Isoperistaltic vs antiperistaltic anastomosis after right hemicolectomy:A comprehensive review

To optimize the efficiency of ileocolic anastomosis following right hemicolectomy,several variations of the surgical technique have been tested.These include performing the anastomosis intra-or extracorporeally or performing a stapled or hand-sewn anastomosis.Among the least studied is the configuration of the two stumps(i.e.,isoperistaltic or antiperistaltic)in the case of a side-to-side anastomosis.The purpose of the present study is to compare the isoperistaltic and antiperistaltic side-to-side anastomotic configuration after right hemicolectomy by reviewing the relevant literature.High-quality literature is scarce,with only three studies directly comparing the two alternatives,and no study has revealed any significant differences in the incidence of anastomosis-related complications such as leakage,stenosis,or bleeding.However,there may be a trend towards an earlier recovery of intestinal function following antiperistaltic anastomosis.Finally,existing data do not identify a certain anastomotic configuration(i.e.,isoperistaltic or antiperistaltic)as superior over the other.Thus,the most appropriate approach is to master both anastomotic techniques and select between the two configurations based on each individual case scenario.

Candy cane syndrome:A systematic review

BACKGROUND Candy cane syndrome(CCS)is a condition that occurs following gastrectomy or gastric bypass.CCS remains underrecognized,yet its prevalence is likely to rise due to the obesity epidemic and increased use of bariatric surgery.No previous literature review on this subject has been published.AIM To collate the current knowledge on CCS.METHODS A literature search was conducted with PubMed and Google Scholar for studies from May 2007,until March 2023.The bibliographies of the retrieved articles were manually searched for additional relevant articles.RESULTS Twenty-one articles were identified(135 patients).Abdominal pain,nausea/vomiting,and reflux were the most reported symptoms.Upper gastrointestinal(GI)series and endoscopy were performed for diagnosis.Surgical resection of the blind limb was performed in 13 studies with resolution of symptoms in 73%-100%.In surgical series,9 complications were reported with no mortality.One study reported the surgical construction of a jejunal pouch with clinical success.Six studies described endoscopic approaches with 100%clinical success and no complications.In one case report,endoscopic dilation did not improve the patient’s symptoms.CONCLUSION CCS remains underrecognized due to lack of knowledge about this condition.The growth of the obesity epidemic worldwide and the increase in bariatric surgery are likely to increase its prevalence.CCS can be prevented if an elongated blind loop is avoided or if a jejunal pouch is constructed after total gastrectomy.Diagnosis should be based on symptoms,endoscopy,and upper GI series.Blind loop resection is curative but complex and associated with significant complications.Endoscopic management using different approaches to divert flow is effective and should be further explored.

Phrenic and intercostal nerves with rhythmic discharge can promote early nerve regeneration after brachial plexus repair in rats

Exogenous discharge can positively promote nerve repair. We, therefore, hypothesized that endogenous discharges may have similar effects. The phrenic nerve and intercostal nerve, controlled by the respiratory center, can emit regular nerve impulses; therefore these endogenous automatically discharging nerves might promote nerve regeneration. Action potential discharge patterns were examined in the diaphragm, external intercostal and latissimus dorsi muscles of rats. The phrenic and intercostal nerves showed rhythmic clusters of discharge, which were consistent with breathing frequency. From the first to the third intercostal nerves, spontaneous discharge amplitude was gradually increased. There was no obvious rhythmic discharge in the thoracodorsal nerve. Four animal groups were performed in rats as the musculocutaneous nerve cut and repaired was bland control. The other three groups were followed by a side-to-side anastomosis with the phrenic nerve, intercostal nerve and thoracodorsal nerve. Compound muscle action potentials in the biceps muscle innervated by the musculocutaneous nerve were recorded with electrodes. The tetanic forces of ipsilateral and contralateral biceps muscles were detected by a force displacement transducer. Wet muscle weight recovery rate was measured and pathological changes were observed using hematoxylin-eosin staining. The number of nerve fibers was observed using toluidine blue staining and changes in nerve ultrastructure were observed using transmission electron microscopy. The compound muscle action potential amplitude was significantly higher at 1 month after surgery in phrenic and intercostal nerve groups compared with the thoracodorsal nerve and blank control groups. The recovery rate of tetanic tension and wet weight of the right biceps were significantly lower at 2 months after surgery in the phrenic nerve, intercostal nerve, and thoracodorsal nerve groups compared with the negative control group. The number of myelinated axons distal to the coaptation site of the musculocutaneous nerve at 1 month after surgery was significantly higher in phrenic and intercostal nerve groups than in thoracodorsal nerve and negative control groups. These results indicate that endogenous autonomic discharge from phrenic and intercostal nerves can promote nerve regeneration in early stages after brachial plexus injury.

