Hasse Jiborn

Healing of experimental colonic anastomoses: I. Bursting strength of the colon after left colon resection and anastomosis☆

Abstract Mechanical strength of the left colon with anastomosis and the intact transverse colon was studied by the bursting strength technic from four to fourteen days after standardized left colon resection in the rat. Two different single layer inverting suture technics were used, continuous suture and interrupted sutures. Bursting strength was tested by determinations of both bursting pressure and bursting wall tension, both of which provided the same information concerning mechanical strength of the colon. The bursting strength test measures the anastomotic strength only during the early stages of healing, since more than 90 per cent of the left colon segments ruptured outside the anastomosis as early as day 7. The two different suture technics resulted in the same bursting strength of the left colon segment with anastomosis. Both types of anastomoses showed a moderate narrowing at the anastomotic line upon inflation. This was due to the fact that the anastomosis constituted a relatively firm fibrotic ring from day 7, and both types of anastomoses had an equal inner diameter at that time. By supporting the colonic wall above and below the anastomosis, it could be calculated that the anastomosis on day 7 withstood at least 50 per cent higher circular wall tension than the surrounding colonic wall. There was no correlation between collagen concentration of the colonic wall and bursting strength of the colon either in unoperated controls or after resection and anastomosis. When interrupted sutures were used for anastomosis of the left colon, bursting strength of the intact transverse colon was significantly higher on day 7 than when continuous suture was used. It actually exceeded that of the transverse colon in unoperated controls by almost 50 per cent on the seventh postoperative day, although the collagen concentration in the transverse colon was within normal range. This finding indicated changes in the proximal colonic wall after left colon resection, which are probably related to changes in the structure or arrangement of collagen.

Healing of experimental colonic anastomoses

The present experimental study in rats has demonstrated a marked difference in the healing process of anastomoses in the left colon following two different suture technics: continuous and interrupted sutures. Rats having anastomoses constructed of continuous suture showed a high incidence of complications and a marked decrease of collagen concentration in the anastomosis and in the colonic wall proximal to the anastomosis during the first week of healing. In animals with anastomoses made of interrupted sutures there were fewer complications, the decrease in collagen concentration was confined to the anastomotic region, and the recovery of collagen concentration occurred earlier. The findings indicate that the interrupted suture technic is preferable for anastomosis in the left colon.

Healing of experimental colonic anastomoses. III. Collagen metabolism in the colon after left colon resection.

Abstract In a previous study it was shown that resection and anastomosis of the left colon is accompanied by a marked reduction of collagen concentration in the colon. These changes were not confined to the immediate vicinity of the anastomosis but extended a considerable distance along the bowel and were more marked proximally than distally. Whether the decrease in collagen concentration is due to decreased synthesis or increased breakdown of collagen was studied in the present work by measuring the rate of collagen synthesis and comparing the observations with changes in net amounts of collagen. Synthesis of collagen was studied using pulse labeling with 3H-proline. Studies on the time course of incorporation showed a biphasic pattern with maximal specific activities of collagen 4 and 24 hours after injection of the precursor. The maximal labeling occurred after 24 hours. At that time 75 to 90 percent of the label was present in insoluble collagen, indicating a high rate of turnover. Comparison of net amounts with the rate of synthesis indicates an increased breakdown of collagen. The reaction was clearly most pronounced proximal to the anastomosis. During the first 4 postoperative days breakdown (lysis) dominated. On the 7th day increased net amounts of collagen indicate that synthesis had begun to outbalance processes that break down collagen. The results indicate that the entire colon reacts to the trauma of resection and anastomosis and that in healing of the colon a delicate balance exists between the synthesis and breakdown of collagen.

Breaking strength of small intestinal anastomoses

The breaking strength of standardized small bowel anastomoses at different times after surgery was studied in the rat. The anastomotic strength with sutures in place successively decreased during the first 3 postoperative days to approximately 15 percent of the immediate postoperative value. This indicates a rapid decrease in the suture holding capacity of the gut wall in the early postoperative course. From the fourth day onward a rapid increase in strength was recorded. This could be due not only to deposition of collagen in the tissue bridging the anastomosis but also to the regained capacity of the gut wall to withstand tearing forces. After 14 days the strength of the anastomosis was due mainly to healing, and the relative contribution from the sutures was negligible. It may be that tearing of sutures through the tissue is more important than defective healing for anastomotic complications.

Volvulus of the cecum: report of 26 cases and review of the literature

The management of cecal volvulus is controversial. From 1971 to 1986, 26 patients with cecal volvulus were treated at Malmö General Hospital. Treatment and patient follow-up are presented, together with a review of 350 patients reported in the literature during the past 15 years. Anatomic background and types of volvulus are described. Simple detorsion is an alternative in high-risk patients without gangrene, but resection is the method of choice also when there is no gangrene present.

