Microscopic inflammation in ileocecal specimen does not correspond to a higher anastomotic leakage rate after ileocecal resection in Crohn's disease

Background

Patients with Crohn’s disease suffer from a higher rate of anastomotic leakages after ileocecal resection than patients without Crohn’s disease. Our hypothesis was that microscopic inflammation at the resection margins of ileocecal resections in Crohn’s disease increases the rate of anastomotic leakages.

Patients and methods

In a retrospective cohort study, 130 patients with Crohn’s disease that underwent ileocecal resection between 2015 and 2019, were analyzed. Anastomotic leakage was the primary outcome parameter. Inflammation at the resection margin was characterized as “inflammation at proximal resection margin”, “inflammation at distal resection margin” or “inflammation at both ends”.

Results

46 patients (35.4%) showed microscopic inflammation at the resection margins. 17 patients (13.1%) developed anastomotic leakage. No difference in the rate of anastomotic leakages was found for proximally affected resection margins (no anastomotic leakage vs. anastomotic leakage: 20.3 vs. 35.3%, p = 0.17), distally affected resection margins (2.7 vs. 5.9%, p = 0.47) or inflammation at both ends (9.7 vs. 11.8%, p = 0.80). No effect on the anastomotic leakage rate was found for preoperative hemoglobin concentration (no anastomotic leakage vs. anastomotic leakage: 12.3 vs. 13.5 g/dl, p = 0.26), perioperative immunosuppressive medication (62.8 vs. 52.9%, p = 0.30), BMI (21.8 vs. 22.4 m²/kg, p = 0.82), emergency operation (21.2 vs. 11.8%, p = 0.29), laparoscopic vs. open procedure (p = 0.58), diverting ileostomy (31.9 vs. 57.1%, p = 0.35) or the level of surgical training (staff surgeon: 80.5 vs. 76.5%, p = 0.45).

Conclusion

Microscopic inflammation at the resection margins after ileocecal resection in Crohn’s disease is common. Histologically inflamed resection margins do not appear to affect the rate of anastomotic leakages. Our data suggest that there is no need for extensive resections or frozen section to achieve microscopically inflammation-free resection margins.

Method for Acute Intravital Imaging of the Large Intestine in Live Mice

Intravital microscopy is an imaging technique aimed at the visualization of the dynamics of biological processes in live animals. In the last decade, the development of nonlinear optical microscopy has enormously increased the use of this technique, thus addressing key biological questions in different fields such as immunology, neurobiology and tumor biology. In addition, new upcoming strategies to minimize motion artifacts due to animal respiration and heartbeat have enabled the visualization in real time of biological processes at cellular and subcellular resolution. Recently, intravital microscopy has been applied to analyze different aspect of mucosal immunity in the gut. However, the majority of these studies have been performed on the small intestine. Although crucial aspects of the biology of this organ have been unveiled, the majority of intestinal pathologies in humans occur in the large intestine.Here, we describe a method to surgically expose and stabilize the large intestine in live mice and to perform short-term (up to 2 h) intravital microscopy.

What are the Particularities of Colorectal Surgery in Cirrhotic Patients

This work's objective was to review the entire literature on colorectal surgery in order to best define the surgical indications and their management specificities. The literature analysis was carried out according to High Authority for Health (HAS) methodology, by consulting the PubMed database (Medline), from the beginning of January 1995 until the end of June 2015.

Injuries of the small and large intestine

INTRODUCTION

Patients with abdominal trauma appear frequently. The most vulnerable organs in these patients are the liver and the spleen. Injuries of the small and large intestines are relatively less frequent. The diagnostic process of these injuries is complex and requires an analysis of all results. Therefore it is highly probable that the final diagnosis can be delayed and so can be delayed an indication of surgical exploration of the abdominal cavity, which can have serious consequences on the morbidity and mortality of these patients with intestinal trauma.

METHODS

We collected our data using the WinMedicalc 2000 software. We searched for patients hospitalised in years 20082017 in the Department of Surgery, Faculty of Medicine in Pilsen subjected to surgical revision of the abdominal cavity for intestinal trauma.

RESULTS

Our set comprised 41 patients, including 30 men and 11 women. The mean age of the patients was 41 years, 4 of the patients were children. Twenty-three of the patients suffered from polytrauma, while 9 of the patients had a relatively isolated injury of either the small intestine or the colon. Six of the patients died. The small intestine was injured in 17 patients, the colon was injured in 14 patients and both were injured in 10 patients. The intestinal injury was diagnosed in 17 cases based on CT imaging (performed 31 times in total); 23 cases were diagnosed in the peroperative period.

CONCLUSIONS

We assessed a set of patients with an intestinal injury in terms of specific diagnosis, severity of trauma, diagnostic process and treatment. The results are similar to the results of studies in large sets of patients. Even though imaging methods can help to reach the right diagnosis, they are insufficient as a sole diagnostic method, and physical examination plays a major role.

