27
REVISTA ESPAÑOLA DE INVESTIGACIONES QUIRURGICAS
Spanish Jou nal o Su gical Resea ch
Vol. XIV nº:1 (27-32) 2011
TRABAJOS
ORIGINALES
ABSTRACT
B
ACKGROUND AND AIMS
.
The p esen esea ch p ojec has been made mainly wi h he idea o compa ing he ensile s eng h
alues and his ological answe s o h ee ypes o colon ana omises: su u ed wi h silk and su u eless anas omoses wi h 2-oc yl-
cyanoc yla e and N-bu yl-2-cyanoac yla e.
M
ETHODS
.
112 Wis a a s dis ibu ed in o h ee g oups o 35 animals and a las con ol g oup o 7 ha e been used o his.
G oup 1: silk, g oup 2: 2-oc yl-cyanoc yla e, g oup 3: N-bu yl-2-cyanoac yla e, g oup 4: Con ol g oup. The ollowing su -
gical in e en ions we e p ac iced on hem: A c oss sec ion o he colon, ollowed by: g oup 1: an end- o-end discon inuous
su u e anas omoses wi h Silk; g oup 2: su u eless anas omoses wi h 2-oc yl-cyanoc yla e; g oup 3: su u eless anas omoses
wi h N-bu yl-2-cyanoac yla e. On he 10 h, 20 h, 30 h, 40 h and 50 h days we p oceeded o measu e he anas omoses' en-
sile s eng h alue o each se ies. In he same pe iod o ime we ca ied ou he ollowing ana omic-pa hological de e mina-
ions: a) sha p in lamma ion; b) oedema; c) non-speci ic ch onic in lamma o y in il a e; d) g anuloma ous in lamma o y
in il a e o o eign bodies; e) ib osis.
R
ESULTS
.
The esul s ob ained indica e a g ea e anas omoses' ensile s eng h o g oup 2 and 3. The ana omic-pa hologi-
cal alues show a be e esponse o anas omoses wi h adhesi es han wi h con en ional su u es.
C
ONCL USI ONS
.
All hese expe imen al esul s lead us o conclude ha he cyanoc ila es used o ca y ou su u eless anas o-
moses may be an al e na i e o he handmade con en ional anas omoses. Mo eo e hey a e easy o be implemen ed.
SUTURELESS COLIC ANASTOMOSES
WITH CYANOACRYLATES.
Sánchez-Ma amo os Ma ín I, Capi án Mo ales LC, Sánchez-Ma amo os Ma ín MD,
Ca olina Cas ellanos, O ega Be iá J, Oli a Mompeán F.
Gene al and Diges i e Su ge y Se ice. Clinical Managemen Uni . Colop oc ology Uni .
Uni e si a y Hospi al “ Vi gen Maca ena”. Se ille. Spain.
KEYWORDS
Su u eless colic anas omoses. 2-oc yl-cyanoc yla e.
N-bu il-cyanoc yla e. Cyanoc yla es.
ABREVI ATI ONS
NB2C: N-bu yl-2-cyanoc yla e. 2OC: 2-oc yl-cyanoc ila e.
AI: Acu e in lamma ion. CUII: Ch onic unspeci ied in lamma o y in il a e.
CGII: Fo eign body g anuloma ous in lamma o y in il a e.
Ede: Oedema. Fi: Fib osis.
Co espondence:
P o . LUIS CRISTÓBAL CAPITÁN MORALES
A da. Edua do Da o, 40, 4º B-2.
41005 -Se ille. Spain.
