- Citado por SciELO
versión impresa ISSN 1130-0108
Rev. esp. enferm. dig. vol.96 no.2 feb. 2004
A new neovalve type in short bowel syndrome surgery
M. Zurita, J. M. Raurich1, A. Ramírez2, J. Gil2 and J. Darder3
Department of General and Gastrointestinal Surgery. 1Unit of Intensive Care. 2Service of Microbiology. 3Service of
Anesthesiology. Hospital Universitario Son Dureta. Palma de Mallorca, Islas Baleares. Spain
The objective of this study was to compare the clinical and analytical repercussion of a new type of intestinal valve -which can be used in both massive resections and right hemicolectomies requiring the elimination of the ileocecal valve- on two historical series of patients: one group with ileocolic resections and end-to-end anastomoses (EE), and one group with Ricotta valves.
We compared 23 patients with ileocolic resection and end-to-end anastomosis, 15 with Ricotta's valve, and 20 patients with a new valve made with a small intestinal invagination. There were no statistically significant differences in baseline characteristics among patients. Patients with the new valve showed less relevant weight loss and fewer stools at 3 months and one year when compared to patients with Ricotta's valve, and particularly those with ileocolic resection. Moreover, with the new valve technique there was neither colonization of the ileal mucosa nor bacterial overgrowth.
In conclusion, in massive intestinal resections and right hemicolectomies, including the ileocecal valve, the new valve technique would be of choice.
Key words: Short bowel syndrome. Ileocecal valve. Bacterial translocation.
Zurita M, Raurich JM, Ramírez A, Gil J, Darder J. A new neovalve type in short bowel syndrome surgery. Rev Esp Enferm Dig 2004; 96: 110-118.
Correspondencia: Manuel Zurita y Romero. C/ San Roque, 9-3º izda. Tel.: 971 715 293. 07001 Palma de Mallorca. Baleares.
Short bowel syndrome (SBS) includes all pathophysiological symptoms and disorders triggered after massive intestinal resection (MIR), which may include all or a part of the colon. Most frequent causes include mesenteric infarction, Crohn's disease, regional enteritis, trauma, and tumors (1). The main clinical manifestations of SBS are diarrhea, weight loss, and malnutrition due to malabsorption, particularly when the preservation of the terminal ileum and ileocecal valve is rendered impossible.
Different surgical techniques have been applied to reduce the clinical manifestations of SBS, one of them being the formation of valves. With new valve surgical techniques, from a functional point of view we attempt to: a) reduce retrograde bacterial contamination (RBC); b) reduce bacterial overgrowth (BOG), and avoid possible bacterial translocation; c) decrease malabsorption and diarrhea; d) increase time of intestinal transit and absorption; e) reduce hyperoxaluria and the incidence of renal and bladder lithiasis; f) reduce weight loss; and g) provide an improved quality of life for the patient. Although clinical experience in the formation of new valves in SBS is limited, good results have been described (2-5).
AIMS OF THE STUDY
To compare the clinical and analytical repercussion of a new type of valve -which may be used in both MIR and right hemicolectomies requiring the elimination of the ileocecal valve- on two historical series of patients: one group with ileocolic resection and end-to-end anastomosis (EE), and the other with Ricotta's valve.
MATERIAL AND METHODS
Description of the new valve technique by jejunal and/or ileocolic invagination
The application of this new surgical technique to human pathology was carried out after experimental verification in adult dogs. After performing a medial laparotomy in patients, bowel areas to be resected were chosen and excised using an electric scalpel. Subsequently, 3-4 locking sutures were placed 1 cm away from the edge of the small intestine with a double-arm suture, and placed on the mesenteric, antimesenteric and side edges. These are passed 1 by 1 through the colon lumen and brought out in an anatomical situation similar to that corresponding to them in the small intestine. The small intestine invagination in the colon lumen (8 cm) is facilitated by the hand and the soft traction of the 3-4 locking sutures; subsequently, after checking there were no intestinal twists, the locking sutures were tied onto the serosa of the colon. We then carried out a circumferential crown of loose stitches with non-reabsorbable 3-0 material between the sectioned edge of the colon and the small intestine; once finished, we proceeded to take out the locking sutures, which allowed for an evagination of the invaginated small intestine in a slow but progressive way, which will virtually reach the colo-intestinal suture. Finally, we proceeded to close the meso-colic breach, placed a Penrose-type drainage, and closed the laparotomy (Fig. A, 1-5).
