Evaluation of anastomotic microcirculation after low anterior rectal resection: An experimental study with different reconstruction forms in dogs
Department of Surgery, RWTH Aachen, Aachen, Germany. Techniques in Coloproctology
(Impact Factor: 2.04).
10/2006; 10(3):222-6. DOI: 10.1007/s10151-006-0283-0
Data on anastomotic microcirculation of coloanal anastomoses are contradictory. Therefore, it was the aim of the present study to investigate perianastomotic blood perfusion in a standardized experimental setting comparing three forms of reconstruction using laser fluorescence videography, a new method for the evaluation of microcirculation.
After a standardised rectal resection in dogs, reconstruction was performed as straight end-to-end (n = 6), side-to-end (n = 6), or J-pouch (n = 6) coloanal anastomosis. Bowel perfusion was evaluated using IC-View laser fluorescence videography.
The perfusion index was significantly reduced in all three groups compared to the reference regions: endto-end anastomosis, median, 93% (range, 63%-136%); side-to-end-anastomosis, 65% (35%-138%); colonic-J-pouch anal anastomosis, 52% (32%-72%); p < 0.001).
Straight coloanal anastomoses provide better anastomotic microcirculation after rectal resections than colonic-J-pouch anal anastomoses or side-to-end anastomoses. However this effect does not seem to be decisive for the prevention of anastomotic leaks.
Available from: Jochen Grommes
- "particular in a rat model, intestinal leakage is predominantly monitored by pre-existent negative influencing factors such as peritonitis or immunosuppression   . An adequate microcirculation of the bowel wall has to be regarded as an essential condition for proper intestinal wound healing   . In our study, the microperfusion detected by a computer-assisted laserfluorescence videography generally was reduced in all investigated groups compared to the reference region, which certainly can be explained by the surgical manipulation such as knotting and sewing thereby affecting the integrity of the bowel wall perfusion    . "
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If a colonic or small bowel lesion is not accessible for endoscopic mucosal resection, enterotomy is a possible although rarely performed surgical technique. It has never been compared to circular anastomosis regarding leakage rate, bowel wall perfusion, and wound healing. Thus, the aim of this basic experimental scientific study was to investigate perianastomotic microcirculation and wound healing.
Forty rats were divided into four groups (1 jejunal anastomosis, 2 jejunal enterotomy, 3 colonic anastomosis, and 4 colonic enterotomy). Following anastomosis and enterotomy, the intestinal perfusion was measured using laser fluorescence angiography (IC-View). On postoperative day 7, the surface of the mucosal villi, expression of matrix metalloproteinases (MMP) 2, 8, 9, and 13, and the number of proliferating cells (Ki67) as well as the collagen types I/III ratio were analyzed.
The perianastomotic microperfusion was significantly reduced in all groups compared to the reference region. The perianastomotic perfusion index was significantly reduced in group 1 compared with group 2, whereas the perfusion index in group 3 was slightly but not significantly reduced in comparison to group 4. Ki67 was elevated in both circular anastomosis groups. Surface of the mucosal villi, MMP expression, and collagen type I/III ratio revealed no significant differences.
Our study affirms the theoretical consideration of a better microperfusion of the bowel wall following an antimesenterial enterotomy and demonstrates that enterotomy is not inferior compared to circular anastomosis. Even though enterotomy is a rarely used surgical technique, it should be regarded as a possible alternative in particular situations.
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ABSTRACT: Die Chirurgie des Rektumkarzinoms hat im letzten Jahrzehnt weitere Fortschritte gemacht. Die partielle oder totale mesorektale
Exzision (TME) ist Standardverfahren. Die chirurgische Qualität der TME hat prognostisch erheblich an Bedeutung gewonnen.
Der zirkumferenzielle Resektionsrand (CRM) des Präparats stellt neben der Metastasierung den entscheidenden Prognosefaktor.
Aktuelle Studien konnten einen distalen Resektionrand von 1cm etablieren, was die Rate an kontinzenzerhaltenden Eingriffen
gesteigert hat. Dies trifft insbesondere nach neoadjuvanter RCT zu. Die laparoskopische Rektumresektion ist in der Hand des
erfahrenen Operateurs technisch sicher möglich, die onkologische Wirksamkeit kann noch nicht abschließend beurteilt werden.
Die Therapie des Rektumkarzinoms besitzt multilaterale Ansätze und bleibt damit multimodal.
During the last decade surgical treatment of rectal cancer has seen various improvements. Partial or total mesorectal excision
(TME) became standard procedure. The surgical quality of the TME has a high effect on prognosis. Besides metastases, the circumferential
resection margin receives the most attention. As recent studies established a distal resection margin of 1cm, the rate of
continence-preserving resections has grown, especially after neoadjuvant radiochemotherapy. In the hands of an expert, laparoscopic
rectal resection is a technically safe procedure. Its oncological efficacy cannot yet be decided. Modern therapy for rectal
cancer comprises multilateral considerations and therefore needs a multimodal orientation.
Available from: synapse.koreamed.org
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ABSTRACT: Periodic colonoscopic checkup is needed for patients suffering from colorectal cancer, based on the property that a colorectal neoplasm often recurs synchronously or metachronously. Surgical management appropriate to the occasion should be taken in recurrent colorectal cancer. Particularly, recurring colorectal cancer closely above the prior anastomosis for a low anterior resection should be eliminated by using an abdomino-perineal resection, including the preceding anastomotic site or a new anastomotic creation. Under the latter instance, ample possibility exists for postoperative anastomotic stenosis or leakage by reason of insufficient blood supply to the segment between the earlier anastomosis and the later one. The authors report two cases of re-anastomosis for colorectal cancer just above a previous anastomosis taken by a low anterior resection for rectal cancer. In a 52-year-old male with a history of neoadjuvant concomitant chemo-radiotherapy (CCRT) and low anterior resection for rectal cancer located at 6 cm from the anal verge, a new adenocarcinoma was detected 7 cm from the previous anastomotic site and 3 cm from the anal verge. Considering anal sphincter preservation, the re-anastomosis was made at the upper part of the preceding anastomosis. The patient experienced no surgical complications, such as anastomotic stenosis or leakage and functional defecation difficulty. In another patient, a 50-year-old male with a low anterior resection and adjuvant CCRT for rectal cancer 8 cm from anal verge, a new adenocarcinoma was detected in the colon. The new adenocarcinoma was located 10 cm from the anal verge and 8 cm from the previous anastomosis. The same surgical management was applied to this case, with the same postoperative result.
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