Cecal Flap Research Articles

Robotic-assisted laparoscopic Malone appendicostomy: a 6-year perspective.

A robotic-assisted laparoscopic approach to appendicostomy offers the benefits of a minimally invasive approach to patients who would typically necessitate an open procedure, those with a larger body habitus, and those requiring combined complex colorectal and urologic reconstructive procedures. We present our experience performing robotic-assisted appendicostomies with a focus on patient selection, perioperative factors, and functional outcomes. A retrospective review of patients who underwent a robotic-assisted appendicostomy/neoappendicostomy at our institution was performed. Twelve patients underwent robotic-assisted appendicostomy (n = 8) and neoappendicostomy (n = 4) at a range of 8.8-25.8years. Five patients had a weight percentile > 50% for their age. Seven patients underwent combined procedures. Median operative time for appendicostomy/neoappendicostomy only was 185.0min. Complications included surgical site infection (n = 3), stricture requiring minor operative revision (n = 2), conversion to an open procedure due to inadequate appendiceal length (prior to developing our technique for robotic neoappendicostomies; n = 1), and granuloma (n = 1). At a median follow-up of 10.8months (range 1.7-74.3months), 91.7% of patients were consistently clean with antegrade enemas. Robotic-assisted laparoscopic appendicostomy and neoappendicostomy with cecal flap is a safe and effective operative approach. A robotic approach can potentially overcome the technical difficulties encountered in obese patients and can aid in patients requiring both a Malone and a Mitrofanoff in a single, combined minimally invasive procedure.

Antegrade Colonic Enema Channels in Pediatric Patients Using Appendix or Cecal Flap: A Comparative Robotic vs Open Series.

Introduction: We present perioperative outcomes of a single-center experience with robot-assisted antegrade colonic enema (ACE) channel creation for the treatment of chronic constipation refractory to medical therapy and compare it to the traditional open surgical approach. We also demonstrate a step-by-step video presentation of the robotic approach for cecal flap ACE performed as part of a dual continence procedure in patients with short length of appendix. Methods: A retrospective chart review of pediatric patients who underwent ACE channel creation between 2008 and 2020 was performed. We compared demographics and intraoperative and postoperative variables of the open vs robotic approach. Results: Among 28 patients, 15 were open and 13 robotic. To construct the ACE channel, a cecal flap was utilized in 36%, split appendix in 50%, full-length appendix in 11%, and sigmoid colon in 3% of patients. Both approaches showed equivalent estimated blood loss (50 mL [interquartile range; IQR = 20-100]), median length of hospital stay (7 days vs 8 days, p = 0.7), and median time to return to regular diet (4 days vs 5 days, p = 0.5) (Table 1). Patients in the open group were more likely to have a history of prior abdominal surgeries than those in the robotic group (80% vs 38.5%, p = 0.02). The risk of Clavien-Dindo grade 3 or more complications (40% vs 23.1%, p = 0.04) and the rate of ACE channel stenosis (46.7% vs 7.7%, p = 0.02) were significantly higher in the open approach. Channel stenosis was significantly higher in patients with an appendix ACE channel (87.5% vs 12.5%, p < 0.05) compared to those with cecal flap ACE. [Table: see text] Conclusion: Robot-assisted ACE channel creation is a safe and acceptable alternative with a significantly lower rate of channel stenosis and other clavien dindo grade 3 complications compared to the traditional open approach. Cecal flaps are also at a lower risk of stomal stenosis than appendix.

Prevention and management of complications in various antegrade enema procedures in children: a review of the literature.

The antegrade continence enema (ACE) procedures are successful surgical options to achieve bowel cleaning in children with faecal incontinence due to a neuropathy or an anorectal malformation and an intractable constipation. The reversed and orthotopic appendicocecostomy, tubularized ileal conduit and the tubularized cecal flap are frequently applied procedures in the treatment of faecal incontinence (FI). The most common complications are the stoma stenosis, leakage, prolapse, adhesive obstruction and the difficulty in catheterization. Each procedure has its own advantages and disadvantages with different complication rates. The postoperative complications of ACE procedures may reduce patient compliance and quality of life. Most of these complications can be preventable and are easy to manage. This review aimed to discuss the prevention and management strategies for various ACE procedure complications.

