jagomart
digital resources
picture1_Anastomosis Intestinal Pdf 90257 | Annsurg00435 0105


 162x       Filetype PDF       File size 1.07 MB       Source: www.ncbi.nlm.nih.gov


File: Anastomosis Intestinal Pdf 90257 | Annsurg00435 0105
anastomosis by invagination intestinal a historical review of a new technic with controlled study of its potential bernard s linn m d terry m reisman m d roger w yurt ...

icon picture PDF Filetype PDF | Posted on 16 Sep 2022 | 3 years ago
Partial capture of text on file.
                                           Anastomosis by Invagination:
                           Intestinal
                          A Historical Review of a "New" Technic with
                                    Controlled Study of Its Potential
                          BERNARD S. LINN,* M.D., TERRY M. REISMAN,** M.D.,
                           ROGER W. YURT,*"* B.S., HIRAM C. POLK, JR.,t M.D.
                      From the Department of Surgery, University of Miami School of Medicine,
                                                   Miami, Florida
         IN 1812, Travers 17 reported, "the union            fully  used but never widely acclaimed.
      of a divided bowel requires the contact of             Most users of the technic have been enthu-
      the cut extremities in their entire circum-            siastic about and more than a few have
      ference." Thus peritoneal continuity and               claimed the procedure as their own dis-
      bowel healing became synonomous. How-                  coveries. Clinical use of the procedure out-
      ever, around the turn of the century, Hal-             dates   its  experimental research history.
      sted5 emphasized the importance of the                 Moore and Forrest-Hamilton 1"           reported
      submucosa in intestinal anastomosis. It is             that Sonnenburg, in Berlin, first used an
      surprising that this did little, at that time          end-to-end ileo-colic anastomosis, before
      or later, to alter the orthodox end-to-end             the turn of the century. Unfortunately, he
      procedure. Investigators have repeatedly               never published his results and Maylard,10
      explored other methods in attempts to re-              unaware of Sonnenburg's discovery, prac-
      duce operative time and improve func-                  ticed the same technic in Scotland around
      tional results. In fact, Da Costa 2 stated             1910. In their procedure, ileum was invagi-
      that some 250 methods had been described               nated into a longitudinal incision in the
      for doing anastomoses. It is obvious, how-             colon. Again in Germany, in 1923, Goepel 4
       ever, that most of these deviations from              described successful use of the technic and
      the time-honored procedure were met with               later challenged a claim by Babcock' to
       controversy or doubt.                    technic      priority. Babcock's report, in 1926, was the
         The telescoping or invaginating                     first known American use of invagination
       is one such method that has been success-             anastomoses. He reported 10 partial gas-
          Submitted for publication August 11, 1967.         trectomies by means of telescopic anasto-
          * Associate Chief of Staff for Research & Edu-     moses, in which duodenum was turned
       cation, Veterans Administration Hospital, Assistant   into the open end of the gastric stump.
      Professor of Surgery, University of Miami, School         For almost 20 years, the technic lay
       of Medicine, Miami, Florida.      Miami, Florida.     dormant. Then Pringle,14 an army surgeon,
          ** Jackson Memorial Hospital,                      developed a procedure for fast and simple
          * ** Biomedical Engineering.                 of                                                  that
          f Assistant Professor of Surgery, University       repair of war injuries. Pringle wrote
       Miami, School of Medicine, Miami, Florida.            he knew of no earlier accounts of this
          This project was supported in part by 8200         method but acknowledged that his access
       Research  funds   from Veterans Administration,       to the literature was impossible at the time.
       Washington, D. C.
                                                         393
                                      LINN, REISMAN, 'Y(URT AND POLK                      Annals of Surgery
         394                                                                                  March 1968
         He called his operation "a method of end-        invagination process dates back to 1963,
         to-end anastomosis of small intestines."         when we began experimental studies on
           In   1951,  Kimbarovskij,6   described   a     large and small bowel anastomosis. In an
         "new" method of intestinal anastomosis           earlier report by Linn et al.,7 an evaluation
         whereby 4-5 cm. of small intestine was           was made between large and small bowel
         introduced into colon lumen in an attempt        adhesive   invagination  and conventional
         to reproduce the equivalent of an ileo-          control procedures. We concluded that, al-
         cecal valve. Two years later, Moore and          though the experimental procedure was
         Forrest-Hamilton,"l of England, refuted his      faster and safer, precise evaluation of the
         claim, referring him to the Maylard-Son-         invagination technic was hampered by fac-
         nenburg history.                                 tors related to the use of adhesives. In ad-
           Other clinical descriptions of large bowel     dition, there had been questions concern-
         anastomoses followed in which Prioleau 13       ing the need for mucosal dissection. For
