Ileal Segment Research Articles

Increased intestinal phosphate absorption, an often-overlooked effect of vitamin D.

Increased intestinal phosphate absorption, an often-overlooked effect of vitamin D.

Use of right colon vaginoplasty in gender affirming surgery: proposed advantages, review of technique, and outcomes.

Various methods have been described to create a functional neovagina with feminizing (male-to-female) gender affirming surgery. Intestinal vaginoplasty using ileal or colon segments confers natural mucus production and greater canal depth with primary vaginoplasty. In this work we describe an alternative approach to primary and salvage vaginoplasty using right colon. We focus on relative advantages compared to use of other bowel segments, and we review patient outcomes. Transgender women who had previously undergone primary vaginoplasty underwent laparoscopic right colon vaginoplasty at our center between 12/2017 and 7/2019. Demographic, medical, outcome, and satisfaction data was collected and retrospectively reviewed. Twenty-two consecutive transgender women patients underwent laparoscopic right colon vaginoplasty. Mean age was 39.3years. There were two intraoperative complications:1 injury of the ileocolic pedicle, and 1 minor bladder injury. Four of 22 patients (18.2%) had short-term complications (< 30days): 3 had postoperative ileus/small bowel obstruction and 1 had intra-abdominal hemorrhage. All were managed conservatively. Six of 22 patients (27.3%) experienced a total of 14 long-term complications (> 30days): 1 developed Crohn's (not involving the neovagina); 1 developed late small bowel obstruction (SBO) (managed conservatively); 5 developed neovagina prolapse; 4 developed stenosis (2 at the vaginal introitus, and 2 had extrinsic obstruction at the recto-vaginal junction (all underwent successful laparoscopic surgical correction); and 3 were diagnosed with diversion neovaginitis (all treated conservatively). All complications were successfully treated with conservative and/or surgical intervention. All (100%) patients reported satisfaction with neovagina function and appearance. This is the only outcomes series of transgender women patients who have undergone right colon vaginoplasty, to date. Our study finding suggests that laparoscopic right colon for primary or salvage vaginoplasty has several important advantages over use of Sigmoid colon or Ileum, and is a reliable technique whose complications can be managed successfully, with favorable, satisfactory long-term outcomes.

S2765 Autologous Graft vs Host Disease: An Unusual and Unexpected Cause of Bowel Obstruction

INTRODUCTION: Autologous-graft versus host disease (auto-GVHD) is an extremely rare entity comprising only 0.9% of cases of lymphoma patients undergoing autologous hematopoietic stem cell transplantation (HSCT). Although very uncommon, it can lead to serious complications including abdominal pain, rectal bleeding, and profuse diarrhea. We present a very rare case of auto-GVHD leading to small bowel obstruction. CASE DESCRIPTION/METHODS: A 39 year-old man with history of large B cell lymphoma underwent autologous-HSCT after treatment with R-CHOP and cyclophosphamide plus dexamethasone following a relapse. Days later developed fever, nausea, vomiting, abdominal pain and diarrhea. Laboratories showed leukopenia, thrombocytopenia, elevated liver enzymes and bilirubin. Tests for infectious diarrhea were negative. Colonoscopy showed elevated whitish lesions and diffuse loss of vascular pattern up to mid transverse and biopsies revealed marked crypt loss, regenerative atypia with rare apoptotic bodies. A diagnosis of auto-GVHD was entertained. Steroids were started and tapered off after clinical improvement. Months later there was worsening of symptoms associated with distended and tender abdomen with diminished bowel sounds. Abdominal CT scan showed ileal inflammation associated with small bowel dilatation. Colonoscopy showed a stricture at ileum with associated friable mucosa. Biopsy revealed chronic active ileitis and necrotic purulent material with associated ulcer, negative for CMV. Resection of ileal segment was performed and steroids given for 6 weeks. DISCUSSION: The differential diagnosis included auto-GVHD, lymphoma recurrence and Crohn's disease (CD). Lymphoma was unlikely given negative immunohistochemistry and PET scan. No classic endoscopic or histologic features of CD were observed. This led to a diagnosis of GVHD, a multisystem disorder that commonly complicates allogeneic-HSCT but is exceedingly rare in autologous-HSCT. The pathophysiology is unknown and establishing the diagnosis is a challenging task. The clinical presentation of Auto-GVHD is similar to allogeneic GVHD, with the skin, gastrointestinal tract and liver the principal target organs. It commonly begins with a maculopapular rash, diarrhea, hematochezia, abdominal pain, vomiting, and elevated liver tests. The diagnosis of auto-GVHD can be made on the basis of ongoing GI symptoms, endoscopic evidence of mucosal abnormalities, and histological findings of apoptotic epithelial cells or crypt cell dropout with lymphocytic infiltrate.Figure 1.: Elevated whitish lesions, loss of vascular pattern diffusely.Figure 2.: Glandular apoptosis and crypt cell drop out.

