Appendix Length Research Articles

The anatomical position of the vermiform appendix and its morphometry in relation to the extension of the mesoappendix: a study on fresh cadavers

Introduction: the Vermiform Appendix (VA) is a highly variable organ, being an enigma for the surgeon regarding its position, size and symptomatology. Rapid and accurate diagnosis for adequate treatment of acute appendicitis not only depends on the symptoms, but also on the knowledge of variations in its anatomical position. Objective: to determine the occurrence of the anatomical position of the VA in fresh cadavers, its relationship with the mesoappendix and morphometry. Material and method: the Vermiform Appendages (VAs) of 50 fresh cadavers were examined, the morphological aspects and morphometry of the VAs were studied, such as: position, length and diameter of the appendix, in addition to the length of the mesoappendix and whether it occupied the entire length of the appendix length. Morphometric data were performed with a digital caliper with a precision of 0.01 mm. Result: of the 50 cadavers autopsied during the study, 44 (88%) were male and six (12%) were female. Age ranged from 14 to 80 years, with an average of 36.8 years. Regarding the biotype, 44% (22) were athletic, 32% (16) leptosomic and 24% (12) pycnic. The VA was located in six different positions, with the pelvic and retrocecal positions being the most prevalent. The mesoappendix occupied, in 92% of the cases, the entire length of the VA. Conclusion: the most frequent position of the VA was the pelvic type. Knowledge about the anatomical position of the appendix and the complete mesoappendix in the population can contribute significantly to improving the early clinical diagnosis of appendicitis and, consequently, reducing morbidity.

Variation in Anatomical Position of Vermiform Appendix

Background: Delaying acute appendicitis diagnosis may cause appendix perforation and abscess or peritonitis. Appendectomy is one of the most common surgeries in Pakistan, however little is known about vermiform appendix variation architecture. Hence, appendix anatomy may improve prognosis, this research identified appendix anatomical locations, length, and age and sex relationships. Objective: This study aimed to identify the anatomical sites of the appendix, the length of the appendix and to examine the associations between these factors and age and sex. Study Design: Retrospective cross-sectional study Study Setting: This study was conducted in anatomy department of Islamic International Medical College, Rawalpindi from August 2022 to January 2023. Methodology: This retrospective cross-sectional research was completed in the (department and hospital name) between (year). This study was approved from Ethical review committee with IRB (no). The patients reports were taken for the completion of the study. The CT scan of both gender from 8 to 60 years with the help radiologist suggestions were included in this study. Together with a radiologist, we analyzed CT axial images, a coronal of 1.5 mm thickness, and a sagittal reconstruction to assess the anatomical findings of the vermiform appendix retrospectively. Results: There were 300 total participants in this research, 165 (55%) were female and 135 (45%) were male between 8years to 60 years of age. In both sexes, the following sites were found Pelvic, Post ileal, Pre ileal, Retro caecal, Retro colic, Retro Para colic, and Sub caecel. Appendix length and site was shown to be significantly different in gender and age (p<0.001). Children less than 10 years old were more likely to have an incomplete mesoappendix. According to our findings, males have a longer appendix than females do. On the other hand, we discovered that the appendix tends to become longer with age. Practical implication: The location of the appendix reportedly varies among ethnic and geographical groups. Preoperative planning requires knowledge of these variations. Although appendectomy is one of the most common operations in Pakistan, very little is known about vermiform appendix variation anatomy in the country. Conclusion: This study's findings showed that the vermiform appendix is most often seen in the pelvic position on CT in the Karachi-based population. In conclusion, the high prevalence of anterior location and full mesoappendix in our group suggests that acute appendicitis may be more easily and quickly diagnosed in our demographic, with fewer instances of sequelae including perforation and gangrene. Keywords: Vermiform Appendix, Pelvic, Post ileal, Pre ileal, Retro caecal, Retro colic, Retro Para colic, and Sub caecel

Biography and Bernard Bailyn: The Ordeal of Thomas Hutchinson and the “Logical Obligation” of Historical Research