Near-Infrared Indocyanine Green-Enhanced Fluorescence and Evaluation of the Bowel Microperfusion During Robotic Colorectal Surgery: a Retrospective Original Paper

BACKGROUND

Leakage of the anastomosis after colorectal surgery is a severe complication, and one of the most important causes is poor vascular supply. However, a microvascular deficit is often not detectable during surgery under white light. Near-infrared indocyanine green (ICG)-enhanced fluorescence may be useful for assessing microvascular deficits and conceivably preventing anastomotic leakage.

OBJECTIVES

This paper presents a preliminary retrospective case series on robotic colorectal surgery. The aim is to evaluate the feasibility, safety and role of near-infrared ICG-enhanced ?uorescence for the intraoperative assessment of peri-anastomotic tissue vascular perfusion.

MATERIALS AND METHODS

From among more than 164 robotic colorectal cases performed, we retrospectively analyzed 28 that were all performed by the same surgeon (PCG) using near-infrared ICG-enhanced fluorescence technology: 16 left colectomies (57.1%), 8 rectal resections (28.6%), 3 right colectomies (10.8%) and 1 pancolectomy (3.6%).

RESULTS

The rates of conversion, intraoperative complications, dye allergic reaction and mortality were all 0%. In two cases (7.1%)-1 left and 1 right colectomy-the level of the anastomosis was changed intraoperatively after ICG showed ischemic tissues. Despite the application of ICG, one anastomotic leak (after left colectomy for a chronic recurrent sigmoid diverticulitis with pericolic abscess) was observed.

CONCLUSIONS

ICG technology may help to determine when to intraoperatively change the anastomotic level to a safer location. In our case series, ICG results led to a change in the level of the anastomosis in 7.1% of the cases. Despite the use of ICG, we observed one leak. This may have been related to vascularization-independent causes (e.g., infection in this case) or may reflect a need for better standardization of this ICG technology. In particular, we need a way to objectively assess the ICG signal and the related risk of leakage. More randomized, prospective, well-powered trials are needed to unveil the full potential of this innovative surgical technology.

Single-Layer Anastomosis in the Large Bowel: Ten Years' Experience

Satisfactory experience with single-layer colorectal anastomosis during 1969–74 led to an analysis of the results of single-layer large bowel anastomosis during the subsequent years 1975–79. This technique has continued to be associated with a low incidence of anastomotic failure, but anastomotic integrity also depends on rigorous attitudes to bowel preparation, to bacterial contamination and to the avoidance of anastomosis when the risk of anastomotic failure is high.

Surgical Management of Gunshot Injuries of the Large Intestine

Eighty-eight patients suffering from gunshot injuries of the large intestine were admitted during an 8-year period to the Royal Victoria Hospital, Belfast. In 16 patients who died there was an average of 3.8 intra-abdominal organs injured. No patient with an isolated colonic or rectal injury succumbed.

Immunoregulation effects of different γδT cells and toll-like receptor signaling pathways in neonatal necrotizing enterocolitis

The aim of the study was to observe cytokine and T-cell-related toll-like-receptor (TLR) changes in intestinal samples of neonatal necrotizing enterocolitis patients.Four necrotic bowels were collected from neonatal NEC patients with gestational ages of 28 to 29 weeks in our hospital, whereas 4 neonatal patients who underwent intestinal atresia surgery served as the controls. Intestinal flora was examined and IL-1, IL-2, IL-4, IL-6, IL-8, IL-10, TNF-α, IFN-γ, and IL-17 expressions in resected intestine samples, as well as in isolated gamma delta T (γδT) cells, were analyzed immunohistochemically and via quantitative RT-PCR. γδT cells were isolated from the intestinal intraepithelial lymphocytes (IELs) and their TLR4/TLR9 distribution in the intestinal tissues was determined by flow cytometry.The bacterial flora of the neonatal NEC patients' contained significantly higher amounts of Gram-negative Enterobacteriaceae, Klebsiella, and Bacteroides but anaerobic Gram-positive Bifidobacteria occurred significantly less in the NEC than the control group. IL-1, IL-2, IL-4, IL-6, IL-8, IL-10, TNF-α, IFN-γ, and IL-17 expressions in the resected intestine samples and in isolated γδT cells were enhanced in NEC samples compared to the controls. γδT cells were less prevalent in NEC-derived intestinal tissues, but their TLR4/TLR9 expressions were significantly enhanced.The changed bacterial flora in preterm neonatal NEC patients led to an obvious inflammation of the intestines, which was accompanied by reductions of γδT cell localizations to the intestine and a shift of their surface expressions to TLR4 and TLR9.

