Length Of Common Channel Research Articles

Long-term outcome after biliopancreatic diversion type duodenal switch: A single-center experience with up to 20 years follow-up

Abstract Objective Biliopancreatic diversion type duodenal switch (BPD-DS) is the most effective bariatric procedure in terms of weight loss and remission of comorbidities but carries the risk of severe long-term side effects. The aim of this study was to analyze the long-term effects of BPD-DS on weight loss, comorbidities and reoperation rate. Methods This is a retrospective single-center study of prospectively collected data of all patients who underwent BPD-DS from 1999 to 2011 at a single institution. Results 116 patients (83.6% female) underwent BPD-DS with a mean initial body mass index (BMI) of 47 ± 6.5 kg/m2. 68% of the procedures were performed in open technique and 32% laparoscopically. Common channel length was routinely 1 m, mean alimentary limb length (AL) was 1.8 ± 0.6 m and mean bilio-pancreatic limb length (BPL) was 4.9 ± 1.6 m. 76.7% of patients had laparoscopic adjustable gastric banding (LAGB) prior to BPD-DS. Mean follow-up time was 14 ± 4.4 years and follow-up rate at 5, 10 and 14 years was 95.6% (n = 108), 90% (n = 98) and 75.3% (n = 70). Mean excess BMI loss (%EBMIL) at 5, 10 and 14 years was 78% ± 24.1, 76.5% ± 26.7 and 77.8% ± 33.8, respectively. The highest %EBMIL was reached two years postoperatively with 84% ± 23.6. Complete (n = 22) or partial remission (n = 4) of type 2 diabetes mellitus was observed in 92.8% of patients. Reoperation was necessary in 33 patients (28.4%) due to malnutrition or refractory diarrhea (10), excessive weight loss (1), insufficient weight loss or weight rebound (7), reflux or stenosis (7), oxalate nephropathy (2), liver cirrhosis (1) and various/combined indications (5). Mean time to reoperation was 7.7 ± 5 years. The predominant deficiencies were vitamin D (99.1%), zinc (86.9%), iron (83.5%) and calcium (71.3%). The were no procedure-related deaths in the short- or long-term. Conclusion BPD-DS leads to sustainable long-term weight loss with an acceptable reoperation rate. Nevertheless, regular follow-up is necessary to detect and treat malnutrition and vitamin deficiencies.

Laparoscopic Resurrection of an Old Technique: A New Approach for Total Urogenital Separation and Rectal Pull-Through in Patients with Long Common Channel Cloacal Malformation.

Background and Aims:Before the significance of urethral length was highlighted in patients with cloacal malformation, total urogenital mobilization using a posterior sagittal approach was recommended for common channel (CC) length <3 cm, those >3 cm it was followed by urogenital separation. However, many urologists are advocating that the urethral length rather than length of the CC should influence the choice of operation. It is also recommended that total urogenital mobilization should be avoided in patients with short urethral length as intraoperative decision to shift to urogenital separation will risk devascularization of the urethra, advocating total urogenital separation (TUS) from the start; the later technique was deemed difficult using open approach. We describe our experience with laparoscopic TUS and rectal pull-through in patients with cloacal malformation.Methods:Six patients were operated for a period of 3 years from December 2017 to July 2021; they underwent laparoscopic TUS and rectal pull-through. Preoperative investigations included cystoscopy, genitogram, and MRI pelvis and abdominal ultrasound. IRB approval has been obtained from research ethical committee at Cairo University.Results:Six female patients born with single perineal opening had colostomy at birth. Age during the second operation ranged from 1 to 4 years. Length of the CC ranged between 2 and 5 cm. Proximal urethral length ranged between 0.5 and 1.5 cm and vaginal depth >3 cm. Average operative time was 4.25 hours. Postoperative period was 1–5 days and uneventful. On the long-term follow-up. No patient developed urethrovaginal fistula and one patient developed vaginal stenosis. All patients had no urinary problems, dry over 4-hour interval, voiding spontaneously, and had normal kidney functions.Conclusions:Laparoscopic urogenital separation, as well as vaginal and rectal pull-through for cloacal malformation, is feasible in cloacal malformation providing anatomical repair.

2021 Canadian Surgery Forum: Virtual, online Sept. 21-24, 2021.

# 01. Design and validation of a unique endoscopy simulator using a commercial video game {#article-title-2} Procedural simulation has been shown to enhance early endoscopy training. In this proof of concept study, we aimed to show that a first-person shooter (FPS) video game with a novel in-house

Short-term Results of Transit Bipartition to Promote Weight Loss After Laparoscopic Sleeve Gastrectomy.