Biography and Bernard Bailyn: <i>The Ordeal of Thomas Hutchinson</i> and the “Logical Obligation” of Historical Research

Clinical characteristics of recurrent appendicitis

Objective: To analyze clinical characteristics of recurrent appendicitis. Methods: A retrospective cohort study was carried out. Clinical data of patients who underwent appendectomy due to acute appendicitis confirmed by pathology in the Affiliated Hospital of Qingdao University from January 2011 to December 2015 were analyzed retrospectively. Exclusion criteria: (1) age of less than 18 years;(2) chronic appendicitis; (3) periappendiceal abscess; (4) appendiceal mucocele or mucinous neoplasms; (5) appendiceal neuroendocrine tumors or cancers; (6) appendicitis during pregnancy; (7) concurrent AIDS, hematological disease, autoimmune disease, inflammatory bowel disease or advanced cancer; (8) other simultaneous surgery. A total of 373 patients were enrolled the study. These patients were divided into the recurrent group (133 cases) and the first episode group (240 cases) according to the previous history of antibiotic therapy for acute appendicitis. The prevalence of recurrent appendicitis was calculated, and the clinical characteristics were analyzed, including gender, age, comorbidities and preoperative CT images. Results: Of 373 patients, 209 were male and 164 were female, with a median age of 42 (18 to 88) years. Median recurrent time of the recurrent group was 4 (1 to 60) months. Compared to the first episode group, the recurrent group had higher proportion of age <50 years [71.4% (95/133) vs. 57.5% (138/240), χ(2)=7.081, P=0.008], higher proportion of concurrent diabetes [13.5% (18/133) vs. 5.4% (13/240), χ(2)=7.399, P=0.007], shorter onset time [(41.7±13.6) hours vs. (59.4±56.2) hours, t=-3.286, P=0.001], lower proportion of abdominal tension and rebound pain [57.9% (77/133) vs. 66.7% (160/240), χ(2)=5.065, P=0.024], lower score of modified Alvarado score [(5.6±1.9) point vs. (6.1±1.9) point, t=-2.417, P=0.016], lower WBC count [(10.5±4.6) ×10(9)/L vs. (11.5±4.5)×10(9)/L, t=-1.190, P=0.047], higher percentage of lymphocyte [(19.4±14.7)% vs. (16.1±13.3)%, t=2.069, P=0.039]. In the recurrent group, ratio of length of removed appendix ≥7 cm was higher as compared with the first episode group [44.4% (59/133) vs. 32.9% (79/240), χ(2)=4.808, P=0.028], while the ratio of complicated appendicitis was significantly lower [8.3% (11/133) vs. 22.9% (55/240), χ(2)=10.823, P=0.001]. CT images were available in 129 patients, intraluminal appendicoliths was found in 19 of 50 patients (38%) in the recurrent group, while in 16 of 79 patients (20.3%) in the first episode group, and there was statistically significant difference between the two groups (χ(2)=4.880, P=0.027). Conclusions: Clinical characteristics of recurrent acute appendicitis include age less than 50 years, concurrent diabetes, short onset time, less abdominal tension or rebound pain, low modified Alvarado score, low WBC count, high percentage of lymphocyte, appendix length longer than 7 cm, non-complicated appendicitis and intraluminal appendicoliths.

Histopathological features of incidental appendectomy specimens obtained from living liver donors.