Indications and surgical options for small bowel, large bowel and perianal Crohn's disease

Despite advancements in medical therapy of Crohn's disease (CD), majority of patients with CD will eventually require surgical intervention, with at least a third of patients requiring multiple surgeries. It is important to understand the role and timing of surgery, with the goals of therapy to reduce the need for surgery without increasing the odds of emergency surgery and its associated morbidity, as well as to limit surgical recurrence and avoid intestinal failure. The profile of CD patients requiring surgical intervention has changed over the decades with improvements in medical therapy with immunomodulators and biological agents. The most common indication for surgery is obstruction from stricturing disease, followed by abscesses and fistulae. The risk of gastrointestinal bleeding in CD is high but the likelihood of needing surgery for bleeding is low. Most major gastrointestinal bleeding episodes resolve spontaneously, albeit the risk of re-bleeding is high. The risk of colorectal cancer associated with CD is low. While current surgical guidelines recommend a total proctocolectomy for colorectal cancer associated with CD, subtotal colectomy or segmental colectomy with endoscopic surveillance may be a reasonable option. Approximately 20%-40% of CD patients will need perianal surgery during their lifetime. This review assesses the practice parameters and guidelines in the surgical management of CD, with a focus on the indications for surgery in CD (and when not to operate), and a critical evaluation of the timing and surgical options available to improve outcomes and reduce recurrence rates.

Impact of weekday surgery on application of enhanced recovery pathway: a retrospective cohort study

OBJECTIVE

To compare the enhanced recovery after surgery (ERAS) protocol compliance and clinical outcomes depending on the weekday of surgery.

SETTINGS

Cohort of consecutive non-selected patients undergoing elective colorectal surgery from January 2012 to March 2015. This retrospective analysis of our prospective database compared patients operated early in the week (Monday and Tuesday) with patients operated in the second half (late: Thursday, Friday).

PRIMARY OUTCOME MEASURES

Compliance with the ERAS protocol, functional recovery, complications and length of stay.

RESULTS

Demographic and surgical details were similar between the early (n=352) and late groups (n=204). Overall compliance with the ERAS protocol was 78% vs 76% for the early and late groups, respectively (p=0.009). Significant differences were notably prolonged urinary drainage and intravenous fluid infusion in the late group. Complication rates and length of stay, however, were not different between surgery on Monday or Tuesday and surgery on Thursday or Friday.

CONCLUSIONS

Application of the ERAS protocol showed only minor differences for patients operated on early or late during the week, and clinical outcomes were similar. A fully implemented ERAS programme appears to work also over the weekend.

[PECULIARITIES OF SURGICAL TREATMENT OF ADHESIVE DISEASE OF PERITONEUM]

For the adhesive disease of peritoneum (ADP) viscerolysis was performed in 235 patients, of them in 47--a total one, while a great omentum cicatricial-adhesive involvement occurred, so in 33--a partial omental resection was performed. The volume and technique of operative intervention have had depended on the number of operations performed and intestinal changes present. Individualized approach to choice of the surgical method of treatment have permitted to improve its result essentially in ADP, complicated by an acute ileus, in early and remote postoperative period. ; acute adhesive ileus.

[RECONSTRUCTIVE-RESTORATION OPERATIONS AFTER OBSTRUCTIVE RESECTION OF LARGE BOWEL]

The results of reconstructive-restoration operations, performed after obstructive resection of large bowel for colorectal cancer, were analyzed. The postoperative complications rate have constituted 11.7%. The most frequent cause of morbidity, 3.9%, was partial insufficiency of sutures of interintestinal anastomosis, formatted in the end to end fashion. Lethality have constituted 1.1%.

[IMPROVEMENT AND CHOICE OF COLOSTOMY METHOD IN THE TREATMENT OF PATIENTS, SUFFERING AN ACUTE OBTURATIVE IMPASSABILITY OF LARGE BOWEL]

Colostomy was done in 49 patients, suffering an acute obturative impassability of large bowel (AOILB). In 28 patients (1st group) colostomy was conducted in accordance to standard method; in 21 (2nd group)--in accordance to the method, proposed by us. Application of the method proposed for surgical treatment of AOILB have guaranteed a reduction of postoperative paracolostomal complications rate in 6.8 times, of postoperative lethality--in 2.2 times, duration of the patient stationary treatment--in 1.4 times, the rate of dressings and the dressing material expanses--in 10 times.

An unusual outcome of a giant ventral hernia

Hernias are routine general surgical problems that may present in any age group, regardless of the patient’s socioeconomic status. We present a rare case of a complicated ventral hernia leading to short bowel. This is an unusual case and is very rarely reported in the literature. This current case report describes a 54-year-old gentleman who presented to the hospital with a giant strangulated ventral hernia causing massive bowel ischemia and resulting in a short bowel. The literature on large abdominal wall hernias leading to short bowel is reviewed, and a discussion on short bowel syndrome is also presented.

Current outcomes of emergency large bowel surgery

INTRODUCTION

Emergency large bowel surgery (ELBS) is known to carry an increased risk of morbidity and mortality. Previous studies have reported morbidity and mortality rates up to 14.3%. However, there has not been a recent study to document the outcomes of ELBS following several major changes in surgical training and provision of emergency surgery. The aim of this study was therefore to explore the current outcomes of ELBS.

