M. Polivoda

Colon interposition for esophageal replacement: isoperistaltic or antiperistaltic? Experimental results

BACKGROUND Isoperistaltic colon is preferred to antiperistaltic colon for esophageal replacement, but experimental data do not exist to support this practice. METHODS In 7 dogs a 20 cm long colon loop was interposed between the skin and the small bowel, isoperistaltically in 3 dogs and antiperistaltically in 4 dogs. Three months later five strain-gauges were implanted and evacuation was investigated by motility testing, barium studies, and scintigraphy. RESULTS Motility recording showed normal colon motility in the excluded loops. Quiescent states (duration 40.2 +/- 13.6 minutes) were followed by contractile states (duration 7.5 +/- 2.4 minutes, frequency 3.3 +/- 0.6 per minute). The main peristaltic direction of isoperistaltic loops was isoperistaltic, and the main peristaltic direction of antiperistaltic loops was antiperistaltic. Evacuation took place exclusively during the contractile status. Half time emptying was more rapid in isoperistaltic loops (35 +/- 11 vs 69 +/- 16 minutes). The content of antiperistaltic loops was held back by antiperistaltic activity. Application of oatmeal porridge into the loops shortened the quiescent status from 40.2 to 13.2 +/- 4.8 minutes. CONCLUSIONS The colon graft for esophageal replacement is an active system. Food is stored during the quiescent states and evacuated during the contractile states. The original peristaltic direction is preserved so that retroperistalsis in antiperistaltic loops may lead to patient discomfort and pulmonary complications.

Laparoskopie versus laparotomie

We performed laparoscopy (n = 7) or laparotomy (n = 7) for exploration of the small intestine, cecal resection with Endo-GIA or TA-30, deserosation of 2 cm2 of the abdominal wall and resection of the omenturn majus in dogs. After 8 days all dogs were re-examined and the adhesions were quantified by computer-aided measurement. Laparoscopic operations were followed by significantly (P < 0.001) fewer adhesions. After conventional operations extensive adhesions to the abdominal incision and interenteric adhesions were found, together with frequent conglomerates of adhesions, intestinal kinkings or adhesive bands. Identical manipulations, such as cecal resection or deserosation of the lateral abdominal wall, led to the same frequency and severity of adhesions in both groups. Based on our results, the risk of adhesion-related complications may be reduced by the laparoscopic approach.ZusammenfassungAn Hunden wurden laparoskopisch (n = 7) bzw. per Laparotomie (n = 7) nach Exploration des Dünndarms eine Zäkalpolresektion mit Endo-GIA bzw. TA-30 durchgeführt, 2 cm2 der lateralen Bauchwand deserosiert und ein Netzzipfel reseziert. Am B. postoperativen Tag wurden alle Tiere relaparotomiert und die entstandenen Adhäsionen rechnergestützt vermessen. Das Ausmaß der Adhäsionen nach laparoskopischen Eingriffen war signifikant (P < 0,01) geringer. Ausgedehnte Adhäsionen zur Laparotomiewunde und zwischen den Darmschlingen bedingten größere Adhäsionsflächen nach Laparotomie. Konglomeratadhäsionen, adhäsionsbedingte Darmabknickungen und Briden fanden sich häufiger nach konventionellen Operationen. Identische Manipulationen wie Zäkalresektion und Deserosierung der lateralen Bauchwand führten nach laparoskopischen und konventionellen Eingriffen zum gleichen Adhäsionsausmaß. Aufgrund unserer Ergebnisse ist das Risiko adhäsionsbedingter Komplikationen nach laparoskopischen Operationen insgesamt geringer als nach identischen konventionellen Eingriffen einzuschätzen.

Intestinale Motilität nach laparoskopischer vs. konventioneller Cholezystektomie

First descriptions of clinical courses after laparoscopic cholecystectomy indicate a shorter period of postoperative ileus in comparison to conventional cholecystectomy. Early postoperative motility was registered in dogs (n = 10) by implanted serosal electrodes. Furtheron clinical signs of postoperative motility were documented in patients (n = 100) after laparoscopic and conventional cholecystectomy. In animal experiments a significantly reduced period of postoperative ileus (5,5 ± 1 h) occured after laparoscopic cholecystectomy in comparison with the conventional technique (46 ± 5 h). Experimental data correlate well with earlier clinical signs of normal motility after laparoscopic cholecystectomy in patients. The shorter period of postoperative ileus is a further evidence for the minor abdominal trauma of laparoscopic techniques.SummaryFirst descriptions of clinical courses after laparoscopic cholecystectomy indicate a shorter period of postoperative ileus in comparison to conventional cholecystectomy. Early postoperative motility was registered in dogs (n = 10) by implanted serosal electrodes. Furtheron clinical signs of postoperative motility were documented in patients (n = 100) after laparoscopic and conventional cholecystectomy. In animal experiments a significantly reduced period of postoperative ileus (5,5 ± 1 h) occured after laparoscopic cholecystectomy in comparison with the conventional technique (46 ± 5 h). Experimental data correlate well with earlier clinical signs of normal motility after laparoscopic cholecystectomy in patients. The shorter period of postoperative ileus is a further evidence for the minor abdominal trauma of laparoscopic techniques.ZusammenfassungErste Beschreibungen klinischer Verläufe nach laparoskopischen Eingriffen lassen im Vergleich zur konventionellen Vorgehensweise eine verkürzte Periode der postoperativen Darmatonie vermuten. Die frühe postoperative Motilität wurde im Tierexperiment (Hund, n = 10) mittels implantierter Serosa-Elektroden verifiziert. Desweiteren wurden die klinischen Parameter der postoperativen Motilität nach laparoskopischer und konventioneller Cholezystektomie bei Patienten (n = 100) vergleichend erfa\t. Es zeigte sich eine signifikant verkürzte Periode der Darmatonie nach laparoskopischer Cholezystektomie (5,5 ± 1 h) im Vergleich zur konventionellen Technik (46 ± 5 h) im Tierexperiment. Dies korrelierte mit den deutlich früher einsetzenden klinischen Zeichen einer normalen Motilität bei Patienten nach einer laparoskopischen Cholezystektomie. Die kürzere Periode der postoperativen Darmatonie ist ein weiteres Indiz für das geringere Abdominaltrauma laparoskopischer Verfahren.