To determine the histopathological features of incidental appendectomy specimens obtained from living liver donors (LLDs) Materials and Methods: Between September 2005 and November 2018, 1910 LLDs underwent living donor hepatectomy at our institute. Incidental appendectomy together with living donor hepatectomy (LDH) was performed in 170 LLDs. The decision for incidental appendectomy was made by experienced gastrointestinal surgeons. Histopathological features of the appendectomy specimens were analyzed by two pathologists, and the following parameters were retrospectively evaluated: age, sex, appendix length (mm), appendix width (mm), presence of appendicitis, and unusual histopathological findings. Histopathological findings from 97 male and 73 female LLDs aged between 18 and 64 (median: 30) years were retrospectively examined. The length of the appendix vermiformis ranged from 25 to 120 (median: 70) mm, whereas its width ranged from 4 to 13 (median: 6) mm. The following histopathological findings were observed: normal appendix vermiformis (n=137), fibrous obliteration (n=13), acute appendicitis (n=5), enterobius vermicularis (n=4), lymphoid hyperplasia (n=4), low-grade appendiceal mucinous neoplasm (n=2), mucinous cystadenoma (n=1), grade 1 neuroendocrine tumor (n=1), hyperplastic polyp (n=1), enterobius vermicularis with fibrous obliteration (n=1), and acute appendicitis with eosinophilic infiltration (n=1). This study showed that a careful inspection of the abdominal cavity was useful, and appendectomy should be performed when required. In addition, even if the macroscopic appearance of the appendectomy specimens is normal, histopathological evaluations facilitate an early diagnosis of numerous unusual appendiceal diseases.

Comparison of clinical and histopathological features of patients who underwent incidental or emergency appendectomy.

BACKGROUNDIncidental appendectomy can be defined as the removal of a clinically normal appendix during another surgical procedure unrelated to appendicitis or other appendicular diseases.AIMTo compare the demographic, biochemical, and histopathological features of the patients who underwent incidental and standard appendectomy.METHODSThe demographic, biochemical, and histopathological data of 72 patients (Incidental App group) who underwent incidental appendectomy during living donor hepatectomy at our Liver Transplant Center between June 2009 and December 2016 were compared with data of 288 patients (Acute App group) who underwent appendectomy for presumed acute appendicitis. The Incidental App group was matched at random in a 1:4 ratio with the Acute App group in the same time frame. Appendectomy specimens of both groups were re-evaluated by two experienced pathologists.RESULTSStatistically significant differences were found between groups in terms of age (P = 0.044), white blood cell count (P < 0.001), neutrophil (P < 0.001), lymphocyte (P < 0.001), red cell distribution width (P = 0.036), mean corpuscular hemoglobin (P = 0.001), bilirubin (P = 0.002), appendix width (P < 0.001), and presence of acute appendicitis histopathologically (P < 0.001). However, no statistically significant differences were found between groups in terms of gender, platelet, mean platelet volume, mean corpuscular volume, platelet distribution width, appendix length. While the most common histopathological findings in the Incidental App group were normal appendix vermiformis (72.2%), fibrous obliteration (9.7%) and acute appendicitis (6.9%), the most common histopathological findings in the Acute App group were non-perforated acute appendicitis (62.8%), perforated appendicitis (16.7%), lymphoid hyperplasia (8.3%), and appendix vermiformis (6.3%).CONCLUSIONCareful inspection of the entire abdominal cavity is useful for patients undergoing major abdominal surgery such as donor hepatectomy. We think that experience is parallel to the surgeon’s foresight, and we should not hesitate to perform incidental appendectomy when necessary

Evaluation of Liver Transplant Recipients Underwent Incidental Appendectomies

OBJECTIVE:To assess the clinicopathological features of liver transplant recipients underwent incidental appendectomies.METHODS:Between September 2002 and July 2019, 2500 patients underwent liver transplantation at our Liver Transplant Institute, including 38 (24 males, 14 females) who also underwent incidental appendectomies. Incidental appendectomies were performed on 24 patients during recipient hepatectomies and on 14 during relaparotomies due to various surgical conditions. The following patient parameters were retrospectively evaluated: age, sex, underlying liver disease, liver transplant type, appendectomy indication, appendix length (mm) and diameter (mm), presence of appendicitis, and histopathological findings.RESULTS:The 38 patients who underwent incidental appendectomies had a mean age of 18.3±21.7 (range: 1–66) years and median appendix lengths and diameters of 55 (range: 19–90) mm and 6 (range: 4–20) mm, respectively. Histopathologically, the appendectomy specimens were classified as follows: vermiform appendix (n=16), lymphoid hyperplasia (n=13), acute appendicitis (n=3), fibrous obliteration (n=3), perforated appendicitis (n=1), mucinous cystadenoma (n=1), and appendiceal serosa invasion by sigmoid adenocarcinoma (n=1). There were no postoperative complications, including wound infections, abscesses, or leakage from the appendiceal stumps, related to the incidental appendectomies.CONCLUSION:This study demonstrated that incidental appendectomies can be successfully performed in immunosuppressed patients. However, additional studies are required to confirm these results.