S2117 The GIST of It: A Rare Presentation of Neurofibromatosis Type I

INTRODUCTION: Neurofibromatosis Type 1 (NF1) is an autosomal-dominant disease with an incidence of 1 in 2500–3000 individuals. NF1 confers up to a four-fold increase in overall malignancy risk compared to the general population, and patients are 34 times more likely to develop gastrointestinal stromal tumors (GIST). GIST are rare mesenchymal tumors involving the gastrointestinal tract (GI) and their increased incidence has been associated with the history of NF-1. We present a case of a patient with NF-1 associated with an unusual presentation of GIST. CASE DESCRIPTION/METHODS: 42 years old female with past medical history of NF-1 initially presented to the ED for maroon-colored stools for 2 days. She endorsed infrequent use of ibuprofen with last use being 3 months ago. Initial physical exam was significant for mild hypotension responding to fluid resuscitation, and rectal exam negative for blood. The hemoglobin in the ER was 7.9 g/dL (baseline 11.3 g/dL) with an elevation of BUN: Creatinine ratio (24 mg/dL, 0.65 mg/dL). An EGD was performed which demonstrated mild duodenitis. An ileocolonoscopy was performed and blood clots were in the entire colon including the terminal ileum. No source of active bleeding in the colon seen after extensive suctioning done. The patient underwent a video capsule endoscopy (VCE) and an abdominal CT with contrast. VCE demonstrated a endophytic mass with active bleeding. CT revealed numerous exophytic and endophytic masses with the largest mass at the anterior wall of the ileum measuring 2.4 cm × 2.2 cm, which was noted to have a brisk active arterial bleeding. Surgery was consulted and she underwent emergent exploratory laparotomy with surgical resection of the ileal segment containing the actively bleeding mass. Histopathologic staining was positive for receptor tyrosine kinase (C-KIT) and DOG-1, consistent with GIST. Patient was initiated on imatinib therapy and has remained symptom free. DISCUSSION: Our novel case describes life-threatening GI bleeding from GIST in a patient with NF-1. GISTs are 34 times more common in patients with NF-1. In NF-1 patients presenting with GI bleeding, Small bowel GISTs should be considered as a differential and clinicians must have a low threshold for obtaining abdominal imaging by CT, VCE or nuclear imaging in case endoscopy does not detect the source of GI bleeding. Emergent surgery stands alone as a curative form of therapy for actively bleeding GISTs in patients with NF-1.Figure 1.: CT Abdomen with IV contrast : A lobulated endophytic avidly enhancing mass is identified in the Ileum, which measures approximately 2.4 × 2.2 cm. This lesion demonstrates brisk active arterial bleeding into the intestinal lumen.Figure 2.: CT abdomen with IV contrast: There is a round partially exophytic avidly enhancing mass measuring approximately 1.6 × 1.5 cm in the 4th portion of the duodenum, favored to represent a GIST. This lesion is without evidence of active bleeding on the current exam.Figure 3.: Capsule endoscopy – Brisk active bleeding lesion noted on the capsule endoscopy.

A rare acute presentation of intestinal malrotation in the elderly

Intestinal malrotation, a congenital anomaly of the midgut, typically presents in pediatrics age group with the most feared complication of midgut volvulus and its catastrophic sequelae. Midgut volvulus secondary to intestinal malrotation is a rare presentation in adults more so in the elderly. Its rarity portends a diagnostic dilemma for both the surgeon and radiologist. We report a 65-year-old man admitted following a referral with a 12-hour history of acute abdomen with an initial diagnosis of acute pancreatitis but later had laparotomy with intraoperative findings of a midgut volvulus and gangrenous ileal segment secondary to intestinal malrotation. This case emphasizes the importance of early diagnosis to prevent the disastrous complication of this disease. The rarity of this condition portends a formidable diagnostic challenge in adults hence the awareness of its possibility and a high index of suspicion is crucial in diagnosis.

