Marjanovic Goran, Villain Christian, Juettner Eva, zur Hausen Axel, Hoeppner Jens, Hopt Ulrich Theodor, Drognitz Oliver, Obermaier Robert
Department of General and Digestive Surgery, University of Freiburg, Germany.
Ann Surg. 2009 Feb;249(2):181-5. doi: 10.1097/SLA.0b013e31818b73dc.
Anastomotic insufficiency still remains an unsolved problem in digestive surgery. Little clinical data, regarding the impact of perioperative volume management exist, which suggest lower complication rates in intestinal surgery under restrictive volume regimens. The aim of our study was to investigate the effect of the extent of intraoperative fluid administration with crystalloids on the stability of intestinal anastomoses.
Twenty-one rats were randomly assigned to 3 experimental groups (n = 7 rats/group): control group CO (9 mL kg h crystalloid infusion), volume restriction group V (-) (3 mL kg h), and animals with volume overload V (+) (36 mL kg h). After midline incision, all animals received the corresponding infusion for a 30-minute period. Infusion was continued for further 30 minutes whereas an end-to-end small bowel anastomosis was performed 15 cm proximal to the Bauhin valve with 8 nonabsorbable interrupted inverting sutures. At reoperation on the 4th postoperative day, the anastomotic segment was dissected and the bursting pressure [mmHg] was measured. As a second parameter for the quality of anastomotic healing, hydroxyproline concentration was examined with a spectrophotometric method [microg/g dry tissue]. Histologically, structural changes of the anastomotic segments were assessed by 2 pathologists. Data are given as mean +/- SEM.
Anastomotic insufficiency was not seen in all animals. Bursting pressure of CO animals was 102 +/- 8 mmHg. Bursting pressure was lowest in V (+) with high volume exposure at 77 +/- 6 mmHg and significantly lower than V (-) (112 +/- 9 mmHg; P = 0.01) whereas the difference compared with the CO group did not reach significant values. Hydroxyproline concentration in V (+) (64.4 microg/g dry tissue +/- 7.7) was significantly lower compared with V (-) (91.7 microg/g dry tissue +/- 9.1) animals (P < 0.05). In all animals with volume overload a marked submucosal edema was found.
We could demonstrate for the first time in a systematic investigation, that the quantity of crystalloid infusion, applied intraoperatively, has a significant impact on functional (bursting pressure) and structural (hydroxyproline) stability of intestinal anastomoses in the early postoperative period. Because the stability and quality of an intestinal anastomosis have an impact on insufficiency rates, it should be noted that volume overload may have deleterious effects on anastomotic healing and postoperative complications in digestive surgery, possibly because of a marked bowel wall edema.
吻合口漏仍是消化外科尚未解决的问题。关于围手术期容量管理的影响，临床数据较少，提示在限制性容量方案下肠道手术的并发症发生率较低。本研究的目的是探讨术中晶体液输注量对肠吻合口稳定性的影响。
将21只大鼠随机分为3个实验组（每组n = 7只大鼠）：对照组CO（9 mL·kg⁻¹·h⁻¹晶体液输注）、容量限制组V(-)（3 mL·kg⁻¹·h⁻¹）和容量超负荷组V(+)（36 mL·kg⁻¹·h⁻¹）。经中线切口后，所有动物接受相应输注30分钟。继续输注30分钟，同时在距回盲瓣近端15 cm处用8根不可吸收间断内翻缝合线进行端端小肠吻合。在术后第4天再次手术时，解剖吻合段并测量破裂压力[mmHg]。作为吻合口愈合质量的第二个参数，用分光光度法检测羟脯氨酸浓度[μg/g干组织]。组织学上，由2名病理学家评估吻合段的结构变化。数据以平均值±标准误表示。
并非所有动物都出现吻合口漏。CO组动物的破裂压力为102±8 mmHg。V(+)组在高容量暴露下破裂压力最低，为77±6 mmHg，显著低于V(-)组（112±9 mmHg；P = 0.01），而与CO组相比差异未达到显著水平。V(+)组（64.4 μg/g干组织±7.7）的羟脯氨酸浓度显著低于V(-)组（91.7 μg/g干组织±9.1）动物（P < 0.05）。在所有容量超负荷的动物中均发现明显的黏膜下水肿。
我们在一项系统研究中首次证明，术中应用的晶体液输注量对术后早期肠吻合口的功能（破裂压力）和结构（羟脯氨酸）稳定性有显著影响。由于肠吻合口的稳定性和质量会影响吻合口漏发生率，应注意容量超负荷可能对消化外科的吻合口愈合和术后并发症产生有害影响，可能是由于明显的肠壁水肿。
