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The significance of the ileocecal valve in massive resection of the gut in puppies
The Significance of the Ileocecal Valve in Massive Resection of the Gut in Puppies By Ian S.
Reid
0
VER THE LAST DECADE an increasing number of newborn infants have survived after operative procedures with very short segments of small bowel. Study of case reports suggests that the preservation of the ileocecal valve is vital to survival in newborn infants who have near total loss of small bowel.’ 4 Wilmore5 in 1972 reviewed the English literature and found 50 neonates who had 75 cm or less of small bowel remaining after resections. Of those with 15 to 39 cm of small bowel remaining there were no survivors in five babies who had the ileocecal valve removed but eight survivors in 15 who had an intact valve. There were four babies with more than 40 cm of small bowel but the ileocecal valve removed and all these survived. No baby in Wilmore’s series with less than 15 cm survived. At the Royal Alexandra Hospital for Children, Sydney, in 1972 a child had a massive resection of small bowel for strangulated volvulus and only 7 cm of small bowel remained together with an intact ileocecal valve. This baby finally was being fed orally but at 4 mo of age died. A postmortem examination revealed candida ulceration of the small bowel. Richardson had a child who was “psychologically, intellectually and biochemically normal” at 44 yr of age who in the neonatal period had two bowel resections resulting in only 7.5 cm of bowel remaining between the pylorus and cecum. The ileocecal valve was retained. It appears from these clinical observations that the critical length for survival if the ileocecal valve is removed is 40 cm of small bowel while survival may be possible with smaller lengths remaining in conjunction with the ileocecal valve. The present study was undertaken to elicit the effect of destruction of the ileocecal valve in puppies undergoing 90’4 resection of small bowel. MATERIAL
AND METHODS
Twenty-four mongrel puppies were weaned, dewormed, and immunized against distemper at the age of 5 to 6 wk. They were paired using litter mating, sex. and weights as guides. AU puppies underwent resection of small bowel leaving only IO cm of jejunum measured from the duodenojejunal flexure and IS cm of terminal ileum -a total of 25 cm distal to the duodenum. The two ends of bowel were then anastomosed. One puppy of each pair also had, at the same operation, what will be referred to as an ileocecal valvotomythe valve was made incompetent in a manner similar to pyloroplasty by longitudional incision and transverse repair. Postoperative intravenous or subcutaneous fluids were given for 48 hr and then identical oral feedings introduced to all puppies. If death occurred within 48 hr of operation, that pair of puppies was excluded from the trial and replaced by another pair.
From
the
Camperdown, Address for Camperdown.
Children’s
Medical
Research
Foundation,
Royal
Alexandra
Hospital
for
Children.
N.S. W.. Australia. reprint
requests:
I. S. Reid,
Children’s
Medical
Research
Foundation.
P.0.
Bo.r 61,
N.S. W. 2050. Australia.
3 IQ75 hv Grtme & Stratton.
Inc.
Journal of Pediatric Surgery, Vol. 10, No. 4 (August), 1975
507
IAN S. REID
__--_
resection
only
resection
+
days Fig. I.
valvotomy
post-op
Weight patterns in puppies undergoing massive resection of gut.