E-mail: lcapi [email protected]
INTRODUCTION
Anas omo ic dehiscence a e s ill he mos impo an cause
o mo bidi y and mo ali y in colo ec al esec ions. Nowadays,
anas omo ic dehiscence complica ions ollowing a su gical
p ocedu e a e loca ed be ween 0.1 and 30%
1-4
. When he wo
cu ends o he bowel a e su u ed oge he he healing begins
wi h an in lamma o y eac ion ha p o okes he eplacemen
o damaged cells by kni ing o g anula ion and ib oblas s
and la e on by he deposi o conjunc i e kni ing ha equi-
es econs uc ing he in es inal wall. The healing o he colon
s a s wi h a a ying le el o collagen in he submucous laye ,
whe e i s concen a ion is he highes . The mos c i ical pe iod
o he healing is he i s 3-5 days. Du ing his ime he e is an
in asion o he colon anas omoses by placke s, mac ophages,
g anules and ib oblas s. This in asion leads o an inc ease in
he collagenolysis and a dec ease in he collagen ac i i y,
which in e s ha he colic anas omoses will be mainly held
oge he by he uni ing su u e.
The complica ions o anas omoses leakage a e in ec ion
and sep icaemia consecu i e o pe i oneal o e ope i oneal
con amina ion due o he aecal con en
5
.
Di e en echniques ha e been de eloped o es o e he
diges i e con inui y in hose cases whe e i is necessa y o
esec he colon and pe o m anas omoses. The expe imen al
possibili y o con ec su u eless colic anas omoses has been
es ablished
6
. This s udy has been ca ied ou wi h he aim o
compa ing he esis ance and his ological esponses o h ee
ypes o colonic anas omoses: su u es wi h Silk 5/0 and su u e-
less anas omoses wi h N-bu yl-2-cyanoac yla e and 2-oc yl-
cyanoc ila e.
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Spanish Jou nal o Su gical Resea ch
28 SÁNCHEZ-MATAMOROS MARTÍN I
N-bu yl-2-cyanoac yla e and 2-oc yl-cyanoc yla e was
de eloped in he se en ies and was he i s ’s adhesi es o
ha e insigni ican issula oxici y and good closing s eng h. I
has been widely used in Eu ope because o i s bac e ios a ic
powe and minimum issula oxici y in: bone and ca ilage
unions, medium ea su ge y, co neal ulce s, emboliza ion o
gas oin es inal a ix, neu o ascula su ge y and closu e o
supe icial wounds
7-11
.
The aim is o e i y whe he su u eless anas omoses using
cyanoac yla es a e use ul in expe imen al animals in e ms o
ensile s eng h and cica isa ion o he anas omoses as i
shows biological ole ance, app aised in deg ees o his ologi-
cal in lamma ion and cica isa ion in li e in es inal issue.
MATERIALS AND METHODS
M ATERIAL
1. Animals. 112 whi e emale Wis a a s wi h an a e age
weigh o 200 g. we e used unde he ollowing expe imen al
condi ions: App oxima e empe a u e 21°C, ci cadian hy hm,
40 o 60% humidi y and nu i ion wi h special odde o a s.
The animals we e kep on a as 24 hou s be o e he ope a-
ion, wi h access o wa e " ad libi um" . 24 hou s a e su ge y
he habi ual alimen a ion o he a s was con inued.
The Wis a a s we e dis ibu ed in o h ee g oups o 35
animals and a con ol g oup o 7. Each g oup, in i s u n, was
subdi ided in o i e se ies o 7 animals depending on he ime
hey we e going o be sac i iced pos ope a i ely (10, 20, 30, 40
and 50 days).
G oup 1.- 35 animals. Anas omoses wi h Silk. G oup 2.- 35
animals. Anas omoses wi h N-bu yl-2-cyanoac yla e. G oup 3.-
35 animals. Anas omoses wi h 2-oc yl-cyanoc ila e. G oup 4.-
Con ol g oup. 7 animals.
The esis ance o ensile s eng h (measu ed wi h an
ex ensome e ) and he ollowing ana omopa hological de e -
mina ions we e s udied in each se ies: ch onic and acu e
in lamma ion (unspeci ied and o eign body ype g anuloma-
ous), oedema and ib osis.
2. Anas omoses ma e ial. Th ee ypes o ma e ials we e
employed: Silk (S), N-bu yl-2-cyanoc yla e (NB2C) and 2-oc yl-
cyanoc yla e (2OC).
