Digestive Surgery
Original Paper
Improved Healing of Extraperitoneal Intestinal Anastomoses in the Early Phase when Surrounded by OmentumPierie J.P.E.N.a · de Graaf P.W.a · van Dijk M.a · Renooij W.a · van Vroonhoven T.J.M.V.a · Obertop H.bDepartments of Surgery,aUniversity Medical Center, Utrecht and bAcademic Medical Center Amsterdam, The Netherlands
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Article / Publication Details
Published online: December 11, 2000
Issue release date: 2000
Number of Print Pages: 6
Number of Figures: 1
Number of Tables: 3
ISSN: 0253-4886 (Print)
eISSN: 1421-9883 (Online)
For additional information: https://www.karger.com/DSU
Abstract
Background: The extra-anatomical position of a cervical oesophagogastrostomy is a reason for impaired anastomotic healing, but transposition of the omentum that is covered with mesothelial cells may be a way to improve that. Method: This hypothesis was tested in a rat model. An end-to-end jejuno-jejunostomy was placed subcutaneously in group I (n = 29), subcutaneously surrounded by omentum in group II (n = 29) and intra-abdominally surrounded by omentum in group III (n = 20). After 3, 7 or 14 days, the rats were sacrificed and bursting pressure (BP) of the anastomosis or jejunum was measured and the hydroxyproline (HP) level was determined. Results: In group I 5/29, in group II 2/29 and in group III 0/20 rats died following anastomotic leakage (nonsignificant) and were excluded from other measurements. BP was decreased after 3 days in group I (60 ± 9 mm Hg) compared with group II (101 ± 8 mm Hg) and group III (107 ± 11 mm Hg) (p = 0.002). After 7 days, BP in groups I (122 ± 10 mm Hg) and II (132 ± 10 mm Hg) were lower as compared with group III (230 ± 8 mm Hg) (p < 0.001). Differences in HP levels were not statistically significant between the groups after 3, 7 and 14 days. Conclusion: The healing of intestinal anastomoses in an extraperitoneal position is improved in the early phase only when surrounded by omentum.
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Article / Publication Details
Published online: December 11, 2000
Issue release date: 2000
Number of Print Pages: 6
Number of Figures: 1
Number of Tables: 3
ISSN: 0253-4886 (Print)
eISSN: 1421-9883 (Online)
For additional information: https://www.karger.com/DSU
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Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
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PubMed IDW.T. Knoefel, J.R. Izbicki
Department of Surgery, University of Hamburg, Germany
Subtotal esophagectomy with cervical esophagogastrostomy represents the standard treatment for adeno- or squamous cell carcinoma of the esophagus in most institutions. Although overall results concerning postoperative mortality and morbidity are satisfactory, anastomotic leaks are frequent. These leaks obliterate after adequate local drainage in most cases, but strictures will usually result in the need for repeated endoscopic dilatations. Many factors have been accused of being responsible for this Achilles heel of esophagectomy. Among them are insufficient blood supply, tension, and lack of mesothelial factors in this extraperitoneal position, The latter is the indirect subject of the present study.
In a well-designed experimental study, Pierie et al. examined the effect of omental wrapping on healing of extraperitoneal anastomoses in order to supply peritoneal cells and potential mesothelial factors. In a subcutaneous pouch, jejuno-jejunostomies healed significantly better during the 1st week if they were surrounded by an omental patch. Since BPs were not significantly different after 7 and 14 days the authors concluded that his effect was limited in their study to the early phase of anastomotic healing.
This very restrained conclusion is a wise one, since further speculations cannot be supported by data at the present state.
Seven of 58 rats in the extraperitoneal groups were excluded from further analysis because they died of an anastomotic dehiscence. These must have been the ones with the lowest bursting strength. Since the deaths were not equally distributed among groups, statistical analysis of bursting strength and HP content must have been skewed. Bursting strength after 3 days, in addition, was in the same range after extraperitoneal anastomoses without wrapping in this study as for intraperitoneal anastomoses in a previous study by the same authors [1]. Surprisingly, the HP content in this study was about twenty times lower than that reported in a rat model of esophagogastrectomy [
Mesothelial factors may well play an important role in anastomotic healing. It is, however, not possible to exclude them in the present model in any of the groups, since the visceral peritoneum of the jejunum will also deliver them and the abdominal cavity seems to communicate with the subcutaneous pouch. Most likely this was the reason for the 100% mortality of subcutaneously jejunal dehiscence. Previous work on free or pedunculated peritoneal or pleural wrapping has not resulted in a breakthrough in the technique of esophageal anatomoses and even produced more stenoses [3–6]. A simple wrapping consequently sounds appealing but may be a simplistic approach to a multifactorial problem.
Omental wrapping of cervical esophagogastrostomies might cover minor leaks. The bulkier gastric tube, however, will also be subject to an increased risk of strangulation in the thoracic outlet. Effective drainage seems more convincing than mesothelial covering of the risky cervical anastomosis.References
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03 Cramer I, Kleinsasser LJ: Anastomosis of the cervical esophagus: II. Experimental evaluation of peritoneal grafts. Arch Surg 1951;63:243–246.
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06 van Oosterom FJT, van Lanschot JJB, Oosting J, Obertop H: A free peritoneal patch does not affect the leakage rate but increases stricture formation of a cervical esophagogastrostomy. Dig Surg 1999;16:379–384.
