Devascularization (Devitalization) of the Small and Large Intestine and Some Possibilities of Therapeutic Utilization of this Operational Method
Authors evaluate experiences concerning various
possibilities for devitalizations of parts of the intestine by devascularization.
Segment of the intestine, left in the peritoneal alveole, was slowly absorbed
and rebuilt into a small fibrous remainder. Even up to 180 cm long segment
of the intestine, left in the peritoneal alveole of the laboratory animals
together with its content, did not endanger the lives of these animals.
These experiences were then utilized in the clinical practice in the cases with
inoperable
left-sided carcinoma of the large intestine and carcinoma of the
rectum. Case
study of four successful operations of carcinoma of the large intestine and two
successful operations of carcinoma of rectum
(skirrhus) is presented.
In the series of animal (pig) experiments we have separated 1 to 5 cm long segments of the intestine from the mesenterium, and devitalized them by intensive ligature and electrocoagulation. These segments were then inserted into the lumen of the intestine (invaginated) and secured there by series of button-sutures. In all these cases, gradual absorption occurred and the invaginate separated itself out within 6 to 11 days (3).
In the second series of experiments, the destiny of isolated segments of intestine, which were left, together with its contents, in the peritoneal cavity was observed. The observed animal had a 30 to 180 cm part long segment of intestine isolated and removed from the body. Continuity of the intestine was provided by anastomosis. The removed part of intestine was ligated on its both sides, and returned back to the peritoneal cavity and sewed on the peritoneum parietale by several button sutures. Then we closed the peritoneal cavity without inserting a drainage.
In another series of experiments we separated the small intestine, large intestine, and both small and large intestines from the mesenterium, like during resection of intestine. The devascularized part of intestine was ligated on its both ends and left on its original place. Continuity of the intestine passage we provided by the anastomosis, type side to side. Contrary to the opinions recognized up to that time, no animal (41 operations) died as a result of peritonitis caused by necrosis of isolated segment of intestine. By interruption of vascular system, also the lymphatic flux is stopped. This fact has importance for onco-surgery. Absorption of the necrotic intestine without dangerous complications was an unexpected, but for the practice very important knowledge, on which, however, we did not find any information in the literature,. During relaparotomies performed in 4 to 6 weeks after devascularization, only several centimeters large fibrous remnants were found (14).
The number of cases of carcinoma of the large intestine and rectum has been increasing over the last years (1, 5, 6, 9-11, 13). In 24% of these cases, an acute ileotic state was observed and in 2 to 9% the perforation of the intestine occurred (2, 5, 10). Mortality after operations of colorectal carcinoma, as presented in the world literature, is around 10%, while in cases with ileotic state, it is up to 40%.
Until our times, the fundamentals of surgical techniques and tactics are valid, which were laid down by Goetz, Westhues, Fischer and Americans Keen and Coftey (1931-1936). In 1965, Strauss et al. have used (12) electrocoagulation for carcinoma of rectum, a method, tried already by von Block in 1898 . Strauss et al.. (12) have observed that coagulated tissue of tumor becomes a source of antigen, which supports an immuno-biological response of organism to the presence of tumor. Technique of electrocoagulation begins again its advancing in the recent time (4, 7, 8). It is convenient, however, only for such tumors that are maximally about 10 cm from the anus. Not too many authors address this idea (4). Results of our experiments indicate that tissue of the intestine, devitalized by devascularization, may have analogical impact on the organism as coagulation. Advantage of the devitalization technique is in broader spectrum of indications, e.g. for tumors on the large intestine, primarily in the situations, when the radical surgical operation cannot be performed.
Brief descriptions of the cases when we have used the devitalization procedure in the clinical practice follow :
3.1.
Devitalization of Section of Intestine,
Bearing Tumor, Followed
by Insertion of this
Formation into the Intestine
3.1.1. Patient 79 year
old
79-year old patient with 3 days lasting symptoms of ileus. Lower medial laparotomy. On the border between rectum and colon sigmoideum, the inside diameter of intestine was closed by a well-defined, hard, about 4 x 3 cm big tumor. No metastases were found. Tumor was identified as Skirrhus´ carcinoma. As the first, with regard to favorable general and local state, content of the intestine was emptied Isolation of section of the intestine with the tumor was followed by ligature accompanied by electrocoagulation at the border of the isolated section (without coagulation of tumor !). Invagination of the intestine section with carcinoma into the ampule of rectum with use of series of sero-muscular button-sutures was performed without any problem. This intervention was finished by axial colostomy on sigmoideum.