RESULTS
At the end of 2 mo the puppies were assessed using two criteria: survival and weight. Of the 12 puppies with resection alone, eight survived; while of the 12 puppies with resection and valvotomy, only one survived. These results are statistically significant. The puppies were weighed weekly and the weights expressed as a percentage of each dog’s preoperative weight. These were then averaged for the two groups of dogs and presented in a composite graph (Fig. 1). The graph shows a more rapid loss of weight postoperatively in the dogs with valvotomy and a slow rise of weight in surviving puppies with resection but no valvotomy so that at 2 mo the graph reached the preoperative level. Any significant rise in the weights of the valvotomy group was due to the sole surviving puppy in the group. Postmortem examinations were carried out on all puppies which died and those surviving for the 2 mo were then sacrificed for postmortem examination. The internal circumference of the ileocecal valve or region was measured and the following differences noted:
Resection only Valvotomy In the group of puppies
Range 9927 mm 30-55 mm
with valvotomy,
Average 18 mm 45 mm
the course was generally
one of diar-
ILEOCECAL
VALVE
509
rhea and loss of weight, although the puppies eagerly took food. The animals became emaciated and died in a weakened state after 4 to 8 wk. In three of these puppies, postmortem examination revealed some antral ulceration which was regarded as terminal. The anastomosis in one puppy perforated 4 days after operation and death was due to general peritonitis. Of the four puppies which died in the group with resection alone, two had wound infections from which they seemed to recover, Both of these dogs later died with acute gastric bleeding and at postmortem examination had antral ulceration of the stomach. The other two puppies failed to gain weight as did the others in the group and finally died in an emaciated state from no apparent cause. DISCUSSION It is usually stated that the value of the valve in massive resection is to delay passage of small bowel contents and thus increase absorption. Richardson and Griffen,‘,* however, believed that the ileocecal valve acts as a bacterial barrier and that after massive resection in which the ileocecal valve is removed, cola.. nization of the remaining small gut is the critical factor in interfering with the absorptive processes. The only puppy to survive in the group which underwent valvotomy is of particular interest. A barium meal and followthrough taken just prior to sacrifice showed that at 1 hr very little of the barium had reached the colon and it was not until 3 hr that appreciable amounts had arrived at the colon. At postmortem examination there was a Z-shaped kinking of the small bowel by adhesions just 3 cm from the ileocecal region which was considered to be acting as a valve. The study supports the contention that the retention of the ileocecal valve is crucial for a survival in massive resection of small bowel. There are increasingly frequent reports of survival of babies with very short segments of small bowel especially with long-term intravenous nutrition. As a rule, babies with less than 40 cm remaining and no ileocecal valve are most unlikely to survive. The practical application is illustrated in a neonate who had necrotizing enteritis with resection of all but 60 cm of small bowel. It appeared at the initial operation that the remaining terminal 5 cm of ileum, the cecum, and part of the ascending colon were also necrotic. However, it was argued that removal of this section in addition would jeopardize the chances of survival. The jejunum and ileum were brought to the skin and 3 days later the abdomen reexplored when it was found necessary only to resect 2 further cm of ileum as the cecum, ileocecal valve, and ascending colon were viable. A direct end-to-end anastomosis was performed and the child survived and is thriving normally. SUMMARY
Clinical observations suggest that retention of the ileocecal valve is vital for survival in neonates who undergo resection of small bowel to the extent that less than 40 cm remain. Twenty-four puppies underwent 909, resection of small bowel and 12 of these also had a destructive procedure performed on the ileocecal valve. Survival and weight patterns were used to assess results when it was
IAN S. REID
510
found both parameters supported the clinical observations. The practical application is that all attempts should be made to retain the ileocecal valve in situations in which only short lengths of small bowel remain. REFERENCES 1. Rickham PP: Massive small intestinal resection in newborn infants. Ann R Colt Surg Engl41:480, 1967 2. Wilkinson AW, McCance RA: Clinical and experimental results of removing the large intestine soon after birth. Arch Dis Child 48:121, 1973 3. Mackenzie GW, Boileau CR, St Clair WR: Short gut syndrome: A review with a case report. Can J Surg 16:1, 1973 4. Clatworthy HW, Saleeby R. Lovingood C: Small bowel resection in young dogs: its effect on growth and development. Surgery 32: 341, 1952
5. Wilmore DW: Factors correlating with a successful outcome following extensive intestinal resection in newborn infants. J Pediatr 80:88, 1972 6. Richardson 1973
JD: Personal
7. Richardson JD, Gritfen valve substitutes as bacteriologic Surg 123:149, 1972
communication.
