Cercetãri Experimentale & Medico-Chirurgicale

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Anul XIII l Nr.1/2006 l Pag. 37-40 Cercetari
e x p e r i m e n ta le &
m edico-chirurgicale

INTRAOPERATIVE EVALUATION OF BOWEL VIABILITY

COMPARATIVE EXPERIMENTAL STUDY THROUGH THREE
METHODS
Codruþa Miclãuº1, Summary:
T. Nicola1, Background: The intraoperative assessment of intestinal viability when dealing with ischemic bowel
C. Igna2, remains a challenge. The purpose of this study was intraoperative assessment of bowel viability in
M. Miclãuº3 strangulated intestinal obstructions. The accuracy of this assessment allows avoiding useless
intestinal resections and consequently the secondary morbidity and mortality.
Study design: This is an experimental study using the canine experimental model. Bowel viability
was assessed in four dogs before and after mesenteric arterial ligation in a 10 cm (length) segments
of jejunum and colon. We have used three methods: visual- traditional method, computerized
analysis of test with fluorescein and measurement of the oxigen saturation of intestinal segments by
pulse oximetry. Determination of the bowel ischemia after vascular ligatures was made at intervals of
10, 30 and 60 minutes. The last determination being made at 24 hours postoperatively by
relaparotomy.
Results: The analysis of results reveals a high degree of subjectivism for the visual assessment of the
degree of bowel ischemia, which could cause severe decisional errors.
By assessing the standard deviation of the results obtained through the three methods, similar results
were found throught computerizing fluorometry and pulse oximetry.
Conclusions: This experimental study showed that the pulse oximetry and fluorometry represent
efficient and objective methods in assessment of the ischemic modifications at the intestinal wall in
Received for publication:
strangulated intestinal obstructions. Pulse oximetry is the preferred alternative for objective
12.11.2005
intraoperative assessment of intestinal viability because is easy to interpret and repeat, is well
Revised: 06.01.2006
tolerated and help preserve bowel of doubtful viability.
Key-words: intraoperative pulse oximetry, intestinal viability, dog.

1 - 2nd Clinic of General and Oncological Surgery, University of Medicine and Pharmacy Timiºoara
2 - Department of Surgery, University of Veterinary Medicine, Timiºoara
3 - 2nd Clinic of Surgery, University of Medicine and Pharmacy Timiºoara

EVALUAREA INTRAOPERATORIE A ISCHEMIEI INTESTINALE STUDIU EXPERIMENTAL COMPARATIV PRIN TREI METODE
Rezumat:
Material si metoda. Evaluarea intraoperatorie a viabilitatii intestinale în prezenta unui intestin aflat în ischemie ramâne o
provocare. Scopul acestui studiu a fost evaluarea intraoperatorie a viabilitatii intestinale în ocluziile mecaanice strangulate.
Acuratetea acestei evaluari permite evitarea rezectiilor inutile si consecutiv a morbiditatii si mortalitatii secundare.
Este un studiu experimental folosind modelul canin. Viabilitatea intestinala a fost evaluata pe un lot de patru câini înainte si dupa
ligatura vasculara arteriala a unor segmente de intestinale de circa 10 centimetri de jejun si colon. Am folosit trei metode: metoda
vizuala (traditionala), analiza computerizata a testului cu fluoresceina si masurarea saturatiei în oxigen a segmentelor intestinale
prin pulsoximetrie de suprafata. Determinarea comparativa a ischemiei intestinale dupa ligatura vasculara s-a facut la interval de
10, 30, 60 minute, ultima determinare fiind efectuata la 24 postoperator prin relaparotomie.
Rezultate. Analiza rezultatelor a relevat un grad înalt de subiectivism în evaluarea gradului de ischemie intestinala prin metoda
vizuala, care poate fi urmata de erori decizionale cu consecinte importante. Calculând deviatia standard a rezultatelor obtinute
prin cele trei metode, s-au decelat rezultate similare obtinute prin analiza computerizata a fluorometriei si prin puls oximetrie.
Concluzii. Studiul experimental a relevat ca pulsoximetria si fluorometria reprezinta metode eficiente si obiective în aprecierea
modificarilor ischemice de la nivelul peretelui intestinal în obstructiile mecanice strangulate. Puls oximetria este alternativa
preferata estimarii vizuale pentru aprecierea viabilitatii intestinale intraoperatorii, deoarece este usor de interpretat si repetat,
este bine tolerata si permite evitarea rezectiilor intestinale în situatiile de viabilitate intestinala "la limita".
Cuvinte cheie: intraoperative pulse oximetry, intestinal viability, dog

