Colon Conduit Research Articles

PS01.166: COLONIC INTERPOSITION FOR ESOPHAGEAL REPLACEMENT AFTER ESOPHAGECTOMY FOR CANCER: A SINGLE CENTER EXPERIENCE

Abstract Background The method of choice for esophageal replacement after esophagectomy for cancer is the gastric tube. However when the stomach is not available a colon graft interposition can be performed. The purpose of this retrospective study was to review our experience with colon interposition following esophagectomy for cancer and to assess the early surgical outcomes. Methods We reviewed clinical data from 26 consecutive patients who underwent colon interposition after esophagectomy for cancer between January 1990 and December 2017 at the Brazilian National Cancer Institute. Outcomes were compared with data in international publications on colon interposition. Results There were 22 (85%) males and 4 females with a mean age of 56 years (range, 28 to 79 years). Indications were adenocarcinoma in 21 (81%) and squamous cell carcinoma in 5 (19%). Seven (30%) patients received neoadjuvant treatment: in 3 cases chemotherapy and in 4 patients chemoradiation. Transhiatal esophagectomy and transthoracic esophagectomy were performed in 21 (81%) and 5 patients, respectively. The mean operative time was 389 min (range 120–660 min). The most common option for colon conduit was the left colon (63%). We performed hand-sewn anastomosis in the neck in all cases. Surgical morbidity was 65%, most commonly due to pulmonary complications. Anastomotic leakage occurred in 13 patients (50%). One case graft necrosis were observed and 9 (35%) reoperations were necessary. In-hospital mortality was 15%. Conclusion Our results are in line with the literature and demonstrate that colon interposition after esophagectomy is feasible and, despite having a significant morbimortality, appears to be a valuable alternative for the challenging situation where the stomach is not available. Disclosure All authors have declared no conflicts of interest.

PS01.127: SURGICAL RECONSTRUCTION OF ESOPHAGO-INTESTINAL CONTINUITY IN PATIENTS WITH SURGICAL CONDUIT FAILURE AFTER ESOPHAGEAL RESECTION AND RECONSTRUCTION

Abstract Background Surgical restoration of gastrointestinal tract integrity for failed esophageal conduit is technically challenging with significant morbidity and mortality. The purpose of this study was to evaluate the feasibility and safety of restored esophago-intestinal integrity for the failed reconstructed esophagus. Methods From January 1990 to July 2017, a total of 1923 patients underwent esophageal cancer surgery. 29 patients (1.5%) presented with a clinical picture of failed conduits secondary to frank conduit necrosis, tracheoesophageal fistula, conduit stricture, and conduit cancer. We retrospectively analyzed 22 patients who planned to go for surgical reconstruction for a failed esophageal conduit. Results The median age was 62.5 (14–72) years old, and all of the patients were males. The underlying pathology was esophageal squamous cell carcinoma for all patients. The interval between the first esophagectomy and the surgery for failed conduits was 14 days for conduit necrosis (n = 9), 43 days for TEF (n = 7), 1256 days for conduit stricture and 1520.5 days for conduit cancer(n = 4). Of the 22 patients, 18 patients (81.8%) underwent a successful surgical restoration of the esophago-intestinal integrity. Three of the remaining 4 patients who planned for reconstructive surgery died of pneumonia-related complications within 30 days and one patient elects to have a cervical esophagostomy.Among reconstructed patients, 14 patients had failed gastric conduit and 4 had failed colon conduit. For the gastric group, restoration of the gastrointestinal continuity achieved using esophagocolostomy in 12 patients, free jejunal flap in 1 patient and colon with a free jejunal flap in 1 patient. While in the colon group, restoration was accessible using free jejunal flaps in 2 patients, ileocolon in 1 patient and gastric conduit in 1 patient. During post-operative follow-up, 7 patients died with pneumonia or mediastinitis related complications, 3 died of cancer progression, and 1 unknown origin. The median survival time after conduit reconstruction was 36 months. Conclusion Once a failed esophageal conduit is diagnosed, the decision of surgical reconstruction of gastrointestinal continuity can be feasible with a relatively good outcome if efficiently treated. In our study, reconstruction was possible in 81.8% of patients with a median survival time of 36 months after esophago-intestinal integrity restoration. Disclosure All authors have declared no conflicts of interest.