Defining Endpoints and Biomarkers in Inflammatory Bowel Disease: Moving the Needle Through Clinical Trial Design

Defining Endpoints and Biomarkers in Inflammatory Bowel Disease: Moving the Needle Through Clinical Trial Design

Urinary diversion in patients with muscle-invasive bladder cancer and severe ureteral stricture: A case report of a new surgical technique

The use of an ileal segment has been previously described in the treatment of long-segment ureteral strictures. The aim of this study was to describe the use of a skin and muscle flap tube as an alternative procedure to perform ureterocutaneostomy in patients who are not eligible for the use of bowel segments in the urinary diversion or when the patients are at high risk of morbidity and mortality. We describe the case of a 74-year-old male patient. The technique was performed without complications and complete recovery of the patient. No anastomotic leaks and stenosis were reported at a follow-up of 36 months. The use of a skin and muscle flap tube can be a feasible and safe procedure in case of huge loss of tissue (long-segment ureteral strictures), in patients whose underwent radical cystectomy with UCS, in particular when the patients are not eligible for the use of bowel segments in the urinary diversion or when the patients are at high risk of morbidity and mortality.

The relationship among gut microbiota, short-chain fatty acids, and intestinal morphology of growing and healthy broilers

The gut microbiota play an important role in the growth and intestinal health of broilers. The present study was to investigate the gut microbiota, short-chain fatty acids, and intestinal morphology of broilers at different ages. A total of 320 one-day-old male broilers were raised in 8 replicates and fed the same corn–soybean diets for 42 D. The duodenal, jejunal, and ileal segments and their and cecal microbiota were collected on day 1, 7, 14, 21, and 42, respectively. The villous height (VH), crypt depth (CD), and their ratio of VH:CD in the duodenum, jejunum, and ileum all increased (P < 0.05) with age. Caecal acetate, propionate, butyrate, valerate, and isovalerate increased (P < 0.01), but isobutyrate decreased (P < 0.001) with age. The cecum had the greatest (P < 0.001) alpha diversity of bacterial community in broilers at different ages. Beta diversities showed distinct differences in gut microbial compositions among different ages (R = 0.55, P < 0.002) and different intestinal segments (R = 0.53, P < 0.002). Lactobacillus was the most abundant genus in the duodenum (36∼97%), jejunum (39∼72%), and ileum (24∼96%) at all ages, and in the ileum, it was positively correlated with VH (R = 0.559, P < 0.03), VH:CD (R = 0.55, P < 0.03), and acetate contents (R = 0.541, P < 0.04) but negatively correlated (R = -0.50, P < 0.05) with isobutyrate contents. Escherichia–Shigella and Salmonella dominated in the cecum of newly hatched broilers, and then the Bacteroides dominated in the cecum on day 42. In the cecum, Escherichia–Shigella was positively correlated (R = 0.577∼0.662, P < 0.05) with isobutyrate contents and Salmonella negatively correlated (R = -0.539∼-0.843, P < 0.05) with isovalerate, butyrate, and acetate contents. These aforementioned results indicated that the most abundant Lactobacillus from the small intestine and the most diversity of microflora community and short-chain fatty acids in the cecum might contribute to the development of intestinal structure in the whole growing period of broilers.

Dietary supplementation with a microencapsulated blend of organic acids and botanicals alters the kinome in the ileum and jejunum of Gallus gallus.