METHODS

A retrospective review was performed of a prospectively maintained database of the clinical records of all patients who had ELBS between 2006 and 2013. Data pertaining to patient demographics, ASA (American Society of Anesthesiologists) grade, diagnosis, surgical procedure performed, grade of operating surgeon and assistant, length of hospital stay, postoperative complications and in-hospital mortality were analysed.

RESULTS

A total of 202 patients underwent ELBS during the study period. The mean patient age was 62 years and the most common cause was colonic carcinoma (n=67, 33%). There were 32 patients (15.8%) who presented with obstruction and 64 (31.7%) had bowel perforation. The overall in-hospital mortality rate was 14.8% (n=30). A consultant surgeon was involved in 187 cases (92.6%) as either first operator, assistant or available in theatre.

CONCLUSIONS

ELBS continues to carry a high risk despite several major changes in the provision of emergency surgery. Further developments are needed to improve postoperative outcomes in these patients.

[Modern surgical tactics in Crohn's disease in coloproctological centre of Ukraine]

Surgical tactics in Crohn's disease (CD) was elaborated by the authors, basing, on analysis of modern views on pathogenesis, peculiarities of clinical course, possibility of diagnosis and experience of treatment of the disease. It envisages a modern diagnosis of the disease, prognostication of the recurrence and postoperative complications occurrence, the indications optimization, the choice of surgical treatment method Application of the surgical tactics elaborated for CD in 121 patients have permitted to improve objective estimation of the disease severity, to prognosticate the complications occurrence, to optimize indications for surgical treatment and the choice for method o conditionally radical, restorational, reconstructive--restoration stages of operative intervention, to reduce the disease recurrence rate, postoperative complications and postoperative lethality.

[ULTRASONIC DIAGNOSIS OF GIRSHPRUNG ILLNESS AT CHILDREN]

Use of ultrasonic diagnostics reduces number of the low-informative, invasive and connected with beam loading procedures. Objectivity of results of ultrasonic structure of an intestinal wall depends on many subjective parameters: from the device on which examination, from the expert experience, from extent of preparation of intestines, from the applied solution for contrasting, from degree of expressiveness of a desire on a defecation is conducted when filling a thick gut.

Effects of intravenous versus epidural lidocaine infusion on pain intensity and bowel function after major large bowel surgery: a double-blind randomized controlled trial

BACKGROUND

We compared the effects of intravenous lidocaine (IVL) with lumbar epidural lidocaine analgesia (LEA) on pain and ileus after open colonic surgery.

METHODS

Between December 2011 and February 2013, 60 patients were randomly allocated to IVL, LEA, or control group. The IVL group received intraoperatively lidocaine 2 % intravenously (1.5 mg/kg bolus, 2 mg/kg/h infusion) and normal saline (NS) epidurally. The LEA group received lidocaine epidurally (1.5 mg/kg bolus, 2 mg/kg/h infusion) and NS intravenously. The control group received NS both intravenously and epidurally, as bolus and infusion. All NS volumes were calculated as if containing lidocaine 2 % at the aforementioned doses. We assessed pain intensity at rest/cough at 1, 2, 4, 12, 24, and 48 h postoperatively (numerical rating scale 0-10), 48-h analgesic consumption, and time to first flatus passage.

RESULTS

Data from 60 patients (20 per group) were analyzed. The IVL group had significantly lower pain scores at rest and cough compared to LEA or control group only at 1, 2, and 4 h postoperatively (P < 0.005 for all comparisons). The 48-h analgesic requirements and time to first flatus passage did not differ significantly between IVL group and LEA or control group (P > 0.05).

CONCLUSIONS

Compared with LEA-lidocaine or placebo, intravenous lidocaine offered no clinically significant benefit in terms of analgesia and bowel function.

[Combined operative interventions for locally-spread diseases of large bowel]

In the clinic of general surgery, based on The Rural coloproctological centre, in 2012-2013 yrs 469 patients were operated for various diseases of large bowel. There were analyzed the results of treatment in 51 (10.8%) patients, to whom the combined operative interventions (COI) were conducted. For the large bowel tumors 48 (94.1%) patients were operated, for nontumoral diseases--3 (5.9%). COI, as a palliative procedures for the large bowel tumors of various localization, were performed in 22 (13.1%) patients, in 34 (67%)--with resection and excision of one organ, and in 17 (33%)--of two organs and more. In 49 (96%) patients the operation was completed by formation of interintestinal anastomosis or using colonic descendence. In adequate conduction of diagnostic measures and preoperative preparations of patients the COI performance is expedient, because it do not compromise the indices of the patients quality of life. For estimation of the COI risk grade it is necessary to take into account the volume and severity of each stage, expressiveness of the disorders in the organs and systems function as well as the tumors resectability.