Simultaneous Robotic-Assisted Laparoscopy for Bladder and Bowel Reconstruction

Patients with neurogenic bladder frequently also have bowel dysfunction and a simultaneous urologic and colorectal reconstruction is possible. We present our experience with combined reconstructive procedures using robot-assisted laparoscopy, and demonstrate the utility of a minimally invasive approach that considers both the bowel and bladder management of these patients. We retrospectively reviewed all patients who underwent combined bowel and urologic reconstruction at our institution since the start of our multidisciplinary robotic program. Seven patients were identified in our cohort with a mean age of 6.4 years (3.8-10.1 years). Six patients had myelomeningocele and 1 had caudal regression. Malone appendicostomies were placed in all 7 patients. A split appendix technique was used as a conduit in 5 patients, in situ appendix in 1, and neoappendicostomy with cecal flap in 1. Six patients had a Mitrofanoff appendiceal conduit created, while 1 patient had a sigmoid colovesicostomy for urinary diversion. Five patients required bladder neck repair. One patient had stenosis of the Mitrofanoff and one patient had an anastomotic leak of the sigmoid anastomosis. The average operating time was 526 minutes (313-724 minutes). The median length of stay (LOS) was 5 days (4-7 days), excluding one outlier who suffered an anastomotic leak and had an extended LOS (50 days). All patients who underwent continent bladder reconstruction are dry on their current catheterizing regimen, 6/7 are clean with antegrade flushes. Patients with neurogenic bladder often have coexisting bowel dysfunction, which provides an opportunity to reconstruct both organ systems simultaneously and achieve social urinary and bowel continence. Before committing to any intervention, the surgeon should consider both the urologic and gastrointestinal needs of the patient, and perform the needed procedures simultaneously. We describe a number of combined operations aimed at bowel and bladder management that can be performed safely using robot-assisted laparoscopy.

No Appendix is Too Short—Simultaneous Mitrofanoff Catheterizable Vesicostomy and Malone Antegrade Continence Enema (MACE) for Children with Spina Bifida

To present the results of simultaneous creation of both Mitrofanoff stoma and Malone antegrade continence stoma (MACE) using simple division of the appendix and a cecal extension method. Between June 2011 and November 2016, simultaneous Mitrofanoff and MACE was performed in 16 children (12 children-simple division of the appendix, 4 children-appendicovesicostomy and cecal extension of the appendix). Extension of the appendix was achieved by tubularization of the excised cecal flap next to the short appendicular stump. The new extended channel was then wrapped by cecal wall. Follow-up was 40 months (10-74 months). Currently, in all children, both stomas are easily catheterizable. Obstruction of MACE occurred in 5 children (4 with split appendix, 1 with extended appendix); Mitrofanoff stomal stenosis occurred in 1 child. Endoscopic revision and prolonged catheterization of stenotic stomas were effective in all cases. Wound infection and dehiscence was noted in 2 children (both with split appendix). Drainage and intravenous antibiotics were effective. All Mitrofanoffs are continent. In 4 children there is incident minor leakage of the MACE (3 with split appendix and in 1 with extended appendix). The split appendix procedure is feasible. Cecal extension of the appendix seems to be a good option when the appendix is too short for a simple split procedure.

Open and Robotic Techniques for Appendiceal Interposition in Ureteral Stricture Disease