The use of natural products as feed additives in the poultry industry is increasing; however, most studies focus on performance and growth with little regard for determining mechanism. Our laboratory designed a chicken (Gallus gallus)-specific immunometabolic kinome peptide array. Using this tool to examine the active enzymes responsible for phosphorylation events (kinases) provides important information on host and cellular functions. The objective of this project was to determine if feeding a microencapsulated product comprised of a blend of organic acids and botanicals (AviPlus®P) impacts the intestinal kinome of broiler chickens (Gallus gallus). Day-of-hatch chicks were provided 0 or 500g/MT of the additive and jejunal and ileal segments collected for kinome analysis to determine the mode-of-action of the additive. Gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis was performed by uploading the statistically significant peptides to the Search Tool for the Retrieval of Interacting Genes database. As a whole, GO and KEGG analysis showed similar activities in the ileum and jejunum. However, there were a small number of KEGG pathways that were only activated in either the ileum or jejunum, but not both. Analysis of the adipocytokine and PI3K-AKT signaling pathways showed differences between ileal and jejunal activity that were controlled, in part, by AKT3. Additionally, cytokine/chemokine evaluation showed the ileum had higher IL1β, IL6, IL10, TNFα, IFNγ, CXCL8, and CCL4 mRNA expression levels (P<0.05). As a whole, the data showed the addition of microencapsulated organic acids and botanicals to a broiler diet activated many of the same signaling pathways in the ileum and jejunum; however, distinctions were observed. Taken together, the findings of this study begin to define the mode-of-action that microencapsulated organic acids and botanicals have on two important intestinal segments responsible for nutrient digestion and absorption in chickens.

Intestinal Intussusception in an Adult Affected by Vanek Tumor: A Case Report

Inflammatory fibroid polyp (IFP) is a rare benign lesion, originating from the submucosa in the gastrointestinal tract. It generally appears as an isolated benign lesion, rarely located at the level of the ileum. Its origin is controversial. Clinical presentation varies depending on its location; invagination and obstruction are the most common indicative symptoms when the polyp is located at the level of the small intestine. We report the case of a 60-year old patient with abdominal pain, nausea and vomiting and a personal history of intermittent constipation. Radiological imaging objectified ileo-ileal invagination completely obstructing the ileum light. Segmental resection of the obstructed ileal segment and terminalterminal anastomosis were performed. The final diagnosis of IFP was established using histological examination.

Giant mesenteric teratoma

Abstract Mesenteric teratoma is a rare tumor in children. The present case is huge mesenteric teratoma (20 × 20 × 10 cm) and (1.96 kg) arising near the root of mesentery with ileal segment attached to it. Complete surgical excision of the mass with adherent intestinal segment with primary anastomosis. The histopathological examination showed bengin muture teratoma with no atypia or malignancy.

Kinetics of selenium absorption in ligated small intestinal loops of chicks

Selenium (Se) is an essential trace element that has a large number of biological functions for broilers. However, the absorption kinetics of Se from sodium selenite in the small intestine of broilers remains unclear. Therefore, two experiments were conducted with 28-d-old commercial male broilers to study the kinetics of Se absorption in ligated small intestinal segments. In experiment 1, the Se absorption in duodenal, jejunal, and ileal segments at different post-perfusion time points (0, 20, 40, 60, 80, 100 and 120 min) were compared. In experiment 2, a kinetic study of Se absorption was conducted with the duodenal, jejunal, and ileal loops perfused with solutions containing 0, 0.0375, 0.075, 0.15, 0.30, or 0.60 μg mL−1 of Se as sodium selenite, and Se contents in perfusates were determined at 100 min after perfusion. The results from experiment 1 showed that the Se absorption increased in an asymptotic response (P<0.0001) to post-perfusion time within 120 min in all the small intestinal segments, but increased linearly (P<0.0001) at less than 100 min after perfusion in duodenal and ileal segments, while more than 96.0% of the maximum Se absorption occurred at 100 min after perfusion in each small intestinal segment. In experiment 2, there was no difference (P>0.05) in the Se absorption rate among different ligated small intestinal segments perfused with solutions containing 0.0375–0.15 μg mL−1 of Se, however, the Se absorption rate was higher (P<0.05) in the jejunum than that in the duodenum perfused with solutions containing 0.30–0.60 μg mL−1 of Se. The kinetic curves of Se absorption demonstrated that the Se absorption was a saturated carrier-mediated process in the duodenum, and the maximum absorption rate was 1 271 pg min−1 cm−1; whereas the Se absorptions were a non-saturated diffusion process in the jejunum and ileum, and the diffusive constants were 2 107 and 1 777 cm2 min−1, respectively. The results from the present study indicate that the jejunum is the main Se absorption site, and the Se absorption is a saturated carrier-mediated process in the duodenum, but a non-saturated diffusion process in the jejunum and ileum of broilers.

Validation of the effectiveness of a modified Studer orthotopic neobladder in a single center after 3 years of its application.