Electrophysiological and Mechanical Activity of the Upper Gastrointestinal Tract After Duodenoplasty or Segmental Resection of Benign Gastric Outlet Stenosis

In an animal experimental study we examined the postoperative recovery of the motility of the upper gastrointestinal tract after operative treatment of a benign gastric outlet obstruction. At 45 Days after induction, a duodenal stenosis was resected in six dogs, and resolved by Finneys duodenoplasty in another six dogs. Fourteen days after segmental resection, the gastric emptying was faster [half evacuation time (T1/2) for semisolid food = 44.4 ± 16.8 min] than following duodenoplasty [T1/2 = 56.8 ± 25.3). Here motor migrating complexes (MMCs) started in the antrum and could be traced down to the jejunum. After segmental resection we recognized MMC only distal to the anastomosis. The duration of the whole MMC cycle (69.0 ± 18.6 min) as well as of the single phases was significantly shorter in the resection group than after duodenoplasty (108.0 ± 15.1 min). At 28 days after operation the differences in the electromyographic findings were smaller (82.0 ± 15.1 min vs. 111.4 ± 11.2 min), but still significant. Obviously humoral transmitters and the extrinsic neural system lead to good propagation of the MMC across the anastomosis, even before the intramural pathways are reestablished. Concerning the fast recovery of the motility of the upper gastrointestinal tract, duodenoplasty is superior to segmental duodenal resection.

Artifizielle Drucksteigerung im subkutanen Abszeß mit Nachweis einer systemischen Allgemeinreaktion

Abscess is customarily thought of as a collection of a large number of microorganisms, inflammatory cells and necrotic debris separated from the surrounding tissue by a fibrous capsule. Modern work focussed attention on more physico-chemical parameters in abscess pathogenesis. Recent experiences from animal models underline the impact of abscess pressure and bio-physicochemical parameters in the “abscess compartement” for systemic spreading. Arteficial raising of abscess-pressure in pigs up to 80 mmHg was followed by increase of temperature and heartbeat rate and decrease of median arterial pressure. Elevated levels of TNFα, IL-1 and positive blood cultures support the theory of abscess pressure as a most important variable in abscess formation. We conclude that abscess pressure may play a pivotal role in systemic spreading of the primarily localized process.ZusammenfassungDer Abszeß wird üblicherweise als eine lokale Ansammlung von Entzündungszellen und liquifizierenden Gewebenekrosen in einem nicht präformierten Raum, der sich vom angrenzenden Gewebe durch eine Abszeßmembran pathomorphologisch abgrenzen läßt, beschrieben. Bei der Pathogenese der Abszedierung stehen in der Literatur v. a. ätiologische Gesichtspunkte im Vordergrund. Erst moderne Arbeiten haben die biophysikalischen Grundlagen der Abszeßpathologie erarbeitet. In einem tierexperimentellen Modell am Hausschwein konnte die besondere Rolle des Abszeßdrucks und anderer physikochemischer Parameter bei der systemischen Propagierung des zunächst lokal begrenzten Geschehens nachgewiesen werden. Durch eine artifizielle und initiale Anhebung des Abszeßdrucks auf 80 mmHg, der über einen Zeitraum von 6 h konstant gehalten wurde, konnte ein Temperaturanstieg auf über 38°C, ein Anstieg der Herzfrequenz sowie ein Abfall des mittleren arteriellen Drucks belegt werden. Der Anstieg von TNFα und IL-1 sowie der Nachweis positiver Blutkulturen unterstreichen die wichtige Rolle des Abszeßdrucks bei der Systemisierung der primär lokalen Infektion. Das traditionelle „Ubi pus ibi evacua“ gewinnt durch die vorliegende Untersuchung eine aktuelle, pathophysiologisch fundierte Bedeutung.

