w w w . j c o l . o r g . b r
Journal
of
Coloproctology
Original
Article
Comparative
evaluation
of
healing
response
between
colo-colic
invagination
anastomosis
and
single-layer
running
suture.
Experimental
study
in
dogs
Miguel
Augusto
Arcoverde
Nogueira
a,
Francisco
Sérgio
Pinheiro
Regadas
b,∗,
Carlos
Renato
Sales
Bezerra
a,c,d,
Welligton
Ribeiro
Figueiredo
d,e,
Erbert
Portela
Martins
Filho
eaUniversidadeEstadualdoPiauí(UESPI),EscoladeMedicina,Teresina,PI,Brazil
bUniversidadeFederaldoCeará(UFC),EscoladeMedicina,Fortaleza,CE,Brazil
cProgramadeCirurgiaAbdominal,UniversidadeEstadualdoPiauí(UESPI),Teresina,PI,Brazil
dUniversidadeFederaldoCeará(UFC),Fortaleza,CE,Brazil
eFaculdadeIntegralDiferencial(FacidDevry),Teresina,PI,Brazil
a
r
t
i
c
l
e
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n
f
o
Articlehistory:
Received18March2016 Accepted13April2016 Availableonline27May2016
Keywords:
Anastomosis WoundHealing Colon
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b
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t
Objective:Evaluatehealingresponseofcolo-colicanastomosisbyinvaginationvs. single-layersuture.
Methods:Sixtydogswererandomlydistributedintwogroupsandanastomosedwith single-layersuture(G-I,control)orbyinvaginationandcardinalsutures(G-II,study).Intheend, the animalswereeuthanized(10fromeachgroupon POD7and20 onPOD21) andthe anastomosedsegment wasretrievedforhistology andimmunohistochemistry. Parame-ters includedbodyweight, adhesions,edema,vasoproliferation,type IandIIIcollagen, myeloperoxidaseandnitricoxide.FindingswereanalyzedwithStudent’sttestandthe Mann–Whitneytest.
Results:Noanimaldiedpriortoeuthanasia. Thegroupsweresimilarwithregardtoall parameters:medianweight10.86kg(G-I)and9.98kg(G-II)onPOD7(p=0.41)and11.86kg (G-I)and11.55kg(G-II)onPOD21(p=0.71);abdominaladhesions(p=0.7383POD7;p=0.5685 POD21), level of edema (p=0.3006 POD7; p=0.7990 POD21), vasoproliferation(p=0.1191 POD7;p=0.0758POD21),typeIcollagen(p=0.4591POD7;p=0.3357POD21),typeIII colla-gen(p=0.2166POD7;p=0.2712POD21),nitricoxide(p=0.3980POD7;p=0.4796POD21)and myeloperoxidase(p=0.580POD7;p=0.755POD21).
Conclusion: Nosignificantdifferenceinhealingresponsewasobservedbetweenthetwo anastomosistechniques(single-layersutureandinvagination).
©2016SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.This isanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).
∗ Correspondingauthor.
E-mail:sregadas@hospitalsaocarlos.com.br(F.S.P.Regadas).
http://dx.doi.org/10.1016/j.jcol.2016.04.008
Avaliac¸ão
comparativa
da
resposta
cicatricial
entre
anastomose
colocólica
por
invaginac¸ão
e
sutura
contínua
em
plano
único.
Estudo
experimental
em
cães
Palavras-chave:
Anastomose Cicatrizac¸ãodeferida Cólon
r
e
s
u
m
o
Objetivo: Avaliararespostacicatricialda anastomosecolocólica porinvaginac¸ãoversus
suturaemplanoúnico.
Métodos: Sessentacãesforamrandomicamentedistribuídosemdoisgrupose anastomosa-doscomsuturaemplanoúnico(G-I,controle)ouporinvaginac¸ãoesuturascardinais(G-II, estudo).Aofinal,osanimaisforamsubmetidosàeutanásia(10decadagrupono7◦dia
dopós-operatório[DPO7]e20emDPO21)eosegmentoanastomosadofoirecuperadopara estudoshistológicoseimunoistoquímicos.Osparâmetrosforam:pesocorpóreo, aderên-cias,edema,vasoproliferac¸ão,colágenodostiposIeIII,mieloperoxidaseeóxidonítrico.Os achadosforamanalisadoscomostestestdeStudentedeMann-Whitney.
