Catanozi, Sergio

Chaib, Eleazar

Cruz-Jr, Ruy Jorge

D'Albuquerque, Luiz Augusto Carneiro

Galvao, Flavio Henrique Ferreira

Hirano, Hugo

Seid, Victor Edmund

Waisberg, Daniel Reis

English

Cadernos Espinosanos (E-Journal)

TECHNICAL NOTEAn innovative model of autologous anorectal trans-plantation with pudendal nerve reconstructionFlavio Henrique Ferreira Galvao, Victor Edmund Seid, Daniel Reis Waisberg, Ruy Jorge Cruz-Jr, HugoHirano, Sergio Catanozi, Eleazar Chaib, Luiz Augusto Carneiro D’AlbuquerqueFaculdade de Medicina da Universidade de Sa˜o Paulo, Department of Gastroenterology, Division of Transplantation, Laboratories of MedicalInvestigation (LIM37 and LIM10), Sa˜o Paulo/SP, Brazil.Email: fgalvao@usp.brTel.: 55 11 3061 8319Fecal incontinence is an important public health problemthat has a significant impact on the quality of life of individualpatients. The prevalence of fecal incontinence in the UnitedStates ranges from 2 to 17%, but this may be an under-estimation (1). The current treatments for severe fecalincontinence are often complex and have disappointingresults (1). Anorectal transplantation may be a definitivemethod for restoring normal sphincter function in thesepatients. We and others have previously investigated anor-ectal transplantation in rats with promising results (2-4).However, there is a lack of pre-clinical large animal models tostudy the potential benefits of this procedure. In this paper, wedescribe an innovative surgical technique of anorectal auto-transplantation, which allows for physiological studies with-out the immunologic effects related to allotransplantation.The technique was initially performed in three swineweighing 25-35 Kg. After general anesthesia, an abdominaland perineal incision was performed in which the rectum,anal sphincter, and skin surrounding the anus wereprocured en bloc. The graft’s vascular pedicle containedthe inferior mesenteric artery (IMA) with a patch of theaorta and inferior mesenteric vein (IMV), which wasdivided near the splenic vein (Figure 1A). The pudendalnerve was carefully isolated and transected. The graft wasremoved and immediately flushed with 250 ml of coldheparinized preservation solution through a catheterinserted in the IMA. The graft was then placed in a coolerwith cold solution without heparin for a total of 20 minutes.Copyright  2012 CLINICS – This is an Open Access article distributed underthe terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided theoriginal work is properly cited.No potential conflict of interest was reported.Figure 1 - (A) An anorectal graft showing the inferior mesenteric artery (IMA) and vein (IMV) and the rectum (R). (B) The infrarenalaorta (Ao) and vena cava (IVC) were cross-clamped at the site of anastomosis. (C) The anastomoses between the Ao and IMA andbetween the IVC and IMV. (D) The anorectal graft following reperfusion. (E) Pudendal nerve anastomosis (arrow head). (F) Analanastomosis in the perineum.CLINICS 2012;67(8):971-972 DOI:10.6061/clinics/2012(08)20971The infrarenal aorta and vena cava were isolated and cross-clamped, and the graft was implanted by arterial andvenous anastomoses between the IMA and the aorta(Figure 1B) and the IMV and vena cava (Figure 1C). Afterreperfusion (Figure 1D), the entire graft was placed insidethe abdominal cavity, and the pudendal nerve wasreconstructed (Figure 1E). Finally, the anus was placed inits original position, and the perineum was closed(Figure 1F). Digestive tract continuity was reestablished byan end-to-end colorectal anastomosis. The abdominal cavitywas closed, and the animals were observed for an additionaltwo hours. At the end of the experiment, the graft wasremoved for histological analysis. The average times forgraft recovery and implantation (including vascular, ner-vous and GI reconstruction) were 57 and 99 minutes,respectively. No problems regarding graft perfusion wereobserved at the end of the experiment. Histological graftassessment showed normal aspects in one graft and mildischemia-reperfusion injury in two.To the best of our knowledge, there is only one report of apre-clinical model of anorectal transplantation (5). Thoseauthors described the donor and recipient surgical techniquein four swine allotransplantations, with a 25% rate of technicalfailure after a 24-hour observation period. The experimentalmodel described in this paper mimics the surgical stress andpotential effects of graft denervation of allotransplantation butprecludes, for obvious reasons, the antigen-mediated immuneresponse. In addition, the technical modifications wereassociated with a significant reduction in the surgical timeand cost. Therefore, anorectal autotransplantation in swine is afeasible and relatively simple procedure that may be a relevanttechnique to study regeneration, anorectal physiology, and thepotential benefits of this unique type of transplantationwithout the interference of immune-mediated effects.ACKNOWLEDGMENTSThis study was supported by Laboratory of Medical Investigation (LIM37),University of Sa˜o Paulo School of Medicine.AUTHOR CONTRIBUTIONSGalvao FH conceived and designed the study, provided the hypothesis,performed the operative procedure, was responsible for the data analysisand interpretation, manuscript writing and approval of the manuscriptfinal version. Seid VE conceived and designed the study, providedtechnical help with the operative procedure, was responsible for the dataanalysis, interpretation of results and approval of the manuscript finalversion. Waisberg DR conceived and designed the study, providedtechnical help with the operative procedure, was responsible for the dataanalysis and interpretation of results. Cruz Jr RJ conceived and designedthe study, provided advice and consultation, was responsible for themanuscript writing, critical review and approval of the manuscript finalversion. Hirano H and Catanozi S provided technical help with theoperative procedure, were responsible for the data analysis andinterpretation of results. Chaib E and D’Albuquerque LA provided adviceand consultation, were responsible for the manuscript writing and approvalof the manuscript final version.REFERENCES1. Wald A. Fecal incontinence in adults. New Engl J Med. 2007;356(16):1648-55, http://dx.doi.org/10.1056/NEJMcp067041.2. Galvao FHF, Seid VE, dos Santos RMN, Kitamura M, Galvao RD, PintoRA, et al. Anorectal transplantation. Tech Coloproctol. 2009;13(1):55-9,http://dx.doi.org/10.1007/s10151-009-0459-5.3. Galvao FHF, Waisberg DR, Vianna RMD, Galvao RD, Seid VE, AndrausW, et al. Intestinal transplantation including anorectal segment in the rat.Microsurg. 2012;32(1):77-9, http://dx.doi.org/10.1002/micr.20958.4. Araki J, Mihara M, Narushima M, Iida T, Sato T, Koshima I. VascularizedAnal AutotransplantationModel in Rats: Preliminary Report. Transplant P.2011;43(9):3552-6, http://dx.doi.org/10.1016/j.transproceed.2011.08.042.5. O’Bichere A, Shurey S, Sibbons P, Green C, Phillips RKS. Experimentalmodel of anorectal transplantation. Brit J Surg. 2000;87(11):1534-9,http://dx.doi.org/10.1046/j.1365-2168.2000.01557.x.Autologous Anorectal TransplantationGalvao FH et al.CLINICS 2012;67(8):971-972972

An innovative model of autologous anorectal transplantation with pudendal nerve reconstruction

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An innovative model of autologous anorectal transplantation with pudendal nerve reconstruction

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