Esophageal Resection for End-Stage Achalasia

Achalasia is a rare disease characterized by impaired lower esophageal sphincter relaxation loss and of peristalsis in the esophageal body. Endoscopic balloon dilation and laparoscopic surgical myotomy have been established as initial treatment modalities. Indications and outcomes of esophagectomy in the management of end-stage achalasia are less defined. A literature search was conducted to identify all reports on esophagectomy for end-stage achalasia between 1987 and 2017. MEDLINE, Embase, and Cochrane databases were consulted matching the terms "achalasia," "end-stage achalasia," "esophagectomy," and "esophageal resection." Seventeen articles met the inclusion criteria and 1422 patients were included in this narrative review. Most of the patients had previous multiple endoscopic and/or surgical treatments. Esophagectomy was performed through a transthoracic (74%) or a transhiatal (26%) approach. A thoracoscopic approach was used in a minority of patients and seemed to be safe and effective. In 95 per cent of patients, the stomach was used as an esophageal substitute. The mean postoperative morbidity rate was 27.1 per cent and the mortality rate 2.1 per cent. Symptom resolution was reported in 75 to 100 per cent of patients over a mean follow-up of 43 months. Only five series including 195 patients assessed the long-term follow-up (>5 years) after reconstruction with gastric or colon conduits, and the results seem similar. Esophagectomy for end-stage achalasia is safe and effective in tertiary referral centers. A thoracoscopic approach is a feasible and safe alternative to thoracotomy and may replace the transhiatal route in the future.

No Anastomosis" Combined Colon Conduit and Colostomy Diversion with Pelvic Exenteration: An Underutilized, Cost-Effective Technique Reducing Bowel Complications

Experimental Techniques in Urology & Nephrology "No Anastomosis" Combined Colon Conduit and Colostomy Diversion with Pelvic Exenteration: An Underutilized, Cost-Effective Technique Reducing Bowel Complications Sayyid KR, Neal DE, Albo D, Kruse EJ, Wallbillich JJ, Rungruang BJ, Ghamande SJ and Martha K Terris* Department of Urology, Augusta University, USA *Corresponding author: Martha K Terris, Department of Urology, Medical College of Georgia, Augusta University, Augusta, GA, USA Submission: January 31, 2018; Published: February 12, 2018 DOI: 10.31031/ETUN.2018.01.000519 ISSN: 2578-0395 Volume1 Issue4

Endourologic strategies for a minimally invasive management of urinary tract stones in patients with urinary diversion.

ABSTRACTObjectiveTo present our experience in minimally invasive management of urinary tract stones in patients with urinary diversion.Materials and MethodsWe retrospectively reviewed 26 patients with urinary tract stones after cystectomy and urinary diversion. The types of urinary diversion were ileal conduit, colon conduit, ileal orthotopic neobladder in 19, 4, and 3 patients, respectively. At postoperative days 2, a plain KUB and urinary ultrasonography were performed in order to assess stone fragmentation or hydronephrosis. According to postoperative imaging, stone free rate (SFR) was defined as complete absence of fragments or residual stones less than 4mm.Results19 patients were treated with minimally invasive percutaneous lithotripsy (MPCNL) and 2 patients required second-look MPCNL. Anterograde flexible ureteroscopy was performed in 2 patients, while in 2 patients a combined anterograde and retrograde approach was required. Three reservoir stones were treated by transurethral neo-bladder lithotripsy. Postoperative significant complications occurred in 2 patients (7.7%). The highest percentage of stone composition was struvite, as a result of chronic urinary tract infection (UTI). SFR was 88.5% (23 of 26).ConclusionsOur experience showed that MPCNL is a safe and effective treatment modality with little morbidity for renal and upper ureteral stones in patients with urinary diversion. For middle and lower ureteral stones, an anterograde approach could be also considered as a first line treatment, but a combined anterograde and retrograde approach was required when the anterograde access alone cannot provide acceptable results.

Laparoscopic and open transhiatal oesophagectomy for corrosive stricture of the oesophagus: An experience.

