Endoscopic ultrasound-guided colo-colostomy for the treatment of benign complete occlusion of colonic anastomosis: a case series and description of technique.

AIM: The incidence of benign colonic anastomotic stricture is approximately 2% in patients undergoing left hemicolectomy or anterior resection and as high as 16% in patients undergoing low anterior or intersphincteric resection. In the majority, rather than complete occlusion, a stenosis forms, which can be managed with endoscopic balloon dilatation, a self-expanding metallic stent or endoscopic electroincision. In the less common scenario of a completely occluded colonic anastomosis, surgery is often required. In this study, we aim to describe the technique we used to treat this condition non-operatively METHOD: We describe a case series of three patients with benign complete occlusion of their colorectal anastomosis and how we managed them nonoperatively with a colonic/rectal endoscopic ultrasound (EUS) anastomosis technique and a Hot lumen-apposing metallic stent. RESULTS: We demonstrate that the technical and clinical success for this technique is 100%. CONCLUSIONS: We believe that the technique we describe is effective and safe. It should be widely reproducible in centres with expertise in interventional EUS, given the similarity to well-established procedures such as EUS-guided gastroenterostomy. Patient selection and timing of reversal of ileostomy need careful consideration, especially in patients with a history of keloid formation. Given the shorter hospital stay and reduced invasiveness of this technique, we believe it should be considered for all patients who have complete benign occlusion of a colonic anastomosis. However, given the small number of cases and short period of follow-up, the long-term outcome of this technique is not known. More studies with higher power and a longer period of follow-up should be conducted to further ascertain the effectiveness of this technique.

Effects of Oral Pirfenidone on Colon Anastomosis Healing and Adhesion Formation in Rats.

INTRODUCTION: Many experimental studies have examined multiple drugs or treatments to improve the healing of intestinal anastomoses. Synthetic prostacyclin analogs, immunosuppressants, erythropoietin, growth hormone, insulin-like growth factor type 1, synthetic metalloproteinases inhibitors, and hyperbaric oxygen therapy have produced promising results in low-risk models of anastomosis dehiscence. However, in high-risk models, only hyperbaric oxygen therapy has been shown to be useful. Pirfenidone (PFD), a commonly used antifibrosing drug, has not been shown to be effective for this purpose. Our objective was to evaluate the effects of PFD on anastomosis healing and adhesion genesis in a low-risk rat model of dehiscence of colonic anastomosis. METHODS: An experimental study was conducted on 40 healthy Wistar rats randomly assigned to the control group or PFD experimental group (20 rats in each group). Colon anastomosis was performed 3 cm above the peritoneal reflection using the same technique in all animals. Mechanical resistance was studied by measuring bursting pressure. Adhesions were evaluated macroscopic and histologically using common staining techniques. Animals received the first PFD dose 12 h after surgery at a dose of 500 mg/kg one a day (SID) for 5 consecutive days. On day 6, the animals were reoperated on to measure the bursting pressure in situ and to classify adhesions macroscopically, and the anastomosed colon was resected for histological analysis. RESULTS: There were no deaths, complications, or anastomosis dehiscence in either group. The mean bursting pressure was 120.8 ± 11 mm Hg and 135.5 ± 12.4 in the control and PFD groups, respectively (p < 0.001). The adhesions were less dense and had less inflammatory cell infiltration in the PFD group (p < 0.02 and 0.002, respectively). Collagen content was slightly higher in the PFD group (p = 0.04). CONCLUSIONS: Our results revealed favorable effects of PFD in this low-risk colon anastomosis model; for example, the bursting pressure was higher, and the macroscopic adhesions were soft and exhibited less inflammatory infiltration and higher collagen content in the PFD group than in the control group. The results showing that PFD treatment was associated with better healing of minor adhesions seem to be paradoxical because the therapeutic indications for this drug are directed at treating fibrosing diseases.

Effect of Human Amniotic Membrane on Prevention of Colorectal Anastomosis Leakage in Cases with Neoadjuvant Radiotherapy: An Experimental Animal Study.