Morphological variations of the vermiform appendix in Iranian cadavers: a study from developing countries.

The vermiform appendix is a worm-like tube containing a large amount of lymphoid follicles. In our knowledge, there is a little standard data about the vermiform appendix in Iranian population. Therefore, the objective of this study was to investigate the normal appendix size in Iranian cadavers. A cross-sectional study was undertaken between June 2014 and July 2015, in the autopsy laboratory, Legal Medicine Organisation, Razavi Khorasan province, Iran. A total of 693 cadavers with the mean age of 40.46 ± 20.99 years were divided into 10 groups. After writing down position of the appendix, the length, diameter and weight of the appendix were measured. Statistical analysis was performed using SPSS software. The mean values of the demographic characteristics included - age: 40.46 ± 20.99 years; weight: 63.47 ± 17.84 kg; height: 159.95 ± 28.23 cm. The mean values of the appendix length, diameter, weight and index in the cadavers were 8.52 ± 2.99 cm, 12.17 ± 4.53 mm, 6.43 ± 3.26 g and 0.013 ± 0.01, respectively. The most common position of the appendix was retrocaecal in 71.7% of cases. Significant correlations were evident between the value of demographic data and appendix size (p < 0.05). The diameter (p = 0.002) and index of the appendix (p = 0.003) showed significant difference between males and females. Having standard data on the vermiform appendix is useful for clinicians as well as anthropologists. The findings of the present study can provide information about morphologic variations of the appendix in Iranian population.

A prospective clinical study of the effects of the physical features of the appendix on perforation.

Acute appendicitis (AA) is one of the most common surgical emergencies, whosepostoperative morbidity and mortality increase significantly when the appendix perforates. The identification of factors that lead to perforation in these patients might effectively reduce morbidity. In this study, factors associated with perforation in AA were examined. The study included sixty patients divided into equal non-perforated and perforated groups. Preoperative body mass index (BMI) and prehospital delay of the patients, the appendix location, presence of fluid or abscesses during surgery, and the appendix wall thickness, root and end diameters, and length in the surgery specimen were compared. The patients were comprised of forty males and 20 females, with a median age of 27 (range 16-84) years. BMI was significantly higher in the perforated group than the non-perforated group (p=0.039). There was no difference between the groups in terms of the presence of fluid (p=0.792); the presence of abscess was higher in the perforated group (p=0.017). The most common location of the appendix was retrocecal in the perforated group (p=0.007). While there was no difference in the appendix end diameter, root diameter was significantly higher in the perforated group (p=0.041), as were wall thickness (p<0.001) and appendix length (p=0.037). BMI, prehospital delay, a retrocecally positioned appendix, presence of an abscess, and appendix wall thickness, root diameter, and length are risk factors for perforation in AA.

Incidental Appendectomy in Donors Undergoing Hepatectomy for Living-Donor Liver Transplantation