Introduction: Robot-assisted techniques for large ureteral strictures usually involve reconstruction with ureteroneocystostomy, Boari flap, psoas hitch, or with intestinal interposition with an ileal segment. These measures are highly involved, add significant operating room time, and have well-known complications. We present a novel robotic technique for management of right-sided ureteral stricture using an appendiceal interposition. Methods: Using the DaVinci XI Robotic System, we utilized standard right-sided port placement similar to a nephrectomy setup. The appendix was identified, dissected free, and stapled off the cecum, making sure to preserve the mesoappendix. The appendix was then serially dilated using feeding tubes and S-dilators over a guidewire. The ureteral segment to be excised was identified using collecting system administration of indocyanine green (ICG) both in antegrade and retrograde manners. Intravenous ICG was also used to help delineate the strictured ureteral segment as well as the appendiceal segment perfusion. An end-to-end anastomosis between appendix and ureteral ends, in a spatulated manner, was then performed over a Double-J stent. This novel approach was compared with a conventional open laparotomy technique, in which an appendix and cecal flap were utilized for a right-sided ureteral interposition. This patient had a previous ileal interposition for stricture disease that required a long segment replacement. The appendix was mobilized, preserving the blood supply, with the cecum to provide additional length. Dilation of the lumen was not required, and an end-to-end anastomosis was performed over a Double-J stent to bridge the gap between renal pelvis and the bladder. Results: The patient tolerated the procedure well. Operative time was 4 hours, and estimated blood loss was found to be less than 50 mL. The patient developed a postoperative MRSA bacteremia that was treated to resolution with antibiotics. A right antegrade nephrostogram at 6 weeks showed opacification of the entire collecting system with free flow of contrast into the bladder over the stent without evidence of a leak. In the open appendiceal–cecal interposition case, there were no postoperative complications, and antegrade nephrostogram at 6 weeks after stent removal illustrated a patent anastomoses, with excellent passage of contrast as well. Conclusions: Robotic appendiceal interposition for right-sided ureteral stricture is a safe alternative approach to management of right-sided mid ureteral stricture disease. The use of intravenous and intracollecting system-administered ICG significantly aids in identification of the diseased segment as well as vascularity to improve surgeon confidence in the healing capability of the interposed appendix and ureteral ends. This approach is comparable with the more traditional open laparotomy technique of appendix substitution. No competing financial interests exist. Runtime of video: 8 mins 16 secs

The association of the severity of anorectal malformations and intestinal malrotation

IntroductionIntestinal malrotation is a known association of anorectal malformations (ARM). Exact incidence, prognosis and surgical implications related to ARM are unknown. The aim of this study was to identify relevant associations between ARM and the presence of malrotation. MethodsRecords of patients from two referral centers were retrospectively analyzed looking for malrotation associated to ARM and its management, as well as factors for functional prognosis. Results40 patients out of 2572 with ARM (1.6%) were found to have malrotation. Females were more commonly affected, and severe malformations were more frequent (cloaca, covered cloacal exstrophy in females and rectoprostatic and rectobladder neck fistula in males). Factors significantly associated with malrotation included Müllerian or Wolffian duct anomalies (P<0.05), while fecal continence status, presence of constipation, and use of laxatives or enemas were not. Detecting and correcting malrotation early on or at the time of colostomy creation represented a protective factor against additional surgeries for bowel obstruction and volvulus (P<0.001). Removal of the appendix during malrotation treatment required constructing a neoappendicostomy using a cecal flap in 9 out of 14 patients needing antegrade enema administration. ConclusionsMalrotation presence in patients with ARM has the same frequency as in the general population, but it is more common in severe malformations. Surgeons treating these patients should address the malrotation at the time of colostomy opening if detected. The appendix should be preserved for potential future use as an appendicostomy for antegrade administration of enemas.

Outcomes following Malone antegrade continence enema and their surgical revisions

Background/PurposeThe Malone antegrade continence enema (MACE) channel is an effective means to manage patients with neurogenic bowel; however, complications may occur that may require surgical revision. Specific reports of the outcomes of these interventions are limited. We describe our clinical results following revision of MACE. MethodsWe retrospectively identified patients undergoing MACE revision for at our institution between 1997 and 2009. Type of MACE (in situ appendicocecostomy (AC=247), ileocecostomy (IC=25), cecal flap (CF=10)) performed was recorded, time from creation to revision, site of revision, and need for repeat surgical revision were recorded. ResultsOf a total of 282 patients that underwent creation of MACE during the study period, 49 patients (17%) required surgical revision. Of these 49 patients, 42 had undergone AC, four had IC and three had CF. Mean time from MACE creation to revision was 19months. Sixty-eight revision procedures were performed in the 49 patients. Skin level or endoscopic procedures accounted for 52/67 (78%) procedures. Sixteen patients (33%) required more than one revision and three patients (6%) required more than two procedures. ConclusionsSkin level revisions accounted for over three-fourths of MACE revisions. In our series, two thirds of patients requiring revision required only a single procedure, but one third required more than one revision.

