Comparison of different surgical repairs in the treatment of experimental duodenal injuries

Comparison of a simple continuous versus simple interrupted suture pattern for the repair of a large, open duodenal defect with a jejunal serosal patch in a canine cadaveric model

OBJECTIVE

To determine whether jejunal serosal patches could securely seal large, open defects in duodenal segments harvested from canine cadavers and to compare intraluminal pressures at which leakage first occurred and maximal intraluminal pressures for repaired duodenal segments between 2 suture patterns.

SAMPLE

Duodenal and jejunal segments from 9 canine cadavers.

PROCEDURES

20 constructs were created through repair of large, open duodenal defects with circumferential suturing of an intact jejunal segment (jejunal serosal patch). Constructs were randomly assigned to have the serosal patch anastomosed to the duodenal segment by a simple continuous or simple interrupted suture pattern. The pressure at which the first leakage was observed and the maximum pressure obtained during testing were recorded and compared between suture patterns.

RESULTS

Initial leakage pressure was significantly higher with the simple interrupted pattern (mean ± SD, 68.89 ± 5.62 mm Hg), compared with the simple continuous pattern (59.8 ± 20.03 mm Hg). Maximum intraluminal pressures did not significantly differ between the simple interrupted (91 ± 8.27 mm Hg) and simple continuous patterns (90.7 ± 16.91 mm Hg). All constructs, regardless of suture pattern, withstood supraphysiologic pressures.

CONCLUSIONS AND CLINICAL RELEVANCE

Jejunal serosal patches adequately sealed large, open duodenal defects and prevented leakage in these constructs. Constructs with simple continuous or simple interrupted suture patterns withstood physiologic and supraphysiologic intraluminal pressures, although constructs with a simple interrupted suture pattern initially leaked at higher pressures. (Am J Vet Res 2020;81:985-991).

PARIETAL PERITONEUM GRAFT FOR DUODENUM INJURIES IN AN ANIMAL MODEL

Background:

Duodenal injuries and their surgical procedure cause a high morbidity and mortality.

Aim:

To assess the overall effectiveness of the auto-graft of peritoneum in the treatment of the perforation of the duodenum, aiming to reduce surgery time, costs, complexity and mortality.

Methods:

Twelve New Zealand rabbits, ages 4-6 months, both sexes, underwent designed surgical grade III duodenal injuries that were repaired 18 h after. Rabbits were surgically treated with the proposed auto-graft of peritoneum.

Results:

No postoperative deaths were observed; the animals presented corporal weight increase and were euthanized six months later. There was no significant difference between both groups relating to the postoperative evolution or in the histological changes.

Conclusion:

Auto-graft of the peritoneum and posterior fascia is a useful option for duodenal repair and that is worth of evaluation for humans.

Two cases of laparoscopic direct spiral closure of large defects in the second portion of the duodenum after laparoscopic endoscopic co-operative surgery

Curative endoscopic resection of non-ampullary duodenal lesions, although possible, is challenging. In recent years, although a novel surgical technique named laparoscopic-endoscopic cooperative surgery (LECS), which combines laparoscopic and endoscopic techniques, has made the resection of nonampullary duodenal lesions relatively easier, closure of the defect is still controversial. We report two cases of the duodenal lesion which were closed using a novel technique for primary closure utilising the free wall of the duodenum. Two cases of the duodenal lesion in the second portion of the duodenum were undergone full thickness resection using the LECS technique. The defect is designed spirally to ensure maximum use of the free wall of the duodenum. The mucosal layer is closed using a running suture, and the seromuscular layer is closed using interrupted sutures. The suture line is then reinforced with omentum. There were no intraoperative complications and had uneventful post-operative courses with no leakage, stenosis, or relapse.

Extensive regeneration of the stomach using bioabsorbable polymer sheets

BACKGROUND

The growing prevalence of endoscopic surgery in recent years has led to the minimization of postoperative scarring. However, this procedure does not allow for the regeneration of the resected digestive tract, which compromises the postoperative maintenance of digestive function. In this preliminary study, we developed an artificial gastric wall (AGW) using bioabsorbable polymer (BAP), and evaluated the ability of this BAP patch to repair and regenerate a widely defective gastric wall in an animal model.

METHODS

Pigs were laparotomized under general anesthesia. An 8 × 8-cm, round portion of the anterior gastric wall was excised and replaced by an AGW. The AGW was composed of a copolymer comprising 50% lactic acid and 50% caprolactone. The animals were relaparotomized 4, 8, or 12 weeks after implantation, after which they underwent resection of the entire stomach for gross and histologic evaluation of the graft sites.