BackgroundThe aim of this study was to investigate the morbidity associated with appendectomy in living liver donors undergoing hepatectomy. MethodsThe medical records of 338 donors who underwent hepatectomies for living-donor liver transplantation between 2008 and 2010 were reviewed retrospectively. The patients were divided into 2 groups on the basis of appendectomy: patients in group A (n = 126) received incidental appendectomies in conjunction with donor hepatectomy, and those in group B (n = 212) underwent hepatectomy alone. ResultsNo significant difference in age, gender, or body mass index was found between groups. The wound infection rate (P = .037) and length of hospital stay (P = .0038) were higher in group A than in group B. Intraoperative findings in 126 donors in group A were subserosal (n = 4), retrocecal (n = 6), or hard nodular (n = 11) appendix; hyperemic appendix with edema (n = 9); appendix length ≥8 cm (n = 18); and palpable fecalith (n = 78). Histopathologic examination of appendix specimens revealed lymphoid hyperplasia with a fecalith (n = 32), fecalith only (n = 32), acute appendicitis (n = 20), normal anatomy (n = 18), fibrous obliteration (n = 9), lymphoid hyperplasia (n = 9), Enterobius vermicularis (n = 3), appendiceal neuroma (n = 1), carcinoid tumor (n = 1), and mucoceles (n = 1). ConclusionAlthough incidental appendectomy increased the wound infection rate and length of hospital stay, this procedure is necessary for the prevention of potential complications due to appendicitis when the exploration of the ileocecal region in patients undergoing donor hepatectomy reveals one or more of the following: appendix length ≥8 cm; dropsical, hyperemic, subserosal, nodular, and/or retrocecal appendix; and/or palpable fecaloma.

Development of Fetal Intestinal Length during 2nd-Trimester in Normal and Pathologic Pregnancies

Linear growth of the human fetal gastrointestinal tract is not often discussed in the literature, and little is known about the effects of chromosomal abnormalities and intrauterine growth restriction (IUGR) on intestinal length, especially during the 2nd trimester. Accurate evaluation of intestinal length and knowledge of normal and reference values are of clinical importance. For example, intestinal resection may be necessary in preterm infants with necrotizing enterocolitis or mid-gut volvulus, and the surgeon should use data to be judicious in the amount removed. Linear measurements are essential in evaluating fetal development ultrasonographically and are an integral part of the postmortem examination. The intestinal lengths of 203 2nd-trimester fetuses and premature infants were measured. Small intestine length (SIL), colon length (CL), total bowel length (TBL; TBL = SIL + CL), and the length of the appendix (AL) increased with gestational age. No differences between the genders were observed. Colon length increased secondary to maceration, but no such effects were shown on SIL, TBL, or AL. No differences were shown in relation to IUGR. Small intestine length, CL, and TBL, but not AL, were shorter in fetuses with trisomy 21. Appendix length was not affected by any of the studied factors. We propose that the measurement of the length of the appendix may be used as an additional parameter for the postmortem evaluation of gestational age. Furthermore, its assessment may have potential as an ultrasonographic indicator of gestational age, particularly for the 2nd trimester.

Design and instrumentation of new devices for performing appendectomy at colonoscopy (with video)

There is increasing interest in natural orifice surgery (NOS). Because the lumen of the appendix is connected to the cecum, a minimally invasive method for removing the appendix by colonoscopy may be feasible. Our purpose was to design, develop, and test new devices for inverting and removing the appendix by colonoscopy. Prospective prototype development program. University-based study in 25 colons from adult human cadavers. Various prototypes were evaluated by inserting them into the appendiceal orifice to its luminal tip, with the intent to invert the appendix in a controlled fashion into the lumen of the cecum. The advantage of using a tubular structure as a counterforce to aid inversion of the appendix was evaluated. When inversion was incomplete, the growing tissue strain was relieved by endoluminal incision of the mesenteric side of the appendix. Closure methods with endoloops or ligating loops were studied. Appendiceal resection was completed by snare diathermy, leaving an inverted intraluminal stump. Ability to invert the appendix into the cecum. The mean appendix length and luminal diameter were 84 +/- 23 mm and 4.9 +/- 1.2 mm, respectively. It was possible to advance various types of inversion devices to the tip of the appendiceal lumen. Partial inversion of the appendix was successful in 22 of 25 tests. Mesenteric tissue tension, tissue volume, and device slippage were the main reasons for incomplete inversion. The complete inversion was achieved with a combination of vacuum, tip grip, counterforce at the appendix base, and eventually endoluminal incision. The inversion of the human appendix by colonoscopy seems feasible and may be an alternative approach to conventional appendectomy.