Resultados: Nãoocorreramóbitosantesdaeutanásia.Osgruposeramsemelhantescom relac¸ãoa todososparâmetros considerados:pesomediano10,86Kg(G-I) e9,98Kg (G-II) em DPO7(p=0,41) e11,86 Kg (G-I) e11,55 Kg(G-II) em DPO21(p=0,71); aderências abdominais(p=0,7383DPO7;p=0,5685DPO21),níveldeedema(p=0,3006DPO7;p=0,7990 DPO21), vasoproliferac¸ão(p=0,1191 DPO7;p=0,0758 DPO21),colágeno tipoI (p=0,4591 DPO7;p=0,3357DPO21),colágenotipoIII(p=0,2166DPO7;p=0,2712DPO21),óxidonítrico (p=0,3980DPO7;p=0,4796DPO21)emieloperoxidase(p=0,580DPO7;p=0,755DPO21). Conclusão:Nãofoiobservadadiferenc¸asignificativanarespostacicatricialentreasduas técnicasdeanastomose(suturaemplanoúnicoeinvaginac¸ão).
©2016SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Introduction
Colorectalsurgeryisoneofthemodalitiesofdigestivesystem surgerymoststronglyassociatedwithpostoperative compli-cations.Unsurprisingly,Hippocrates(460–377BC)considered itunfeasible.Inthesixteenthcentury,morbidityrateswere stillprohibitive,butprognosisimprovedconsiderablyinthe twentiethcenturywiththeadventofantibiotictherapy.1,2
Much effort has been put into improving the methods ofcolorectal anastomosisinordertoreducecomplications. Advancesincludenewtypesofthreadwhichinducelesstissue inflammation,devicessuchasstaplersandentirelynovel sur-gicaltechniques.Theseadvanceshavesignificantlyreduced therateofanastomoticdehiscence.Nevertheless,dehiscence remainsanimportantriskfactorforpostoperativemortality incolorectalsurgery.2–5
Anastomosis by invagination was first performed by Sonnenburg in the late nineteenth century,6 but the case
(ileocolic anastomosis) was not described in detail. More recently,atechniqueofgastroesophagealanastomosisbased on the invaginationofgastrointestinal tract segments was described in a patient with megaesophagus submitted to esophagectomy.7
Anastomosisbycolo-colicinvaginationwasrecently eval-uated in dogs with regard to inflammatory and healing parameterstodeterminetheadvantageofbowelpreparation.8
Thepurposeofthisexperimentalstudyistoevaluatethe healingresponseofcolo-colicinvaginationanastomosis com-paringwithsingle-layerrunningsuture.
Materials
and
methods
Sixtyhealthyfemalemongreldogs(Canisfamiliaris)weighing 8.0–19.5kgwere usedinthis study.Theanimalswere sup-pliedbythemunicipaldogpoundofTeresina(Piauí,Brazil)and quarantinedfor15daysataprivateveterinaryclinicaffiliated withtheSchoolofMedicalSciencesofPiauíStateUniversity (UESPI).Theanimalswerekeptinseparatecages,vaccinated againstrabiesandevaluatedatbaselineandperioperatively by a Veterinarian. After the quarantine, the animals were randomlydistributed(MicrosoftExcel®)intwogroupsof30
animalseach.InGroupI(Control),theanimalsweresubmitted toend-to-endcolo-colicanastomosiswithsingle-layer run-ningsutureusingpolypropylenethreadsize000andinGroup II(Study),theanimalsweresubmittedtoend-to-endcolo-colic anastomosisbyinvagination(introducingtheproximal seg-mentintothedistallumen),securedbyfourcardinalsutures usingpolypropylenethreadsize000.
Surgicaltechnique
Fig.1–Colonidentifiedat20cmfromtheanalmarginand securedwithastraightintestinalclamp.
6and12hrespectivelyduringthefirst24hafterthe proce-dure. Meloxicam (0.2mg/kg s.c.)was done every 12hfor 3 daysandTramadol(2mg/kgi.m.)wasadministered preopera-tivelyandateach4hduringthefirst24haftertheprocedure. Followinganesthesiawithpropofol(5mg/kgi.v.)and orotra-cheal intubation, the animals were placed on mechanical ventilationwithisofluraneinasemi-closedcircuit.The anes-thetizedanimalsweresubmittedtodigitalrectalexamination toevaluatethebowelpreparationaccordingtothe classifica-tionofO’Dwyer etal.9 (excellent=nofeces; good=minimal
fecal residue; acceptable=liquid feces; soiled=solid feces). Thegrading was confirmed during the surgical procedure. Subsequently,the animalswere placedindorsal decubitus and the laparotomy was performed through a transumbil-ical, medianincision measuring approximately 12cm. The abdominalcavitywasinspectedtoruleouthematogenicor gynecologicaldisorders.Initially, thedescending colonwas identifiedat20cmfromtheanalmarginandsecuredwitha straightintestinalclamp(Fig.1).
Alineartransversecolotomywasperformedusingscissors. TheanimalsfromGroupIwerethensubmittedtocolo-colic anastomosis,eitherwithasingle-layerrunningsutureusing polypropylenethreadsize000(Fig.2)or byinvaginationin GroupII,approximately3cmfromthedissectedmesocolon, inserting the proximal segment into the distal lumen and securedbyfourcardinalsuturesusingpolypropylenethread size000,involvingallintestinallayers(Fig.3).Afterthefirst postoperativeevacuation,theanimalswereallowedaccessto standardfeedandwateradlibitum.