V544 SIMULTANEOUS ROBOTIC ASSISTED LAPAROSCOPIC CONTINENT CATHETERIZABLE CHANNELS: THE SPLIT APPENDIX TECHNIQUE

You have accessJournal of UrologyPediatrics1 Apr 2012V544 SIMULTANEOUS ROBOTIC ASSISTED LAPAROSCOPIC CONTINENT CATHETERIZABLE CHANNELS: THE SPLIT APPENDIX TECHNIQUE Dennis Liu, Marcelo Orvieto, and Mohan Gundeti Dennis LiuDennis Liu Chicago, IL More articles by this author , Marcelo OrvietoMarcelo Orvieto Chicago, IL More articles by this author , and Mohan GundetiMohan Gundeti Chicago, IL More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.618AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Creation of continent catheterizable channels with and without augmentation is often necessary for children with neurogenic bladders to obtain fecal [Malone Antegrade Continent Enema (MACE)] and urinary continence (Mitrofanoff Appendicovesicostomy). Traditionally, these channels have been created with open surgery, often requiring creation of a Monti channel and/or a cecal flap. We present our experience with simultaneous robotic assisted laparoscopic Mitrofanoff Appendicovesicostomy (RALMA) and robotic assisted laparoscopic MACE (RALMACE) using the split appendix technique, enabling creation of both channels using solely the appendix. METHODS The patient is positioned in a modified 25° trendelenburg position with legs positioned in Allen stirrups. A 12 mm camera port is placed 12 cm superior to the pubic symphysis and 2 8 mm robotic ports are placed on either side of the camera port. An assistant port is placed in the left upper quadrant. The appendix is isolated and split into a 5 cm distal segment for use as the Mitrofanoff and the proximal 2 cm for use as the MACE. The appendicovesicostomy is created by formation of an anti-refluxing tunnel in the anterior wall of the bladder. When concomitant augmentation cystoplasty is performed, the appendicovesicostomy is tunneled intravesically in the posterior wall of the bladder. The appendicovesicostomy is brought out to the skin at the umbilicus. The MACE is brought out in the right lower quadrant without imbrication. Stomas are matured using the V-flap technique. RESULTS We have performed the RAL split appendix technique in three patients. Two of the patients also required augmentation cystoplasty while one did not. Fecal and urinary continence has been obtained in all patients and no complications have been encountered. CONCLUSIONS Simultaneous RAL creation of the Mitrofanoff appendicovesicostomy and MACE using the split appendix is an effective minimally invasive surgical technique that avoids the need for a Monti channel. Longer follow-up and comparison with open surgery are needed to confirm the utility of this approach. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e223 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Dennis Liu Chicago, IL More articles by this author Marcelo Orvieto Chicago, IL More articles by this author Mohan Gundeti Chicago, IL More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Success of Malone's Antegrade Continence Enema (MACE) from the Patients' Perspective

Fecal incontinence (FI) is a devastating problem for children. The failure of optimal medical treatment may require further interventions such as appendicocutaneostomy. We report on a patients' perspective of the success of a Malone procedure for FI. The records of 32 patients who had undergone ACE procedure in the past 9 years were reviewed. Patients and families were contacted, and telephone inquiries were conducted to assess the overall success of the operation. The questionnaire covered the concerns of patients/families about the stoma, functional results and changes in the patients' quality of life (QOL). The indications for ACE stomas were meningomyelocele in 17 patients, anorectal malformation in 8, Hirschsprung/NID in 3, spinal tumor in 3 and traumatic spinal injury in one. 7 laparoscopic and 25 conventional operations were performed. The vermiform appendix was used in 27 of the patients and a cecal flap was used in 5. The most frequent complication was stenosis of the stoma orifice observed in 14 patients. 8 patients responded to dilatations while 6 patients required minor surgical revision. There were 2 perforations during catheterization, and they required surgical repair of the conduit. 5 patients had mild leakage from the stoma; all 5 were open ACE procedures, and required revision. 25 patients could be reached by phone. 5 of these children stopped using the stoma due to previous perforation in 2 patients and stricture in 1. The remaining 2 stopped using their stomas because "they did not like the idea of it". 16 patients are completely clean. 3 patients have occasional soiling. Only one patient was not satisfied with using the ACE stoma and stated that it did not sufficiently improve her condition. 8 patients complained about the duration of the enema (longer than 1 h); however, 5 of them refuse to use the stoma every day. All patients but one perceived a significant improvement in their QOL. Mean QOL scores before and after the procedure were 5.8 (2-9) and 11.5 (5-14), respectively. ACE stomas provide a satisfactory improvement in patients' quality of life. Stoma-related complications are not uncommon. The most common problems are strictures, followed by stoma leakage.