In this study, we reported the 2 years outcomes of orthotopic neobladder diversion according to the Studer modified technique described by Bianchi G. et al. This technique improves the stability of the reservoir and the urine-storage capacity. After radical cystectomy, urinary diversion is created with a spheroidal-shaped reservoir with a conic distal-part, obtained with 40 cm detubulized ileal segment, and a 15 cm of tubular afferent limb, where a Wallace ureteral anastomoses is made. The conic distal part of the neobladder that is anastomized to the urethral stump. After the reconstructive part, the neobladder and the afferent limb are attached to the elevator ani and psoas muscles, respectively. In all, 18 patients underwent radical cystectomy with the reconstruction of urinary diversion with the Modified-Studer Orthotopic technique, at S. Giuseppe Hospital. We studied the post-operative years of follow-up, especially with anamnesis of lower urinary tract, axial computerized tomography, and blood tests, according to the EAU guidelines. We discover with TC 2 cases of low-grade bilateral hydronephrosis, associated with a slight increase in creatinine levels (1.4-1.8 mg/dL). No stricture at the neobladder-urethral anastomosis was detected. Three patients complain daytime urinary incontinence; only two patients report nocturnal urinary incontinence. One patient underwent ureteroscopy for lithiasis and 1 patient died for non-onco-urological disease. The modifications we applied to the Studer-Neobladder seems to improve urinary tract restoration, potentially decreasing long-term complications like hydronephrosis connected to ureteral anastomotic stenosis (11.1% vs 16.9% reported in literature) and urinary retention (0% vs 12% reported in literature). However, we discovered the same risk of diurnal and nocturnal incontinence reported in literature for the classic Studer Neobladder.

Enterotoxic, neurotoxic and cytotoxice demonstrated by shiga toxin (2d) producing escherichia coli in experimental models

Background: Shiga toxin (Stx) producing Escherichia coli (STEC) colonize human intestinal tract and their infections have asymptomatic clinical manifestations which cause local and systemic pathological changes.&#x0D; Objectives: This study intended to establish the role of Shiga toxin (Stx2d) in developing clinical manifestations in STEC infections using experimental models.&#x0D; Methods: A total 300 stool samples were screened from hospitalised diarrhoeal patients enrolled in 2% surveillance system at International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b). The stx gene profile including their variants was identified byPCR.stx2d gene positive STEC PT187 was selected for toxin (s) preparation.Toxin was prepared by centrifugation of culture supernatant. Enterotoxicand paralytic-lethal activities were tested in rabbit ileal loops and mice, respectively. Histopathological study of the rabbit ileal loop segments and different tissues of mice by paraffin embedded method and stained by H &amp; E staining. Cytotoxic effect was performed on HeLa cells.&#x0D; Results: Nine STEC strains were identified for stx2 gene positive. Among them STEC PT187 was found stx2d gene positive strain and selected for toxic activities. Toxin (s) responsible for causing accumulation of fluid in rabbit ileal loops and its segments showed inflammation and enterocytenecrosis. In mouse model, toxin(s) was found to cause hind limbs paralysis and death. Brain, spinal cord and kidney tissue of mice showed histopathological changes. Toxin (s) also showed positive cytotoxic activity in HeLa cell.&#x0D; Conclusion: In this study, results indicated that Stx2d producing E. coli exhibit not only enterotoxic activity, but also cause impaired neurological functions and cytotoxic effect.&#x0D; Bangladesh Med Res Counc Bull 2020; 46(1): 41-47

Reconstruction of Complex Abdominal Wall Defect With Autogenous Pedicled Demucosalized Seromuscular Flap

Abdominal wall reconstruction is indicated when 1 or more of the abdominal wall components (skin, fascia, or muscle) are either injured or absent. When faced with defects requiring flap reconstruction, the decision regarding flap choice should take into consideration the volume of soft tissue required, the extent of the defect, donor site morbidity, and prior surgical scars that affect flap vascularity. We present a case of an abdominal wall defect with limited reconstructive options in which a spare ileal bowel segment was filleted to create a seromuscular flap for improving the abdominal wall blood supply. The postoperative course was complicated by abdominal fluid collection, which resolved following an ultrasound-guided drain. The patient had normal wound healing and recovery without further postoperative complications at the 7-month follow-up. Seromuscular flaps are a practical option in the armamentarium of plastic surgeons performing abdominal wall reconstruction, especially when other alternatives are limited.

