The effects of surgery on gastrointestinal motor activity

Gastrointestinal surgical procedures have the potential to disrupt motor activity in various organs of the gastrointestinal tract or, indeed, throughout the entire alimentary canal. Several of these motor effects have important clinical consequences and have also served to advance our understanding of the regulation of gastrointestinal motor activity. This review will focus, in particular, on the effects of surgery on the small intestine, and will attempt to emphasize the implications of these studies for our understanding of small intestinal motility, in general.

motility; motor activity; small intestine; surgery; intestinal resection; intestinal transplantation

Authorship

.M.M. Quigley

, Department of Internal Medicine, Department of Internal Medicine

J.S. Thompson

University of Nebraska Medical Center, Department of Surgery, Section of Gastroenterology and HepatologyUniversity of Nebraska Medical CenterUniversity of Nebraska Medical Center, Department of Surgery, Section of Gastroenterology and Hepatology

SCIMAGO INSTITUTIONS RANKINGS

, Department of Internal Medicine, Department of Internal Medicine

Figures

Figures (9)

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Figure 1
- A schematic presentation of the gut illustrating the components of the motor apparatus that may be disrupted by surgical procedures. These include the intestinal muscle layers (circular and longitudinal), the enteric nervous system (submucous and myenteric plexuses) and extrinsic autonomic nerves.

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Figure 2
- The migrating motor complex (MMC).
A, Recording of intraluminal pressure activity from the proximal small intestine in man. Note the various components of the migrating motor complex which include phase 2, irregular phasic contractions (seen on the left of this figure), phase 3, a band of rhythmic phasic contractions that slowly migrates through the gut (seen in the center of the figure), and phase 1, motor quiescence (on the right hand side of this figure). This cycle comprising phases 1-3 will continue to occur as long as the individual remains fasted.
B, Migrating motor complex. Recording of myoelectrical activity from a dog. Note phase 3, represented by an uninterrupted band of spike activity, migrating through the proximal small intestine.
C, Schematic presentation of an entire 4-h-fasting recording from a dog. Each dot denotes phase 3 of the migrating motor complex. Note that phase 3 recurs at a regular interval of approximately 90 min and migrates through the small intestine.

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Figure 3
- Fasting motor activity of canine ileo-colonic junction. Note phase 3 of the migrating motor complex migrating through the distal ileum, across the ileocecal sphincter (ICS) into the colon.

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Figure 4
- The postprandial motor response. On feeding, migrating motor complex activity is lost and, as illustrated in recordings of intraluminal pressure activity (A) and myoelectrical activity (B) from the proximal small intestine in man and dog, respectively, is replaced by intense irregular activity.

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Figure 5
- Effects of intestinal transection on intestinal motor activity.
A, Schematic presentation illustrating the effects of transection on intestinal motor apparatus. A complete transection disrupts the longitudinal continuity of intestinal muscle and the enteric nervous system.
B, Effects of transection on slow-wave frequency in the canine small intestine. Graphic representation of slow wave frequency along the canine small intestine in control animals and in three groups of animals who had undergone jejunoileal autotransplantation (AT) and were studied at varying intervals following the procedure. Electrode at 5 cm was located in the intact duodenum. All other electrodes were distal to the site of transection and reanastamosis in autotransplanted bowel. Note sharp drop at slow wave frequency distal to site of transection and reanastamosis in all groups.

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Figure 6
- Effects of autotransplantation (total extrinsic denervation) on intestinal motor activity in a canine model.
A, Autotransplant model. Note that autotransplantation involved removal and reimplantation of the entire jejunoileum with heterotopic vascular anastamoses and complete disruption of all nerves and lymphatics to the autotransplanted segment.
B, Schematic presentation of the effects of autotransplantation on the intestinal motor apparatus. Autotransplantation involves disruption of longitudinal continuity of intestinal muscle and the enteric nervous system, as well as complete extrinsic denervation.
C, Effects of autotransplants on migrating motor complex. In this part of an entire fasting recording from an autotransplanted dog, note retention and normal propagation of phase 3 of the migrating motor complex (denoted by filled circles) through the autotransplanted segment. Phase 3 also recognized in intact proximal duodenum but there is a complete lack of coordination between phase 3 activity in the intact duodenum and the autotransplanted segment. Open circles represent propagating phasic bursts.
D, Effects of autotransplantation on postprandial motor response. Note the complete absence of postprandial motor response in the autotransplanted segment.

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Figure 7
- The motor response to an extensive intestinal resection. Recordings of motor activity from the intestinal remnant in an animal following resection of the distal 75% small intestine. Note the dominance of intense "cluster" activity throughout the intestinal remnant.

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Figure 8
- Motor activity in the transplanted small intestine. Recording of intraluminal pressure activity three weeks following transplantation of the entire small intestine in a child. Note preservation of phase 3 activity in the transplanted intestine.