Testicular histology after intestinal pedicle flap (cecum) apposition in rats

Histological study of vascularization between a cecal pedicle flap and the testicle of Wistar rats. Fifty-three rats were studied. G1: submitted to celiotomy (a), mobilization of the right testicle (RT) to the abdomen (b), cecal flap suture to the RT (d) and cavity closure. G1: procedures a, b and d and fixation of RT into abdomen. G3: procedures a, b and d, exposition of RT to air and reposition into scrotum. G4: not operated. Euthanasia and histology was done after 20 days. Histometry and lesions score classification was done. Testicular vascularization was studied with comparison between G1 and G3. A p < .05 was considered significant. The G1 RT diameters were not different to G2 RT and all have decreased size in comparison with RT of G3 and G4. The lesions score in the RT was 5.83 in G1 and 3.3 in G2 without statistical difference. The vascularization's average in G1 was 16.9 vessels in 400X field in the RT. In the G3 this average was 0.96 to the RT and 0.92 to left testicles. The weight's average in G1 was similar with G2 but different of G3 and G4. A significant increase of vascularization was observed between the intestinal flap and the rat testicle.

Application of Appendicular-Based Cecal Flap for Less Invasive Augmentation Cystoplasty: A Novel Technique

Objectives: To evaluate the use of a new modified technique for augmentation cystoplasty on selected cases, both in terms of improvements in bladder urodynamics and creating an ideal conduit for clean intermittent catheterization. Methods: Ten patients suffering from intractable low-compliance bladder and reasonable capacity underwent appendicular-based cecal flap augmentation cystoplasty. The procedure comprised the isolation of a 10 to 12 × 3 to 5-cm cecal flap on the base of the appendicular pedicle, by which the bladder was augmented and the appendix was brought out through the abdominal wall for catheterization. Without any bowel anastomosis, the cecal anterior wall was repaired. Results: After a mean follow-up of 23.8 months, 9 of 10 patients became continent. Postoperative urodynamic study revealed a 53.8% increase in mean maximal cystometric capacity (from 171.4 to 263.7 ml; p = 0.012) and a 7.7-fold increase in mean bladder compliance (from 3.39 to 26.66 ml/cm H₂O; p = 0.012). Mean maximal detrusor filling pressure decreased by 79% (from 62.2 to 13 cm H₂O; p = 0.012). Renal function remained stable in all patients. Appendicular stoma was easy to catheterize, and no stomal stenosis occurred during the follow-up period. Conclusions: Early results of this less invasive technique could be promising in patients with high filling pressure and acceptable maximum bladder capacity.

Totally Laparoscopic Combined Freehand Ileocystoplasty and Malone Procedures

Cecostomy performed together with open enterocystoplasty can allow continent bowel evacuation in children with neurogenic dysfunction. We present the first report on a combined approach to fecal and urinary incontinence in children with myelomeningocele that was performed exclusively by freehand laparoscopy. We treated six dysrhaphic patients for total urinary and fecal incontinence by laparoscopy. Through five ports, a selected segment of ileum was isolated with cautery. A single-layer intestinal anastomosis, fashioning of the U-shaped patch, and anastomosis to the opened bladder dome were all done by endocorporeal freehand suturing. The tip of the appendix was simply brought to the skin via a trocar site. The procedures took 5 to 8.5 hours. Patients remained hospitalized for 5 to 16 days (median 5 days). At 13 to 16 months' follow-up, all patients remain continent of urine, and nearly perfect fecal continence has resulted on antegrade enema. Leak from the ileal anastomosis in one patient resolved rapidly with conservative management. One short retrocecal appendix later developed stenosis and was replaced by a tubed cecal flap. Apart from its cosmetic advantage, this procedure is notable for addressing all evacuation problems at one session. Our suturing time seems reasonable compared with open sutured precedents. Use of a gastrointestinal stapling device for anastomosis would have significantly increased the cost while not necessarily guaranteeing against complications. We present this laparoscopic combination as an effective alternative to its open counterpart.