RESULTS

All recipient pigs survived until killing. By 4-8 weeks, the graft site revealed progressively fewer mucosal defect after each day. Moreover, the grafted area was indistinguishable from the native stomach 12 weeks after AGW implantation. The structures of the regenerated mucous membrane and muscle layers were identical to those of the native stomach. Furthermore, proton pumps were found in the regenerated tissue.

CONCLUSION

The BAP sheets helped to restore extensive gastric defects without causing any deformation. The use of BAP sheets may become a new therapeutic method that prevents alterations of gastric volume after extensive gastrectomy for stomach cancer and other diseases.

Repair of gastric defects with an equine pericardial patch

PURPOSES

The objective of this study was to test the efficacy of an equine pericardial patch for repairing full-thickness defects of the stomach wall.

METHODS

Circular defects, 1.5 cm in diameter, were created on the anterior wall of the stomach of 12 female New Zealand rabbits. The defects were repaired by an equine pericardial patch. After euthanasia at different time intervals (3 days to 8 weeks) a macroscopic evaluation of the abdominal cavity (including adhesion scoring), mechanical testing and a histological examination of the stomach were performed.

RESULTS

The animals survived the surgical procedure and underwent an uneventful recovery until euthanasia. None of the patches failed. Adhesions were observed in all animals and were significant in 3/12 animals. Bursting pressure testing indicated that the repair was durable and that adequate strength to prevent patch failure was achieved by the second week. A histological examination showed gradual narrowing of the perforation site by mucosal and limited muscular regeneration.

CONCLUSIONS

The equine pericardial patch was successfully used to repair a gastric defect in our experimental model, and it seems that it could have potential as a material suitable for further research concerning the repair of upper gastrointestinal defects.

Abdominal wall defect with large duodenal disruption treated by a free tissue flap with a help of temporary expandable metallic stent

Abdominal wall defect with large duodenal disruption after penetrating abdominal injury is a rare emergency situation that can result in life-threatening complications. We report on a 64-year-old man who had abdominal wall defect with large duodenal disruption after penetrating abdominal injury. The patient presented with intra-abdominal exsanguinating bleeding, duodenal disruption, and multiple small bowel perforation. The rarity of this complex injury and its initial presentation as a posttraumatic large duodenal disruption with abdominal wall defect warrant its description. The present case indicates that combining a free tissue flap with a covered expandable metallic stent can effectively and successfully repair an abdominal wall defect that is associated with a large duodenal disruption.

Fibrin glue with gentamicin as an alternative to conventional surgery in experimental treatment of duodenal fistula in rats

Duodenal fistula is a significant ongoing surgical problem. Minimal invasive treatment might be an alternative to conventional open surgery. This study aimed to investigate whether addition of gentamicin to fibrin adhesive can augment current surgical methods. Having established a fistula, the defect was closed using the following: simple suturing, suturing covered with fibrin sealant only, or suturing with fibrin sealant mixed with gentamicin. Bursting pressure and macroscopic and microscopic examination were evaluated on the second and sixth day after surgery. The study demonstrated there was no significant difference in overall outcome between the 3 groups. However, on macroscopic examination, the mixture of antibiotic and fibrin adhesive decreased formation of adhesions and abscesses. Microscopically, there was decreased inflammation, improved granulation, and earlier onset of fibrin filament deposition, possibly leading to enhanced wound healing. The addition of gentamicin to fibrin sealant can be a useful adjunct to standard surgical closure in duodenal fistula management.

Salvage repair of anastomotic dehiscence following colon surgery using an expanded polytetrafluoroethylene graft

Anastomotic dehiscence is a serious complication of colorectal surgery that causes death in up to 40% of cases in which it occurs. Edema and inflammation due to abdominal sepsis can prevent the use of standard management (i.e., colostomy, ileostomy or Hartmann's procedure), in which case alternative salvage repair methods are required. The present report describes the treatment of a 73-year-old female patient at high risk of mortality because of intraabdominal sepsis due to suture dehiscence following a right hemicolectomy and ileo-transversostomy. Several surgical repair procedures were tried, but all failed. We then used an expanded polytetrafluoroethylene (ePTFE) graft in salvage repair, and this approach proved successful. This is the first report to describe clinical, macroscopic and histopathological findings, following use of an ePTFE graft in colorectal repair in humans.

Bioprosthetic repair of complex duodenal injury in a porcine model

BACKGROUND

Complex duodenal injury remains a challenging problem for the trauma surgeon. Although primary repair of small injuries is often possible, extensive damage requires complex enteric reconstruction and drainage procedures. We sought to determine the efficacy of a bioprosthetic repair for large duodenal wounds in a porcine model.

