Gastrointestinal Tract Lined With Consistent Animal Experiments And Clinical Studies

Objectives To explore the feasibility of seromuscular anastomosis of gastrointestinal tract in rabbit.Methods Chinese rabbits were divided into four groups, double-layer invertedanastomosis(DLIA) group(n=10), single-layer inverted anastomosis(SLIA) group(n=10), extramucosal anastomosis(EA) group (n=10) and seromuscular anastomosis(SA) group(n=10). Five anastomoses were performed on each animal, one in side-to-side gastroduodenal anastomosis, two in end-to-end ileal and colonic anastomoses, respectively. Half of each group was sacrificed on postoperative days 3 and 7 to determine in situ anastomostic bursting pressure(ABP), hydroxyproline(HP) content and histopathologic evaluation of the anastomotic sites.Results (1) Comparison of ABP between the four anastomoses There were no significant differences in ABP among the four groups on day 3, and also among DLIA, SLIA and EA group on day 7 in gastroduodenal, ileal and colonic anastomoses. On day 7, ABP was dramatically higher in SA group than in DLIA and SLIA group(200.4±19.4 vs. 144.0±30.8, 144.8±42.4 cmH2O, P<0.005, P<0.025, respectively) in gastroduodenal anastomosis, and in DLIA group(217.6±30.8 vs. 149.4±14.7 cmH2O P<0.005) in ileal anastomosis, and also in DLIA and SLIA group(306.2±47.5 vs. 234±33.7, 247.6±32.1 cmH2O, P<0.05, respectively) in colonic anastomosis.(2) Comparison of HP content between the four anastomoses There was no statistical difference in terms of HP content among the four groups in gastroduodenal and ileal anastomoses on day 3(P>0.05), and also in ileal and colonic anastomoses on day 7(P>0.05). HP content was higher in DLIA group than in SLIA group on day 3(913.3±165.9 vs. 712.4±160.1. g/g tissue wet weight, P <0.05), and also higher in SA group than DLIA group on day 7(1015.7±99.6 vs. 616.5±87.9. g/g tissue wet weight, P<0.025).(3) Comparison of sites of bursting between the four anastomoses On postoperative day 3, bursting often occurred within the anastomotic line between the sutures, only 5(12.5%) wasoutside of the anastomostic line. On day 7, bursting often occurred at the suture of the intestinal wall within the anastomotic region, and 32.5% was outside of the anastomosis, most(53.8%) was seen in seromuscular anastomosis, especially in ileum.(4) Comparison of inflammatory reaction between the four anastomoses Histological examination of the anastomoses showed no differences among groups in gastroduodenal anastomosis in inflammatory cell infiltration on day 3 and 7. On day 3, there was a trend toward a decrease in inflammatory index in DLIA, SLIA, EA, and SA group in ileal anastomosis, but on day 7, the inflammatory index of DLIA group was higher than that of SAgroup(2.8±0.8 vs. 1.6 + 0.5, F<0.05). For colonic anastomosis, a more profound inflammatory reaction were found in DLIA and SLIA group, followed by SAand EA group on day 3, the inflammatory response was increased in SA group and similar as DLIA group on day 7 (1.6 + 0.9 vs. 1.8 + 1.3, P>0.05).(5) Comparison of mucosal healing between the four anastomoses On day 7, there were no significant differences in index of mucosal healing among the four groups in gastroduodenal and ileal anastomoses. Although no statistical significance, the index of DLIA group( 1.0 + 0.0) was lower than that of SLIA, EAand SAgroup(2.2 + 1.6, 2.0 + 1.2 , 2.0 + 1.4) in colonic anastomosis.(6) Comparison of the edema between the four anastomoses there were no significant differences in width of the muscular layer and submucosal layer among the groups in gastroduodenal, ileal and colonic anastomoses on day 3 and 7.(7) Comparison of the tissue apposition between the four anastomoses The apposition in EA and SA group were better than that in DLIA and SLA group. The apposition in ileal and colonic anastomoses were belter than that in gastroduodenal anastomosis.