Auswirkungen der intraabdominellen Applikation von Phospholipiden auf Wundheilung und Adhäsionsbildung

Background: Adjuvant therapy is needed to prevent adhesion formation as a major cause of postoperative morbidity and mortality. Previously published data proved the efficacy of phospholipids (PL) for this indication; however, additional information on drug safety was still outstanding. This study was designed to investigate the influence of phospholipids on three different types of healing tissue. Materials and Methods: A total of 48 Chinchilla rabbits underwent median laparotomy, standardized abrasion of the visceral and parietal peritoneum, jejunal anastomosis, and an electrocautery incision of the liver. The operation was completed by intraperitoneal administration of 10 ml/kg of either normal saline (NaCl, 0.9%) or phospholipids (PL, 12%). After intervals of 5 and 10 days, respectively, 50% of the surviving animals were sacrificed and adhesions were measured using a digitizer board. The fresh 10-cm long segment of the jejunum carrying the anastomosis was examined using a bursting experiment. Tensile strength of the midline laparotomy wound was assessed. Specimens of the scar tissue of liver, anastomosis, and abdominal wall were stained with Sirius red and Fast green to determine the collagen protein ratio. Results: After 5 (NaCl 691 mm2 vs. PL 192 mm2 ) and after 10 days (NaCl 625 mm2 vs. PL 88 mm2) the control group presented with significantly larger adhesion areas (p < 0.05). The bursting pressure of the anastomosis on the fifth (NaCl 16.1 kPa vs. PL 18.2 kPa) and tenth (NaCl 19.7 kPa vs. PL 18.6 kPa) postoperative day showed no statistically significant difference. The tensile strength of the laparotomy wound measured after intervals of 5 (NaCl 8.5 N cm-1 vs. PL 6.8 N cm-1) and 10 days (NaCl 23.0 N cm-1 vs. PL 20.2 N cm-1) was not statistically different either. The collagen protein ratio of anastomoses, laparotomy wounds, and liver incisions, as well as the inflammatory reparative response of the different tissues, were not affected by PL. Conclusions: These results prove the efficacy of phospholipids in adhesion prevention. The findings of uncompromised healing of anastomoses, laparotomy wounds, and liver incisions reveal the safety of this agent. Further data may qualify phospholipids for a clinical trial.

Intestinale Motilitt nach laparoskopischer vs. konventioneller Cholezystektomie@@@Intestinal motility after laparoscopic versus conventional cholecystectomy. An experimental (animal) and clinical study: Eine tierexperimentelle studie und klinische beobachtung

First descriptions of clinical courses after laparoscopic cholecystectomy indicate a shorter period of postoperative ileus in comparison to conventional cholecystectomy. Early postoperative motility was registered in dogs (n = 10) by implanted serosal electrodes. Furtheron clinical signs of postoperative motility were documented in patients (n = 100) after laparoscopic and conventional cholecystectomy. In animal experiments a significantly reduced period of postoperative ileus (5,5 ± 1 h) occured after laparoscopic cholecystectomy in comparison with the conventional technique (46 ± 5 h). Experimental data correlate well with earlier clinical signs of normal motility after laparoscopic cholecystectomy in patients. The shorter period of postoperative ileus is a further evidence for the minor abdominal trauma of laparoscopic techniques.SummaryFirst descriptions of clinical courses after laparoscopic cholecystectomy indicate a shorter period of postoperative ileus in comparison to conventional cholecystectomy. Early postoperative motility was registered in dogs (n = 10) by implanted serosal electrodes. Furtheron clinical signs of postoperative motility were documented in patients (n = 100) after laparoscopic and conventional cholecystectomy. In animal experiments a significantly reduced period of postoperative ileus (5,5 ± 1 h) occured after laparoscopic cholecystectomy in comparison with the conventional technique (46 ± 5 h). Experimental data correlate well with earlier clinical signs of normal motility after laparoscopic cholecystectomy in patients. The shorter period of postoperative ileus is a further evidence for the minor abdominal trauma of laparoscopic techniques.ZusammenfassungErste Beschreibungen klinischer Verläufe nach laparoskopischen Eingriffen lassen im Vergleich zur konventionellen Vorgehensweise eine verkürzte Periode der postoperativen Darmatonie vermuten. Die frühe postoperative Motilität wurde im Tierexperiment (Hund, n = 10) mittels implantierter Serosa-Elektroden verifiziert. Desweiteren wurden die klinischen Parameter der postoperativen Motilität nach laparoskopischer und konventioneller Cholezystektomie bei Patienten (n = 100) vergleichend erfa\t. Es zeigte sich eine signifikant verkürzte Periode der Darmatonie nach laparoskopischer Cholezystektomie (5,5 ± 1 h) im Vergleich zur konventionellen Technik (46 ± 5 h) im Tierexperiment. Dies korrelierte mit den deutlich früher einsetzenden klinischen Zeichen einer normalen Motilität bei Patienten nach einer laparoskopischen Cholezystektomie. Die kürzere Periode der postoperativen Darmatonie ist ein weiteres Indiz für das geringere Abdominaltrauma laparoskopischer Verfahren.