Healing of experimental colonic anastomoses: IV. Effect of suture technique on collagen metabolism in the colonic wall

Abstract A previous study showed that after left colon resection an early and marked reduction of collagen concentration occurred not only in the anastomotic region but also proximally in the colon. This reaction was influenced by the suture technique used. In the present study collagen turnover in different segments of the colon was studied using 3 H-proline as a precursor. There was an increased synthesis of collagen in all colonic segments at an early stage after operation, indicating that the entire colon reacted to the trauma of resection and anastomosis. The changes were asymmetrical in relation to the anastomotic line, with a higher rate of both lysis and synthesis of collagen proximal to the anastomotic line. During the first days after operation lysis dominated over synthesis. It was found that the suture technique influenced the rate of collagen turnover. Continuous suture led to more marked disturbance of the balance between lysis and synthesis and to retarded restoration of collagen concentration. Colonic dilatation and fecal stagnation proximal to the anastomosis were observed in some animals with continuous suture. This condition was associated with an enhanced rate of collagen turnover and a greater breakdown of collagen in the colonic wall than in animals with uncomplicated healing. This may be the cause of the higher frequency of anastomotic complications after continuous suture observed in this and previous studies.

Influence of selective mesenteric arteriography on the outcome of emergency surgery for massive, lower gastrointestinal hemorrhage: A 15-year experience

From 1970 to 1984, 64 patients with massive hemorrhage of lower gastrointestinal origin were treated at the intensive care unit, Surgical Department, Malmö General Hospital. The records of these patients have been studied retrospectively. Emergency exploration for homostasis was performed on 31 patients, while in 33 patients hemorrhage stopped with conservative therapy. Acute selective mesenteric arteriography revealed the bleeding site in 16 of 28 patients (57 percent). The commonest bleeding sources detected by selective mesenteric arteriography were diverticular disease and angiodysplastic lesions of the colon. Fourteen patients with positive arteriography finding were operated on as emergencies, resulting in two postoperative deaths. Ten patients were operated on a asemergencies without preoperative arteriography. Despite intraoperative efforts, no bleeding source was found in three of those patients. In the remaining seven patients, the diagnoses were similar to the 14 patients with positive arteriography. Five of 10 patients in this group died postoperatively. Emergency laparotomy eventually was necessary in seven of 12 patients with negative arteriography. This group had a variety of diagnoses and no postoperative mortality. Positive preoperative mesenteric arteriography findings allowed the surgeon to perform a limited resection of the bleeding bowel segment with a reduced postoperative mortality.

Compartment syndrome after prolonged surgery with leg supports

Compartment syndrome has been reported in a few cases after prolonged surgery with patients in leg supports. A recent case in our hospital (57-year-old man undergoing cystourethrectomy because of cancer) made us interested in the problem. This case together with six from the literature are analysed. Moreover, the first 11 cases operated on with a pelvic pouch and ileoanal anastomosis at our department were reviewed. They had been in the leg support position for a median duration of 6.4 (5.8–8) h. In four of them leg pain and swelling developed within 12 h. Three showed regression within a few days, one after a week. In one patient with swelling compartment pressure was measured with a transducer tipped catheter. Intermittently the pressure was up to 50 mm Hg. There was an obvious decrease in pressure on knee bending. Also, in a patient without swelling large pressure variations were seen but not to critical levels.

Surgery for fulminating colitis during pregnancy

Two cases of fulminating colitis presenting during pregnancy are described. In both cases, resectional surgery was performed. In the first case, cesarean section was combined with subtotal colectomy and ileostomy during the 32nd week of gestation. In the second case, cesarean section was performed during the 33rd week of gestation and proctocolectomy in the puerperium. In both cases, histopathologic examination showed colitis more consistent with Crohns disease. It is concluded that if fulminating colitis appears during pregnancy it should be treated in the same manner as in the nonpregnant state.

Collagen metabolism in small intestinal anastomosis

Collagen metabolism in the small intestinal wall during the first week of anastomotic healing in operated and nonoperated rats was studied. During this period, marked changes in anastomotic strength have been observed. A general and marked increase of collagen synthesis was found throughout the intestine already on the second day. This resulted in increased collagen content. Collagen concentration remained relatively unchanged despite an increase in collagen content as a result of concomitant increase of noncollagenous substances. The previously reported loss of anastomotic strength in the early phase of healing could not be explained by changes in collagen content or metabolism in this study. Cutting of sutures seems to be due to a local process. After 4 days, collagen content increased predominantly in the anastomotic region. It correlated well to the previously observed increase of anastomotic strength.