         and Ferrara3 used the technic for rectosig-     these reasons, the present study was un-
         moid anastomoses. Although they reported         dertaken to evaluate the use of suture in-
         success, they cautioned against rectosig-       vagination with and without mucosal dis-
         moid invagination, except in the presence        section for large and small bowel anasto-
         of dense scar tissue resulting from chronic     moses.
         inflammation in the rectal stump.                                  Method
           To our knowledge, the first experimental         Twenty-four mongrel dogs weighing 10
         studies of this method were those of Mc-        to 15 Kg. were randomly assigned to one
         Caughan 12 who reported axial enteren-          of two groups. In the first group anasto-
         terostomy successfully performed on 11          moses were performed on proximal and
         dogs in 1954. After preparing cuffs, de-        distal small intestine; in the second group
         nuded proximally of the seromucular layer       anastomoses were performed on proximal
         and distally of the mucosal layer, he tele-     and distal large intestines. The experimen-
         scoped the ends of the intestines and           tal procedures of invagination alone (IA)
         united them by a continuous stitch. He          and invagination with dissection of distal
         concluded this was a simple, safe, and          bowel mucosa (ID) were compared with
        rapid method of anastomosis.                     the standard end-to-end procedures (C).
           In 1965, Shrum and his associates 15 in-      The project was designed so that each ani-
        vestigated the fate of the telescoped seg-       mal would have two anastomoses per-
        ment of ileum in ileocolostomies in 20           formed during the same operation, either
        dogs. A segment from the ileo-colic junc-        an experimental and a control or two ex-
        tion was later excised for gross and micro-      perimentals.  Procedures were alternated
        scopic examination, and continuity was re-       within each group so that each type of
        established by the same experimental pro-        anastomosis was performed as many times
        cedure.   They found that the segments           proximally as distally. A total of 48 proce-
        decreased in size and eventually were com-       dures were done: 16 IA, 16 ID, and 16 C.
        pletely covered by ileal mucosa. They were         Animals scheduled for small bowel anas-
        encouraged enough to employ the proce-           tomoses received only water for 48 hours
        dure in 13 patients. They concluded the          preoperatively. Dogs scheduled for large
        experimental method was superior to the          bowel operations also received two enemas
        conventional end-to-end procedure.               and 8 Gm. of neomycin during this preop-
           Although the invagination method ap-          erative period. Pentobarbital anesthesia and
        peared, in these studies, to be superior,        midline incisions were used. Fluids were
        data comparing test animals with controls        given intravenously at the time of opera-
        had been lacking. Our own interest in the
       Volume 167                          ANASTOMOSIS BY INVAGINATION
       Number 3              INTESTINAL                                                          395
                                   FIG. 1. Experimental invagination technics.
      tion and one day postoperatively. Diets           stay suture for the IA, or from the place-
      were progressively advanced to regular            ment of the first approximation suture for
       chow. Dogs were individually caged until         the control.
       the passage of the first postoperative stool.      Animals were sacrificed on the 28th post-
       Penicillin (600,000 units) and streptomycin      operative day. Anastomoses were removed
       (0.25 Gm.) were administered parenterally        for gross and microscopic examination. On
       for five days postoperatively.                   gross examination, they were rated as good
         Details of the ID procedure are shown in       if there were no evidence of leak, stricture,
       Figure 1. After bowel transection, extra-        or significant adhesions. A rating of fair
       luminal fat and vessels were first dissected     was assigned if there were either stricture
       from the terminal inch of the bowel to be        or adhesions. A rating of poor was reserved
       invaginated. One inch of mucosal lining          for any evidence of leak. On microscopic
       was then dissected from the distal bowel.        examination, the presence or absence of
       A temporary stay suture was used to pull         inflammation,   accumulation of polymor-
       proximal into distal bowel. Interrupted No.      phonuclear leukocytes or edema fluid was
       4-0 silk sutures were used for the serosa.       noted. In addition, continuity was rated as
         Details of the IA follow the same technic      good if mucosa and muscle were present in
       with the exception that no mucosa was dis-       all parts of the bowel wall, fair if either
       sected. Conventional anastomoses for the          nucosa or muscle were present, and poor
       controls were done by the standard two           if there were gaps of both muscle and mu-
       layer end-to-end procedure.                      cosa. To statistically evaluate the degree of
         All procedures were carefully timed, be-       stricture, the circumferences of the anasto-
       ginning with the dissection of the mucosa        motic line and of bowel one inch proxi-
       for the ID, the placement of the temporary        mally were measured and a ratio of the de-
                                                                                                           Annals of Surgery