[Surgical treatment of acute large bowel ileus]

The results of treatment were analyzed in 47 patients, suffering operable cancer of left half of large bowel, complicated by an acute obturation ileus of the large bowel (AOILB), in whom radical obstructive operation of the Hartmann type was performed. In 26 patients (the 1-st group) a typical obstructive operation of Hartmann type was accomplished, and in 21 (2-nd group)--a radical obstructive operation in accordance to the method proposed. In a 1-st group postoperative complications have occurred in 7 (26.9%) patients, duration of stay in stationary was 19 days on average; in the 2-nd group the complications were observed in 2 (9.5%) patients. Duration of treatment in stationary was 13 days. Thus, application of the method of surgical treatment of the AOILB proposed have permitted to reduce postoperative morbidity rate in 2.8 times, the lethality--in 2.4 times, duration of a stationary treatment--in 1.4 times, necessity in postoperative wound dressing procedures and expenditure on dressing material--in 10 times.

[Approaches for formation of the large bowel anastomoses for prophylaxis of their sutures insufficiency]

The results of surgical treatment of 424 patients, in whom the postponed and elective surgery was done for the large bowel malignancies, were analyzed. Advantages of a one-layer suture while formation of a large-bowel anastomoses in comparison with a two-layer suture were noted: minimal rate of the sutures insufficiency--(4.9 +/- 0.8)%, and (7.9 +/- 1.7)%, accordingly (p<0.001). Mostly often insufficience of the colorectal anastomosis sutures was observed after anterior rectal resection--in (9.7 +/- 1.9)% and (7.2 +/- 1.5)% patients. Postoperative lethality was 2.6%, for majority of the patients the reasons of the death were pulmonary thromboembolism and an acute cardio-vascu- lar insufficiency.

Trilogy of foregut, midgut and hindgut atresias presenting in reverse order

We present a case of triple gut atresias (foregut, midgut and hindgut) with multiple congenital anomalies presenting as imperforate anus. Abdominal radiography showed the double bubble sign. Upper gastrointestinal study through a nasogastric tube confirmed duodenal obstruction. Exploratory laparotomy, duodeno-duodenostomy for duodenal atresia and a left descending colostomy for anorectal malformation were performed. During extubation, the nasogastric tube came out and could not be reinserted by the anaesthetic team under laryngoscopic guidance. A chest radiograph showed the tube curled in the upper pouch. Bronchoscopy and oesophagoscopy confirmed oesophageal atresia (OA) with a distal tracheoesophageal fistula (TOF). The patient underwent right-sided extrapleural thoracotomy and division of the fistula with primary repair of OA uneventfully. Triple gut atresias presenting in reverse order with multiple anomalies is rare and passage of a nasogastric tube into the stomach in the presence of OA+TOF is exceptional. Alimentary tract obstruction should be corrected in proximal to distal direction.

[Surgical treatment of Hirschprung's disease total form in children]

It was analyzed the treatment results of 24 patients under the age of 2 years with total aganglionosis for the period from 2000 to 2013. Each of these patients underwent several surgical interventions (on the average 7.8±2.1). All children were operated radically. It was performed ileojejunorectal anastomosis at transitional fold of peritoneum in patients with concomitant short bowel syndrome. Soave's operation was done in 14 patients including by using of laparoscopic technique in 3 cases. Inflammatory complications (paraproctitis) developed in 2 children on maceration background. Perirectal fistula was observed in 1 patient subsequently. In long-term period liquid stool incontinence persisted up to 6 months in 28% of children. In terms of more than 1 year stool incontinence was observed in 12.6% of patients. Increased growth of D-lactate-producing gram-positive anaerobes was revealed during microbiological investigation of feces in 35% of patients in long-term period. Increased growth was accompanied by systemic acidosis and infectious enteritis clinically. Course monthly treatment with antibacterial drugs (Alpha-Normix, Trichopolum, Gentamicin) was prescribed in patients with short bowel syndrome and high frequent of enteritis recurrence. Treatment was used In terms from 6 to 12 months of longer if it was necessary. It was concluded that timely diagnosis and right tactic in neonatal period leads to decrease significantly the number of complications, vain interventions and to improve treatment outcomes. Our experience shows that the best results of surgical treatment were observed in children aged from 2.5-3 years when a child can control urination and defecation. The most mistakes are caused by wrong or failed morphological investigation of large bowel.

Laser-induced tissue fluorescence in radiofrequency tissue-fusion characterization

Heat-induced tissue fusion is an important procedure in modern surgery and can greatly reduce trauma, complications, and mortality during minimally invasive surgical blood vessel anastomosis, but it may also have further benefits if applied to other tissue types such as small and large intestine anastomoses. We present a tissue-fusion characterization technology using laser-induced fluorescence spectroscopy, which provides further insight into tissue constituent variations at the molecular level. In particular, an increase of fluorescence intensity in 450- to 550-nm range for 375- and 405-nm excitation suggests that the collagen cross-linking in fused tissues increased. Our experimental and statistical analyses showed that, by using fluorescence spectral data, good fusion could be differentiated from other cases with an accuracy of more than 95%. This suggests that the fluorescence spectroscopy could be potentially used as a feedback control method in online tissue-fusion monitoring.