Zur Beziehung zwischen Körperbau und Appendixlänge

In the last decades a lot of significant correlations between clinical and anthropometric parameters were found, e.g. the relationships between somatotypical and endocrine parameters or between body dimensions and echocardiographic heart size. During operation, surgeons often find a wide range of appendix size of patients with varying body dimensions. A goal of this work is the detection of the relationships between anthropometric characteristics (height, weight, body mass index (= BMI)), inflammation parameters (histological inflammation degree, leukocyte count and C-reactive protein (= CRP)) and the appendix length with n=167 consecutive patients (time period 1.1.2004 - 31.12.2006; range of age 7-95 years, median age 20 years; average age of men 27.7, women 26.6 years), which had to be operated because of acute appendicitis. Appendectomy was laparoscopic in 95 % of the patients and open in 5 %. The appendix length of the male patients was high-significantly longer with a mean of 7.5 cm (SD = 2.1) than those of the female patients with 6.3 cm (SD = 1.6). The following mean anthropometric values were registered: height 169.8 (SD = 15.6) cm for the males and 165.2 (SD = 9.6) cm for the females, weight 70.4 (SD = 23.4) kg for the males and 61.9 (SD = 16.1) kg for the females, BMI 24.1 (SD = 5.4) kg/m2 for the males and 22.9 (SD = 4.8) kg/m2 for the females. The mean leukocyte count was 12,700 (SD = 5500)/ml for the males and 11,600 (SD = 4900)/ml for the females, CRP was 4.3 (SD = 5.4) mg/l for the males and 4.5 (SD = 8.9) mg/l for the females. Concerning the histopathological diagnosis, n=76 patients (45.5 %) suffered from a submucous fibrosis bliteration, n 1 (12.6 ) from an acute purulent inflammation degree, n = 65 (38.9 ) from an ulcerative hlegmonous inflammation degree and n (3 ) from a perforation. While no significant Spearman's correlation coefficient between appendix length and CRP was found, the appendix length correlated highly significantly to the body weight (r = 0.25) and significantly to leukocyte count (r = 0.16), body height (r = 0.16), BMI (r = 0.17) and the histological inflammation degree (r = 0.18). Thus, the correlations found were lower than the relationships between anthropometric and endocrine or echocardiographic parameters described in literature.

Sitobion graminis Takahashi, 1950 (Hemiptera, Aphididae): first record in Brazil, biological and morphometric parameters

The species Sitobion graminis Takahashi, 1950 (Hemiptera, Aphididae) was first detected in Brazil in 1998, in Curitiba, Parana state, associated with the grass species Erianthus sp., Calamagrotis sp. and Paspalum urvilei. Both the field-collected and laboratory-reared specimens presented a noticeable intrapopulational variation in body and appendix length and in dorso-abdominal sclerotization. This species has been recorded in Malaysia, New Guinea, India, Philippines and Africa, where it colonizes several species of Poaceae. S. graminis differs from other Sitobion species from Brazil associated with grasses, as it presents black cauda and siphunculi and exhibits a constriction in the base of the last rostral segment. Biological data were obtained in the laboratory by rearing newborn nymphs on the inflorescence of the host plants. They passed through four nymphal instars. The mean duration of the nymphal stage was of 11.4 days, with a mortality ratio of 36.5%. The mean pre-larviposition period was of 1.8 days; mean longevity of the females was 25.2 days; and mean fecundity was 18.7 nymphs/female, ranging from 2 to 41 nymphs/female.