Background:Oesophagectomy for corrosive stricture of the oesophagus (CSE) is rarely performed due to high risk of iatrogenic complications. The aims of this study were to review our experience of transhiatal oesophagectomy (THE) in patients with CSE as well as to compare results of open and laparoscopic methods.Materials and Methods:This is a retrospective analysis of prospectively maintained data of patients with CSE who underwent open transhiatal oesophagectomy (OTE) or laparoscopic-assisted transhiatal oesophagectomy (LATE) by a single surgical team from 2012 to 2016. All study patients had either failed endoscopic dilatation or had a long stricture which was not amenable to endoscopic dilatation.Results:Totally, 35 patients were included in the study, of which 19 (54.3%) were female. OTE was performed in 20 (57%) patients, and LATE was performed in 15 (43%) patients. Gastric and colonic conduits were used in 23 (65.7%) and 10 (34.3%) patients, respectively. Demographic and clinical parameters were comparable between LATE and OTE groups (P > 0.05). Median intra-operative blood loss, post-operative requirement of analgesic and hospital stay were lower in LATE group (P ≤ 0.05). There was no hospital mortality (30 days), but three patients (8.6%) died during a median follow-up of 36 months.Conclusion:THE is a safe procedure for patients with CSE, and LATE may be an alternative approach in selected patients.

Chemical colitis in posterior mediastinum colonic conduit

For patients with severe corrosive injury of the esophagus and stomach, the colon is considered a well-functional and durable esophageal substitute. We report a Chinese male suffered from chemical colitis of the colon conduit located in the posterior mediastinum after drinking strong liquor. To the best of our knowledge, this is the first case reported in the literature. After conservative and supportive therapy with antibiotics and oral fasting, he recovered from chemical conduit colitis completely.

Utilization of Gastric Conduit in the Management of Combined Corrosive Esophageal and Stomach Stricture.

Corrosive stricture of esophagus may be associated with variable involvement of stomach. We analyzed the outcome of gastric conduit used in the management of corrosive esophageal stricture with concomitant antro-pyloric stricture. Among 101 esophageal replacements performed, 53 patients had combined esophagus and stomach strictures. Colon was used as a conduit in 43 patients, while stomach was used in ten patients. Indications, perioperative complications and early/late outcomes of patients with gastric pull-up were reviewed and compared with those undergone colon pull-up. The indications of using gastric conduit were impromptu in four patients [colonic conduit ischemia (n=2) and an oversight of antro-pyloric stricture after forming the gastric conduit (n=2)]. Six patients had preconceived gastric conduit (distal antro-pyloric stricture with distended stomach). The median age was 29years (range 16-50), and median BMI was 15.4kg/m2 (range 14.5-20.1). The stomach was drained using loop gastrojejunostomy (n=7) or Roux-en-Y gastrojejunostomy (n=3). One patient died due to sepsis secondary to anastomotic leak. Median hospital stay was 9days (range 7-22). At median follow-up of 25months (range 14-80), the remaining nine patients are able to have solid diet and have gained weight. The level of esophageal stricture was low (p=0.01), and duration of surgery (p=0.02) and median hospital stay (p=0.04) were significantly less in patients with gastric conduit plus drainage as compared to patients undergone colonic pull-up. Gastric conduit in a subject with distal antro-pyloric stricture can be used safely along with gastrojejunostomy in selected patients of corrosive esophageal stricture.

MP24-15 MANAGEMENT OF PUBIC OSTEOMYELITIS FOLLOWING PELVIC RADIATION WITH SIMULTANEOUS PUBIC DEBRIDEMENT AND URINARY DIVERSION