[Two cases of acute large bowel obstruction caused by advanced cancer treated with stenting "bridge to surgery" procedure]

Obstructive colorectal cancer accounts for 3.1-15.8% of total colorectal cancer cases, therefore it is not a rare condition. Formerly, it has been often treated with emergent operation such as colostomy or trans-anal tube decompression. Since 2012, revision of the medical payment system, it has become possible to be treated with elective operation when using endoscopic metal stent placement that enable to decompress enlarged intestine by transanal approach. This procedure provides safe elective surgery with sufficient preoperative inspection and conventional bowel preparation. We report two cases of acute large bowel obstruction due to colon cancer treated with endoscopic stent placement as a "bridge to surgery".

Double circular stapler technique for bowel resection in rectosigmoid endometriosis

To reduce bladder function impairment and avert the serious complications of anastomotic leakage after segmental rectosigmoidectomy and to minimize the persistence of endometriotic lesions associated with discoid resection, we used the double circular stapling (DCS) technique. This technique enables excision of bowel endometriosis nodules larger than those that can be removed with the single-load technique of the circular stapler. Of 120 patients who underwent surgery to treat bowel endometriosis, intestinal shaving was performed in 24, discoid resection with single circular stapling in 40, and rectosigmoidectomy in 55. Eleven patients (9.2%) underwent the DCS technique. In the DCS group, the size of the rectosigmoid lesion ranged from 2.2 cm to 4.2 cm. Median operative time for the DCS technique was 100 minutes, compared with 150 minutes for rectosigmoidectomy (p = .04). Only 1 of 11 patients (9%) had urinary retention, compared with postoperative urinary retention in 14 of 55 patients (25%) who had undergone rectosigmoidectomy (difference not significant). Only 1 patient, with a 4.2-cm nodule, had a positive margin in the specimen obtained at the second stapling. DCS is a promising technique and may avert rectosigmoidectomy in selected patients.

[Differential surgical treatment of victims with damage to the small and large intestines in a closed abdominal injury combined, depending on the prediction of traumatic disease course and morphological changes of the intestinal wall]

Use of differentiated surgical approach to the management of surgical treatment, depending on the degree of violation of systemic hemodynamics, the timing and volume of surgical procedures, depending on the prognosis of traumatic disease course of cardiac index, interventions in the small and large intestine depending on morphological changes of the intestinal wall by cardiac and stroke indexes, put method extra-enteric anastomosis in patients with damage to the small intestine and colon combined with closed abdominal injury permitted to reduce the rate of postoperative complications from 22.2 to 10.1%, mortality at 2.1 times in shock period (from 19.3 to 9.2%) and the overall mortality from 33.3 to 21.1%.

Multiple large bowel resections: potential risk factor for anastomotic leak

OBJECTIVES

Identify risk factors of anastomotic leak (AL) after large bowel resection (LBR) for ovarian cancer (OC) and compare outcomes between AL and no AL.

METHODS

All cases of AL after LBR for OC between 01/01/1994 and 05/20/2011 were identified and matched 1:2 with controls for age (±5 years), sub-stage (IIIA/IIIB; IIIC; IV), and date of surgery (±4 years). Patient-specific and intraoperative risk factors, use of protective stomas, and outcomes were abstracted. A stratified conditional logistic regression model was fit to determine the association between each factor and AL.

RESULTS

42 AL cases were evaluable and matched with 84 controls. Two-thirds of the AL had stage IIIC disease and >90% of both cases and controls were cytoreduced to <1cm residual disease. No patient-specific risk factors were associated with AL (pre-operative albumin was not available for most patients). Rectosigmoid resection coupled with additional LBR was associated with AL (OR=2.73, 95% CI 1.13-6.59, P=0.025), and protective stomas were associated with decreased risk of AL (0% vs. 10.7%, P=0.024). AL patients had longer length of stay (P<0.001), were less likely to start chemotherapy (P=0.020), and had longer time to chemotherapy (P=0.007). Cases tended to have higher 90-day mortality (P=0.061) and were more likely to have poorer overall survival (HR=2.05, 95% CI 1.18-3.57, P=0.011).

CONCLUSIONS

Multiple LBRs appear to be associated with increased risk of AL and protective stomas with decreased risk. Since AL after OC cytoreduction significantly delays chemotherapy and negatively impacts survival, surgeons should strongly consider temporary diversion in selected patients (poor nutritional status, multiple LBRs, previous pelvic radiation, very low anterior resection, steroid use).

