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Summary From the time of Hippocrates until the beginning of the eighth decade of the 19th century, the few anastomotic procedures that were performed were primarily for traumatic wounds of the gastrointestinal tract. During this period there emerged one group, the four masters of Salerno and their students, who practiced and taught the art of intestinal surgery. Beginning with the 18th century, there was a slow but progressive increase in the quest for basic knowledge related to all fields of medicine, including that of intestinal anastomotic wound healing. The works of Blegny, Scacher, Ramdohr, Heister, Richerand, Larrey, the Bells, and Cooper laid the foundation for the acceptance of the experimental results of Travers, Jobert, Denans and Lembert. However, despite the results obtained through the experimental surgical procedures of these men at the beginning of the eighth decade of the 19th century, there had been less than 10 documented survivals of stomach and small intestinal approximations and only several hundred survivals from large bowel approximations. Those who survived did so with a gastrocutaneous or enterocutaneous fistula in the immediate postoperative period, although some of the fistulas subsequently closed. Following the introduction of anesthetic agents, resectional surgery became possible. Beginning in 1880, there was a tremendous increase in the performing of and the success with gastrointestinal procedures. From the clinics of Czerny, Gussenbauer, Wolfler, Billroth, Halsted, Bell, Senn and Maunsell, to mention a few, the technics of resectional surgery were established and the basic principles of anastomotic wound healing evaluated. During the 20-year period from 1880 to the turn of the 20th century, there were more significant advances in the field of intestinal surgery, than in any other time to date. Bell, Halsted, Senn, Maunsell, Murphy and others established beyond a doubt that end-to-end intestinal anastomoses healed satisfactorily, whether the approximated bowel wall was inverted or everted, with or without a stent and with or without telescoping. Halsted demonstrated in 1887 that intestinal anastomotic wound healing required only one row of sutures and that each suture of that row must pierce the submucosa layer in order to secure a good union. Sutures through the mucosa, muscularis or serosa had no significant holding power. A second or third row of sutures added no additional strength to the anastomosis. With the beginning of the 20th century, there was a tremendous upsurge in gastrointestinal surgical procedures. Accompanying the increase in anastomotic procedures, there was an increase in the usage of the aseptic anastomotic technic introduced by Parlavecchio in 1893. The closed or aseptic anastomotic technics resulted in a significant anastomotic diaphragm, producing a greater incidence of anastomotic obstruction than had been seen with the open anastomoses. However, for fear of wound infections from the escape of bowel content into the operative field, the closed technics were the dominant until the introduction of antimicrobial therapy, between 1942 and 1945. The usage of the closed anastomoses resulted in two primary routes of experimental and clinical anastomotic evaluations: the end-to-side or side-to-side anastomoses and the technical construction of anastomoses with a minimum of an anastomotic cuff. With the former, there was a tendency to increase the number of rows of sutures used in the anastomotic construction from one to two, three or even four rows of either interrupted or continuous sutures or a combination of both. With the latter, the surgeons relied on special anastomotic clamps or basting stitches, with frequent complicated technical maneuvers. Since the introduction of antimicrobial agents to the field of intestinal surgery, there has been a progressive return to the open anastomosis, constructed with a maximum of two rows of sutures. Furthermore, the usage of end-to-side or side-to-side anastomoses has decreased in preference to the end-to-end anastomosis. Lastly, there has been an upsurge in the usage of a single row of sutures in all anastomoses throughout the gastrointestinal tract. Dennis, in 1947, re-emphasized the point made by Halsted in 1887 that one row of accurately placed sutures resulted in excellent anastomotic wound healing. Since then Gambee, Weinberg, Getzen and others have made the same observation. The present surgical mortality for anastomotic procedures in elective cases throughout the gastrointestinal tract is from 0.5 to 2.0%. A significant factor in this mortality rate is associated with anastomotic obstruction, with or without anastomotic leakage. Efforts to reduce the anastomotic obstruction to a minimum by everting the bowel wall at the point of the anastomosis have not resulted in an increase in the mortality rate. Postoperative morbidity from wound infections, intra-abdominal abscesses and fistulas has not increased. Furthermore, the immediate postsurgical morbidity from gastrointestinal dysfunction appears to be significantly less. The likelihood of mucocele production from exposed gastrointestinal mucosa cells has been disproved. The wound healing of a meticulously constructed anastomosis, whether it is inverted or everted, constructed with one, two or three rows of sutures, telescoped or stented, depends more on the preoperative nutritional state of the patient, the intra-abdominal inflammatory reaction at the time of the surgical procedure and the vascular supply of the anastomosis than on the particular type of anastomosis performed. The postoperative morbidity associated with anastomotic obstruction appears to be less with the use of an accurately placed single row of sutures than when two or three rows of sutures are used in constructing the anastomosis. Lastly, end-on or everted anastomosis appears to further reduce the morbidity associated with anastomotic obstruction, and there is no apparent adverse, effect from mucosa eversion. |
