients with dilated bowel segments may benefit from intestinal tapering or lengthening. Growing neomucosa holds promise but has not been evaluated clinically. Recent improvement in the results of intestinal transplantation in animals may warrant clinical trials. The efficacy of H2 receptor antagonists makes procedures for reducing gastric hyperacidity less necessary. None of the operations to treat the short bowel syndrome are sufficiently safe and effective to recommend their routine use. Operations should be performed only on selected patients to achieve specific goals. Although investigation continues, our emphasis should continue to be conservation of as much of the intestine as possible when massive resection is necessary.

An experimental model of a submucosally tunnelled valve for the replacement of the ileo-cecal valve

An enteric valve to prevent colonic content reflux and to prolong small bowel transit time was created by passing small bowel through a submucosal tunnel in the colon. Barium enema, Gl tract series, and iso- and antiperistaltic pressure measurements showed the valve to be of competence equal to the ileo-cecal valve. Late pathological examination revealed a patent valve with minimal scar formation. The optimal submucosal tunnel length was between 4 and 6 cm. This valve can, theoretically, increase the absorptive capacity in short bowel syndrome and may serve as a substitute for the critically important ileo-cecal valve.