The reasons for end-to-side coaptation:how does lateral axon sprouting work?

Nerve fibers are attracted by sutureless end-to-side nerve coaptation into the recipient nerve. Opening a window in the epineurium enhances axon attraction and myeliuation. The authors analyze the features of nerve repair by end-to-side coaptation. They highlight the known mechanisms of axon sprouting and different hypotheses of start up signals （presence or absence of an epineurial window, role of Schwann cells, signaling from the distal trunk）. The clinical literature is also presented and differences between experimental and clinical applications are pointed out. The authors propose their point of view and perspectives deriving from recent experimental and clinical experiences.

The Current State of Pancreas-kidney Transplantation in China:The Indications,Surgical Techniques and Outcome

It is currently estimated that 50 million Chinese have diabetic mellitus （DM） with more than 90% of these being afflicted with type 2 DM. Concomitantly, the socio-economic improvements in China are supporting the adoption of pancreas-kidney transplantations as a treatment option for these patients. Recipient candidate pool has yet to be expanded and the final effect to be improved in clinical practice. To date, more than 250 pancreas-kidney transplants have been performed on patients with type 1 and type 2 DM. To improve the outcome, a new surgical technique that involves anastomosis of the graft duodenum to recipient jejunum side-to-side but not Roux-en-Y, has been devised for enteric drainage. Furthermore, the systemic venous drainage （SVD） has been used as the method of choice for endocrine secretions. Graft and recipient long-term survival in China was similar to that in America and Europe. Three-year survival rate of pancreas and kidney grafts was 92.2% and 90.2%, respectively, in our center. No difference in survival and graft function between type 1 and type 2 DM recipients was noted. It is concluded that pancreas-kidney transplantation is an effective way for the treatment of type 1 DM and some type 2 DM complicated with uremia.

Endogenous automatic nerve discharge promotes nerve repair: an optimized animal model

Exogenous electrical nerve stimulation has been reported to promote nerve regeneration. Our previous study has suggested that endogenous automatic nerve discharge of the phrenic nerve and intercostal nerve has a positive effect on nerve regeneration at 1 month postoperatively, but a negative effect at 2 months postoperatively, which may be caused by scar compression. In this study, we designed four different rat models to avoid the negative effect from scar compression. The control group received musculocutaneous nerve cut and repair. The other three groups were subjected to side-to-side transfer of either the phrenic(phrenic nerve group), intercostal(intercostal nerve group) or thoracodorsal nerves(thoracic dorsal nerve group), with sural nerve autograft distal to the anastomosis site. Musculocutaneous nerve regeneration was assessed by electrophysiology of the musculocutaneous nerve, muscle tension, muscle wet weight, maximum cross-sectional area of biceps, and myelinated fiber numbers of the proximal and distal ends of the anastomosis site of the musculocutaneous nerve and the middle of the nerve graft. At 1 month postoperatively, compound muscle action potential amplitude of the biceps in the phrenic nerve group and the intercostal nerve group was statistically higher than that in the control group. The myelinated nerve fiber numbers in the distal end of the musculocutaneous nerve and nerve graft anastomosis in the phrenic nerve and the intercostal nerve groups were statistically higher than those in the control and thoracic dorsal nerve groups. The neural degeneration rate in the middle of the nerve graft in the thoracic dorsal nerve group was statistically higher than that in the phrenic nerve and the intercostal nerve groups. At 2 and 3 months postoperatively, no significant difference was detected between the groups in all the assessments. These findings confirm that the phrenic nerve and intercostal nerve have a positive effect on nerve regeneration at the early stage of recovery. This study established an optimized animal model in which suturing the nerve graft to the distal site of the musculocutaneous nerve anastomosis prevented the inhibition of recovery from scar compression.