Systematic review: the impact of exercise on mesenteric blood flow and its implication for preoperative rehabilitation

BACKGROUND

Exercise in the preoperative period, or prehabilitation, continues to evolve as an important tool in optimising patients awaiting major intra-abdominal surgery. It has been shown to reduce rates of post-operative morbidity and length of hospital stay. The mechanism by which this is achieved remains poorly understood. Adaptations in mesenteric flow in response to exercise may play a role in improving post-operative recovery by reducing rates of ileus and anastomotic leak.

AIMS

To systematically review the existing literature to clarify the impact of exercise on mesenteric arterial blood flow using Doppler ultrasound.

METHODS

PubMed, EMBASE and the Cochrane library were systematically searched to identify clinical trials using Doppler ultrasound to investigate the effect of exercise on flow through the superior mesenteric artery (SMA). Data were extracted including participant characteristics, frequency, intensity, timing and type of exercise and the effect on SMA flow. The quality of each study was assessed using the Downs and Black checklist.

RESULTS

Sixteen studies, comprising 305 participants in total, were included. Methodological quality was generally poor. Healthy volunteers were used in twelve studies. SMA flow was found to be reduced in response to exercise in twelve studies, increased in one and unchanged in two studies. Clinical heterogeneity precluded a meta-analysis.

CONCLUSION

The weight of evidence suggests that superior mesenteric arterial flow is reduced immediately following exercise. Differences in frequency, intensity, timing and type of exercise make a consensus difficult. Further studies are warranted to provide a definitive understanding of the impact of exercise on mesenteric flow.

The enteric nervous system and gastrointestinal innervation: integrated local and central control

The digestive system is innervated through its connections with the central nervous system (CNS) and by the enteric nervous system (ENS) within the wall of the gastrointestinal tract. The ENS works in concert with CNS reflex and command centers and with neural pathways that pass through sympathetic ganglia to control digestive function. There is bidirectional information flow between the ENS and CNS and between the ENS and sympathetic prevertebral ganglia.The ENS in human contains 200-600 million neurons, distributed in many thousands of small ganglia, the great majority of which are found in two plexuses, the myenteric and submucosal plexuses. The myenteric plexus forms a continuous network that extends from the upper esophagus to the internal anal sphincter. Submucosal ganglia and connecting fiber bundles form plexuses in the small and large intestines, but not in the stomach and esophagus. The connections between the ENS and CNS are carried by the vagus and pelvic nerves and sympathetic pathways. Neurons also project from the ENS to prevertebral ganglia, the gallbladder, pancreas and trachea.The relative roles of the ENS and CNS differ considerably along the digestive tract. Movements of the striated muscle esophagus are determined by neural pattern generators in the CNS. Likewise the CNS has a major role in monitoring the state of the stomach and, in turn, controlling its contractile activity and acid secretion, through vago-vagal reflexes. In contrast, the ENS in the small intestine and colon contains full reflex circuits, including sensory neurons, interneurons and several classes of motor neuron, through which muscle activity, transmucosal fluid fluxes, local blood flow and other functions are controlled. The CNS has control of defecation, via the defecation centers in the lumbosacral spinal cord. The importance of the ENS is emphasized by the life-threatening effects of some ENS neuropathies. By contrast, removal of vagal or sympathetic connections with the gastrointestinal tract has minor effects on GI function. Voluntary control of defecation is exerted through pelvic connections, but cutting these connections is not life-threatening and other functions are little affected.

Intrinsic primary afferent neurons and nerve circuits within the intestine

Intrinsic primary afferent neurons (IPANs) of the enteric nervous system are quite different from all other peripheral neurons. The IPANs are transducers of physiological stimuli, including movement of the villi or distortion of the mucosa, contraction of intestinal muscle and changes in the chemistry of the contents of the gut lumen. They are the first neurons in intrinsic reflexes that influence the patterns of motility, secretion of fluid across the mucosal epithelium and local blood flow in the small and large intestines. In the guinea pig small intestine, where they have been characterized in detail, IPANs have Dogiel type II morphology, that is they are large round or oval neurons with multiple processes, some of which end close to the luminal surface of the intestine, and some of which form synapses with enteric interneurons, motor neurons and with other IPANs. The IPANs have well-defined ionic currents through which their excitability, and their functions in enteric nerve circuits, is determined. These include voltage-gated Na(+) and Ca(2+) currents, a long lasting calcium-activated K(+) current, and a hyperpolarization-activated cationic current. The IPANs exhibit long-term changes in their states of excitation that can be induced by extended periods of low frequency activity in synaptic inputs and by inflammatory mediators, either applied directly or released during an inflammatory challenge. The IPANs may be involved in pathological changes in enteric function following inflammation.

The enteric nervous system and regulation of intestinal motility

The enteric nervous system exerts local control over mixing and propulsive movements in the small intestine. When digestion is in progress, intrinsic primary afferent neurons (IPANs) are activated by the contents of the intestine. The IPANs that have been physiologically characterized are in the intrinsic myenteric ganglia. They are numerous, about 650/mm length of small intestine in the guinea pig, and communicate with each other through slow excitatory transmission to form self-reinforcing assemblies. High proportions of these neurons respond to chemicals in the lumen or to tension in the muscle; physiological stimuli activate assemblies of hundreds or thousands of IPANs. The IPANs make direct connections with muscle motor neurons and with ascending and descending interneurons. The circular muscle contracts as an annulus, about 2-3 mm in minimum oral-to-anal extent in the guinea pig small intestine. The smooth muscle cells form an electrical syncytium that is innervated by about 300 excitatory and 400 inhibitory motor neurons per mm length. The intrinsic nerve circuits that control mixing and propulsion in the small intestine are now known, but it remains to be determined how they are programmed to generate the motility patterns that are observed.