3. Measu ing appa a us o esis ance. A se o ou ex en-
siome ic gages a anged in a Whea s one b idge s uc u e,
lodged on a lexible me al s ap has been used. The gages a e
ixed on o he s ap wi h an adhesi e which p o ides solidi i-
ca ion by polyme iza ion and is a anged in such a way ha
he compensa ion o he sec ion, o which Poisson’s p inciple
e e s, is ob ained. The eade in ol s in he measu e is con-
e ed, by means o a con e sion ac o , in o Kilog ams-
s eng h and co esponds o he ac ion o ce ha is applied
in he es . The ci cui is equipped wi h a ze o-se ing sys em
which pe mi s balance on he b idge o la e es s.
M ETHODS
1. Anaes he ic me hods. The animals we e anaes he ized
by means o in ape i oneal injec ion o Ke amine, 0.2 cc dosis
pe 100 g . o weigh .
2. Su gical me hods.
a) G oup wi h Silk. A e pe o ming a medium lapa o-
omy, he in es inal loops we e e ealed and once he colon
was loca ed a ans e sal sec ion was ca ied ou ollowed by
i s e minal-end anas omoses wi h discon inuous su u e wi h
silk 5/0. The abdominal wall was closed wi h silk 2/0, in con i-
nuous su u e in pe i oneum block and aponeu osis and skin
sepa a ely.
b) G oup wi h NB2C. A e pe o ming he ans e sal
sec ion o he colon, h ee loose s i ches wi h Polyglicolic Acid
we e applied o iangle and app oxima e he sec ion ends,
applying NB2C on he h ee lines which cons i u e he union
o he ex emi ies. A comple e closu e o he union was ob ai-
ned in his way.
c) G oup wi h 2OC. We p oceeded in a simila way o he
p e ious g oup, al hough 2OC was used (Figu e 1).
3. Me hod o ob ain samples and measu emen o ensile
s eng h o su u es. Employing he same anaes he ical me -
hod as in he ope a ions, once he a was sac i iced on he
co esponding pos ope a i e day and p ope ly ixed o he
wo kbench, we p oceeded o emo e he co esponding
egion o he in es inal anas omoses. One cen ime e, ma ked
by wo ine hypode mic needles, was measu ed wi h a p eci-
sion mic ome e , lea ing he anas omoses jus in he middle,
and a e i s sec ion, i was placed be ween wo suppo s on
he esis ance measu e , ixing i wi h wo se a ed clamps.
The appa a us was s a ed un il he anas omoses b oke; he
e e ed alue in he ol me e is he ensile s eng h o esis-
ance exp essed in g ams/cen ime es, gi en ha he agmen
o anas omoses measu ed exac ly one cen ime e.
We p oceeded he same way in he con ol g oup, ex ac-
ing one cen ime e o he descending colon wi hou p e ious
in e en ion, which allowed us o ob ain he ensile s eng h
o a no mal colon.
4. Ana omopa hological me hod. The anas omo ic egion
o he sample used a e measu ing esis ance was ixed in
amponed o mol a 10%.
Wi h he objec o s udying he exis ence o no o acu e
in lamma ion (AI), ch onic unspeci ied in lamma o y in il a e
(CUII) and o eign body ype g anuloma ous in lamma o y
in il a e (CGII), oedema (Ede) and ib osis (Fi), he 3 µ hick
his ological c oss sec ions we e p ocessed in pa a in and s ai-
ned wi h Hemo oxiline-Eosine.
Figu e 1.- Applica ion o 2-oc yl-cyanoac ila e.
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SUTURELESS COLIC ANASTOMOSES WITH CYANOACRYLATES
5. S a is ical me hods. The pa ame ic ANOVA Tes was
pe o med o a ensile s eng h ac o and he T o S uden
Tes o a sample o compa e wi h no mal colon.
In he case o ob aining a non-no mal a iable, such as he
ana omopa hological, he compa ison was ca ied ou by means
o he K uskal-Wallis Tes . On he o he hand, he mul iple com-
pa isons we e pe o med by means o he U o Mann-Whi ney
educing he global signi icance le el om · o 0.005 so as o be
able o main ain a global signi icance le el o = 0.05.