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion I1 Apr 2017MP24-15 MANAGEMENT OF PUBIC OSTEOMYELITIS FOLLOWING PELVIC RADIATION WITH SIMULTANEOUS PUBIC DEBRIDEMENT AND URINARY DIVERSION Daniel Shapiro, David Goodspeed, and Wade Bushman Daniel ShapiroDaniel Shapiro More articles by this author , David GoodspeedDavid Goodspeed More articles by this author , and Wade BushmanWade Bushman More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.3309AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Pubic osteomyelitis (PO) is an uncommon but challenging complication of pelvic radiation for urologic and gynecologic malignancies. Some cases of PO result from urethral strictures requiring endoscopic management. Others occur spontaneously. We describe here our experience with urinary fistula complicated by PO. METHODS We retrospectively reviewed patients with fistula and PO who underwent pubic debridement and simple cystectomy with urinary diversion from 2014-2016. PO was diagnosed by history, physical exam, C-reactive protein (CRP) and imaging (CT or MRI). We analyzed patient demographics, treatment history, management, and outcomes. RESULTS Eight patients met study criteria (7 males, 1 female). All had a history of radiation for pelvic malignancy (7 prostate cancer, 1 cervical cancer). All but one patient had history of tobacco use. The median time between radiation and PO diagnosis was 9.5 years (range 1-15 years). Six had undergone interventions for urethral stricture disease, ranging between 1 to 3 procedures. All had a history of pelvic pain, urinary tract infection, and elevated CRP prior to the diagnosis of PO. Most underwent MRI for diagnosis of PO (5 MRI, 3 CT). Average CRP was 14.1 (range 4-24). All had pubic symphysis resection and bone cultures obtained during surgery. The most common organism was Staphylococcus aureus. Seven patients underwent ileal conduit urinary diversion and 1 patient had a transverse colon conduit. The average length of stay was 11.5 days. Two patients were admitted within 30 days of discharge. Complications consisted of one post-operative death due to pulmonary embolism, and 2 patients required drain placement for pelvic abscesses. No patient had recurrent PO. Average follow-up was 8 months (range 3-21 months). CONCLUSIONS Patients with fistula and PO can be definitively managed by combined pubic debridement, simple cystectomy and urinary diversion. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e307 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Daniel Shapiro More articles by this author David Goodspeed More articles by this author Wade Bushman More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Efficacy of camera sleeve in conveyance of conduits.

Esophageal substitutes need conveyance from the abdomen into the neck for restoration of alimentary continuity. Reports suggest that the use of plastic camera sleeve may prove advantageous in restoring conveyance. This study aims to evaluate the practicability of this approach, specifically, in laparoscopy-assisted surgeries. The efficacy of camera sleeve in conduit transposition was prospectively evaluated over 2 years. The following parameters were assessed: success/failure; time taken; blood loss; adequacy of length of the conduit delivered into the neck; conduit orientation; ease of procedure through different routes; conduit damage; complications; and drawbacks. The technique was used in 25 consecutive patients. Two ileo-colonic, 13 gastric, and 10 colonic conduits were transposed. Posterior mediastinal, retro-sternal, and ante-sternal routes were used in 15, 8, and 2 cases, respectively. There were no failures. The technique was easy to adopt. It added < 10 minutes to the procedure. It entailed no additional blood loss. Adequate length of the conduit was transposed into the neck, atraumatically. Conduits maintained their orientation without effort. Although no complications per se were associated with its use, extra conduit length became transposed into the neck, twice, necessitating its trimming/adjustment. In one case, traction suture became avulsed from the conduit, midway in the tunnel. This could easily be rectified by pulling out the sleeve from the neck, which brought up the conduit along with it, as desired. Use of camera sleeve proves efficacious in interposition of esophageal substitutes.

Clinical outcome of using gastric remnant or jejunum or colon conduit in surgery for esophageal carcinoma with previous gastrectomy.

For esophageal carcinoma patients with early gastrectomy, individualized surgical plans-including selection of replacement conduit and operation route based on patient's new lesion and surgical history-can achieve the desired therapeutic effect and improve postoperative life quality. We investigated the outcomes at our institution. The clinical data of 42 esophageal carcinoma patients with early gastrectomy were analyzed retrospectively. Esophagectomy was performed combining replacement with remnant stomach in 16 patients, jejunum in 17, and colon in 9. Esophagectomy combining replacement with gastric remnant got advantages of shorter operation time and less bleeding over that of replacement with jejunum or colon. Gastric remnant group scored higher on the QLQ-C30 questionnaire than jejunum or colon group with respect to overall quality of life, physical function, and social relationships. In QLQ-OES18 questionnaire, the scores of appetite recovery and reflux mitigation were more favorable in remnant stomach group than those in jejunum or colon group. Survival analysis showed no significant difference in survival rate among the patients undergoing replacement with gastric remnant, jejunum, or colon. For esophageal carcinoma patients with early gastrectomy, esophagus-gastric remnant anastomosis possesses advantages of shorter operation time, less surgical trauma, and greater life quality after surgery.