After the smooth post-operative period, the necrotized section of intestine with the tumor separated itself out, after 15 days, and left the body in a natural way. No histological examinations of the tumor were done. After another four weeks, rectoscopic examination was done, followed by liquidation of colostomy After two weeks the patient was released from the hospital in good state with perfectly healed wound. For another four weeks, the patient was observed clinically and rectoscopically. He was well till his 83, when he died at the internal medicine department of the same hospital for ictus. During dissection, no signs of cancer proliferation were found, as well as no post-operative adhesions in area of the operation.
3.1.2. Patient 82 year
old
82 year old patient. Colicky pain in abdomen Two days of blocking of flatus and faecal discharge. Laparotomy : In area of rectosigmoideum there was a walnut size tumor of harder consistence, No metastases. Procedure of devitalization : Isolation of tumor, closing of the intestine by electrocoagulation, as well as inserting of tumor into the ampule of rectum with securing by several button-sutures were done without any complication. Operation was finished by axial colostomy in area of sigmoideum. Smooth post-operative period. On the 16th day, the tumor separated itself out. Remainder of already necrotic skirrhus-carcinoma was histologically confirmed.
Rectoscopic examination was done, and 4 weeks later the colostomy was liquidated. With perfectly healed operation wounds and in good state, the patient was released. He lived till his 87 years. Till that time he was coming to check-ups. During dissection, icterus was determined as the cause of death. No signs of cancer relapse were found in the peritoneal cavity.
3.2. Devitalization (Devascularization) of Tumor, Adjacent Part of Intestine and their Leaving in the Peritoneal Cavity
3.2.1. Patient 75 year old
75 year old patient, obstipation for about one year, current pain in the left part of hypogastrium, and at the same time blocking of flatus and faecal discharge. There was a suspicion of obstruction in the large intestine, and the lower medial laparatomy was done. In the relatively long sigmoideum we have found a fist-size tumor, which had infiltrated into the neighboring loops of the small intestine (Picture 1). The inflammatory changes had spread so far as into mesosigmoideum. Not a delicacy during the revision could prevent perforation of the intestine in the close proximity of the tumor and rupture of mesosigmoideum. After stopping of bleeding, we realized that the part of the intestine bearing the tumor and its surrounding are substantially devascularized. Because conditions in the adjacent areas were also favorable for growing of the tumor, there was no chance for primary removal of the tumor or for reaching the original state. We decided to use the devitalizations procedure.
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Picture 1. In the colon. sigmoideum there is a tumor, which had infiltrated into the adjacent loops of the small intestine. In its close proximity, there is a inflammatory infiltrate. The arrow shows the place, where perforation of intestine occurred. Tumor infiltrated here into the mesosigmoideum. Here, rupture and bleeding had occurred.
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Before and behind the tumor of the sigmoideum, we performed
double ligature of the intestine, and stitched it down by the sero-muscular
button-sutures (Picture 2). We tried to narrow the perforation on sigmoideum by
a situational-sutures and covering with process of omentum. Oral part of sigmoideum
was sufficient for performance of axial colostomy. Into the Douglas space,
we had embedded a rubber drain. Then the operational wound was sutured, antibiotics
therapy applied, as well as infusions and blood transfusions.
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Picture 2. Devitalization of sigmoideum with tumor by separation from mesosigmoideum. On the border between the devitalized part of sigmoideum and its part supplied by blood, the intestine was closed by double ligature and stitching by seromuscular sutures. The oral part of the S-loop was brought out by the axial colostomy
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For the first four days, the state with a temperature between 38 and 39 'C lasted. Since the third day excretion went through the colostomy. During remaining two days a turbid fluid flew through the rubber drain in the amount of up to 100 ml per day. Secretion was then decreasing and fully stopped on the eights day. One day later the rubber drain was removed. The wound was perfectly healed in spite of all unfavorable circumstances. No secretion was coming out from about 4 cm long lower part of colostomy. Condition of the patient was continually improving, so he could be released from the hospital after his total stay of 4 weeks. Before this, a rectoscopy was performed, which detected presence of still about 7 cm long piece of the blinded and closed intestine.
After 4 months, during which the patient was in good condition, we decided to perform revision of the operation. The aboral part of colostomy was around 3 cm long and ended in a solid tissue, same as the aboral part of sigmoideum. In its surrounding we found fine adhesions. For the section of the S-loop with the tumor we looked in vain (see left side of Picture 3). The loops of the intestine, joint originally with the tumor, were free except some small adhesions. The peritoneal cavity was free of metastases, no recurrence of cancer proliferation. Surprised by these findings, we decided to perform anastomosis of both ends of sigmoideum (see right side of Picture 3) with resection of lower part of colostomy. After smooth post-operative period we released the patient four weeks later.