The dicho omic a iables (obs uc ion/non obs uc ion)
we e compa ed wi h he Chi-squa ed Tes in he causes o
mo ali y.
6. Mo ali y s udies. All he animals o each g oup, acco -
ding o he days elapsed om he ope a ion o he aking o
esis ance measu emen s, we e obse ed, no ing he numbe
o dea hs o de e mine su i al.
RESULTS
1.- Tensile s eng h. The a i hme ical mean (g /cm) and
he ypical de ia ion o he alues ob ained o he di e en
g oups we e calcula ed, wi h he esul s ha show hemsel es
in he Tables I and Figu e 2.
I has been e i ied ha he ensile s eng h alue in he
echnically con en ional g oups as well as in he su u eless
anas omosis g oups inc eased p og essi ely in ime om 10 o
50 days.
2.- Ana om opa hological esul s. The alues o he ele-
men s s udied ha e been exp essed h ough a scale o 0 o 3
and he a i hme ical mean has been ound. (Figu e 3)
2.1.- Silk g oup (Table II).
In his g oup an acu e in lamma o y componen was
globally obse ed in mos cases, e en in se ies V, some i-
mes, wi h o ma ion o au hen ic pe ianas omo ic absces-
ses. The ch onic in lamma o y eac ion was seen in e e y
se ies.
The su u e ma e ial caused a o eign body ype g anu-
loma ous eac ion in e e y case, mo e e iden in se ies II,
IV and V.
Table I
1.1. Colic anas om oses w i h Silk.
Se ies I Se ies II Se ies III Se ies IV Se ies V
Mean 248.9 345.6 304 407.7 436.5
Typical de ia ion 2 15 36.5 16.5 12.5
1.2. - Colic anas om oses w i h N-bu yl-2-cyanoac ila e.
Se ies I Se ies II Se ies III Se ies IV Se ies V
Mean 410.14 491.33 543.3 552 549.14
Typical de ia ion 38.62 59.28 68.38 38.68 33.06
1.3. - Colic anas om oses w i h 2-oc yl-cyanoc ila e.
Se ies I Se ies II Se ies III Se ies IV Se ies V
Mean 516.2 519.4 530.16 568.28 572.28
Typical de ia ion 41.96 80.15 64.76 27.30 29
1.4. - Con ol g oup. The m ean w as 541.1 g /cm ( ypical de ia ion 2.6)
Table II
ANATOMOPATHOLOGICAL RESULTS. SILK GROUP.
AI Ede UCII CGII Fi
Se ies I 1.43 0.57 0.86 1.43 1.14
Se ies II 1.16 0.17 0.83 1.83 1.17
Se ies III 1.16 0.17 1.17 1.50 1.00
Se ies IV 1.67 0.17 1.33 1.83 1.67
Se ies V 1.83 0.00 1.17 1.67 1.83
Figu e 2.- Resul s o ensile s eng h.
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30 SÁNCHEZ-MATAMOROS MARTÍN I
Inso a as he o ma ion o connec i e issue we obse -
ed ha i inc eased as he pos ope a i e ime did.
2.2.- N-bu yl-2-cyanoac yla e g oup (Table III).
The acu e in lamma o y eac ion was ele an in he
i s se ies.
Al hough he unspeci ied ch onic in lamma o y eac-
ion exis ed i was no e y impo an ; howe e he ch o-
nic g anuloma ous was.
2.3.- 2-oc yl-cyanoc yla e g oup (Table IV)
3.- Mo ali y s udy. (Table V)
I has been e i ied ha he h ee g oups showed a o al
mo ali y o 12.38 % which oscilla ed be ween 11.42% o S
and NB2C g oups and 14.28% o 2OC g oup du ing he obse -
a ion pe iod. In he ollowing able he o al numbe o
dea hs and he causes o each animal in each g oup.
Figu e 3.-
Anas omoses wi h 2-oc yl-cyanoac yla e
( ig 2.a.) and wi h N-Bu yl-cyanoac yla e
( ig 2.b.) in 50 days ime.
