Wednesday, June 5, 2013

Small animal surgery: history of the anastomosis

An intestinal anastomosis (http://www.wjes.org/content/figures/1749-7922-4-30-2.jpg)

The anastomosis is a surgical technique frequently performed in small animal practice, most commonly following resection of a non-viable intestine. (And the most common reason for non-viable intestine in our practice is the presence of a foreign body, i.e. something the dog or cat should not have ingested but did...like a tennis ball, a peach pit or rubber).

Anastomosis is also performed by vascular surgeons or anyone wishing to join two sections of a tubular structure. And back in the days before we had lovely disposable intravenous lines, it was used by a very bold pioneer to save a five-day-old child with anaemia. 

The episode is documented in The Immortalists: Charles Lindbergh, Dr Alexis Carrel and their quest to live forever by David Friedman, which - if you are interested in the history of medicine and science - is a worthy read. 

Friedman writes that the event occurrred 
“...on March 8, 1908, when Carrel received an unexpected visit from Dr Adrian V.S. Lambert, a Professor at Columbia University’s medical school. Lambert’s wife had given birth to a daughter who exhibited symptoms of melena neonatorum, a rare disease marked by bleeding from the nose, mouth and anus.
When none of the known treatments proved effective, Lambert frantically searched the medical literature for alternatives until he found Carrel’s paper on anastomosis. Perhaps a direct blood transfusion using Carrel’s new technique would save his daughter’s life. Lambert was desperate: he knew that no one in New York – not even Carrel – had ever attempted such a transfusion on a human patient.
Even so, Carrel agreed to do the procedure, rushing with Lambert to his apartment on West Thirty-Sixth Street, where Carrel found the baby’s anxious mother, the father’s two brothers, and the sick infant, unconscious and white as a sheet. After a brief discussion with his wife, Dr Lambert said he would be his daughter’s blood donor.  (This turned out to be a lucky choice, as very little was then understood about blood groups).
The baby was taped onto an ironing board next to the Lambert’s dining room table, where Lambery lay down. Carrel would anastomose an artery in Lambert’s wrist to a vein behind the child’s knee, thus joining the healthy father to his sick daughter, so that his blood would replace that being lost by her. After Carrel began cutting, one of Lambert’s brothers blotted up the blood with a dishtowel. Once under the baby’s skin, Carrel – working without the magnifying lenses today’s surgeons take for granted – occluded the appropriate vessels, severed them, then used his revolutionary anastomosis method to join them end to end.

Carrel’s Nobel-winning innovation involved placing stay sutures in the two vessels he planned to join; once gently tugged, those stays transformed two round vessels into two triangles, which Carrel sewed together, one straight line at a time. As every tailor knows, it’s easier to sew a straight line than a curved one.
What Carrel the surgeon knew was that sewing in a straight line prevented the tissue from being linked from buckling, and so prevented damage to the vessels inner lining. This in turn eliminated the possibility of clotting and infection, the problems that had defeated all previous attempts to devise a workable anastomosis method.
Soon the vascular bond was complete on the Lambert infant – no small feat, considering that her vein was thinner than copper wire and flimsier than wet tissue paper. Within moments the baby’s colour changed from white to pink, then red. “You’d better turn it off, or she’ll burst!” one of Lambert’s brothers said, his joy tinged with anxiety. Two decades later Carrel attended his patient’s twenty-first birthday party.” (p10-11).
The reference this account is based on is an article by SW Lambert (Melena neonatorum with report of a case cured by transfusion, Medical Record 1908; 73: 885–887).

But the anastomosis - like so many advances in modern medicine - has a checkered past. This case was used to defeat an anti-vivesection bill in parliament at the time, and Carrel himself experimented prolifically on animals and was a proponent of eugenics. Friedman tackles these very important issues in his book. 






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