BACKGROUND: Radiotherapy is one of the most important factors which results in negative effects on wound healing and increases anastomosis leakage. Diverting loop ileostomy has been usually performed after colorectal anastomosis in cases of colorectal cancer with a history of neoadjuvant radiotherapy to decrease the chance of leakage. Considering the side effects of diverting loop ileostomy, the objective of the present study is to investigate the effect of human amniotic membrane (HAM) on colorectal anastomosis leakage after neo-adjuvant radiotherapy. METHODS: In this experimental animal study, 20 crossbreed rabbits were randomly divided into two groups (case group: 13 rabbits, control group: 7 rabbits) after receiving an equal dose of external beam radiation. Four weeks after irradiation, resection of 4 cm of colorectal segment and end-to-end single layer anastomosis were conducted. In the case group, a 2×2 cm wrap of HAM applied around the site of anastomosis. Eight weeks later, all the survived rabbits were sacrificed. A segment of anastomotic sites was resected in all expired and survived rabbits and sent for pathological evaluation. Mann-Whitney U Test (SPSS for Windows, Ver. 16, Chicago, IL) was applied to analyze healing scores between the two groups. RESULTS: Due to anastomosis dehiscence, 5 rabbits expired in the control group, but all the 13 rabbits (case group) survived after 8 weeks and showed no leakage. In addition, pathological evaluation revealed significant epithelialization and neovascularization in the case group. Statistically, healing score was higher in the case group rather than the control group (P<0.001). CONCLUSION: To prevent post irradiation colorectal anastomosis leakage, the use of HAM might play a significant role and a feasible technical approach.

The effects of iloprost on colonic anastomotic healing in rats under obstructive ileus conditions.

BACKGROUND: The aim of this study was to investigate the effects of iloprost, on colonic anastomotic healing in rats, under obstructive ileus conditions. MATERIALS AND METHODS: Eighty male Albino rats were randomized into four groups of 20 animals each. They underwent colonic resection followed by an inverted anastomosis. The rats of group 1 (control) and group 2 (ileus) received 3 mL of saline 0.9% intraperitoneally and those of group 3 (iloprost), and group 4 (ileus + iloprost) iloprost (2 µg/kg of body weight), immediately postoperatively and daily until the day of sacrifice. Each group was further divided into two equal subgroups, depending on the day of sacrifice. The animals of subgroup "a" were sacrificed on the fourth postoperative day, whereas those of "b" on the eighth day. Macroscopic and histologic assessment was performed, whereas anastomotic bursting pressures and the tissue concentrations in hydroxyproline and collagenase I were evaluated. RESULTS: Means of bursting pressure, neoangiogenesis, fibroblast activity, and hydroxyproline concentration were significantly increased in group 4 compared with group 2. In addition, on the fourth postoperative day, the inflammatory cell infiltration and the collagenase I concentration were significantly decreased in group 4 compared with group 2. Moreover, on the eighth postoperative day, collagen deposition was significantly increased in group 4 compared with group 2. CONCLUSIONS: Iloprost after intraperitoneal administration reverses the negative effect of obstructive ileus. It promotes not only the angiogenic activity but also collagen formation, resulting in increased bursting pressures on the fourth and eighth postoperative days.

Effects of TachoSil and 5-fluorouracil on colonic anastomotic healing.

BACKGROUND: The administration of intraperitoneal (IP) 5-fluorouracil (5-FU) during the early postoperative period after cytoreductive surgery can decrease local cancer recurrence but may also cause impairment of the anastomotic healing. This study examined the effects of the use of this therapy and of the anastomotic sealing with TachoSil, a fibrin-thrombin coated sealant (FTCS), on the healing of colon anastomoses. MATERIALS AND METHODS: Forty male rats were divided into four groups (1-4, 10 rats each) that underwent transection and anastomosis of the left colon. The anastomoses were covered with FTCS in groups 2 and 4. Saline solution (2 mL/d-groups 1 and 2) or 5-FU (20 mg/kg/d; groups 3 and 4) was administered IP once daily for 3 d. Bursting pressure (BP) was recorded, and the anastomoses were examined macroscopically and graded histologically. RESULTS: The relative weight loss was significantly higher in group 3 than in the other groups (P = 0.0004). Anastomotic dehiscence, postoperative adhesion formation, perianastomotic collections, and preanastomotic dilatation did not differ significantly among groups. BP was significantly lower in group 3 compared with all other groups (P = 0.001). Neoangiogenesis was significantly lower in group 3 compared with groups 1 and 2 (P = 0.05). Fibroblastic activity was significantly higher in group 1 compared with group 3 (P = 0.035). Inflammatory cell infiltration and collagen deposition did not differ significantly among groups. CONCLUSIONS: Our results shown that the early postoperative IP chemotherapy with 5-FU impaired the healing of colon anastomoses. However, anastomotic sealing with FTCS reversed some of the negative effects of this therapy.

