Fibrin glue and coats compromise the integrity of colonic anastomosis: an experimental trial on rats.

Background: Anastomotic leak remains a dreaded complication in colorectal surgery. Identifying optimal techniques that minimize its incidence is an active area of investigation. The aim of this experimental study was to evaluate the effect of commonly used hemostatic products on the integrity of colonic anastomoses. Methods: Male Wistar rats were randomized into 4 groups. In the control group (A), the anastomosis was performed using the standard hand-sewn technique in the ascending colon. In group B the hand-sewn technique was reinforced with a collagen-fibrinogen patch, in group C with fibrin glue, and in group D with a polyethylene glycol (PEG)-coated oxidized cellulose patch. On the 7th postoperative day, anastomotic bursting pressure measurements were obtained. A specimen surrounding the anastomosis was retrieved for histopathologic evaluation. Results: Of the 19 rats, 17 survived and 15 were included in the analysis (5 in each of groups A, B and C). Testing in group D was discontinued following adverse events in the preliminary experiments. The mean bursting pressure of the anastomosis was significantly higher in the control group (A: 221±19.41 mmHg, B: 151±14.42 mmHg, and C: 112±13.57 mmHg; P=0.001). Anastomotic healing parameters were not different between groups. Conclusions: Although experimental data support the use of sealants in defective anastomoses, in this study the reinforcement of colonic anastomosis with fibrin or oxidized cellulose-PEG sealants did not improve either bursting pressure values or anastomotic healing. More data from robust anastomoses of animals and humans are needed before sealing becomes common clinical practice in colorectal surgery.

Preoperative Assessment of Perianal Fistulas with Combined Magnetic Resonance and Tridimensional Endoanal Ultrasound: A Prospective Study.

BACKGROUND: we designed a prospective study of diagnostic accuracy that compared pelvic MRI and 3D-EAUS with pelvic MRI alone in the preoperative evaluation and postoperative outcomes of patients with perianal fistulas. METHODS: the sample size was 72 patients and this was divided into two imaging groups. MRI alone was performed on the first group. Both MRI and 3D-EAUS were performed in parallel on the second group. Surgical exploration took place after two weeks and was the standard reference. Park's classification, the presence of a concomitant abscess or a secondary tract, and the location of the internal opening were recorded. All patients were re-evaluated for complete fistula healing and fecal incontinence six months postoperatively. All of the collected data were subjected to statistical analysis. RESULTS: the MRI group included 36 patients with 42 fistulas. The MRI + 3D-EAUS group included 36 patients with 46 fistulas. The adjusted sensitivity and negative predictive value were 1.00 for most fistula types in the group that underwent combined imaging. The adjusted specificity improved for intersphincteric fistulas in the same group. The adjusted balanced accuracy improved for all fistula types except rectovaginal. The combination of imaging methods showed improved diagnostic accuracy only in the detection of a secondary tract. The healing rate at six months was 100%. Fecal incontinence at six months did not present a statistically significant difference between the two groups (Fisher's exact test p-value > 0.9). Patients with complex perianal fistulas had a statistically significant higher probability of undergoing a second surgery (x2 test p-value = 0.019). CONCLUSIONS: the combination of pelvic MRI and 3D-EAUS showed improved metrics of diagnostic accuracy and should be used in the preoperative evaluation of all patients with perianal fistulas, especially those with complex types.

Perianal fistulas: A review with emphasis on preoperative imaging.

PURPOSE: We aim to present a comprehensive literature review which focuses on the preoperative imaging of perianal fistulas. MATERIAL/METHODS: Pelvic magnetic resonance imaging (MRI) and endoanal ultrasound (EAUS) are the two first-line imaging modalities for the preoperative evaluation of patients with perianal fistulas. We conducted a search in PubMed, Scopus and Google Scholar concerning articles comparing pelvic MRI with EAUS, which were published from 1994 until 2019. RESULTS: In most articles, pelvic MRI is superior to EAUS for the evaluation of perianal fistulas (especially for supralevator and extrasphincteric ones). Preoperative pelvic MRI is associated with statistically significant better results and prognosis after surgical treatment of the disease. Preoperative EAUS poses high sensitivity and specificity in identifying intersphincteric and transsphincteric perianal fistulas, as well as the internal opening of a fistula-in-ano. There is only one meta-analysis which compares the diagnostic accuracy of the two mentioned imaging modalities in preoperative fistula detection. Sensitivity of both - pelvic MRI and EAUS, is acceptably high (0.87). Specificity of pelvic MRI is 0.69 in comparison to EAUS (0.43), but both values are considered low. CONCLUSIONS: Future well-designed prospective studies are needed to investigate the diagnostic accuracy of pelvic MRI and EAUS in the preoperative assessment of patients with perianal fistulas. Moreover, the combination of pelvic MRI and EAUS should also be studied, since several published articles suggest that it could lead to improved diagnostic accuracy. A novel treatment algorithm for perianal fistulas could arise from this study.

Detrimental effect of apoptosis of lymphocytes at an early time point of experimental abdominal sepsis.