Correspondence to: Codruþa Miclãuº, 2nd Clinic of General and Oncological Surgery, City Hospital Timiºoara
str. Gh. Dima 5, 300079 Timiºoara
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Background
In the case of mechanic occlusions by strangulation
(hernias and strangulated eventration) and by intestinal
volvulus, it is produced a significant ischemia at the level
of the intestinal wall as a result of the consecutive
vascular disorders. Assessment of bowel viability in
cases with bowel ischemic lesions continues to remain
one of the important intraoperatively moments. The
accuracy of this assessment allows avoiding useless
intestinal resections and consequently the secondary
morbidity and mortality.
The accepted methods for intraoperative assessment
of the intestinal vascularization are represented by the
clinical criteria, the Doppler ultrasound, the test with
intravenous fluorescein and intestinal surface pulse
oximetry (1,2,3,4).
Some of these methods have the disadvantage of the
subjective assessment, while others are laborious (5).
Purpose of the study
In this study we made a comparative evaluation of
three intraoperative assessment methods of the bowel
viability represented by the visual method, the
computerized analysis of the perfusion with fluorescein
and intestinal transserosal pulse oximetry.
Materials and method
The experimental study was performed using the
canine experimental model. The batch taken to study
included four mongrel dogs to which we assessed the
degree of tissue perfusion of some unharmed intestinal
segments, of approximately 10 cm, located in the small
intestine and the colon.
The animal’s preparation
The immobilization of the animals was made in dorsal
decubitus, followed by local preparation, consisting of
hair removal at the level of the abdominal wall and
tegument disinfection with betadine.
It was used general anesthesia in order to create an
optimum intraoperative comfort. For this we preferred
the narco – neuroleptic- analgesic anesthesia type. The
used anesthetics were acetylpromazine in dosage of
0.04 mg x kg, ketamine in dosage of 5 mg x kg, sodic
tiamilal in dosage of 10 mg x kg and halothane 1%.
The anesthesia was well tolerated and the awakening
was very good. The anesthetic and operating technique
was identical for all the dogs.
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The bowel ischemia of the studied intestinal segments
was obtained through the ligature of the convergent
vascular arcades and of the ones located at the level of he
proximal and distal ends of each intestinal segment. The
assessment of the tissue perfusion was made before and
after the ligature of the vascular arcades.
The bowel viability assessment was made using three
methods represented by:
n visual assessment of the color, pulsation and
motility modifications;
n computerized analysis of the test with fluorescein
(fluorometry) (4,5,6);
n bowel surface pulse oximetry (1,2,6,7).
The intraoperative bowel pulse oximetry was made
using a Minimon 7133 B (Kotron Instruments Ltd.
England) monitor having a digital type sensor.
Experimental study
To all the dogs taken into study the determination of
the bowel viability by the three methods was made
initially and then after applying the vascular ligatures at
intervals of 10, 30 and 60 minutes, the last determination
being made at 24 hours postoperative.
The visual assessment of the bowel viability was
made after the infiltration of the mezentery with xilocaine
1% and after having rapped the loops in compresses with
warm physiologic serum.
The results of the visual assessments of the color
modifications, motility and pulsation of the intestinal
loop were classified in five stages;
n normal = ischemia degree 0 %;
n minor = ischemia degree 5 %;
n moderate = ischemia degree 15 %;
n increased = ischemia degree 30 %;
n severe = ischemia degree 45 %.
The data obtained as a result of assessments through
pulse oximetry represent a percentage value of the
oxygen saturation of the intestinal surface on which the
digital sensor was placed - % SaO2. After making the
computerized analysis of the fluorescein test we
obtained values that represent a percentage ratio of the
ischemic surface form the whole examined area.
With the help of the Spearman rank test were made
correlations between the three intra-operating
assessment methods of the bowel ischemia.
Results
The results of the comparative evaluation of the bowel
ischemia before and after the vascular ligature of the four
dogs included in the study are presented in the table1 as
an arithmetic mean.
Table 1. Results of evaluation of intestinal viability throught three methods