The Effect of Local Papaverine Use in an Experimental High-Risk Colonic Anastomosis Model: Reduced Inflammatory Findings and Less Necrosis.

Objectives: To assess the impact of topical papaverine administration in complete and incomplete colonic anastomosis, by examining bursting pressure, hydroxyproline concentration, collagen content, inflammation levels, inflammatory cell infiltration, neoangiogenesis, and necrosis grades. Methods: We performed an experimental study on rats, in which they were divided into the following 4 groups of 16 subjects each. Group 1 [complete anastomosis (CA) without papaverine (CA -P) group], Group 2 [CA with papaverine (CA +P) group], Group 3 [incomplete anastomosis (ICA) without papaverine (ICA -P) group], and Group 4 [ICA with papaverine (ICA +P) group]. Results: The lymphocyte infiltration score of the ICA +P3 (day 3) group was significantly higher compared to the ICA -P3 group (p = 0.018). The median Ehrlich-Hunt score (p = 0.012), inflammation score (p = 0.026), and neutrophil infiltration score (p = 0.041) of the CA +P7 (day 7) group were significantly lower than the corresponding data of the CA -P7 group. Additionally, the necrosis score of the ICA +P7 group was significantly lower than that of the ICA -P7 group (p = 0.014). Conclusions: Data from the current study reveal that, although topical papaverine seems to suppress inflammation in anastomosis tissue and reduce necrosis at 7 days, definite conclusions regarding its impact on anastomotic leak cannot be drawn without further studies investigating anastomotic wound healing and anastomotic leak, preferably with both shorter- and longer-term evaluations.

Influence of different magnetic forces on the effect of colonic anastomosis in rats.

BACKGROUND: Despite much work having been conducted on magnetic compression anastomosis (MCA) in the digestive tract, there are no reports on the influence of magnetic force on the anastomosis. AIM: To investigate the effect of different magnetic force magnets on the MCA of the digestive tract. METHODS: Two groups of magnets of the same sizes but different magnetic forces were designed and produced. A total of 24 Sprague-Dawley rats were randomly assigned into two groups (powerful magnet group and common magnet group), with 12 rats in each group. Two types of magnets were used to complete the colonic side-to-side anastomosis of the rats. The operation time and magnet discharge time were recorded. The anastomotic specimens were obtained 4 wk after the operation and then the burst pressure and diameter of the anastomosis were measured, and the anastomosis was observed via the naked eye and subjected to histological examination. RESULTS: The magnetic forces of the powerful and common magnet groups at zero distance were 8.26 N and 4.10 N, respectively. The colonic side-to-side anastomosis was completed in all 24 rats, and the operation success rate and postoperative survival rate were 100%. No significant difference was noted in the operation time between the two groups. The magnet discharge time of the powerful magnet group was slightly longer than that of the common magnet group, but the difference was not statistically significant (P = 0.513). Furthermore, there was no statistical difference in the burst pressure (P = 0.266) or diameter of magnetic anastomosis (P = 0.095) between the two groups. The gross specimens of the two groups showed good anastomotic healing, and histological observation indicated good mucosal continuity without differences on healing. CONCLUSION: In the rat colonic side-to-side MCA model, both the powerful magnet with 8.26 N and the common magnet with 4.10 N showed no significant impact on the anastomosis establishment process or its effect.

Effect of growth hormone on colonic anastomosis after intraperitoneal administration of 5-fluorouracil, bleomycin and cisplatin: An experimental study.