BACKGROUND: Apoptosis of lymphocytes is considered a late sequelum in the sepsis cascade. The role of apoptosis of lymphocytes as a driver of final outcome was investigated. METHODS: Abdominal sepsis was induced after cecal ligation and puncture (CLP) in 31 rabbits. Blood was sampled at serial time intervals and peripheral blood mononuclear cells (PBMCs) were isolated. Apoptosis of lymphocytes and monocytes was measured through flow cytometric analysis. PBMCs were stimulated with LPS and Pam3Cys for the release of tumor necrosis factor-alpha (TNFα). Tissue bacterial growth was quantitatively measured. In a second set of experiments, CLP was performed in another 40 rabbits; 20 received single intravenous infusions of ciprofloxacin and of metronidazole 4 hours after surgery. RESULTS: Animals were divided into two groups based on the percentage of lymphocyte apoptosis at 4 hours after surgery; less than or equal to 32% and more than 32%. Survival of the former was shorter than the latter (p: 0.017). Tissue growth was similar between groups. Apoptosis of lymphocytes and of monocytes was lower in the former group over follow-up. Release of ΤNFα did not differ. The above findings on survival were repeated in the second set of experiments. Administration of antimicrobials prolonged survival of the former group (p: 0.039) but not of the latter group (pNS). CONCLUSIONS: Lymphocyte apoptosis at an early time point of experimental peritonitis is a major driver for death. A lower percentage of apoptosis leads earlier to death. Antimicrobials were beneficial even at that disease state.

Clarithromycin modulates immune responses in experimental peritonitis.

Based on clinical data revealing a promising immunomodulatory effect of clarithromycin in sepsis due to ventilator-associated pneumonia, the efficacy of clarithromycin in experimental peritonitis and sepsis was assessed with particular emphasis on immune function. Cecal puncture and ligation was performed in rabbits assigned to the following groups: Group A, controls (n=12); Group B, intravenous clarithromycin treatment (n=15); Group C, piperacillin/tazobactam (TZP) treatment (n=10); Group D, clarithromycin+TZP combination treatment (n=12). Blood was sampled at serial time intervals and peripheral blood mononuclear cells (PBMCs) were isolated. Apoptosis of lymphocytes and monocytes was measured by flow cytometric analysis. PBMCs were stimulated with lipopolysaccharide (LPS) and Pam3Cys for the release of tumour necrosis factor-alpha (TNFα). Tissue bacterial growth was quantitatively measured after death or sacrifice. Survival in Group D after 10 days was prolonged compared with the other groups. Early apoptosis of lymphocytes in Group B was lower compared with Group D at 2h and compared with Group C at 4h. Early apoptosis of monocytes in Group B was lower compared with Group C at 24h. Following stimulation of PBMCs with LPS, release of TNFα was decreased in Group B compared with Groups A and D at 2h. Bacterial growth in tissues of Groups C and D was decreased compared with Group A. It is concluded that clarithromycin modulates the function of the immune response in experimental peritonitis by decreasing the rate of early apoptosis of lymphocytes and monocytes and by decreasing the ex vivo release of TNFα by blood monocytes.

Incarcerated femoral hernia containing ipsilateral fallopian tube.

Femoral hernias are more common in women and lead to a substantial higher rate for an emergency operation, due to strangulation. Incarcerated femoral hernia with fallopian tube as a content is an extremely rare condition. A 20-year-old woman presented to the emergency department complaining of a 6-day right groin swelling, which became painful and tender to palpation during the last 48 hours. Preoperative ultrasonography detected an oedematous hernia sac, above the femoral vessels, suggesting the presence of an incarcerated femoral hernia. The patient eventually underwent emergency surgery and the diagnosis of a strangulated femoral hernia sac, containing fallopian tube, was established. No resection of the uterine tube was performed and the hernia was repaired with polypropylene plug. The postoperative period was uneventful and the woman was discharged on the second postoperative day.

Ectopic papilla of vater in the stomach, blind antrum with aberrant pyloric opening, and congenital gastric diverticula: an unreported association.

We present an extremely rare combined congenital anomaly consisting of ectopic drainage of the common bile duct in the lesser curvature of the stomach, congenital gastric diverticula, blind antrum with aberrant pyloric opening, and redundant spleen. The diagnosis was made during routine endoscopy in a 35-year-old woman, who presented complaining for regurgitation and retrosternal burning in the last 4 years. To our knowledge this is the first description of this rare combination of congenital anomalies. The possible embryogenetic backgrounds, and the possible clinical significance of this rare condition are discussed.

Pancreatitis complicating mucin-hypersecreting common bile duct adenoma.

Villous adenomas of the bile ducts are extremely uncommon. We describe a 58-year-old man presenting with clinical signs and laboratory findings of acute pancreatitis and obstructive jaundice. Preoperative investigation demonstrated a dilated papillary orifice with mucus exiting (fish-mouth sign) and a filling defect in the distal common bile duct. He underwent a modified Whipple operation and histological examination of the surgical specimen showed villous adenoma with rich secretion of mucus.