Attheendofthestudyperiod,theanimalswere submit-tedtoasecondlaparotomytoexcisetheanastomosedcolon segment for histological and immunohistochemical analy-sis.Thestudyparametersincludedbodyweight,presenceof abdominaladhesions,edema,vasoproliferation,typeIandIII collagen,nitricoxideandmyeloperoxidase.Subsequently,the animalswereeuthanizedwith20%potassiumchloride(i.v.) underanesthesiawithketamine.Tenfromeachgroupwere euthanizedonthe7thpost-operativeday(POD7)andtwenty onthe21stpost-operativeday(POD21).
Thefindings were statisticallyanalyzed using Student’s
t test (non-paired samples, parametric data) and the
Fig.2–TheanimalsfromGroupI,submittedtocolo-colic anastomosiswithasingle-layerrunningsutureusing polypropylene000.
Mann–Whitneytest(non-parametricdata).Thelevelof sta-tisticalsignificancewassetat5%(p<0.05).
Results
Body weight was statistically similar in both groups. The medianweightwas10.86kgand9.98kginGroupsI,II respec-tively on POD7 (p=0.41) and 11.86kg, 11.55kg on POD21 (p=0.71).
Theabdominaladhesionsincidencewasstatistically simi-larinbothgroupsonPOD7(p=0.7383)andPOD21(p=0.5685), as well as for the levels of edema on POD7 (p=0.3006); onPOD21(p=0.7990),vasoproliferationonPOD7(p=0.1191); POD21 (p=0.0758), type I collagen on POD7(p=0.4591); on POD21 (p=0.3357),typeIIIcollagenon POD7(p=0.2166);on POD21 (p=0.2712) andnitric oxideon POD7(p=0.3980) and POD21(p=0.4796).Therewasn’talsosignificantstatistical dif-ferenceofthemyeloperoxidaselevelsbetweenbothgroupson POD7(p=0.580)andPOD21(p=0.755).
Discussion
Thereare manystudiesdiscussingaboutthesurgical tech-niques currently used to perform colorectal anastomosis. Alltypesofsuture(single-layered,double-layered,running, interrupted)andthedifferenttypesofthreadusedtryingto reducetheadherencerates.10–12Inthisexperimentalstudy,it
wasusedtheinvaginationtechniquedevelopedbyLuchesi13
whichisperformedbyinvaginatingthetransectedproximal wallintothelumenofthedistalcolonandcomparingwith single-layerrunningsutureanastomosisregardingtothe heal-ingresponse.Noneexperimentalstudywasfoundinliterature usingtheinflammatoryandhealingmarkerstoevaluate colo-colicinvaginationanastomosis.
Therewasn’tstatisticalsignificantdifferencebetweenthe animalsfrombothgroupsregardingthefrequencyofedemaat theanastomosissiteonPOD7andPOD21.Mostanimalsfrom bothgroupspresentedverymildedemaonPOD7andnone onPOD21aspreviouslydemonstrated inanother study14,15
alsodemonstratedthatedematendstosubsideafterPOD14. So,basedonthefindingsinthisstudy,thesurgicaltechnique didnotchangethefrequencyandintensityofedemaatthe anastomosissite.
According withprevious studies,8,16 agood
vasculariza-tion plays an important role on the viability of intestinal anastomosis. And in this study, there wasn’t a significant statisticaldifferencebetweenbothgroupswithregardto vaso-proliferationonPOD7andPOD21,suggestingthatthesurgical technique had no influence on the vascularization inten-sity,accordingwiththefindingspreviouslydemonstratedin anotherstudy.8
Mooreetal.6demonstratedthatanastomosisinvaginating
theproximalsegmentintothelumenofthedistalcolondoes notincreasetheriskofcontaminationoftheperianastomotic tissuesandperitoneum.Inthisstudy,thegroupsdidnotdiffer significantlywithregardthepresenceofabdominaladhesions accordingwithanotherstudy.12Likewise,theamountoftype
IandIIIcollagenattheanastomosissiteonPOD7andPOD21 wasnotsignificantlyaffectedbythesurgicaltechniqueused, aspreviouslysupportedbyBezerraetal.8
Large amounts of iNOS are usually found inside macrophages up to one month after surgery.17 Moreover,
increasedlevelsofnitricoxidemaybeobservedin endothe-lial cells in the anastomoses area, even inthe absence of macrophages.18 Using immunohistochemistryexam,itwas
determinedthelevelsofnitricoxideandmyeloperoxidasein bothgroupsofanimalsonPOD7andPODO21butitwasnot foundany significant difference betweenthem, suggesting thatthesurgicaltechniquehasnomeasurableeffectonthese parametersaswell.8
Conclusion
It was not demonstrated in this experimental study any significant difference on healing response between colo-colic invagination anastomosis with single-layer running suture.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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