Fig 2.a (H.E.x10) Fig 2.b (H.E.x10)
Table III
ANATOMOPATHOLOGICAL RESULTS.
N-BUTYL-2-CYANOACRYLATE GROUP.
AI Ede UCII CGII Fi
Se ies I 2.14 0.00 1,14 1.42 0.00
Se ies II 1.00 0.00 1.00 2.00 0.60
Se ies III 0.83 0.00 1.16 1.66 1.33
Se ies IV 0.00 0.00 2.00 1.80 0.16
Se ies V 0.16 0.00 1.33 1.66 0.50
Table IV
ANATOMOPATHOLOGICAL RESULTS.
2.3. 2-OCTYL-CYANOCRYLATE GROUP.
AI Ede UCII CGII Fi
Se ies I 2.20 0.00 1,00 1.40 0.60
Se ies II 2.00 0.00 1.80 2.00 0.20
Se ies III 1.50 0.00 1.30 2.00 0.33
Se ies IV 1.71 0.00 1.28 2.28 0.24
Se ies V 1.00 0.00 1.28 0.28 0.00
Table V
MORTALITY STUDY
To al numbe Causes Numbe o
o dea hs dea hs
Immedia e pos ope a i e 2
Colic anas omoses wi h Silk 5/0 4 Wall dehiscence 1
Sepsis due o abscess in abdominal wall 1
Colic anas omosis wi h NB2C 4 Anas omo ic leakage 1
In es inal obs uc ion 3
Colic anas omosis wi h 2OC 5 Anas omo ic leakage 2
In es inal obs uc ion 3
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SUTURELESS COLIC ANASTOMOSES WITH CYANOACRYLATES
DISCUSSION
In his expe imen al s udy we ha e endea ou ed o e i y
he e iciency o N-bu yl-2-cyanoac yla e and 2-oc yl-cyanoc y-
la e used as su u eless colonic anas omoses as opposed o con-
en ional echnique wi h Silk 5/0 in a s. We s udied he ensi-
le s eng h he su u es a e able o suppo and he ana omo-
pa hological epe cussions ela ing o cica isa ion such as
acu e in lamma ion, oedema, unspeci ied ch onic in lamma-
o y in il a e and o eign body ype g anuloma ous, and
anas omo ic ib osis.
Inso a as he ensile s eng h, i has been e i ied ha in
any o he g oups whe he hey a e con en ional echnique o
su u eless anas omosis hei alue inc eases p og essi ely in
ime om 10 o 50 days. NB2C and 2OC show a much g ea e
ensile s eng h han he o he g oup (S) as om 10 days wi h
clea s a is ically signi ican di e ences wi h hem; NB2C each
he no mal colon mean a 30 days and 2OC each he no mal
colon mean a 40 days. Signi ican s a is ical di e ences a e
only ound a 10 days be ween bo h cyanoac yla e .
Ki kegaa d
12
ca ied ou a compa a i e s udy be ween
su u ed colonic anas omoses o hose pe o med wi h iso-
bu ylcyanoac yla e in a s, concluding ha he e a e no signi-
ican di e ences be ween ei he ensile s eng h; some hing
which con as s o ou esul s, pe haps due o a cyanoac yla e
es e wi h di e en alcohol in i s s uc u e.
As ega ds o he ana omopa hological s udy, beginning
wi h he acu e in lamma o y eac ion, he 2OC g oup ob ai-
ned he highes alues.
Fa ías-Llamas e al
13
in a s udy ealized wi h 2-oc il-ciano-
ac ila e, N-2-bu il-cianoac ila e and ib inogen in a es, con-
cluded ha an inc ease exis s in he bu s ing p essu e in he
g oups ea ed wi h ib inogen, which exp essed inc ease o
he ensile s eng h o he anas omosis and ha p essu es
we e simila on ha ing ea ed he anas omosis wi h any o
he syn he ic adhesi es.
Inso a as N-bu yl-2-cyanoac yla e is conce ned, he e is a
signi ican s a is ical di e ence a 40 and 50 days when com-
pa ed o S g oup, he acu e in lamma o y eac ion being less
in he o me . In he s a is ical s udy hey did no ind signi i-
can di e ences o bo h ypes o cianoac yla es.