Pregnancy After Urinary Diversion at Young Ages—Risks and Outcome

To assess the urologic and obstetric outcomes during and after pregnancy following urinary diversion (UD) performed during childhood or adolescence. From our UD database, we identified 25 women who became pregnant between 1981 and 2013. Reasons for UD were neurogenic bladder, exstrophy, trauma, sinus urogenitalis, and interstitial cystitis. Seventeen had continent cutaneous diversion, 4 had continent anal diversion, and 4 had colonic conduit. The average age at delivery was 27.8 (18-39) years. Thirty-seven pregnancies occurred; 1 patient decided for an induced abortion. Thirty-two healthy children were born. Five patients had a spontaneous abortion before the 12th week. Main urologic complications were urinary tract infections in 11 of 32 successful pregnancies. Twelve patients presented with dilatation of the upper urinary tract; 3 of them required a temporary nephrostomy tube. Four of 25 patients required an indwelling catheter because of difficulties of clean intermittent catheterization. One small bowel injury occurred during cesarean section. One patient with exstrophy developed uterine prolapse; 1 nipple prolapse was surgically repaired in the same anesthesia after the cesarean section. Two patients had 3 vaginal deliveries, whereas 28 had a cesarean section. All children were healthy, without malformation, and with mean Apgar scores of 7.8, 8.9, and 9.7 for the 1st, 5th, and 10th minutes of life, respectively. No persistent urologic complications were observed. After UD, pregnancy is possible without major complications. Because of an increased risk of pyelonephritis and dilatation of the upper urinary tract requiring intervention, these pregnancies should be considered high-risk pregnancies. Delivery should be carried out in a center of expertise with urologic standby.

Surgical Treatment Results of Burn-Related Oesophageal Strictures.

Post-burn oesophageal stricture is a late complication, which may require surgical intervention. The aim of the study was to compare gastric and colonic conduits and to evaluate the safety, efficacy and complications of these techniques. Retrospective analysis of all patients treated for burn-related oesophageal strictures between 1989 and 2013. Oesophagectomy was performed via laparotomy and right thoracotomy, and/or cervical incision. Forty-six patients, including 29 men, aged 17-67years (mean: 41years), had burn-related oesophageal strictures. The post-operative follow-up period ranged between 3months and 30years. Colonic transposition was used in 23 patients. In 21 patients, the oesophageal substitute was introduced through the posterior mediastinum, and in two patients the retrosternal route was used. Gastric conduit in was used in 21 patients and jejunal interposition in one patient. One patient underwent segmental oesophageal resection with end-to-end anastomosis. One patient had necrosis of the colonic conduit with anastomotic leakage, two patients had oesophago-colonic anastomosis leakage, five developed anastomotic stenosis, and two had respiratory insufficiency. Among patients with a gastric conduit, anastomotic leakage occurred in four, cervical anastomotic stenosis occurred in two, and respiratory insufficiency occurred in three, and one patient had impaired gastric emptying that required surgical re-intervention. Operative mortality was three patients (6.5%). The use of colonic and gastric conduit is an effective and safe method for restoring the continuity of the gastrointestinal tract, with an acceptable rate of post-operative complications. Patients who undergo oesophageal resection for post-burn stricture require post-operative systematic endoscopic control.

Endoscopic hemostasis of diverticular hemorrhage in a colonic conduit by use of an over-the-scope clip.

Endoscopic hemostasis of diverticular hemorrhage in a colonic conduit by use of an over-the-scope clip.