BACKGROUND: Growth hormone (GH) plays a crucial role in wound healing and tissue repair in postoperative patients. In particular, colonic anastomosis healing following colorectal surgery is impaired by numerous chemotherapy agents. AIM: To investigate whether GH can improve the healing of a colonic anastomosis following the adverse effects of intraperitoneal administration of 5-fluorouracil (5-FU), bleomycin and cisplatin. METHODS: Eighty Wistar rats underwent laparotomy and a 1 cm-resection of the transverse colon, followed by an end-to-end anastomosis under general anesthesia. The rats were blindly allocated into four equal groups and administered a different daily intraperitoneal therapeutic regimen for 6 days. The control group (A) received normal saline. Group B received chemotherapy with 5-FU (20 mg/kg), bleomycin (4 mg/kg) and cisplatin (0.7 mg/kg). Group C received GH (2 mg/kg), and group D received the aforementioned combination chemotherapy and GH, as described. The rats were sacrificed on the 7th postoperative day and the anastomoses were macroscopically and microscopically examined. Body weight, bursting pressure, hydroxyproline levels and inflammation markers were measured. RESULTS: All rats survived until the day of sacrifice, with no infections or other complications. A decrease in the body weight of group D rats was observed, not statistically significant compared to group A (P = 1), but significantly different to groups C (P = 0.001) and B (P < 0.01). Anastomotic dehiscence rate was not statistically different between the groups. Bursting pressure was not significantly different between groups A and D (P = 1.0), whereas group B had a significantly lower bursting pressure compared to group D (P < 0.001). All groups had significantly more adhesions than group A. Hydroxyproline, as a measurement of collagen deposition, was significantly higher in group D compared to group B (P < 0.05), and higher, but not statistically significant, compared to group A. Significant changes in group D were recorded, compared to group A regarding inflammation (3.450 vs 2.900, P = 0.016) and fibroblast activity (2.75 vs 3.25, P = 0.021). Neoangiogenesis and collagen deposition were not significantly different between groups A and D. Collagen deposition was significantly increased in group D compared to group B (P < 0.001). CONCLUSION: Intraperitoneal administration of chemotherapy has an adverse effect on the healing process of colonic anastomosis. However, GH can inhibit the deleterious effect of administered chemotherapy agents and induce colonic healing in rats.

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.

A challenging upper digestive tract continuity restoration after recurrent esophago-colonic anastomosis complications.

BACKGROUND: Acute and chronic complications in esophago-colonic anastomosis have a significant impact in the postoperative course of patients with colonic transposition. Evidence about their management is poor and surgical treatment is mostly based on tailored approaches, so each new experience could be useful to improve knowledge about this peculiar condition. We report a unique case of an esophago-colonic resection and re-anastomosis without sternal approximation after recurrent anastomosis failure and strictures. CASE PRESENTATION: A 69-year-old woman was referred to our hospital for worsening dysphagia. The patient had undergone esophago-gastrectomy with right colon interposition 12 years prior due to caustic ingestion. The esophago-colonic anastomosis was initially complicated by an enterocutaneous fistula, which was treated with anastomosis resection and left colon transposition. This was then further complicated by dehiscence and sternal infection treated with resection of the distal portion of the sternum and a new colo-jejunal anastomosis. Finally, a chronic anastomotic stricture occurred, refractory to endoscopic dilatation and prothesis positioning. We planned a new colonic-esophageal resection and re-anastomosis. The main technical challenges were addressing the adhesions resulting from previous surgery and mobilizing an adequate length of the intestinal tract to allow conduit continuity restoration. Blood supply was assessed through Indocyanine Green Fluorescence. To avoid compression of the digestive conduit sternal margins were not re-approximated, and the transposed tube was covered and protected using both pectoralis major muscles flap. We decided to avoid the use of any prosthetic material to reduce the risk of infection. The patient was able to resume oral food intake on the 12th day postoperatively after a barium swallowing test showed an adequate conduit caliber. CONCLUSION: Esophago-colonic anastomosis complications represent a life-threatening condition. Therefore, reports and sharing of knowledge are important to improve expertise in management of these conditions.

Platelet rich plasma effectiveness in bowel anastomoses: A systematic review.