Patients were divided into 3 groups according to surgical technique as applied in successive periods of time: a) ileocolic EE group: surgical procedure consisted of an ileo-transversotomy with EE anastomosis after intestinal resection, performed between 1975 and 1983; b) Ricotta group: application of a Ricotta's valve after intestinal resection, performed between 1984 and 1994; and c) new valve group: application of an ileal invagination in the colon lumen to form a new valve after intestinal resection, carried out throughout the period 1995-2000.
Ileocolic EE. This was performed in 23 patients with a mean age of 68 years (64-73), and a male-female ratio of 12:11. Twenty right colon cancers, 2 mesenteric ischemias, and 1 complicated Crohn's disease were operated on.
Ricotta. This was used in 15 patients with a mean age of 70 years (40-86), with a male-female ratio of 13:2. Two right colon cancers, 11 mesenteric ischemias, 1 complicated Crohn's disease, and 1 ileal lymphoma were operated on.
New valve. This was carried out in 20 patients with a mean age of 70 years (59-83), with a male-female ratio of 12:8. It was performed for 15 right colon cancers, 3 mesenteric ischemias, 1 complicated Crohn's disease, and 1 ileal lymphoma.
Follow up, which was not possible for 3 patients (1 case of ileocolic EE anastomosis caused by mesenteric ischemia stopped attending the surgery; another case with a Ricotta's valve to treat a right-sided colon carcinoma rejected any type of exploration or study because of old age; a third case in which a new valve had been built up moved to a different Autonomous Community), consisted of opaque enema, colonoscopy, and a study of BOG using the hydrogen breath test with glucose at 3, 6 and 12 months after surgery.
Results are expressed as a mean ± s.e.m. Statistical studies were carried out using the ANOVA test.
There were no statistically significant differences between-group regarding baseline weight (Table I). After 3 months there was some weight loss, which was lowest in patients in the group treated with the new valve technique, and highest in the group with the ileocolic EE technique (Table I). After 1 year, patients recovered weight, which was greatest in patients in whom the new valve technique was used and smallest in patients submitted to the ileocolic EE technique (Table I).
The number of postoperative stools after 3 months and 1 year was lowest with the new valve technique and highest with the ileocolic EE technique, and these differences reached statistical significance (Table I).
Serum bile acid (normal range: 0-8.1 µmol/l), ferritin (normal range: 30-400 ng/dl) and zinc (normal range: 80-130 µg/dl) fell after 3 months, with a tendency to return to normal values at 1 year; this fall was most marked for the ileocolic EE technique. Serum copper (normal range: 70-140 µg/dl) showed a rise in baseline value, which was greatest with the ileocolic EE technique (Table I).
When comparing patients who underwent a dilated right hemicolectomy to those who had MIR, the number of stools was lower with the new valve and Ricotta's techniques compared the ileocolic EE technique, and this lower intestinal rhythm was maintained over time (Table II). Between the new valve and the Ricotta's technique differences did not attain statistical significance (Table II).
Barium enemas performed in 17 patients with ileocolic EE anastomosis showed important retrograde filling in the small intestine. Fifteen patients in the new valve group and 10 in the Ricotta group had a continent valve, with neither obstruction nor reflux showing up in barium enema (Fig. A, 6).