MP33-13 PERCUTANEOUS ANTEGERADE URETEROSCOPY FOR TREATMENT OF URETEROINTESTINAL ANASTAMOTIC STRICTURES

You have accessJournal of UrologyStone Disease: Surgical Therapy III1 Apr 2016MP33-13 PERCUTANEOUS ANTEGERADE URETEROSCOPY FOR TREATMENT OF URETEROINTESTINAL ANASTAMOTIC STRICTURES Natalia Hernandez, Patrick Gomella, Brian Matlaga, Gyan Pareek, Vernon Pais, Patrick Mufarrij, and Brian Eisner Natalia HernandezNatalia Hernandez More articles by this author , Patrick GomellaPatrick Gomella More articles by this author , Brian MatlagaBrian Matlaga More articles by this author , Gyan PareekGyan Pareek More articles by this author , Vernon PaisVernon Pais More articles by this author , Patrick MufarrijPatrick Mufarrij More articles by this author , and Brian EisnerBrian Eisner More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1370AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Few studies in the literature have examined the efficacy of percutaneous antegrade ureteroscopy with balloon dilation and/or laser incision for treatment of ureterointestinal anastamotic strictures after urinary diversion. METHODS A multi-center retrospective review of longitudional medical records was performed to evaluate the success rates and characteristics of patients who formed ureterointestinal anastamotic stricture after urinary diversion and subsequently underwent percutaneous antegrade ureteroscopic treatment. RESULTS Twenty-six (26) percutaneous antegrade ureteroscopic procedures were performed with balloon dilation and/or laser incision of stricture. Mean patient age was 65.2 years (SD 27), median time between urinary diversion and treatment for stricture was 249 days (SD 2184), and mean follow-up time was 292.6 days (SD 252). Urinary diversion type was ileal conduit in 77% of cases, colon conduit in 11% of cases, Indiana Pouch in 8% of cases, and orthotopic neobladder in 4% of cases. Successful stricture treatment occurred in 24/26 cases (92.3%) and in 2 cases no treatment could be performed due to complete occlusion of the ureter. At most recent follow up, patients who underwent percutaneous antegrade ureteroscopy and stricture treatment demonstrated significant improvement in serum creatinine compared with before treatment (Cr after treatment = 1.3, Cr prior to treatment = 1.6, p = 0.04). At this follow up time, none of the 24 successful stricture dilations had undergone subsequent open or laparoscopic revision. CONCLUSIONS In patients with ureterointestinal anastamotic strictures, percutaneous antegrade ureteroscopy with balloon dilation and/or laser incision of stricture was accomplished in a majority of cases (>90%) and resulted in significant improvements in renal function. This minimally invasive procedure may be considered prior to more extensive reconstructive surgery in patients with ureteroinestinal anastamotic strictures after urinary diversion. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e441-e442 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Natalia Hernandez More articles by this author Patrick Gomella More articles by this author Brian Matlaga More articles by this author Gyan Pareek More articles by this author Vernon Pais More articles by this author Patrick Mufarrij More articles by this author Brian Eisner More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Non-Surgical Management of Critically Compromised Airway Due to Dilatation of Interposed Colon.

We present a rare case of critically compromised airway secondary to a massively dilated sequestered colon conduit after several revision surgeries. A 71-year-old male patient had several operations after the diagnosis of gastric cancer. After initial treatment of pneumonia in the pulmonology department, he was transferred to the surgery department for feeding jejunostomy because of recurrent aspiration. However, he had respiratory failure requiring mechanical ventilation. The chest computed tomography (CT) scan showed pneumonic consolidation at both lower lungs and massive dilatation of the substernal interposed colon compressing the trachea. The dilated interposed colon was originated from the right colon, which was sequestered after the recent esophageal reconstruction with left colon interposition resulting blind pouch at both ends. It was treated with CT-guided pigtail catheter drainage via right supraclavicular route, which was left in place for 2 weeks, and then removed. The patient remained well clinically, and was discharged home.

The radiological assessment of colonic replacement of the esophagus in children: A review of 43 cases

PurposeTo define the characteristic radiological features following colonic replacement of the esophagus in children. Materials and methodsThe upper gastro-intestinal contrast studies of 43 patients who underwent colonic replacement of the esophagus at our pediatric surgery unit were available for analysis. UGI contrast studies were performed routinely in the post-surgical period in 17 cases (first asymptomatic group), while the rest of contrast studies (26) belonged to a second group of out-patients complaining of dysphagia (18) or dyspepsia (8) following colonic replacement of the esophagus. Based on our observations, we proposed a grading system to describe the degree of colonic redundancy in the thorax. ResultsRedundancy of the colonic conduit in the thoracic cavity was a common radiological finding (62.8%). The redundancy was mild (grade 1) in 18 patients, moderate (grade 2) in eight, and severe (grade 3) in only one patient. In 88.9%, the redundancy was in the right hemi-thorax.Patients presenting with postoperative dysphagia had a stricture at the site of the esophago-colic anastomosis in the neck, which should be differentiated from other sites of anatomical narrowing at the inlet and outlet of the thoracic cavity.Gastro-colic reflux was common among patients who underwent colonic replacement of the esophagus without an anti-reflux procedure. ConclusionColonic replacement of the esophagus in children results in considerable anatomical alterations. Knowledge about the normal post-surgical changes and imaging features of the commonly encountered complications can increase the diagnostic confidence among radiologists and clinicians when dealing with these cases.