BACKGROUND: Anastomotic leak constitutes a major problem in abdominal surgery. Technical insufficiency, topical or systemic factors contribute to disrupted healing of the performed bowel anastomosis and result in anastomosis leakage, with detrimental effects on patient postoperative outcomes. Despite the investigation of several factors and the invention of protective materials, the ideal agent to prevent anastomotic leaks is yet to be determined. AIM: To study the effect of platelet rich plasma (PRP) on the healing of bowel anastomoses. METHODS: A systematic literature search was performed in PubMed, EMBASE, and Scopus databases to identify studies investigating the effect of PRP application on bowel anastomosis. RESULTS: Eighteen studies were eligible with a total population of 712 animals including rats (14 studies), rabbits (2 studies) and pigs (2 studies). No postoperative complications were reported following PRP application. Fourteen out of 18 studies reported a statistically significant higher anastomosis bursting pressure in PRP groups compared to control either in healthy animals or animal models with underlying condition or intervention, such as intraperitoneal chemotherapy or peritonitis. Similar results were reported by ten studies in terms of tissue hydroxyproline levels. One study reported significant increase in collagen deposition in PRP groups. PRP application resulted in significantly decreased inflammatory cell infiltration in the presence of peritonitis or intraperitoneal chemotherapy (6 studies). CONCLUSION: The application of PRP is associated with improved bowel anastomosis outcomes, especially in animal models having an underlying condition affecting the normal healing process. PRP application seems to augment the normal healing process under these circumstances. However, further studies are needed to investigate the potential role of PRP on bowel anastomosis healing, especially in clinical settings.

Systematic use of the serum C-reactive protein concentration and computed tomography for the detection of intestinal anastomotic leaks.

BACKGROUND: This study aimed to characterize the time-dependent relationship between serum C-reactive protein (CRP) and anastomotic integrity in the early post-operative period and to develop a systematic use of CRP and computed tomography. METHODS: Patients aged 18 years or over who had the formation of a left-sided colonic or a colorectal anastomosis, in Royal Sussex County Hospital, were included. The post-operative day (POD) CRP cut-off values were calculated according to receiver operating characteristic analysis to evaluate the sensitivities and specificities of the proposed cut-off parameters. RESULTS: A total of 125 left-sided colonic and colorectal anastomoses were recruited and analysed. When comparing to POD1 CRP cut-off, the calculated CRP ratio cut-off values of all the rest of PODs (2-5) were highly significant in the laparoscopic group and the overall group (P < 0.001). This statistically significant ratio was also demonstrated in the open group at POD2 (P < 0.0001). CONCLUSION: CRP and CRP ratios cut-off values were sensitive to detect an anastomotic leak in the early post-operative period. The cut-off values could facilitate the development of systematic use of CRP and computed tomography.

Comparison of metamizole and paracetamol effects on colonic anastomosis and fibroblast activities in Wistar rats.

BACKGROUND: Leakage following colorectal anastomosis surgery causes various complications associated with high morbidity and mortality, especially in pediatric patients. It might be caused by the use of non-steroidal anti-inflammatory drugs (NSAIDs) as postoperative analgesics. This study aimed to compare the effect of metamizole and paracetamol on colonic anastomosis and fibroblast activities, including proliferation, migration, and collagen synthesis, in Wistar rats. METHODS: Rats were divided into control, paracetamol and metamizole groups. The colonic anastomosis was evaluated by determining the integrity of the muscle layers, the formation of granulation tissue, and mucosal anastomosis. Fibroblast activities were analyzed by measuring the proliferation, migration, and collagen synthesis. RESULTS: Metamizole caused more damage to muscle layer integrity, more inhibition of granulation tissue formation in the anastomosis area and lower mucosal anastomosis compared with paracetamol and control groups. Metamizole had a higher cytotoxic effect than paracetamol, which suppressed the proliferation and migration of fibroblasts. Furthermore, both drugs did not affect the synthesis of collagen. CONCLUSION: Metamizole shows worse effects on the integrity of muscle layers, inhibition of granulation tissue formation, mucosal anastomosis, fibroblast proliferation, and migration, but not collagen synthesis, than paracetamol in Wistar rat intestines following colonic anastomosis. These findings might indicate that paracetamol is safer than metamizole as analgesic following colonic anastomosis.

Capsule Endoscopy Versus Colonoscopy in Patients With Previous Colorectal Surgery: A Prospective Comparative Study.