METHODS

A 60% circumferential wall defect in the second portion of the duodenum was created in eight female Yorkshire swine (38 kg +/- 5 kg). After 30 minutes of peritoneal soilage, a bioprosthetic repair using 1.5 mm porcine acellular dermal matrix was performed. Animals were recovered and resumed a normal diet on day 3. Repeat abdominal exploration and anastomotic bursting pressure strength was performed at 1-, 2-, 3-, and 6-week intervals. Pathologic analysis of all specimens was performed.

RESULTS

All animals tolerated a normal diet postoperatively, with progressive weight gain and normal bowel function. On re-exploration, no animal had evidence of duodenal stenosis, proximal dilation, or abscess formation. Pathologic analysis demonstrated progressive in-growth of native bowel tissue, with almost complete incorporation at 6 weeks. Mean bursting pressure (202 mm Hg +/- 60 mm Hg) occurred at native bowel, not patch repair site, in three of eight animals.

CONCLUSION

Bioprosthetic repair of enteric wall defects, even in proximity to upper intestinal secretions, allows successful recovery of bowel function and injury repair without extensive anatomic reconstruction. This technique may provide a more conservative approach to the treatment of complex duodenal injuries after trauma.

Biliogastric diversion for the management of high-output duodenal fistula: report of two cases and literature review

High-output duodenal fistula occurs as a result of a duodenal wall defect caused by gastroduodenal surgery, endoscopic sphincterotomy, duodenal injury, and tumors with high morbidity and mortality rate. A new technique for its management is reported along with literature review. This procedure consists of transection of the duodenum 2 cm distally to the pylorus, transection of the common bile duct, and end duodenostomy with or without suturing the duodenal wall defect. The continuity of the alimentary tract is reinstated by an end-to-end duodenojejunostomy, end-to-side choledochojejunostomy, and end-to-side Roux-en-Y jejunojejunostomy, obtaining biliogastric diversion from the duodenum and closure of the fistula. This technique was performed in two patients with excellent results.

The repair of a large duodenal defect by a pedicled gastric seromuscular flap

PURPOSE

The aim was to evaluate the efficacy of a pedicled gastric seromuscular flap for the closure of a large duodenal defect.

METHODS

A large defect of the second duodenal part was repaired by a gastric seromuscular flap. Of 35 rats, 9 rats were euthanized at 2 weeks, 12 rats at 2 months, and 14 rats at 4 months for the histopathological evaluation of the patch and normal duodenum (control) adjacent to the patch.

RESULTS

All rats survived. The patch was completely covered by neomucosa in all of the 4-month rats, and in 8 of the 12 2-month rats. The villous height of the neomucosa was significantly higher in the 4-month rats in comparison to the other rats (P < 0.001). However, a normal duodenum had higher villi than in that of the patches (P < 0.001). The crypt density of the neomucosa was significantly increased in the 4-month rats in comparison to the 2-week and the 2-month rats (P < 0.001 and P < 0.05 group, respectively). The crypt density was higher in the controls than in the neomucosa covered patch of the 2-week and the 2-month rats (P < 0.001 and P < 0.05, respectively). The crypt depth of the neomucosa increased significantly in the 4-month rats and in the controls versus the 2-week rats (P < 0.05).

CONCLUSION

The new mucosal barrier overlaying the patch appeared to be satisfactory. This technique, which has not been described previously, is likely to be useful for the repair of the large duodenal defect.

A novel method of dealing with a large rectal enterotomy in an irradiated pelvis

Pelvic irradiation as part of adjuvant therapy for rectal cancer is frought with many complications. We describe the case of a young man who presented with frequent intestinal obstruction after resection and radiotherapy for a low rectal cancer. Subsequent laparotomy and adhesiolysis resulted in a large defect at the previous anastomotic site. A loop of sigmoid colon was used to cover the pelvic brim in an effort to preserve the sphincter and intestinal continuity.

Repairing large duodenal injuries in dogs by expanded polytetrafluoroethylene patch

BACKGROUND

One of the most challenging problems in clinical surgery is management of injured duodenum. In this experimental study, we treated large duodenal defects by an expanded polytetrafluoroethylene (ePTFE, Gore-Tex; W.L. Gore, Elkton, MD) soft-tissue patch and compared it with the jejunal serosal patch.

MATERIALS AND METHODS

A duodenal defect (about 50% of the total circumference) was created in the second portion of the duodenum in 20 dogs. The effectiveness and gross and histological examinations of the ePTFE patch technique was compared with the jejunal serosal patch.