Acco ding o he p e ious esul s, we can e u e he con-
clusion es ablished by Nash and Bellege
14
in hei s udy on ca
in es ine using con en ional su u e and N-bu yl-2-cyanoac yla-
e, which a i ms hey ob ain a g ea e in lamma ion a 7 days
in su u es han in adhesi e, al hough he in lamma ion pe sis-
ed a 28 days in he la e as opposed o wha happened in
su u es.
We ha e no ob ained s a is ically signi ican di e ences
in he g oup o he 2-oc yl-cyanoc yla e in he alues o sha p
in lamma ion o wi h any o he o he se ies o ou enclosed
s udy in he compa ison wi h he N-bu yl-2-cyanoac yla e.
Ma e a
15
e eals he g ea in lamma o y and g anuloma-
ous eac ion o anas omoses pe o med wi h cyanoac yla e in
a s udy wi h dogs.
Oedema did no appea in he g oup ea ed wi h 2OC
and NB2C. I appea ed in S g oup, al hough i diminished un il
disappea ing a 50 days, wi hou any signi ican di e ences
among he esul s a di e en pe iods o ime.
The unspeci ied ch onic in lamma o y in il a e (U.C.I.I.) in
all g oups and a all imes was e iden , ob aining he lowes
alues o S. Excep o his las echnique, he e is a clea
inc ease in said ana omopa hological pa ame e in ime, i he
esul s a 10 and 50 days a e compa ed. As ega ds o he s a-
is ical s udy, no signi ican s a is ical di e ences amongs he
di e en g oups ha e been ound.
G anuloma ous ch onic in lamma o y in il a e o o eign
body ype (G.C.I.I.) was obse ed in all he g oups.
The esul s we e a i ied by pape s such as Ma e a
15
and
Oli e
16
who a i m ha cyanoac yla es ac as o eign bodies.
Inso a as N-bu yl-2-cyanoac yla e and 2-oc yl-cyanoc yla-
e we did no ga he signi ican di e ences wi h S g oup and
nei he o bo h ypes o cianoac yla es.
Wi h espec o he ib osis pa ame e , i was obse ed
how he cica ices became mo e and mo e compac in all
g oups om 10 o 50 days, i.e. he alue o said pa ame e
inc eases; his eaches i s minimum alues in he case o 2-
oc yl-cyanoac yla e.
I has been e i ied how he h ee g oups showed a o al
mo ali y a e o 12.38% which oscilla ed be ween 11.42% o
S and NB2C g oups and 14.28% o he 2OC g oup du ing he
obse a ion pe iod. Acco ding o he esul s i can be obse -
ed how he cause o g ea e mo ali y is cons i u ed by he
in es inal obs uc ion which ook place in anas omoses pe -
o med wi h he adhesi e bu did no appea in hose wi h
con en ional su u e; ha is why i is hough ha as he o -
me ha e a g ea e endency o o m adhe ences, hese could
be he cause o he obs uc ion.
The s a is ical s udy aking as a dicho omic a iable obs-
uc ion/ non obs uc ion and he h ee independen echni-
ques did no show signi ican s a is ical di e ences. On he
o he hand, g ouping he echniques in o con en ional and
adhesi es, signi ican s a is ical di e ences did appea .
The e o e, we can a i m ha he adhesi es used as an al e -
na i e o con en ional su u e in colon anas omoses a e mo e
inclined o he o ma ion o adhe ences and, as a consequen-
ce, o he o ma ion o in es inal obs uc ion han su u es.
A he sigh o he esul s, i is hough ha cyanoac yla-
es can be used as an al e na i e o con en ional manual anas-
omoses o con ec a su u eless anas omoses om he expe i-
men al poin o iew.
Acknow ledgemen : This wo k was suppo ed by he
Conseje ía de Salud de la Jun a de Andalucía and he
Asociación Sani a ia Vi gen Maca ena de Se illa.
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