SIMULTANEOUS MALONE ANTEGRADE CONTINENT ENEMA AND MITROFANOFF PRINCIPLE USING THE DIVIDED APPENDIX: REPORT OF A NEW TECHNIQUE FOR PREVENTION OF STOMA COMPLICATIONS

We determine the results and complications of continent urinary diversion and simultaneous Malone antegrade continent enema (MACE) and the Mitrofanoff principle using the divided appendix, and report on the VQQ and VQ technique for prevention of complications at the stoma level. Between June 1995 and June 1999, 40 patients 4 to 22 years old (mean age 9.5) underwent Mitrofanoff procedures in conjunction with the MACE and augmentation cystoplasty as primary (5) or salvage (35) therapy. Of the patients 35 had neuropathic bladder, and 5 had bladder and bowel dysfunction without detectable neurological abnormalities. All patients had an antireflux Mitrofanoff channel constructed using distal part of the appendix with its divided mesothelium. The proximal half of the appendix was preserved as a modified MACE. Average length of appendix was 10.3 cm. (range 9 to 15) and no correlation was found between the length of appendix and age of child. The stoma construction was performed as 2 different techniques. The 2 appendix stomas were initially anastomosed with 2 separate triangular posterior V shape skin flaps on the right lower abdominal wall. Both appendix mucosae were completely buried with a single or double quadrilateral skin flap (VQQ and VQ technique). All patients are continent day and night without diapers. Mean followup was 22 months (range 8 to 48) and the overall incidence of complications was 7.5%. Mitrofanoff stomal stenosis due to catheter false passage occurred postoperatively in 1 case, gas leakage from the MACE in 1 and partial mucosal prolapse in 1. The MACE and Mitrofanoff principle have proved invaluable for the treatment of children with urinary and fecal incontinence. The divided appendix with 2 separate mesotheliums is an ideal channel for simultaneous Mitrofanoff and MACE when the appendix length is 9 cm. or more with a suitable branching mesothelium. When the appendix is short we prefer to use it as the Mitrofanoff and create a pediculed tube flap from the cecum for the MACE. All patients with a short appendix or history of appendectomy operated on by different techniques, such as the Monti procedure, Casale technique, cecal flap or ureteral Mitrofanoff, were excluded from our study. Most of the minor complications are preventable by meticulous technique. The VQQ and VQ stomas have the lowest incidence of complications and produce the most satisfactory cosmetic appearance.

Simultaneous Malone antegrade continent enema and Mitrofanoff principle using the divided appendix: report of a new technique for prevention of stoma complications.

We determine the results and complications of continent urinary diversion and simultaneous Malone antegrade continent enema (MACE) and the Mitrofanoff principle using the divided appendix, and report on the VQQ and VQ technique for prevention of complications at the stoma level. Between June 1995 and June 1999, 40 patients 4 to 22 years old (mean age 9.5) underwent Mitrofanoff procedures in conjunction with the MACE and augmentation cystoplasty as primary (5) or salvage (35) therapy. Of the patients 35 had neuropathic bladder, and 5 had bladder and bowel dysfunction without detectable neurological abnormalities. All patients had an antireflux Mitrofanoff channel constructed using distal part of the appendix with its divided mesothelium. The proximal half of the appendix was preserved as a modified MACE. Average length of appendix was 10.3 cm. (range 9 to 15) and no correlation was found between the length of appendix and age of child. The stoma construction was performed as 2 different techniques. The 2 appendix stomas were initially anastomosed with 2 separate triangular posterior V shape skin flaps on the right lower abdominal wall. Both appendix mucosae were completely buried with a single or double quadrilateral skin flap (VQQ and VQ technique). All patients are continent day and night without diapers. Mean followup was 22 months (range 8 to 48) and the overall incidence of complications was 7.5%. Mitrofanoff stomal stenosis due to catheter false passage occurred postoperatively in 1 case, gas leakage from the MACE in 1 and partial mucosal prolapse in 1. The MACE and Mitrofanoff principle have proved invaluable for the treatment of children with urinary and fecal incontinence. The divided appendix with 2 separate mesotheliums is an ideal channel for simultaneous Mitrofanoff and MACE when the appendix length is 9 cm. or more with a suitable branching mesothelium. When the appendix is short we prefer to use it as the Mitrofanoff and create a pediculed tube flap from the cecum for the MACE. All patients with a short appendix or history of appendectomy operated on by different techniques, such as the Monti procedure, Casale technique, cecal flap or ureteral Mitrofanoff, were excluded from our study. Most of the minor complications are preventable by meticulous technique. The VQQ and VQ stomas have the lowest incidence of complications and produce the most satisfactory cosmetic appearance.