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Picture 3. Left: The state after the resorption of the devitalized parts of intestine with the tumor. Arrows are pointing to the places, where both sections of intestine were blinded. Right: The state after renewal of continuity of intestine by end-to-end-anastomosis of sigmoideum (colostomy is removed). |
During the rectoscopic
examination no pathological changes were found. Patient was then observed for 4
years - no signs of recurrence of the tumor. Patient died for myocardial
infarction after suffering from the chronic heart
ischemia. During dissection no recurrence of cancer in intestine or
metastases
were found. Also no adhesions in the places, where perforation of intestine
ocurred were found. Patency of intestine in place of anastomosis was good.
3.2.2.
Female patient 57 year old
57-year old female patient : Suspicion of incomplete obstruction of patency of intestine due to a tumor in area of large intestine on the left side. Medial laparatomy was performed. On the border between colon descendens and S-loop we have found a tumor of a size of two fists, which had infiltrated up to the branches of Vasae ilicae and further up to crossing of these two veins with urethra and, at the same time, it infiltrated also to the abdominal wall. Lymph glands were turgid in the course of vasa ilica sinistra. On the liver there were several cancer metastases.
Colon transversum as well as the S-loop were long enough and could be moved closer, so that anastomosis side to side could be performed after stopping the blood supply. The veins vasa colica media and vasa colica sinistra were ligated. In area of anastomosis the arteries were left (arteria rectalis cranialis and arteria sigmoidea ima). In neighborhood of the intestine anastomosis we performed closing of the left part of the colon transversum and oral end of sigmoideum by double ligature of the intestine and by stitching the button sutures through (see Picture 4). For decompression of the intestine anastomosis and for bringing the securing drainage out from the left part of colon transversum, the parietale colostomy was performed.
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Picture 4.
Tumor infiltrated from the place of passage of colon
descendens into the colon
sigmoideum medial in the direction towards vasa ilica dextra up to its
crossing with urethra.
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The first faecal discharge came on the third day after the operation. The drainages were removed from the peritoneal cavity on the fifth day. The drain from the devitalized part of the intestine was gradually shortened, and removed definitively on the fourteenth day. The wound after the colostomy closed quickly. After the serous secretion from the operation wound an excellent healing of the wound followed. The patient was released from the hospital 4 weeks after the operation.
After the rectoscopic and irrigoscopic checks also the pararectal
laparotomy was performed. We have found only one part of the colon
transversum and sigmoideum, which were connected with anastomosis with good
patency.
In the places of closures of the intestine, about 1.5 cm long fibrous
tissue was found (see Picture 5). The devitalized part of the colon could not be
found, anymore. On the place of the original tumor, on the serosis, only hardly
recognizable small flat fibrous part remained.
On the liver we did not find any
metastases. Patient was released on the 10th day. 7 years after the operation a
check was performed : Patient enjoyed the best health.
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Picture 5. State after resorption of the devitalized intestine. Anastomosis of the intestine (from the transverse colon to sigmoideum) is patent. In the neighborhood of anastomosis, on the blinded ends of the intestine, a thicker fibrous layer was apparent (marked by the black arrows). The white arrow marks the place, where there was originally the tumor, of which only a piece of the fibrous tissue remained. |
3.2.3. Patient 63 year
63-year female patient : 2 days lasting colicky pain of abdomen. For suspicion of obstruction of the intestine in the left part of colon, we performed a medial laparotomy. Finding: In area of the lienal flexure we have found a large tumor, around 15 x 12 cm, which infiltrated to the lien, to pancreas, into mesocolon transversum and to the back to the left kidney. Because tumor was inoperable by classical way, we decided to use solution by devitalization.
At first we performed the side to side anastomosis of the transversosigmoideum. Then we ligated the left parts of vasa colica sinistra and vasa sigmoidea. In the neighborhood of the anastomosis we blinded the intestine by the double ligature (see Picture 6). Into the part of intestine before the anastomosis and into the two devitalized parts of intestine we established the decompressioning drains. All drains were brought out through the parietal colostomy. Other metastases on the liver were discovered, and numerous turgid lymphatic glands in mesocolon transversum and along the vasa colica sinistra.
Faecal discharge began from the 4th day. We began with removing of the decompressing drainages since the 5th day. After the gradual shortening the drainages were removed from the devitalized parts of the intestine completely on the 7th day after the operation. As in all similar cases, the patient was receiving infusions and antibiotics (PNC, STM). The patient was released in the fourth week since the operation, after an uncomplicated postoperative course.
After 6 month an abdomen revision was made by laparotomy. In the place of the original tumor, there was only a small, firm, and fibrous remainder. On both ends of the blinded part of intestine there were only layers of fibrous ligament. The intestine anastomosis was free, well patent. No metastases and no cancer proliferation in the peritoneal cavity were discovered. Clinical checks were performed during 7 years, showing still good health condition.
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Picture 6.
Carcinoma on flexura
coli sinistra with large infiltration into its surrounding (affected
organs: lien,
pancreas, mesocolon transversum, left kidney).