BACKGROUND: Colonic capsule endoscopy (CCE) derived from the video capsule endoscopy, initially proposed to explore the small bowel, has demonstrated high sensitivity and specificity for colonic polyp detection. The primary outcome of the study was to assess the safety, feasibility, and reliability of CCE after colorectal surgery. Secondary outcomes were to identify the detection rate of colonic lesions and recognition of the surgical anastomosis as compared to colonoscopy. METHODS: This is a prospective single-center study conducted over a 2-year period. Thirty-seven patients with a history of colorectal surgery were prospectively included in this study. Each patient received both CCE and colonoscopy, performed by different operators blinded to each other's results. RESULTS: Thirty-two patients (86.5%) completed the study and were included in the final analysis. All capsules were naturally expelled. In three patients (9.4%), the anal verge was not identified during the CCE recording and the examination of the colon was considered incomplete. Surgical anastomosis was accurately identified by CCE in 78.2% of the patients versus 93.8% for colonoscopy (P = 0.65). Thirty-eight lesions were detected in 14 patients. The sensitivity of CCE to detect colonic polyps was 95.2% (95% confidence interval (CI): 77.3-99.2%), the specificity 82.4% (95% CI: 59.0-93.8%). Positive predictive value (PPV) and negative predictive value (NPV) of CCE to detect colonic polyps were 87.0% and 93.3%, respectively. No complications related to the passage of the capsule through the intestinal anastomosis were detected. CONCLUSIONS: CCE proved to be safe and feasible, reporting a similar detection rate of colonic lesion compared to colonoscopy.

Effects of melatonin on colonic anastomosis healing following chemotherapy in rats.

INTRODUCTION: This study aimed to investigate the effects of melatonin on the healing of colon anastomosis following chemotherapy. METHODS: 32 rats were randomised into four groups: (a) control group, which underwent sigmoid colon transection and primary anastomosis; (b) melatonin group, which received melatonin daily following anastomosis; (c) 5-fluorouracil (5-FU) group, which received 5-FU for five days prior to anastomosis; and (d) 5-FU+melatonin group, which received 5-FU for five days prior to anastomosis and melatonin daily following anastomosis. The rats were sacrificed on Postoperative Day 7 and anastomotic bursting pressures were measured. The anastomotic segment was extracted for hydroxyproline, luminol and lucigenin measurement and histopathological examination. Blood samples were obtained from the vena cava for measurement of tumour necrosis factor-alpha (TNF-α) and interleukin-1 beta (IL-1ß) plasma levels. RESULTS: Compared to the 5-FU group, bursting pressures of anastomosis and hydroxyproline levels were significantly higher, while luminol and lucigenin levels were significantly lower, in the control and 5-FU+melatonin groups. In addition, TNF-α and IL-1ß plasma levels were significantly lower in the control and 5-FU+melatonin groups than in the 5-FU group. Histopathological examination showed a significant decrease in inflammation and necrosis formation in the melatonin group when compared to the control group. The positive effect of melatonin was also seen in the rats that received 5-FU. CONCLUSION: Our study results showed that the adverse effects of chemotherapy on the mechanical, biochemical and histopathological parameters of anastomosis healing were attenuated through melatonin treatment.

Predictive Factors for Small Intestinal and Colonic Anastomotic Leak: a Multivariate Analysis.

Anastomotic leak (AL) is a serious complication of intestinal surgery with various predisposing factors. This study aims to assess several risk factors associated with AL after small intestinal and colonic anastomoses through a multivariate analysis. Two hundred twenty-four patients (126 males) with intestinal anastomosis of a median age of 44 years were reviewed. Independent factors associated with AL were male gender (OR = 2.59, P = 0.02), chronic liver disease (CLD) (OR = 8.03, P < 0.0001), more than one associated comorbidity (OR = 5.34, P = 0.017), anastomosis conducted as emergency (OR = 2.73, P = 0.012), colonic anastomosis (OR = 2.51, P = 0.017), preoperative leukocytosis (OR = 2.57, P = 0.015), and intraoperative blood transfusion (OR = 2.25, P = 0.037). Predicative factors significantly associated with AL were male gender, CLD, multiple comorbidities, emergent anastomoses, colonic anastomoses, preoperative leukocytosis, and intraoperative blood transfusion.

Tannin-based adhesive for protection of colonic anastomosis in the open abdomen.

This study was aimed to evaluate the effect of tannin acid- polyethylene glycol (TP) adhesive on the wound healing process of primary colonic anastomosis in the open abdomen (OA). Adhesion strength test, degradation and hemostatic ability of TP were investigated. In a rat model, after standard colonic anastomoses, rats were divided into three groups: OA group; OA + FG (fibrin glue) group; OA + TP group. Five days after surgery, body weight, anastomotic bursting pressure (ABP), and histology of anastomotic tissue were evaluated. Performance of adhesion strength and hemostatic ability of TP was better than that of FG. The weight of TP decreased by over 50% after 11-day incubation. All rats survived well after surgery. Compared to OA group and OA + FG group, OA + TP group showed a significant improvement in body weight, ABP and healing state. Application of TP adhesive, used as an auxiliary treatment of colonic anastomosis operation, improved the wound strength and promoted the anastomotic healing after OA.