Laparoscopic antegrade continence enema in situ appendix procedure for refractory constipation and overflow fecal incontinence in children with spina bifida.

The antegrade continence enema procedure allows patients with neurogenic bowel to administer large volume enemas through a right lower quadrant stoma to flush the colon every other day. This procedure results in freedom from refractory constipation and diapers required by unexpected episodes of overflow fecal incontinence. We present a simplified laparoscopic technique using in situ appendix. A total of 6 male and 10 female children with a mean age of 12 years (range 4 to 21) and neurogenic bowel secondary to myelomeningocele underwent the antegrade continence enema in situ appendix procedure. The procedure was done with laparoscopic assistance, and associated with other bladder and bladder outlet reconstructive surgery in 5 patients. In 3 patients, a purely laparoscopic antegrade continence enema in situ appendix procedure was performed. The appendix and cecum were mobilized, and the tip of the appendix was anastomosed directly to the skin of the right lower quadrant through 1 of the 5 mm. lower quadrant port sites. The continence mechanism is simply a function of the appendix length and the mucosal coaptation of the appendiceal lumen. A 6Fr silicone Foley catheter is used to stent the mucocutaneous anastomosis. Concomitant procedures included ileocystoplasty, ileovesicostomy, sigmoidovesicostomy or ureterovesicostomy, and/or pubovaginal sling done through a low Pfannenstiel incision after laparoscopic mobilization of the appendix and cecum. The 3 patients treated with the laparoscopic antegrade continence enema procedure ate the day of surgery and were discharged home the next morning. Constipation and fecal incontinence resolved in all cases. All antegrade continence enema stomas were catheterized easily with a 6 or 8Fr feeding tube and were continent. Complications in the 8 laparoscopic and laparoscopic assisted cases included stomal stenosis requiring dilation in the office and obstructive volvulus associated with malrotation requiring segmental resection. Patient mothers in particular were gratified by this procedure at a mean followup of 11/2 years. The simplified antegrade continence enema in situ appendix procedure works well for refractory constipation and overflow fecal incontinence in children with neurogenic bowel secondary to spina bifida. Coaptation of the appendiceal lumen and use of small catheters allow for persistent continence without a formal surgically constructed valve mechanism. The combined antegrade continence enema and either ileovesicostomy or sigmoidovesicostomy continent urinary diversion procedures allow children to control bowel and bladder evacuation programs. A laparoscopic approach is reasonable particularly in cases requiring no other procedures.

Normal length of the human fetal gastrointestinal tract.

Little information is available on the normal length of the gastrointestinal tract in fetuses or on factors that may affect its growth. To determine normal growth patterns of the fetal intestine, 58 fetuses received in the Central Laboratory for Human Embryology between January 1, 1987, and July 1, 1988, in which no abnormalities were noted on autopsy, were studied. The gastrointestinal tract was removed from the fetus en bloc from the esophagogastric junction to the pelvic floor and dissected. Measurements of stomach, small and large intestines, and appendix length were made and correlated with gestational age as determined by footlength. Overall growth of the gastrointestinal tract as well as that of each component was linear with respect to gestational age. In addition, five fetuses with omphalocele, 16 with cardiac malformations, and 20 with chromosomal abnormalities were studied. The total lengths of the gastrointestinal tracts in the first group were below the normal range in four of five fetuses. Those with cardiac defects had intestinal lengths below the mean, but the measurements were abnormal in only three. In both groups those fetuses with chromosomal abnormalities appeared to have shorter intestinal tracts than those with normal or unknown karyotypes. The gastrointestinal tracts of aneuploid fetuses fell within the normal range until approximately 20 weeks gestation, after which growth decreased. This growth failure may reflect the growth retardation seen in fetuses with chromosomal abnormalities.