Evert-Jan C. Lubbers

Wound healing in the intestinal wall

The healing of both rabbit ileal and colonic infected anastomoses has been investigated. Infection was induced by implanting a capsule with human fecal material in the anastomotic area. Infection did result in lowered bursting pressures, which effect was most pronounced in ileum seven days postoperatively. In general, the average hydroxyproline levels in and around infected anastomoses were lower than the hydroxyproline concentrations measured around noninfected anastomoses. This difference was most significant in the segment proximal to the ileal anastomosis seven days after operation, in the segment distal to the colonic anastomosis three days after operation, and in the segment proximal to the colonic anastomosis seven days after operation. It is concluded that infection interferes with the early stages of the healing sequence in rabbit intestinal anastomoses, profoundly affecting collagen metabolism. Our work does not support recent publications that report an unchanged or even increased wound strength under infected conditions.

Surgical aspects of radiation enteritis of the small bowel

Injury to the small bowel is one of the tragic complications of radiotherapy. We performed a retrospective analysis of patients operated upon for stenosis, perforation, fistulization, and chronic blood loss of the small bowel after radiotherapy for multiple malignant diseases. In the period 1970 to 1982 in the Department of General Surgery of the St. Radboud University Hospital, Nijmegen, and the Department of Surgical Oncology of the State University, Groningen, 27 patients were treated surgically. Twenty patients presented with obstruction. In 17 patients a side-to-side ileotransversostomy was performed; in three the injured bowel was resected. Of the five patients with fistulization, three underwent a bypass procedure; in two cases the affected bowel was resected. In one patient with perforation, a resection was performed, as in a patient with chronic blood loss. Two of the 20 patients (10 per cent) in whom the diseased bowel was bypassed died postoperatively. Of the seven patients whose affected bowel was resected four (57 per cent) died of intra-abdominal sepsis. Management of the patient with chronic radiation enteritis is discussed. We conclude, on the basis of our experience, that in patients with obstruction and fistulization, a bypass procedure of the affected bowel is a safe method of treatment. In case of resection, the anastomosis should be performed during a second operation.

Healing of the perineal wound after proctectomy for nonmalignant conditions

A series of 62 patients was studied as regards healing of the perineal wound after proctectomy; 23 patients suffered from ulcerative colitis, 25 from Crohns colitis, and 14 from polyposis coli. The overall results were in keeping with data from the literature: 73.9 per cent of wounds in patients with ulcerative colitis and 60 per cent of wounds in patients with Crohns colitis were healed at six months. The worst results were obtained with packing of the perineal wound, especially in inflammatory bowel disease: 61 per cent of those wounds were not healed at six months. Superior results were obtained with conservative surgery, consisting of perirectal excision and intersphincteric resection. With this technique perineal wounds were not healed at six months in 13.6 per cent of patients with inflammatory bowel disease. In the treatment of persistent sinuses after proctectomy, curettage proved disappointing. Better results were obtained with excision of the sinus tract and primary closure of the resulting wound.

Multicentricity in nonpalpable breast carcinoma and its implications for treatment

During a 9 year period, 300 consecutive women underwent breast biopsies solely because of nonpalpable, mammographically suspicous findings. One hundred clinically occult breast carcinomas were found, 65 of which were invasive and 35 noninvasive. Eighty-three mastectomy specimens were evaluable for evidence of multifocal carcinoma in another quadrant of the breast or at a distance of 5 cm and residual cancer outside the excisional biopsy cavity. Multicentricity was present in 47 percent and residual tumor in 60 percent of the whole group. When only clinically occult invasive carcinomas were considered, other foci of invasive carcinoma were demonstrated in 26 percent of the patients and residual invasive cancer in 35 percent. The rate of bilaterality was 14 percent, occurring synchronously in 11 percent of the patients. Any therapeutic procedure for nonpalpable breast carcinoma, whether invasive or noninvasive ductal carcinoma, should be directed to the whole breast. Mammography of the contralateral side should be an integral part of the preoperative work-up of patients with palpable lesions ipsilaterally.

Anastomotic insufficiency in small bowel surgery —incidence and treatment

ZusammenfassungIn dem Zeitraum 1977–1981 wurden bei 143 Patienten 234 Dünndarmanastomosen angelegt. Acht Anastomosen zeigten eine Nahtleckage (3,4%), bei neun entwickelte sich eine Fistel (3,8%): die Gesamthäufigkeit von Wundheilungsstörungen bei Dünndarmanastomosen war 7,3%. Bei gleichzeitigem Vorliegen intraabdominaler Infektionen betrug die Häufigkeit 14,8%, ohne diese 0,8%. Die Resultate einer Therapie durch Übernähung oder Resektion mit sofort anschließender Reanastomosierung waren enttäuschend. Befriedigendere Ergebnisse wurden durch Aufheben der Anastomosen, Anlage einer ‚split enterostomy’ unter Wiederherstellung der Kontinuität in einer zweiten Sitzung erzielt. Die Mortalität betrug 3/17 (18%). Ein Literaturüberblick wird gegeben.SummaryIn the period 1977–1981 234 small bowel anastomoses were constructed in 143 patients. Eight anastomoses showed leakage (3.4%) and from nine anastomoses a fistula developed (3.8%): a total rate of disturbed healing of small bowel anastomoses (7.3%). In the presence of intra-abdominal infection this rate was 14.8%, in the absence of infection 0.8%. The results of treatment with oversewing and with resection and immediate anastomosis were disappointing. Better results were obtained by dismantling of the anastomosis, establishment of a split-enterostomy and reestablishment of continuity in a second stage. Mortality was 3/17 (18%). The literature is reviewed.

Solubility of tissue hydroxyproline in experimental intestinal anastomoses

Salt and acid solubility of collagen are thought to reflect its degree of crosslinking. In order to examine postoperative changes in crosslinking of intestinal collagen, which are of importance to the stability of the intestinal wall, we have investigated the solubility of hydroxyproline in rabbit ileum and colon, both in unwounded intestine and after construction of an anastomosis. Solubility in salt and dilute acid was increased by a sonication procedure. This way, 9% of total hydroxyproline in the unwounded colonic wall was salt soluble and 65% acid soluble. A similar distribution was observed in ileum. Three days after operation the salt-soluble fraction was significantly elevated in samples from the anastomotic area. In colon, this increase also persisted 7 days postoperatively. Comparison of anastomotic samples collected 3 and 7 days after surgery shows a significant decrease in the acid-soluble and a significant increase in the solid fraction. This phenomenon occurs both in ileum and colon. These results indicate that during the first days after operation the integrity of the intestinal wall is weakened not only by a loss of collagen, but also by a changed solubility of the remaining collagen.

Phantom sensations after excision of the rectum

Forty consecutive patients were questioned after proctectomy to ascertain the presence and characteristics of phantom sensations. Twentysix (65 per cent) reported the presence of these sensation. Once established, the sensations were permanent in 20 patients; in six, they disappeared after a variable lapse of time. The most frequent sensation was an urge to defecate, which may be very disturbing to the patient. Explanation of the phenomenon usually is sufficient to alleviate anxiety.

A Reproducible Model for Protracted Peritonitis in the Rabbit

The intra-abdominal implantation of a gelatin capsule containing human fecal material introduces peritonitis in the rabbit. The severity of the disease and the length of survival depend on the volume of the inoculum. A 7-day survival chance varies between 45 and 92%, depending on fecal loading. All rabbits develop intra-abdominal abscesses and in the surviving animals infection persists for at least a week, allowing further study of several aspects of peritonitis.