[Automation expert system for quantitative risk assessment in reconstructive surgical procedures on the large intestine]

The algorithm of quantitative estimation of operative risk while performing reconstructive-restoration colonic surgery was proposed. There was established high sensitivity and specificity of quantitative estimation of operative risk while application of a neuronet models, especially in usage of a neuronet owing two output neurons. While doing the operative risk estimation, using neuronets, the fault answers rate, as well as of unrecognized states, is trustworthy small, what permits to recommend the method for wide application.

[The risk factors of the sutures insufficiency and the choice of the anastomosis formation method during reconstruction-restoration operations on the large bowel]

Basing on statistical analysis of 17 prognostic risk factors for occurrence of the sutures insufficiency in a large bowel anastomoses (SILBA) in 237 patients there was established a trustworthy correlational connection for 7 factors. The results of a regression analysis have had confirmed the influence of the anastomosis formation method on the complication rate, demonstrated by an active inflammation in the anastomosis formation area, technical faults while the wall mobilization and rude formation of sutures, intramural disorder of the blood circulation, the blood circulation general disorders, local infectioning and hypoproteinemia. Application of analysis of the tables of conjunction and comparison in accordance with the numeral and interval predictors, using nonparametric analysis (the method of a binary logistic regression), have permitted to delineate the most prognostically significant risk factors of the SILBA occurrence.

[A quality of life evaluation in patients with a surgically formed large bowel stoma]

The investigation objective was estimation of the patients quality of life (QL), in whom a large intestine stoma was formed. Presence of colostoma constitutes a traumatizing factor, which reduce significantly the level of the patients social adaptation and QL. Most significant desadaptation was noted after formation of colostoma in patients, suffering trauma and nontumoral diseases of large intestine. The indices dynamics for the patients QL in presence of large intestine stoma reflects the sanogenesis processes and may serve as an indicator of clinical effectiveness of the conducted treatment.

[Creation of models of incomplete external lip-like large bowel fistula in experiment]

The method of experimental simulation of the incomplete external lip-like large bowel fistula creation was elaborated on experimental animals for studying of possibilities forapplication of hyperthermic methods of the fistula channel obliteration and disinfectioning of the neighboring anterior abdominal wall tissues. There were studied up microflora and bacterial seeding of the large bowel contents in the zone of a fistula exit as well as dynamics of changes of inflammatory processes, occurring in tissues of anterior abdominal wall, neighboring the external orifice of a fistula channel.

[The choice of optimal operative intervention in patients, suffering an acute tumoral impassability of large intestine]

The results of treatment of 101 patients, suffering an acute ileus (AI), caused by colonic cancer, were presented. The operation was performed in 88 patients for AI in subcompensated and decompensated stages. Right-sided hemicolectomy with ileotransversoanastomosis formation was done for right-sided localization of the tumor in a subcompensated stage. The outloading end colostomy was done after tumoral excision and ileotransversoanastomosis formation accomplishment in patients, suffering AI in a decompensated stage with purulent peritonitis. Obstructive large-bowel resection was performed for left-sided colonic cancer with AI in a decompensated stage, and for subcompensated stage--a left-sided hemicolectomy with Y-type anastomosis was done. Postoperative complications rate have constituted 27.3% and lethality--12.5%.

[Investigation of the method of electric welding of organs and tissues on the models of clinical operations in experiment]

A new method of sutureless connection of tissues during surgical procedures was developed. Potentialities of the method of electric welding of biological tissues in abdominal surgery are studied. For this purpose an investigation of regeneration processes in the area of using electric welding on the large intestine as well as the liver under conditions of intact tissues and against the background of hyperglycemia and atherosclerosis model was performed.

[Reconstructive-restorative operations by the method of invagination in colorectal surgery]

The authors made an analysis of results of surgical treatment of 41 patients who underwent reconstructive large bowel anastomosis by the Hartman procedure. In 19 (46.3%) patients the anastomoses were performed by traditional methods (end-to-end and end-to-side) using a two-row suture. In 22 (53.7) patients the anastomoses were made by one-row sutures. The authors conclude that the results of formation of invaginated colorectal anastomosis depend on the method of forming anastomosis, with the performing of colorectal anastomosis by traditional method fraught with the development of the content reflux in the outlet. The authors proposed a method of forming colorectal anastomoses by invagination using a one-row suture. The obtained function of the valve prevents regurgitation of the intestinal content and is considered to be a measure for preventing reflux.

Intraoperative contrast-enhanced sonography of bowel blood flow: preliminary experience

OBJECTIVES

The potential to predict, and therefore avoid, anastomotic failure has eluded generations of colon and rectal surgeons to date. A reliable, reproducible method of assessing bowel blood flow therefore would be of enormous potential clinical relevance. To our knowledge, intraoperative contrast-enhanced sonography of the bowel has not been performed previously. We present our study assessing the feasibility of using contrast-enhanced sonography to study bowel perfusion intraoperatively.