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Figure 9
- Morphology of the intestinal motor apparatus in the transplanted intestine. A, Low-power magnification (hematoxylin and eosin stain) view of a cross-section through the small intestinal wall obtained at the time of restoration of intestinal continuity, six months following successful small intestinal transplantation. Note intact, normal-appearing, muscle layers (circular above, longitudinal below). B, High-power view of the myenteric plexus from the same specimen. Neuronal cell bodies in the myenteric plexus appear dilated and vacuolated.

Figure 1 - A schematic presentation of the gut illustrating the components of the motor apparatus that may be disrupted by surgical procedures. These include the intestinal muscle layers (circular and longitudinal), the enteric nervous system (submucous and myenteric plexuses) and extrinsic autonomic nerves.

Figure 2 - The migrating motor complex (MMC).
A, Recording of intraluminal pressure activity from the proximal small intestine in man. Note the various components of the migrating motor complex which include phase 2, irregular phasic contractions (seen on the left of this figure), phase 3, a band of rhythmic phasic contractions that slowly migrates through the gut (seen in the center of the figure), and phase 1, motor quiescence (on the right hand side of this figure). This cycle comprising phases 1-3 will continue to occur as long as the individual remains fasted.
B, Migrating motor complex. Recording of myoelectrical activity from a dog. Note phase 3, represented by an uninterrupted band of spike activity, migrating through the proximal small intestine.
C, Schematic presentation of an entire 4-h-fasting recording from a dog. Each dot denotes phase 3 of the migrating motor complex. Note that phase 3 recurs at a regular interval of approximately 90 min and migrates through the small intestine.

Figure 3 - Fasting motor activity of canine ileo-colonic junction. Note phase 3 of the migrating motor complex migrating through the distal ileum, across the ileocecal sphincter (ICS) into the colon.

Figure 4 - The postprandial motor response. On feeding, migrating motor complex activity is lost and, as illustrated in recordings of intraluminal pressure activity (A) and myoelectrical activity (B) from the proximal small intestine in man and dog, respectively, is replaced by intense irregular activity.

Figure 5 - Effects of intestinal transection on intestinal motor activity.
A, Schematic presentation illustrating the effects of transection on intestinal motor apparatus. A complete transection disrupts the longitudinal continuity of intestinal muscle and the enteric nervous system.
B, Effects of transection on slow-wave frequency in the canine small intestine. Graphic representation of slow wave frequency along the canine small intestine in control animals and in three groups of animals who had undergone jejunoileal autotransplantation (AT) and were studied at varying intervals following the procedure. Electrode at 5 cm was located in the intact duodenum. All other electrodes were distal to the site of transection and reanastamosis in autotransplanted bowel. Note sharp drop at slow wave frequency distal to site of transection and reanastamosis in all groups.

Figure 6 - Effects of autotransplantation (total extrinsic denervation) on intestinal motor activity in a canine model.
A, Autotransplant model. Note that autotransplantation involved removal and reimplantation of the entire jejunoileum with heterotopic vascular anastamoses and complete disruption of all nerves and lymphatics to the autotransplanted segment.
B, Schematic presentation of the effects of autotransplantation on the intestinal motor apparatus. Autotransplantation involves disruption of longitudinal continuity of intestinal muscle and the enteric nervous system, as well as complete extrinsic denervation.
C, Effects of autotransplants on migrating motor complex. In this part of an entire fasting recording from an autotransplanted dog, note retention and normal propagation of phase 3 of the migrating motor complex (denoted by filled circles) through the autotransplanted segment. Phase 3 also recognized in intact proximal duodenum but there is a complete lack of coordination between phase 3 activity in the intact duodenum and the autotransplanted segment. Open circles represent propagating phasic bursts.
D, Effects of autotransplantation on postprandial motor response. Note the complete absence of postprandial motor response in the autotransplanted segment.

Figure 7 - The motor response to an extensive intestinal resection. Recordings of motor activity from the intestinal remnant in an animal following resection of the distal 75% small intestine. Note the dominance of intense "cluster" activity throughout the intestinal remnant.

Figure 8 - Motor activity in the transplanted small intestine. Recording of intraluminal pressure activity three weeks following transplantation of the entire small intestine in a child. Note preservation of phase 3 activity in the transplanted intestine.

Figure 9 - Morphology of the intestinal motor apparatus in the transplanted intestine. A, Low-power magnification (hematoxylin and eosin stain) view of a cross-section through the small intestinal wall obtained at the time of restoration of intestinal continuity, six months following successful small intestinal transplantation. Note intact, normal-appearing, muscle layers (circular above, longitudinal below). B, High-power view of the myenteric plexus from the same specimen. Neuronal cell bodies in the myenteric plexus appear dilated and vacuolated.

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