           396                               LINN, REISMAN, YURT AND POLK                                       March 1968
                                  TABLE 1. Results ofSmall and Large Bowel Anastomoses Performed
                                                         Small Bowel (24)                      Large Bowel (24)
                                                     IA         ID          C               IA        ID          C
                Malfunction                             1          0           0               0         0          0
                Operative time
                  Mean average (min.)                  16         18          46              11        14         36
                  Standard deviation                4 1.5       ±2.7       4±4.7            ±4.1      ±4.6       ±7.9
                Gross appearance
                  Good                                  4          7           8               5         7          7
                  Fair                                  3          1           0               3          1         1
                  Poor                                  1          0          0                0         0          0
                  A/P ratio
                    Mean                             0.78       0.81        0.90            0.82      0.87        1.00
                    Standard deviation               ±.12       ±.08       4.16             ±.90      ±.05      4.07
                Microscopic appearance*
                  Continuity
                    Good                                2                     2               5          6          3
                    Fair                                2          0          5                2         1          4
                    Poor                                1          0          0                0         0          0
               Inflammation
                  Absent                                3          3          2                0         0          0
                  Present                               4          5          5                8         8          8
               * N = < 8 cases where sections could not be prepared for examination.
          gree of stricture computed (hereafter re-                  two sutures of the IA anastomosis had torn
          ferred to as the A/P ratio).                               through the serosa leaving a gaping hole.
             Other data for analysis included clinical               The C anastomosis was still intact.
          courses of the animals judged by weight                      There were no significant weight changes
          changes,     complications,      bowel cultures,           in any animal. All animals had a return of
          bowel functions, and deaths. Finally all                  normal bowel function within 2 or 3 days
          data were subjected to analysis of variance                after operation. Intestinal cultures taken
          on an IBM 7040 computer in which large                     during the anastomotic procedure were
          and small bowel series and IA, ID, and C                  negative in all but two of the small bowel
          procedures were compared. Differences sig-                 series and positive in all of the large bowel
          nificant at p < 0.01 by F ratio and T test                series.
          between means are reported.                                  Anastomotic Time: The most significant
                                Results                             result was found in comparison of opera-
                                                                    tive time. The C anastomoses always re-
             Findings are presented in terms of clini-              quired two to three times longer than the
          cal function, operative time, and anasto-                 invagination technic. Differences between
          motic appearance. Results are summarized                  length of time were highly significant (p
          in Table 1.                                                > 0.001).
             Clinical Function: One animal in the                      Anastomotic Appearance: There were
          small bowel series with an IA-C anasto-                   few differences between the ratings of the
          mosis died on the 12th day after operation.               controls and ID, in terms of gross appear-
          On postmortem examination, 400 cc. of                     ance. The IA, however, were more fre-
          dark fluid and early adhesions were found                 quently rated as only fair and one (that
          throughout the peritoneal cavity. One or                  dehisced on the 14th day) was rated poor.
The words contained in this file might help you see if this file matches what you are looking for:

...Anastomosis by invagination intestinal a historical review of new technic with controlled study its potential bernard s linn m d terry reisman roger w yurt b hiram c polk jr t from the department surgery university miami school medicine florida in travers reported union fully used but never widely acclaimed divided bowel requires contact most users have been enthu cut extremities their entire circum siastic about and more than few ference thus peritoneal continuity claimed procedure as own dis healing became synonomous how coveries clinical use out ever around turn century hal dates experimental research history sted emphasized importance moore forrest hamilton submucosa it is that sonnenburg berlin first an surprising this did little at time end to ileo colic before or later alter orthodox unfortunately he investigators repeatedly published his results maylard explored other methods attempts re unaware discovery prac duce operative improve func ticed same scotland tional fact da costa...

no reviews yet
Please Login to review.