Colonoscopies performed in 15 patients in the new valve group, 8 in the Ricotta group, and 9 in the ileocolic EE group showed that all patients with ileocolic EE anastomosis had colonization of the ileal mucosa; there was colonization of lesser intensity in 4 patients submitted to the Ricotta's technique, and absence of ileal colonization with the new valve technique (Fig. B, 1-5 and Fig. B, 6).
The results of BOG studies performed using the hydrogen breath test with glucose were positive in all patients at 3 months, and in 4 patients at 1 year, with the ileocolic EE technique; with the Ricotta's technique they were positive in 2 patients at 3 months, and in no patient at 1 year; with the new valve technique all patients were negative for BOG at 3 and 12 months.
The main results of the comparative study of these three surgical techniques indicate that patients develop lower weight loss, lower frequency of stools, and lower biochemical alterations with the new valve technique, as opposed to the ileocolic EE technique. Likewise, an absence of ileal mucosa colonization and bacterial retrograde contamination may be seen with the new valve technique, in contrast with the ileocolic EE technique.
Surgical techniques that have been used to reduce clinical symptoms in SBS include: a) antiperistaltic bowel (6-8); b) recirculation bowel (9-11); c) retrograde pacemaker (12); d) reduction of caliber and intestinal plication (13,14); e) intestinal myotomy (15,16); f) intestinal bags (17); g) perintestinal rings (18); h) intestinal neomucosa growth (19); i) small bowel transplantation (20); j) reduction of caliber and small bowel enlargement (21); k) sequential enlargament (22); and l) valve formation.
In experimental studies, different types of valves have been used with better survival. The first bibliographic study found is that by Kellog (23) and, based on these works, Ricotta (24) in 1981 -after carrying out an emergency operation in a child with MIR- performed a nipple type jejunum-colic intubation, 8 cm in length, on 2 planes. Subsequently he performed an experimental study in dogs with a valve, and saw its braking effects. After experimental and clinical verifications, we may now point out that a reestablishment of intestinal transit was simple with hardly any morbidity or mortality, and this invagination may be compared to an ileal valve. When the ileal mucosa evaginates, it comes into contact with the colon mucosa until it reaches the level of the external coloileal suture line, thus avoiding the risk of stenosis by coalescence of the edges of the ileal invagination; it is the ileal mucosa that is in contact with the intracolic contents, which is preferable to the serous surface. This ileal evagination allows a restoration of transit after MIR, which makes it useful in SBS. We believe that this new valve is continent, and allows that all goals of the study be attained.
Historical review of the formation of some types of new valves (Table III): a) Kellog (23) tries to repair an incompetent ileocecal valve with an invagination of the terminal ileum in the ascending colon; b) Ricotta (24) sets up an ileocolic new valve in SBS for a child after experimental studies, and in clinical applications found a lower weight loss and the presence of BOG in the residual small intestine; c) Canarelli (2) forms a hemivalve following Ricotta's technique. Transit time is reduced with no occlusions found; d) Ribault (3) carries out a Ricotta's type ileocolic intubation on a colon mucosa hammock in complicated intestinal typhoid diseases. He reports few complications (3% occlusion and fistula, and 15% mortality not attributable to the technique); e) Vayre (25) follows Ribault's technique and modifies the ileal suture by using a TEA and end-to-end anastomosis on a colon mucosa hammock, reinforcing it with Tissucol. There was no evidence of ileal colonization, and the histological study of the anastomosis showed a transition zone similar to an ileocecal valve; f) Blanco (4) carries out a valve by ileocolic intubation with a colon pouch. He observes a decrease in the number of stools; and g) Casal (5) follows Vayre technique using a GIA stapler instead of a TEA, with bilateral stapling of the ileal nipple. He reports increased pressure levels at the valve and absence of colonization.
In conclusion, when faced with the need for intestinal resection including the ileocecal valve, the surgical technique of choice would be our new valve, because of lower weight loss, lower number of stools, lower biochemical alterations, and absence of colonization of the ileal mucosa and bacterial retrograde contamination. The ileo-colic EE resection technique should be avoided whenever possible.
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