WO: lleocecal barriers. Am J
8. Richardson JD, Medley ES, Griffen WO: Prevention of small bowel contamination by ileo-caecal valve. South Med J 64:1056, 1971
Reid
0
VER THE LAST DECADE an increasing number of newborn infants have survived after operative procedures with very short segments of small bowel. Study of case reports suggests that the preservation of the ileocecal valve is vital to survival in newborn infants who have near total loss of small bowel.’ 4 Wilmore5 in 1972 reviewed the English literature and found 50 neonates who had 75 cm or less of small bowel remaining after resections. Of those with 15 to 39 cm of small bowel remaining there were no survivors in five babies who had the ileocecal valve removed but eight survivors in 15 who had an intact valve. There were four babies with more than 40 cm of small bowel but the ileocecal valve removed and all these survived. No baby in Wilmore’s series with less than 15 cm survived. At the Royal Alexandra Hospital for Children, Sydney, in 1972 a child had a massive resection of small bowel for strangulated volvulus and only 7 cm of small bowel remained together with an intact ileocecal valve. This baby finally was being fed orally but at 4 mo of age died. A postmortem examination revealed candida ulceration of the small bowel. Richardson had a child who was “psychologically, intellectually and biochemically normal” at 44 yr of age who in the neonatal period had two bowel resections resulting in only 7.5 cm of bowel remaining between the pylorus and cecum. The ileocecal valve was retained. It appears from these clinical observations that the critical length for survival if the ileocecal valve is removed is 40 cm of small bowel while survival may be possible with smaller lengths remaining in conjunction with the ileocecal valve. The present study was undertaken to elicit the effect of destruction of the ileocecal valve in puppies undergoing 90’4 resection of small bowel. MATERIAL
AND METHODS
Twenty-four mongrel puppies were weaned, dewormed, and immunized against distemper at the age of 5 to 6 wk. They were paired using litter mating, sex. and weights as guides. AU puppies underwent resection of small bowel leaving only IO cm of jejunum measured from the duodenojejunal flexure and IS cm of terminal ileum -a total of 25 cm distal to the duodenum. The two ends of bowel were then anastomosed. One puppy of each pair also had, at the same operation, what will be referred to as an ileocecal valvotomythe valve was made incompetent in a manner similar to pyloroplasty by longitudional incision and transverse repair. Postoperative intravenous or subcutaneous fluids were given for 48 hr and then identical oral feedings introduced to all puppies. If death occurred within 48 hr of operation, that pair of puppies was excluded from the trial and replaced by another pair.
From
the
Camperdown, Address for Camperdown.
Children’s
Medical
Research
Foundation,
Royal
Alexandra
Hospital
for
Children.
N.S. W.. Australia. reprint
requests:
I. S. Reid,
Children’s
Medical
Research
Foundation.
P.0.
Bo.r 61,
N.S. W. 2050. Australia.
3 IQ75 hv Grtme & Stratton.
Inc.
Journal of Pediatric Surgery, Vol. 10, No. 4 (August), 1975
507
IAN S. REID
__--_
resection
only
resection
+
days Fig. I.
valvotomy
post-op
Weight patterns in puppies undergoing massive resection of gut.
