Initial experience with intraoperative testing and repair of colorectal anastomosis using a TAMIS approach after a positive leak test.

Anastomotic leak is one of the most feared complications of colorectal anastomosis. Different techniques have been described for intraoperative testing of anastomotic integrity. These include air insufflation, methylene blue and endoscopic visualisation. If an anastomotic leak is identified intraoperatively, there are various management options. Redo anastomosis is a possibility, but may be difficult in some cases. Defunctioning is another option, but there is an associated morbidity and signficant detrimental effect on quality of life. Direct transanal repair is only possible when a low anastomosis has been performed. When the anastomotic leak occurs high in the rectum or a partial mesorectal excision is performed a transanal approach is technically very challenging. We present our experience with transanal minimally invasive surgery (TAMIS) approach for anastomotic assessment and repair in four patients. In all cases, a colorectal anastomosis was performed and the air insufflation test was positive. We assessed the anastomosis with TAMIS. In three cases, a defect was found and subsequently sutured. In one case, a scar in the rectal mucosa was found and reinforced with a suture. A protective ileostomy was performed in two cases, while in the other two cases, no stoma was added. All four patients were discharged with no further complications. Both protective ileostomies were taken down after radiological and endoscopic confirmation of anastomotic integrity and all 4 anastomoses remain intact after follow-up. TAMIS intraoperative assessment and repair of anastomotic leak is a safe and feasible technique whcih may avoid the need for a defunctioning stoma.

Relationship between degree of cellular differentiation in colorectal cancer and topographical distribution.

OBJECTIVES: To demonstrate the relationship between degree of cellular differentiation in colorectal cancer and topographical distribution in 215 patients diagnosed with colorectal cancer from 1997 to 2000. MATERIAL AND METHODS: 215 patients (129 men and 86 women) were studied prospectively with a mean age of 64 years (range: 23-84 years). In all patients we performed a full colonoscopy with several biopsies (in patients with colon stenosis we used barium enema), radiographic studies (CT, abdominal ultrasounds), and laboratory tests for serum tumour markers (CEA, Ca 19-9, alpha-fetoprotein). The topographic location of colorectal cancer was: rectum 35%, sigmoid colon 31%, descending colon 10%, transverse colon 6%, ascending colon 9%, caecum 5%, and we included anorectal cancer 4%. RESULTS: According to histological differentiation we found: A) well-differentiated tumours 101/215 (47%); B) moderately-differentiated tumours 98/215 (45.5%), and C) poorly-differentiated tumours 16/215 (7.5%). We found no significant association among histological differentiation, topographic location, stage according to the Astler-Coller classification, sex or age (p = ns). The prevalence of well-differentiated tumours in men was 49% and 43% in women; of moderately-differentiated cancers in men was 43%, and 49% in women; for poorly-differentiated tumours in men was 7.5%, and 7.2% in women. Regarding tumour location, 165 cancers were found in the left colon: 80 were well differentiated, 77 moderately differentiated and 8 poorly differentiated. In the transverse colon we found 12 tumours: 7 well differentiated, 3 moderately differentiated and 2 poorly differentiated. 30 cancers were localized in the right colon: 11 well differentiated, 15 moderately differentiated and 4 poorly differentiated. In the anorectum 8 tumours were found: 3 well differentiated, 3 moderately differentiated and 2 poorly differentiated. According to staging classification, well differentiated tumours (101/215) were more common in Dukes' C2 (20.7%) and B1 (32.6%), moderately differentiated cancers (98/215) were in B1 (28.5%) and C2 (20.4%), and poorly differentiated tumours (16) were more common in Dukes' C2 (25%), without differences among other stages (p = ns). CONCLUSIONS: According to our results we have found that histological differentiation of colorectal cancer has no association with topographic location, and it is independent of sex or age. We have not found any relationship either between histological differentiation and stage in the Astler-Coller classification, but well differentiated cancers were more common at any location, age or sex.

Experimental study of sutureless colorectal anastomosis.