RESULTS

No significant difference was found in early survival rates (90.9% versus 88.9%; P = 0.711). The whole grafted area was covered by neomucosa at the end of the sixth week in all animals with the ePTFE patch. The scar was small; no significant narrowing of lumen was noted and serosal healing was uniformly complete. In histological examination, complete coverage of the ePTFE grafts by neomucosa consisting of columnar epithelium with short villous formations was observed.

CONCLUSION

Use of the ePTFE patch method is easy, reliable, and comparable to the jejunal serosal patch. It can be used in the treatment of large duodenal defects, which cannot be repaired by duodenorraphy.

Experimental Evaluation of Ileal Patch in Delayed Primary Repair of Penetrating Colon Injuries: An Animal Study

Primary repair of traumatic colonic perforation is progressively gaining acceptance as the best method of management. However, when delayed, the risk of infection-related complications may increase. Here, we present a new method of repairing colon perforation in the presence of peritonitis. Acute colon injury was simulated in 22 German shepherd dogs. The dogs were randomly divided into two groups of 11 and after 24 hours they were operated on. The perforations were repaired by subserosal suture technique. In the first group (group A), ileal patch was used. In the other group (group B), the colon was closed by debridement and anastomosis. After 6 weeks, the repairs were assessed on the basis of survival, gross and histological assessments. Nine (82%) dogs in group A and six (56%) in group B survived. Ileal patch utilization significantly decreased the mortality rate (p < 0.05). The cause of death in two group A dogs and five group B dogs was peritonitis and intra-abdominal abscess formation. None of the surviving dogs showed evidence of anastomotic leakage or breakdown. Small bowel patch used in primary repair of colon injury in the presence of peritonitis may decrease the risk of postoperative infection-related complications and the mortality rate.

[Porcine submucosa graft for the treatment of duodenal injuries in dogs]

PURPOSE

To evaluate the biocompatibility and effectiveness of porcine SIS (small intestinal submucosa), when used as a patch to repair a defect on the anterior duodenal wall.

METHODS

The experimental study was performed in 8 dogs. A segment of the anterior duodenal wall was removed and the defect was repaired with a patch of porcine intestinal submucosa. On the 120th post operative day the animals were sacrificed and the segment of duodenum containing the patch was removed to a macroscopic and microscopic evaluation.

RESULTS

There was no infection, suture dehiscence or fistula. The microscopic evaluation showed complete re-epithelization in 75% of the cases, with moderate fibroblastic proliferation in 87.5% of the cases.

CONCLUSION

The porcine SIS used as a patch acts as a tissue substitute for repairing induced lesions in duodenal wall of dogs.

Repair of full-thickness defects in alimentary tract wall with patches of expanded polytetrafluoroethylene

OBJECTIVES

To test the efficacy of patches of expanded polytetrafluoroethylene (ePTFE) for the repair of full-thickness defects in alimentary tract wall.

SUMMARY BACKGROUND DATA

A recent report of successful replacement of duodenal wall with patches of ePTFE was met with skepticism and clearly warranted confirmation as well as evaluation in repair of other segments of the abdominal intestinal tract.

METHODS

Defects of 4 cm2 were created in various segments of canine abdominal alimentary tract (stomach, duodenum, small bowel, and colon) as well as in bladder dome. For the duodenum in 13 dogs, three different ePTFE fabrications were used: CVX (cardiovascular), PDX (preclude dura membrane), and DLM (dual mesh plus). In repair of the other areas in six dogs, the PDX patch was used. When the animals were killed, both gross inspection of the parietes and tissue for histologic study became the basis for evaluation. Peritoneal and intraluminal cultures of the specific study viscera were also taken.

RESULTS

There were no patch failures. Only six significant adhesions were noted in 3 of the 19 dogs. Serosal surface healing was complete without exception by 1 week in all animals. Patches of CVX and PDX had heaping mucosa at the margin of well-sealed patch edges in the study involving duodenum. However, the DLM patch had an undergrowth of mucosa with partial patch separation by 1 week, beginning patch extrusion into gut lumen at 3 weeks, and total separation of patch with complete mucosal repair at 6 weeks. The fate of the PDX patches at 6 weeks in stomach, small bowel, colon, and bladder was identical to what had been observed for the PDX patch in the duodenum. All peritoneal and bladder cultures had no growth, whereas the contents of the alimentary tract grew expected flora.

CONCLUSIONS

These observations suggest that ePTFE may well be an acceptable membrane for at least temporary replacement of full-thickness hollow viscus defects, even in the face of heavy bacterial contamination, and that certain structural configurations of ePTFE may provide a base for increasing absorptive mucosal surface area.