RESULTS
At the end of 2 mo the puppies were assessed using two criteria: survival and weight. Of the 12 puppies with resection alone, eight survived; while of the 12 puppies with resection and valvotomy, only one survived. These results are statistically significant. The puppies were weighed weekly and the weights expressed as a percentage of each dog’s preoperative weight. These were then averaged for the two groups of dogs and presented in a composite graph (Fig. 1). The graph shows a more rapid loss of weight postoperatively in the dogs with valvotomy and a slow rise of weight in surviving puppies with resection but no valvotomy so that at 2 mo the graph reached the preoperative level. Any significant rise in the weights of the valvotomy group was due to the sole surviving puppy in the group. Postmortem examinations were carried out on all puppies which died and those surviving for the 2 mo were then sacrificed for postmortem examination. The internal circumference of the ileocecal valve or region was measured and the following differences noted:
Resection only Valvotomy In the group of puppies
Range 9927 mm 30-55 mm
with valvotomy,
Average 18 mm 45 mm
the course was generally
one of diar-
ILEOCECAL
VALVE
509
rhea and loss of weight, although the puppies eagerly took food. The animals became emaciated and died in a weakened state after 4 to 8 wk. In three of these puppies, postmortem examination revealed some antral ulceration which was regarded as terminal. The anastomosis in one puppy perforated 4 days after operation and death was due to general peritonitis. Of the four puppies which died in the group with resection alone, two had wound infections from which they seemed to recover, Both of these dogs later died with acute gastric bleeding and at postmortem examination had antral ulceration of the stomach. The other two puppies failed to gain weight as did the others in the group and finally died in an emaciated state from no apparent cause. DISCUSSION It is usually stated that the value of the valve in massive resection is to delay passage of small bowel contents and thus increase absorption. Richardson and Griffen,‘,* however, believed that the ileocecal valve acts as a bacterial barrier and that after massive resection in which the ileocecal valve is removed, cola.. nization of the remaining small gut is the critical factor in interfering with the absorptive processes. The only puppy to survive in the group which underwent valvotomy is of particular interest. A barium meal and followthrough taken just prior to sacrifice showed that at 1 hr very little of the barium had reached the colon and it was not until 3 hr that appreciable amounts had arrived at the colon. At postmortem examination there was a Z-shaped kinking of the small bowel by adhesions just 3 cm from the ileocecal region which was considered to be acting as a valve. The study supports the contention that the retention of the ileocecal valve is crucial for a survival in massive resection of small bowel. There are increasingly frequent reports of survival of babies with very short segments of small bowel especially with long-term intravenous nutrition. As a rule, babies with less than 40 cm remaining and no ileocecal valve are most unlikely to survive. The practical application is illustrated in a neonate who had necrotizing enteritis with resection of all but 60 cm of small bowel. It appeared at the initial operation that the remaining terminal 5 cm of ileum, the cecum, and part of the ascending colon were also necrotic. However, it was argued that removal of this section in addition would jeopardize the chances of survival. The jejunum and ileum were brought to the skin and 3 days later the abdomen reexplored when it was found necessary only to resect 2 further cm of ileum as the cecum, ileocecal valve, and ascending colon were viable. A direct end-to-end anastomosis was performed and the child survived and is thriving normally. SUMMARY
Clinical observations suggest that retention of the ileocecal valve is vital for survival in neonates who undergo resection of small bowel to the extent that less than 40 cm remain. Twenty-four puppies underwent 909, resection of small bowel and 12 of these also had a destructive procedure performed on the ileocecal valve. Survival and weight patterns were used to assess results when it was
IAN S. REID
510
found both parameters supported the clinical observations. The practical application is that all attempts should be made to retain the ileocecal valve in situations in which only short lengths of small bowel remain. REFERENCES 1. Rickham PP: Massive small intestinal resection in newborn infants. Ann R Colt Surg Engl41:480, 1967 2. Wilkinson AW, McCance RA: Clinical and experimental results of removing the large intestine soon after birth. Arch Dis Child 48:121, 1973 3. Mackenzie GW, Boileau CR, St Clair WR: Short gut syndrome: A review with a case report. Can J Surg 16:1, 1973 4. Clatworthy HW, Saleeby R. Lovingood C: Small bowel resection in young dogs: its effect on growth and development. Surgery 32: 341, 1952
5. Wilmore DW: Factors correlating with a successful outcome following extensive intestinal resection in newborn infants. J Pediatr 80:88, 1972 6. Richardson 1973
JD: Personal
7. Richardson JD, Gritfen valve substitutes as bacteriologic Surg 123:149, 1972
communication.
WO: lleocecal barriers. Am J
8. Richardson JD, Medley ES, Griffen WO: Prevention of small bowel contamination by ileo-caecal valve. South Med J 64:1056, 1971