BACKGROUND/AIMS: The present research project has been made mainly with the idea of comparing the tensile strength values and histological answers of three types of colon anastomosis: sutured with silk 5/0; polyglycolic acid 5/0; and sutureless anastomosis with human fibrin gum. METHODOLOGY: One hundred and five (105) Wistar breath rats allocated into 3 groups of 35 animals were used to implement this experimental research project: silk, polyglycolic acid and human fibrin gum. Furthermore, each group was subdivided in 5 series respectively to carry out an experimental study on the tensile strength parameter and anatomic-pathological determinations on the 10th, 20th, 30th, 40th and 50th day after the surgical intervention. The following surgical interventions were practiced on them: A cross section of the colon, followed by: group 1: an end-to-end discontinuous suture anastomosis with Silk; group 2: an end-to-end discontinuous suture anastomosis with polyglycolic acid; group 3: sutureless anastomosis with human fibrin gum. On the 10th, 20th, 30th, 40th and 50th days we proceeded to measure the anastomosis' tensile strength value for each series. We used a tensile strength apparatus and waited until the break down of the suture sample took place and wrote down the value, in g/cm, given by the voltmeter at that moment. RESULTS: The results obtained indicate that anastomosis made in group 1 (silk) lasted longer to the tensile strength apparatus; followed by those practiced in group 2 (polyglycolic acid); and finally anastomosis carried out in group 3 (human fibrin gum). However in the anastomotic process carried out with the human fibrin gum the healing started from the 10th day. In the same period of time we carried out the following anatomic-pathological determinations: a) sharp inflammation; b) edema; c) non-specific chronic inflammatory infiltrate; d) granulomatous inflammatory infiltrate to foreign bodies; e) fibrosis. CONCLUSIONS: The results show a better answer for anastomosis made with human fibrin gum than those carried out with the two other suture materials. This conclusion is based on the facts that the human fibrin gum used to carry out sutureless anastomosis during this research project generated a lower sharp inflammation and speediness in its absorption; absence of granular reaction to a foreign body; a minor or non-existent edema at all; as well as a good fibrous healing speediness process. Therefore, all these experimental results lead us to conclude that the human fibrin gum used to carry out sutureless anastomosis may be an alternative to the handmade conventional anastomosis. Moreover they are easy to be implemented.

[Postoperative gastritis due to alkaline reflux. Our results]. / Gastritis postquirúrgica por reflujo alcalino. Nuestros resultados.

We present the results of a retrospective study carried out on 23 patients with alkaline gastric reflux (AGR) verified through endoscopy, biopsies and Tc99m HIDA, which were operated on in our department with Y of Roux, Braun, Henley as the correction techniques of this pathology. The criteria of surgical indications were evaluated in these patients as also the results obtained in reference to residual symptoms and changes in the histologic and gammagraphic patterns.

Liver, spleen and kidney cultures in different conditions of splenic preservation.

The appearance of the postsplenectomy syndrome has made investigators focus all attention on the immunitary aspects that could change following a splenic extirpation. Besides this, bacterial clearance has been considered fundamental in this pathology. We present an experimental study comparing liver, spleen and kidney cultures in different conditions of splenic preservation, including autotransplantation, and with sepsis induced by the inoculation of capsulated Escherichia coli. The majority of tissue cultures were positive, showing, in must cases, a statistical correlation between the number of microorganisms in each organ for every animal. This confirms that all three organs act alike, as bacterial filters.

[Angiodysplasia of the colon. Apropos of 2 cases]. / Angiodisplasia de colon. A propósito de dos observaciones.

Angiodysplasia of the colon is a vascular lesion which involves the arterioles, venules and small venous vessels; usually it is a lesion of the aged and presents with rectorrhagia, melena or chronic anemia due to chronic blood loss. We present two cases of angiodysplasia of the colon in two female patients in the eighth decade of their lives, treated in the Servicio de Cirugía del Hospital Universitario Virgen Macarena de Sevilla. We emphasize the value of the angiographic study for the diagnosis of this lesion, and also the usefulness of isotopic study with labeled erythrocytes for the localization. The treatment of choice is surgical resection of the affected area. It was performed in both patients. One of them died.

[Anatomopathologic repercussions of segmental liver resection]. / Repercusiones anatomopatológicas de las resecciones hepáticas segmentarias.

We present an experimental study of the anatomopathologic repercussions of segmental liver resection. Sixty rats were used, distributed into 3 groups of 18 animals each one with 6, group I, as follows: 1) anesthesia and laparotomy; 2) 30% liver resection; 3) 50% liver resection, and 4) 80% liver resection. The three resection groups were distributed into three subgroups according to parameters studied at 24 hours, 72 hours and 10 days, respectively. The data studied were: 1. Inflammation: activation of Kupffer cells, state of the lobule and portal spaces. 2. Degeneration: steatosis, necrotic foci, infarction and eosinophilic degeneration. 3. Regeneration: hepatocytic hypertrophy, mitosis, binucleation and trabeculation. The results confirm that the resected liver undergoes regenerative processes that condition the adaptation of the animal after hepatic exeresis.