Adipose-Derived Mesenchymal Stromal Cells Improve the Healing of Colonic Anastomoses Following High Dose of Irradiation Through Anti-Inflammatory and Angiogenic Processes.

Cancer patients treated with radiotherapy (RT) could develop severe late side effects that affect their quality of life. Long-term bowel complications after RT are mainly characterized by a transmural fibrosis that could lead to intestinal obstruction. Today, surgical resection is the only effective treatment. However, preoperative RT increases the risk of anastomotic leakage. In this study, we attempted to use mesenchymal stromal cells from adipose tissue (Ad-MSCs) to improve colonic anastomosis after high-dose irradiation. MSCs were isolated from the subcutaneous fat of rats, amplified in vitro, and characterized by flow cytometry. An animal model of late radiation side effects was induced by local irradiation of the colon. Colonic anastomosis was performed 4 wk after irradiation. It was analyzed another 4 wk later (i.e., 8 wk after irradiation). The Ad-MSC-treated group received injections several times before and after the surgical procedure. The therapeutic benefit of the Ad-MSC treatment was determined by colonoscopy and histology. The inflammatory process was investigated using Fluorine-182-Fluoro-2-Deoxy-d-Glucose Positron Emission Tomography and Computed Tomography (18F-FDG-PET/CT) imaging and macrophage infiltrate analyses. Vascular density was assessed using immunohistochemistry. Results show that Ad-MSC treatment reduces ulcer size, increases mucosal vascular density, and limits hemorrhage. We also determined that 1 Ad-MSC injection limits the inflammatory process, as evaluated through 18F-FDG-PET-CT (at 4 wk), with a greater proportion of type 2 macrophages after iterative cell injections (8 wk). In conclusion, Ad-MSC injections promote anastomotic healing in an irradiated colon through enhanced vessel formation and reduced inflammation. This study also determined parameters that could be improved in further investigations.

Effects of albumin/glutaraldehyde glue on healing of colonic anastomosis in rats.

AIM: To evaluate the effect of local surgical adhesive glue (albumin/glutaraldehyde-Bioglue) on the healing of colonic anastomoses in rats. METHODS: Forty Albino-Wistar male rats were randomly divided into two groups, with two subgroups of ten animals each. In the control group, an end-to-end colonic anastomosis was performed after segmental resection. In the Bioglue group, the anastomosis was protected with extraluminar application of adhesive glue containing albumin and glutaraldehyde. Half of the rats were sacrificed on the fourth and the rest on the eighth postoperative day. Anastomoses were resected and macroscopically examined. Bursting pressures were calculated and histological features were graded. Other parameters of healing, such as hydroxyproline and collagenase concentrations, were evaluated. The experimental data were summarized and computed from the results of a one-way ANOVA. Fisher's exact test was applied to compare percentages. RESULTS: Bursting pressures, adhesion formation, inflammatory cell infiltration, and collagen deposition were significantly higher on the fourth postoperative day in the albumin/glutaraldehyde group than in the control group. Furthermore, albumin/glutaraldehyde significantly increased adhesion formation, inflammatory cell infiltration, neoangiogenesis, and collagen deposition on the eighth postoperative day. There was no difference in fibroblast activity or hydroxyproline and collagenase concentrations. CONCLUSION: Albumin/glutaraldehyde, when applied on colonic anastomoses, promotes their healing in rats. Therefore, the application of protective local agents in colonic anastomoses leads to better outcomes.

Crohn's disease with ankylosing spondylitis in an adolescent patient who had undergone long ileo-colonic anastomosis for Hirschsprung's disease as an infant.

Crohn's disease (CD) is a chronic, idiopathic, inflammatory disorder of the gastrointestinal tract. In rare cases, CD has been associated with Hirschsprung's disease (HD); however, the underlying pathophysiology of this and other comorbidities is not yet fully understood. In this report, we describe the case of a 17-year-old patient who was diagnosed with both CD and ankylosing spondylitis (AS), having undergone a long ileo-colonic anastomosis to treat HD at 12 months of age. To our knowledge, this is the first documented case of CD combined with AS in a patient with HD.