Immunization with cytolethal distending toxin B produces autoantibodies to vinculin and small bowel bacterial changes in a rat model of postinfectious irritable bowel syndrome.

Recent data substantiate the importance of acute gastroenteritis in the development of irritable bowel syndrome (IBS). An animal model of postinfectious IBS determined the importance of cytolethal distending toxin B (CdtB) during live Campylobacter jejuni infection and its development of autoimmunity to vinculin. In this study, we examine whether subcutaneous exposure to CdtB alone is sufficient to produce the postinfectious IBS effect and autoimmunity. Sixty adult Sprague Dawley rats were randomized into 2 groups to receive subcutaneous injection of either CdtB or vehicle and administered a booster injection of the same product 3weeks later. Serum was collected for anti-CdtB and anti-vinculin titers. Duodenal and ileal luminal contents for total eubacterial qPCR, and ileal bowel segments were harvested for vinculin and ileal expression. In a second experiment, 4 adult, Sprague Dawley rats were injected with either Cy7-labeled anti-CdtB and anti-vinculin antibodies were injected into the tail vein and imaged to determine organ localization of the antibodies. Rats that received CdtB increased in serum anti-CdtB after injection. CdtB exposure also precipitated significant elevation in anti-vinculin antibodies (P<.001). This was associated with a reduction in intestinal vinculin expression (P<.001) that negatively correlated with serum anti-CdtB levels. CdtB exposure was also associated with greater levels of duodenal (P<.001) and ileal (P<.01) bacteria by qPCR that positively correlated with anti-CdtB levels. Rats injected with CdtB developed a postinfectious IBS-like phenotype and autoimmunity to vinculin with corresponding reduction in intestinal vinculin expression.

Othotopic ileal neobladder “Belgrade pouch” in females

Background/Aim. Orthotopic continent neobladder pro-vides adequate capacity, low pressure reservoir, acceptable rate of continence and satisfactory voiding frequency. Standard surgical techniques require the usage of an ileal segment in the length of 50?65 cm for neobladder creation with favorable results. However, the usage of a long intestinal segment is associated with high neobladder capacity, voiding problems, and metabolic complications. The aim of this study was to analyze clinical outcomes of the ?Belgrade pouch? orthotopic bladder replacement in female patients and to promote the usage of shorter ileal segment for neobladder creation. Methods. A prospective study conducted in our institution from 2009 to 2019 included 37 female patients who underwent orthotopic bladder replacement ac-cording to ?Belgrade pouch? technique with the usage of shorter ileal segment whose average length for neobladder creation was 28 cm. Inclusion criteria were: female continent patients older than 18, organ-confined muscle-invasive bladder carcinoma and, the American Society of Anestesiologists (ASA) score 1 or 2. Exclusion criteria were: diabetes mellitus, obstructive pulmonary diseases, systemic illnesses and metabolic diseases which may have some influence on results interpretation, renal deterioration and preoperative incontinence. We analyzed operative time, blood loss, histopathological findings, continence rate, metabolic disorders, immediate and delayed complications and survival rate in two-year periods of follow-up. Results. Average age of patients was 58 (32?67) years. Average time of surgical procedures was 199 (155?320) min. Blood transfusion was intraoperatively applied in 32.43% of the patients in average volume of 385 (300?640) mL. A total of 29.47% patients had anemia preoperatively. In the early postoperative period we reported one patient with paralytic ileus which was resolved conservatively and one patient with urinary fistula appearance; 56.75% of the patients were in pT2 stage. Two years following the surgery, day-time continence was achieved in 91.89% of the patients, neobladder capacity was 459 (345?592 ) mL, post-void residual urine volume was 27 (0?40) mL, 24 h voiding frequency 6, metabolic acidosis appeared in 2.7% of the patients. Survival rate in 2-year period was 86.48%. Conclusion. Orthotropic ileal neobladder created from the shorter ileal segment (?Belgrade pouch?) in females provides a high level of continence without a significant increase of voiding frequency, with adequate capacity, without urinary tract retention and with decrease of metabolic complications.