Bowel segment Method (%) Time - minutes

0 min 10 min 30 min 60 min 24 hour
Visual 0 26 45 45 ›50
Small bowel Fluorescein 0 9,3 13,4 19,2 49,4
Oximetry 96,5 88 81,5 73 *
visual 0 18,75 30 45 ›50
Large bowel fluorescein 0,11 8,7 14,1 20,8 55,6
oximetry 94 89 80 *
visual 1,36 7,5 10 10 -
Standard
fluorescein 0 0,34 0,36 0,40 0,62
deviation
oximetry 0,57 2,82 2,64 0,81 1,08

* values under 65% was not registered by the sensor

The visual assessment of the jejunum and of the
healthy colon to all the four dogs form the studied
experimental lot was normal, the ischemia degree being
0%. The values of the test with fluorescein varied
between 0 % and 0.11 %. The saturation in oxygen of the
healthy loops had values between 94% and 98%. These
values are consistent to the data from the literature
reported for the canine model. (7,8,9).
In an interval of 10 minutes from inducing the bowel
ischemia by vascular ligatures, we find a moderate to
high ischemia degree (18,75% – 26%) by visual
appreciation. The values obtained by analysis with
fluorescein at the two intestinal sites were of 8,7%
respectively 9,3%, and through intestinal surface pulse
oximetry SO2 were 88% respectively 89%. These values
correspond to a minor degree of tissue hypoperfusion,
the modifications at ultrastructural level being reversible.
(10,11)
The determinations made in interval of 30 minutes
from the ischemic interval, revealed the considerable
increase of the degree of bowel ischemia. The fluoro-
metry revealed increased values of 13.4% respectively
14.1%. In the same time, intestinal pulse oximetry
reveals decreased values of intestinal saturation in
oxygen, 81,5% at the small bowel and 80% at the colon.
This results have the significance of an important
ischemia followed by lesions with irreversibility
tendency. The visual assessment of the bowel ischemia
within a 30 minutes interval was above the instrumen-
tally recorded values being assessed as increased to
severe.
The records made within one hour and 24 hours
revealed an ascending curve consistent to the increase
of the severity of the bowel ischemia. At the same time
we find a decrease of the evaluation differences between
the three methods. The visual method revealed a severe
bowel ischemia (over 45%). Through the determinations
obtained by fluorometry and pulse oximetry the obtained
values were of 19,2% respectively 20,8%, and SaO2
were under 65%, which allowed the interpretation of the
bowel ischemia as being high.
Values of intestinal SaO2 under 65% were not recorded
by the pulse oxymeter sensor which explained the
absence of those values from table 1.
The higher values of the ischemia degree recorded at
the level of the colon segments in relation with the ones
of the small intestine can be explained by the disposal of
the vascularization at the colon level.
By calculating the standard deviation of the results
obtained through the three methods it was found the
increased subjectivity degree for the visual assessment
of the degree of bowel ischemia.
Analyzing the standard deviation of the parameters
obtained on each intestinal segment and using the
Spearman’s test results we found an important
correlation (r=0.934 and p=0.001) between the
fluorescein and pulse oximetry method in assessing the
degree of bowel ischemia.
The ways to obtain the bowel ischemia by ligature of
the converging vascular arcades and of the proximal and
distal located arcades at the ends of each bowel
segment, can explain the recorded differences between
the fluorescein and pulse oximetry method. By vascular
obliteration and the subsequent ischemic modifications,
in the ischemic bowel segment it is retained a quantity of
fluorescein that is drained more slowly which explains
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 the smaller values of the ischemia degree, registered in
the first 30 – 60 minutes. The method of determination of
the oxygen saturation of the ischemic bowel segments is
not influenced from this point of view, making a true
assessment of the ischemia degree.
Conclusions
The experimental study that was made shows that
the pulse oximetry and the fluorometry represent
efficient and objective methods in assessment of the
ischemic modifications at the level of the bowel loops.
Determining the bowel viability through easy technical
pulse oximetry, easy to interpret and to repeat and at the
same time it is well tolerated.(1,2,4,12)
The pulse oximetry is the preferred alternative to the
visual assessment for estimation of the intraoperative
bowel viability, because the visual method is subjective
and submitted to an increased risk of mistaken
evaluation.(1,2)
Intraoperative assessment of bowel ischemia by
pulse oximetry avoids the risk of useless bowel
resections.

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