Posterior Cologastric Anastomosis: An Effective Antireflux Mechanism in Colonic Replacement of the Esophagus

The colon may be used to replace a portion of the esophagus in pediatric patients, but prevention of gastrocolic reflux is a concern. We report our experience with the retrosternal colon bypass, and the effect of combining the procedure with a posterior cologastric anastomosis on prevention of gastrocolic reflux. The study included 35 consecutive pediatric patients who underwent retrosternal colon bypass during the period of 2010 through 2014. In standard practice, the cologastric anastomosis is performed at the anterior gastric wall. Lately, we modified our technique by shifting the cologastric anastomosis to the back of the stomach away from the anterior adhesions around the gastrostomy. In follow-up, a gastrogram was performed to check for gastrocolic reflux. The indication for esophageal replacement was postcorrosive esophageal stricture in 19 patients and long gap esophageal atresia in 16 patients. Their mean ages were 51 and 16 months, respectively. No gastrocolic reflux was detected with the posterior cologastric anastomosis, whereas reflux was always present with the anterior cologastric anastomosis. We had two mortalities and one major morbidity (hematemesis and failure to thrive) that were related to regurgitation of gastric contents into the colonic conduit. The last patient was successfully managed by transferring the cologastric anastomosis from the front to the back of the stomach, with marked symptomatic and radiologic improvement. After colonic replacement of the esophagus, the gastrocolic reflux represents a functional problem that may lead to serious complications. Combining a posterior cologastric anastomosis with retrosternal colon bypass is an effective way to avoid this problem.

Equivocal effect of intraoperative fluorescence angiography on colorectal anastomotic leaks.

Intraoperative fluorescence angiography is beneficial in several surgical settings to assess tissue perfusion. It is also used to assess bowel perfusion, but its role in improving outcomes in colorectal surgery has not been studied. The purpose of this work was to determine whether intraoperative angiography decreases colorectal anastomotic leaks. This was a case-matched retrospective study in which patients were matched 1:1 with respect to sex, age, level of anastomosis, presence of a diverting loop ileostomy, and preoperative pelvic radiation therapy. The study was conducted at an academic medical center. Patients who underwent colectomy or proctectomy with primary anastomoses were included. The intraoperative use of fluorescence angiography to assess perfusion of the colon for anastomosis was studied. Anastomotic leak within 60 days and whether angiography changed surgical management were the main outcomes measured. Case matching produced 173 pairs. The groups were also comparable with respect to BMI, smoking status, diabetes mellitus, surgical indications, and type of resection. In patients who had intraoperative angiography, 7.5% developed anastomotic leak, whereas 6.4% of those without angiography did (p value not significant). Univariate analysis revealed that preoperative pelvic radiation, more distal anastomosis, surgeon, and diverting loop ileostomy were positively associated with anastomotic leak. Multivariate analysis demonstrated that level of anastomosis and surgeon were associated with leaks. Poor perfusion of the proximal colon seen on angiography led to additional colon resection before anastomosis in 5% of patients who underwent intraoperative angiography. The retrospective study design with the use of historical control subjects, selection bias, and small sample size were limitations to this study. Intraoperative fluorescence angiography to assess the perfusion of the colon conduit for anastomosis was not associated with colorectal anastomotic leak. Perfusion is but one of multiple factors contributing to anastomotic leaks. Additional studies are necessary to determine whether this technology is beneficial for colorectal surgery.

Continent urinary diversion following anterior exenteration

Quality of life after anterior or total exenteration is determined, among other factors, by the type of urinary diversion. There are two different types of urinary diversion: incontinent diversion (ureterocutaneostomy, ileal conduit, and colonic conduit) and continent diversions (continent cutaneous pouch, orthotopic neobladder, and rectal reservoir). Invasive bladder cancer and advanced or recurrent gynecological tumors are the main indications for continent urinary diversion in women. In patients with non-irradiated bladder cancer, an orthotopic neobladder (except those with tumor invasion of the bladder neck or urethra) or a rectal reservoir is an option. In patients who had received preoperative radiotherapy, non-irradiated bowel segments should be used for urinary diversion (e.g., the transverse colon). In patients with planned postoperative radiation, the urinary diversion should be outside the radiation field. Advantages and disadvantages of all types of urinary diversion should be objectively discussed with the patient. Especially exenteration for advanced or recurrent gynecological cancers should be performed in centers with a multidisciplinary team (gynecologist, urologist, radiotherapist, and in cases with complete exenteration the gastrointestinal surgeon).