Continent appendicostomy in the treatment of fecal incontinence

Fecal incontinence is common in children with anorectal anomalies or spina bifida. If it is possible to achieve fecal control, patients are given a large volume of enema once a day. Retrograde enemas are often unpleasant in children, particularly in adolescents. Malone procedure of antegrade appendicostomy achieves antegrade colonic irrigation. From 1996 to 2003 Malone antegrade appendicostomy was performed in 10 patients with fecal incontinence. The patients were aged from 5 to 24 years. In 4 patients fecal incontinence was due to an anorectal anomaly, and in 6 patients spina bifida. Preoperatively, all patients were given a clysma to control fecal incontinence. The patients, who remained clean with regular usage of the clysma for 24 hours or longer, fulfilled the criterion for the formation of continent appendicostomy. In 9 patients the cecal appendix was used to create a stoma, while in another one a lateral tubularized cecal flap was applied. In 3 patients a continent conduit was also done due to urinary incontinence. The follow-up period was from 1 to 8 years. A patient was reoperated due to stenosis of the stomal aperture, while another one has not been using the stoma because of social reasons. Continent appendicostomy is a simple surgery, which is effective in the control of fecal incontinence in most children. It is indicated only in patients in whom the rerograde clysma successfully cleans the colon and if patient and parents are motivated to use it. Possible complications, among which stenosis is the most frequent, can be solved with a reoperation.

Modified Cecal Flap Neoappendix for the Malone Antegrade Continence Enema Procedure: A Novel Technique

We report our experience with the creation of a tubularized cecal flap to construct a neoappendix. This flap effectively serves as an alternative means of creating a conduit for antegrade continence enemas in patients who have either an absent or an unusable appendix. We reviewed our results from our initial 4 patients in whom we used this technique. A neoappendix is created from a medially based flap of distal cecum that is tubularized over a catheter and then buried in a seromuscular tunnel to create an antireflux mechanism. A skin stoma is then created. All stomas are continent, functional and without any evidence of stenosis or necrosis of the cecal flap with followup ranging from 3 months to 8 years. A medially based cecal flap neoappendix is an easily created and reliable conduit for antegrade enemas. This procedure should be considered within the surgical armamentarium of urologists and pediatric surgeons when the appendix is absent, atretic or fibrotic.

Use of A Monti Channel For Administration of Antegrade Continence Enemas

Use of A Monti Channel For Administration of Antegrade Continence Enemas

Outcome of the antegrade colonic enema procedure in children with chronic constipation

Background: Chronic constipation and fecal incontinence in children related to pelvic trauma, congenital anomalies, or malignancy will eventually lead to significant social and psychologic stress. Maximal medical treatment (daily enemas and laxatives) can also be difficult to maintain in many children. Methods: At our children’s hospital, 11 children with chronic constipation or fecal incontinence or both underwent the antegrade colonic enema (ACE) procedure. The operation involved constructing a conduit into the cecum using either the appendix (n = 8) or a “pseudo-appendix” created from a cecal flap (n = 3). We report our surgical results. Results: Mean child age was 9.6 (5 to 18) years. With a mean follow-up of 14 (6 to 24) months, 10 of the children (91%) had significant improvement and 7 children (64%) are completely clean with no soiling and controlled bowel movements after irrigation. Conclusions: Regular colonic lavage after the ACE procedure allows children with chronic constipation and fecal incontinence to regain normal bowel habits and a markedly improved lifestyle. This procedure should be considered before colostomy in children and adults for the treatment of fecal incontinence from a variety of causes.

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.

The Results of Treating Fecal Incontinence with Antegrade Continence Enema (ACE)

【Fecal incontinence is not rare in children who have been operated upon for anorectal malformation, Hirschsprung's disease, and meningomyelocele. Incontinence can negatively impact on the emotional and social development of these children. Antegrade continence enema (ACE) was utilized in 9 patients with meningomyelocele from January 1998 to June 1999. Cleanliness and post-operative complications were evaluated. Three operative techniques were employed; reversed appendicocecostomy, in situ appendicostomy and neoappendicostomy with cecal flap. All of the patients achieved complete fecal cleanliness. Four patients had post-operative complications; two with stoma leakage, one with abdominal pain on irrigation and one with stoma stenosis. The leakage was minimal and the pain on irrigation improved spontaneously. The stoma stenosis required revision 6th month postoperatively. The ACE has been shown to be safe and highly effective.】