Functional Results, Complications Associated with the Serosa-lined Tunnel, and Quality of Life with a Cross-folded Ileal Reservoir Combined with an Afferent Tubular Isoperistaltic Segment for Heterotopic Continent Urinary Diversion: An Observational Long-term Cohort Analysis

BackgroundIn patients who do not qualify for an orthotopic urinary diversion, for example, the urethra cannot be spared or is functionally impaired, a heterotopic continent cutaneous cross-folded ileal reservoir offers a good alternative. ObjectiveTo describe the indication, surgical technique, and postoperative management, and to report the reservoir-related outcomes and complications associated with the serosa-lined tunnel. Design, setting, and participantsPerioperative outcomes of 118 consecutive patients after cystectomy and a heterotopic ileal reservoir adapted from the Studer bladder substitute technique, operated between 2000 and 2018, were evaluated. The catheterisable serosa-lined tunnel was constructed from the appendix (Mitrofanoff, n = 63), an ileal segment (Yang-Monti, n = 48), or a fallopian tube (n = 7). Outcome measurements and statistical analysisPre- and postoperative data until last follow-up appointment were entered prospectively in the departmental database. The chi-square test was used to compare proportions. Results and limitationsMedian follow-up was 94 (interquartile range 36–152) mo. No peri- or postoperative mortality was observed within 90 d of surgery. Patient satisfaction was high in 77.5% and moderate in 16.9%. Overall, complications associated with the serosa-lined tunnel occurred in 52% (61/118) of patients. Stenosis of the continent outlet developed in 38% (45/118) of patients: 33/45 (75%) were simply dilated/incised at the outpatient clinic, of those 24% (8/33) required additional endoscopic dilatation. Of patients with stenosis of the continent outlet, 27% (12/45) needed open revision surgery. During follow-up, 8% (nine/118) of patients required revision of the serosa-lined tunnel due to incontinence. Twelve months postoperatively, 95% (92/97) patients were continent. A limitation is the retrospective analysis from prospectively assessed data. This could limit the generalisability of these findings, as selection bias cannot be excluded. ConclusionsThe heterotopic continent cutaneous cross-folded ileal reservoir achieves good functional results. Complications associated with the serosa-lined tunnel occur in about half of the patients but generally are easy to manage. As a result, patient satisfaction is high. Patient summaryIn patients who do not qualify for an orthotopic bladder substitute, a heterotopic continent cutaneous cross-folded ileal reservoir offers a viable alternative with good postoperative functional results and high patient satisfaction.

A new ureteroileal anastomosis technique in modified ileal orthotopic bladder substitution after radical cystectomy

BackgroundThe aim of this study is to describe a modified technique in ileal orthotopic bladder substitution with a new ureteroileal anastomosis.Case presentationAfter a classic open radical cystectomy with bilateral pelvic lymphadenectomy was performed extraperitoneally, a 56-cm ileal segment was used to construct the spheroidal shape bladder substitution. The 8-cm long proximal and distal ends of the ileal segment were used as afferent limbs. Two-centimeter ileal segments of afferent limbs were detubularized and transversally tubularized. The elongated ileal tube was anastomosed with the ureter in an end-to-end fashion. The pathway of the ureteroileal anastomosis was placed between the abdominal cutaneous fat and the anterior rectus muscular sheath. Perioperative data and long-term functional outcomes were assessed. Between December 2011 and December 2015, seven male patients underwent this procedure with a median 46 (30–77) months follow-up in our hospital. There was no difference between preoperative and postoperative estimated glomerular filtration rates (Z = − 1.693, P = 0.09). One of 14 sides had ureteroileal anastomotic stenosis; two of 14 sides in one patient had ureteroileal anastomotic stenosis caused by invasion of pelvic recurrence 15 months postoperatively. Reflux was completely prevented by placing pressure on the corresponding point on the abdominal surface when voiding urine in all patients.ConclusionsWe describe a feasible technique modification in detail, which provides some advantages for effective anti-reflux by mechanical finger pressing and abdominal contraction, a low incidence of stricture, and ease for a secondary operation in the long-term follow-up period.

MP41-04 THE URINARY MICROBIOME AFTER RADICAL CYSTECTOMY AND URINARY DIVERSION

INTRODUCTION AND OBJECTIVE:Radical cystectomy (RC) and urinary diversion (UD) is a complex operation with associated morbidity. Recent studies have demonstrated the existence of a urinary microbiom...