METHODS

We studied 8 patients (4 male and 4 female) with an age range of 52 to 81 years who underwent colorectal surgery (right hemicolectomies, n = 3; Hartmann procedure, n = 1; anterior resections, n = 2; and bowel resections with ileocolic anastomoses, n = 2). A 5-mL bolus of a sulfur hexafluoride contrast agent solution was injected before and after vascular ligation with simultaneous noncompression ultrasound scanning directly over the large bowel. The patients were followed clinically to assess for leaks. Contrast-enhanced sonographic time-intensity curves were generated for the time to peak and maximum amplitude.

RESULTS

Moderate interobserver agreement was shown for the time to peak (κ = 0.50) and maximum amplitude (κ = 0.42), and moderate intraobserver agreement was shown for the time to peak (κ= 0.53) and maximum amplitude (κ= 0.53). No significant differences were shown between the time to peak (P = .28) and maximum amplitude (P = .49) for the preligation and postligation scans.

CONCLUSIONS

To our knowledge, intraoperative contrast-enhanced sonography of the bowel has not been performed previously. We have shown the technique to be feasible with good intraobserver and interobserver agreement. Further work is ongoing to optimize the technique and assess its use in predicting anastomotic breakdown.

[Management of colonoscopic perforations of large bowel]

Perforation of large bowel during elective colonoscopy is rare but serious life threatening complication. Early diagnosis of perforation during or soon after colonoscopy shortens time of peritoneal contamination and allows to get good results of surgical treatment. The aims of this study were to determine the incidence of perforation due to colonoscopy in our hospital and to assess methods and results of surgical treatment.

MATERIAL AND METHODS

We reviewed our prospectively collected data of 957 patients operated on because of colorectal diseases in the period from January 2003 to December 2010. Data of 16 patients (1.7%) aged from 22 to 89 years of life (average age 67.5 years) operated on because of colonoscopic perforations were analysed.

RESULTS

Perforation of large bowel occurred in 9 patients (0.13%) of 6570 persons colonoscopised in our hospital. All 16 patients were operated on in the period of 0.5-32 hours since colonoscopy was performed. Simple suture of the laesion was the most common procedure performed in 12 patients (4 of them had proximal colostomies performed as well). Postoperative complications occurred in 3 patients (18.7%). Nobody died--mortality 0. Average time of hospital postoperative stay was 8.3 days.

CONCLUSIONS

Colonoscopic perforation of large bowel requires surgical treatment. Choice of repair method depends on diameter of perforation, time since onset to operation passed, spread and degree of peritoneal contamination and general patient's condition.

[Immunity and cytokine status after surgeries on the large intestine]

The aim of our study was to examine the effect of individual schemes of multimodal analgesia on indicators of immunity and inflammation markers after operations on the colon. Patients of group 1 (n=15) received paracetamol, lornoxicam and epidural ropivacaine, 2nd group of patients (n=15)-paracetamol, epidural ropivacaine and tramadol. Comparison group (n=10) patients underwent patient controlled analgesia by promedol. Before surgery, 1st and 3rd days after surgery we examined the contents of cytokines in plasma: interleukin 12p70, interleukin 10, interleukin 6, and TNF. Before surgery and at 5-7 days after surgery indicators of cellular, fagocytal and humoral immunity were monitored. Before surgery patients with colorectal cancer revealed changes in the indices of different components of immunity, as well as an increase in pro-and anti-inflammatory cytokines compared with healthy donors. Multimodal analgesia in patients after operations on the colon is not accompanied by changes in plasma concentrations of cytokines and parameters of immune status in comparison with monoanalgesia by promedol.

[Surgical treatment of chronic coprostasis]

Surgical treatment of 27 patients with chronic colostasis and dolichocolon was analyzed. Groups of patients with cologenic and proctogenic colostasis were defined, diagnostic criteria were formulated and optimal surgical tactics were described for each group. Short and long-term results were analyzed and proved to be excellent and satisfactory in majority of patients.

[Morphological changes of tissues in formation of a welding suture on the large intestine]

Abdominoanal resection with descending of left colon on perineum, leaving additional part of a descended intestine, was performed. For the hemorrhage arrest the welding sutures were put on intestinal wall. According to morphological investigations data, a damage of intestinal wall in the zone of a welding suture application is a reversible one, it spreads from the electrode branch on 2-3 mm. The presence of undamaged structures witnesses the presence of an active regeneration process in tissues around the welding suture.

[An improved single-layer suture in the surgery of small and large intestines]

The methods and results of using single-layer interrupted intestinal suture in operations on the small and large intestines are presented. Using the suture decreases the number of complications associated with this technique, improves the direct results of operations and reduces postoperative lethality both in urgent and planned surgery. The proposed intestinal suture is thought to be justified in connecting similar and dissimilar parts of the intestinal tube in the variants of longitudinal, transversal, terminal, lateral and termino-lateral interintestinal anastomoses.