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3.2.4. Patient 66 year
old
66-year old patient : Symptoms of ileus with suspicion of obstruction in the small intestine Medial laparotomy was performed: At around 60 cm from valvula ileocoecalis (Bauhini), the small intestine was curved by a metastasis, localized in its close proximity. On the top of colon sigmoideum there was a fist-size tumor. It infiltrated also into several neighboring loops of the small intestine, Lymphatic glands in mesosigmoideum were enlarged, and several metastases were on the liver.
At first we isolated about 10 cm long piece of the small intestine with the metastasis, on both ends we closed it by double ligature and performed side-to-side anastomosis to renew continuity of the intestine passage (see Picture 7). Then we devitalized the colon sigmoideum together with the tumor. Devitalization was performed only to the extent allowing establishment of side-to-side anastomosis on the rest of the S-loop. Both arms of sigmoideum, leading towards the tumor, were blinded. We inserted a drain into the closeness of anastomosis on the sigmoideum. On the 5th day, secretion of serum from the wound ceased. Infusions and antibiotics therapy (PNC, STM) were applied identically as in the preceding cases.
Patient left the hospital in good condition with well healed wounds. Later a hemia of about 7 cm diameter appeared in cicatrice. Patient did not want to undergo another operation, with reference to his truly good state of health. He died 5 years after the operation for cardiac infarct. Dissection was not performed.
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Picture 7.
Closure of the small intestine by implantation of the metastasis (black).
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Our experiences (3) with the local devitalization of the intestine by ligation accompanied with use of electrocoagulation in the zone bordering with invaginated intestinal wall, offer certain perspective concerning liquidation of tumors. We have used this operational method successfully in two clinical cases with Skirrhus carcinoma in area of the rectosigmoideum. This form of Cancer, however, is relatively not too frequent. Therefore, this type of devitalization technique has only a limited significance.
Only experiments with specific liquidation of clearly defined part of the intestine with use of devitalization by devascularization exhibit really promising perspective. Simultaneous closure of both arteries and veins interrupts also the lymphatic flow. It restrains growth of the tumor as well as propagation of metastases through the blood and lymphatic pathways.
Wall of the devitalized intestine desintegrates, according to our experimental knowledge, firstly by autolysis of mucosae and secondly by activity of leukocytes. Place of desintegrating intestine is gradually replaced by fibrous tissue. According to our findings, the identical disintegration takes place at the tissue of the tumor, which is as well transformed into the fibrous tissue. Despite the experimental findings fully confirm these changes of the tissue, nothing else was known for sure about behavior of the tumor tissue. Therefore, we began later with performances of laparotomies, to find out the state in the peritoneal cavity, to be sure about the true state in the peritoneal cavity, and to be able, in case of such necessity, to remove eventual adhesions or remainders of the intestinal tissue.
Originally, we were establishing drainages into the devitalized part of intestine, but not so in the experiment. Work flow of the operations, we have performed up till now, shows that drainages can be kept as a reserve rather for the most complicated cases. Technique for separation of the devitalized intestine by the double ligation by double ligation (Unterbinden) and stitching with sero-muscular sutures is very simple, quick, and reliable. To precise description of the technique of devitalization of certain part of intestine, it is necessary to note that elimination of the supply system must be full and consequent. An experiment had confirmed that partial supply of blood into the devascularized part of the intestine may lead to gangrene and perforation on the border of the devitalized and perfused part of the intestine.
We focused our attention also to the question, if the quick disintegration of the tumor tissue is not a result of acute disintegration syndrome, known from the oncology. However, in no case any blockade of the kidney ducts by the products of disintegrating cell nucleuses during the hyperuricaemia. It is probable that the process of decomposition of necrotic tissue does not exceed the limits, which the organism is still able to control.
Important and
valuable for the practice is the finding of
Strauss et al. (12) on the immunological impact of the necrotic particles of
carcinoma after the electrocoagulation. This method was also used recently by
several authors (4, 7, 8, 12). From this point of view, it is interesting that
no carcinomatous metastases in the liver or in the lymphatic glands were
discovered during the second operations of our clinical cases. Also here, it
can probably be explained by immunity response of the organism to the necrotic
tumor tissue. Our attention deserves also the fact that the wall of
devitalized part of the intestine keeps certain impermeability, and also that
the necrotic tissue is being decomposed relatively quickly, too.
5.
Conclusion
By the series of experiments on the pigs, we have confirmed that there is no danger of peritonitis, which would be a result of leaving a part of intestine in the peritoneal cavity, which is true even if the whole content were left in the intestine, but even when significant amount of pathogenic microorganisms was applied. Our experimental experiences and also selected clinical cases witness that the devitalization technique based on surgical method of devascularization gives a new hope to some patients with the inoperable tumors.
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