(8) Comparison of intraperitoneal adhesion between the four anastomoses On day 3, there were no significant differences in intraperitoneal adhesion between DLIA and SLIAgroup(1.2 + 1.0 vs. 1.2 + 0.8, P>0.05), and between EAand SAgroup(0.2 + 0.4 vs. 0.2 + 0.4, P>0.05). but the adhesion index in DLIA and SLIA group was higher than that in EAand SA group (.P<0.05) . On day 7, there were no significant differences in the adhesion index between DLIA and SLIA group, and between EAand SA group(P>0.05), but the adhesion index in DLIA group was higher than that inEAandSAgroup(2.0 + 0.2vs. 0.6 + 0.5,0.6 + 0.6, P<0.005). Conclusions1 Seromuscular anastomosis is as safe as the double-layer inverted, single-layer inverted and extramucosal anastomoses of gastrointestinal tract at the inflammatory stage of gastrointestinal anastomosis. But at the fibroproliferative stage, the seromuscular anastomosis is stronger than the above-mentioned hand-sewn anastomoses.2 Seromuscular anastomosis of gastrointestinal tract only affects the HP content of anastomotic tissue of gastroduodenal anastomosis, not that of ileal and colonic anastomoses at the fibroproliferative stage.3 The mucosal healing is similar between the seromuscular anastomosis and the other hand-sewn anastomosis.4 The inflammatory reaction is similar between the seromuscular anastomosis and the other hand-sewn anastomosis in gastroduodenal anastomosis, and the slightest in the seromuscular anastomosis and the most prominent in the double-layer inverted anastomosis in ileal anastomosis, but similar profound both the seromuscular anastomosis and the double-layer anastomosis in the colonic anastomosis.5 The similar intraperitoneal adhesive formation caused by the seromuscular and extramucosal anastomoses, which are slighter than that of the double-layer and single-layer inverted anastomoses.In conclusion, seromuscular anastomosis of gastrointestinal tract is as safe as the other hand-sewn anastomosis, but more convenient and simpler.Part II Clinical studies of seromuscular anastomoses of gastrointestinal tract — > Gastrojejunal seromuscular anastomosis (with reports of 71 patients)Objective To determine the feasibility of gastrojejunal seromuscular anastomosisfollowed by partial gastrectomy.Methods Seventy-one gastrojejunal seromuscular anastomosis after partial gastrectomy were carried out between August 1994 to October 2002. There were 62 men and 9 women with average age of 53.0(17-75) years old. Indications of gastrojejunal seromuscular anastomosis were gastroduodenal ulcer(n=52), gastric carcinoma(n=15), pancreatic carcinoma (n=3) and duodenal trauma(n=l), complicated with the perforation(n=4), obstruction(n=8) and hemorrhage(n=25). The coexistent diseases included choledocholiathiasis(n=8) and biliary benign stricture(n=l) and diabetes mellitus(n=l). Synchronous procedures included cholecystectomy(n=4), cholecystectomy, bile duct exploration, T-tube drainage(n=4), Whipple procedure(n=3), cholecystectomy, bile duct exploration, T-tube drainage, left lateral lobe hepatectomy(n=l) and cholecystectomy, Roux-en-ychokdochojejunostomy(n= 1) .Results Of 71 patients with partial gastrectomy with gastrojejunal seromuscular anastomosis, there was no anastomotic leakage, stricture and hemorrhage. Two patients with rebleeding postoperatively were not associated with this technique, one patient with diabetes died of MODS.Conclusion Gastrojejunal seromuscular anastomosis is a sate and feasible method followedby partial gastrectomy.H^ Seromuscular anastomosis of small intestine—a feasible method of small intestinal anastomosisObjective To determine the feasibility of seromuscular anastomosis for intestinal reconstruction followed by small bowel resectionMethods Forty-four seromuscular anastomosis of small intestine were carried out between August 1994 to October 2002. There were 27 men and 17 women with average age of 36.8 (17-81) years old, Indications of the seromuscular anastomosis were periampalliary carcinoma(n=6) and intestinal tumor(n=2), intestinal obslruction(n=10), vascular diseases(n=3), inguinal or femoral hernias with strangulation(n=6). intestinal injury(n=2), and duodenal ulcer complicated with pylorus and billiary tract obstruction(n=l). Coexistent diseases included sigmoid colon carcinoma(n=l), and pancreas trauma(n=l). Synchronous procedures included choledechojejunostomy(n=14), hepaticojejunostomy(n=7), herniorhaphy(n=6), partial gastrectomy(n=l), radical colon carcinoma resection (n=l), and pancreaticojejunostomy(n=l).Results Of 44 patients with seromuscular anastomosis of the small intestine, there was no anastomotic leakage, stricture and hemorrhage. One patient died of shock.Conclusion Seromuscular anastomosis is a safe and feasible method for intestinalreconstruction followed by the small bowel resection.