To evaluate (1) the efficacy of transit bipartition (TB) as revisional bariatric surgery (RBS) after laparoscopic sleeve gastrectomy (LSG); (2) the impact of the length of the common channel (CC) on weight loss. LSG in combination with TB has been shown to be highly efficacious for treating morbid obesity. The role of TB as RBS to address the problem of primary failure or weight recidivism after LSG is less well defined. Observational study of outcomes in 100 morbidly obese patients who received a TB following LSG. Follow-up examinations (FE) were performed at 1, 3, 6, and 12 months. Variables analyzed included BMI, percent excess weight loss (%EWL), total body weight loss (%TBWL), effect on obesity-related conditions and complications. The mean BMI before LSG was 49.9 ± 8.5 kg/m2. A nadir of 32.7 ± 6.1 kg/m2 was reached 22.1 ± 16.9 months after LSG (%EWL 70.0 ± 14.5). The time interval between LSG and TB was 52.2 ± 26.6 months at which the BMI had increased to 37.6 ± 7.1 kg/m2 and %EWL decreased to 49.4 ± 19.7. Following TB, the BMI decreased continuously to 31.4 ± 5.7 kg/m2 after 12 months with a parallel increase in %EWL to 74.7 ± 20.3 and %TWL reaching 36.3 ± 10.5. Weight loss was significantly higher for CC length of 250 versus 300 cm after 12 months (BMI 29.4 ± 5.3/33 ± 5.3 kg/m2, P = 0.002; %EWL 79.8 ± 26.6/70.4 ± 17; P = 0.009). Improvement of comorbidities was observed in a high proportion of patients. Major early complications occurred in 3% of the patients. TB is an effective second-step procedure to address insufficient weight loss or weight recidivism after LSG. CC length of 250 versus 300 cm had a significant impact. While most improvements of obesity-related comorbidities are likely linked to weight loss, amelioration of GERD is largely mediated by accelerated gastric emptying. Major complications were observed in 3% of patients and managed without fatalities.

Correlation between Common Channel Length and Urethral Length in Cloacal Malformations.

This research aimed to study the relationship between common channel length and urethral length in cloaca patients by different diagnostic modalities and the ability of common channel length to predict the urethral length. The study was conducted on 30 cases of cloaca managed at Alexandria University Children Hospital and Cairo University Children Hospital from August 2018 to December 2019. Preoperative assessment included cystovaginoscopy and magnetic resonance imaging (MRI) studies with a recording of common channel length and urethral length by each modality. There is substantial similarity between MRI and cystoscopy in measuring common channel length; 11 patients had common channel length 1 to 3 cm by cystoscopy. It is the same number by MRI measurement. Nineteen patients had common channel length 3 to 5 cm by cystoscopy and MRI. In total, 16 had urethral length <1.5 cm by MRI, while 14 patients with urethral length <1.5 cm by cystoscopy. However, there is a moderate negative correlation by MRI between common channel length and urethral length, while by cystovaginoscope, there is no significant correlation between common channel length and urethral length. Applying MRI or cystoscopy in the preoperative assessment of cloaca cases is equivalent to measuring common channel length, not measuring urethral length. Besides that, the common channel length cannot predict the urethral length.

Does a standardized operative approach in cloacal reconstruction allow for preservation of a patent urethra?

BackgroundCloacal malformations are recognized as a particularly challenging congenital condition to manage and they present with a wide spectrum of anatomical configurations making surgical repair very complicated. Urethral necrosis or urethral loss is a known and devastating complication of cloacal repair. The surgical repair of these malformations has evolved over time and historically only common channel (CC) length was measured. More recently, it has been advocated that the urethral length and the CC are both important in determining surgical repair. The purpose of our study is to evaluate if this surgical approach allows for preservation of a patent urethra. MethodsA prospective database of all cloaca patients maintained with IRB approval (IRB# STUDY00000721) was retrospectively reviewed. We included any girl with cloacal malformation who underwent primary repair at our institution between May 2014 and December 2019. Standardized preop evaluation with endoscopy and 3-dimentional imaging to assess urethral length and CC length. These measurements were used to determine operative approach. Girls with CC < 1 cm undergo posterior sagittal anorectoplasty and introitoplasty (PSARP + I), those with CC measuring 1–3 cm and urethra > 1.5 cm undergo total urogenital mobilization (TUM) and those with CC > 3 cm or urethra < 1.5 cm undergo urogenital separation (UGS). Postoperative urethral patency was determined at the time of cystoscopy and exam under anesthesia (EUA) 4–6 weeks postoperatively by visualizing a viable and healthy urethra that is catheterizable. ResultsA total of 59 patients met inclusion criteria with a median age of 11.6 months. Four girls underwent PSARP + I, 19 girls had a TUM and 36 girls underwent a UGS. All of the girls who had PSARP +I (n = 4) or TUM (n = 19) had a viable and patent urethra that was catheterizable at the cystoscopy and EUA 4–6 weeks postoperatively. Of the 36 girls who had UGS, all but 2 (5.6%) had a viable and patent urethra that catheterized without problems. Overall, 97% of girls in this cohort had a patent urethra after cloacal repair using this surgical protocol. ConclusionsThe use of a standard protocol that considers urethral and common channel length for cloacal repairs results in a viable and patent urethra in 97% of patients. Level of evidenceLevel II.

Analysis of Weight-Loss Outcomes Following Laparoscopic One Anastomosis Duodenal Switch.

Background: Laparoscopic one anastomosis duodenal switch (OADS) is one of the most effective bariatric surgeries aimed at simplifying duodenal switch procedure and reducing malabsorption without compromising weight-loss efficacy. This study analyzed weight-loss outcomes following OADS surgery with a common channel 300 cm. Methodology: Between June 2016 and November 2020, 150 patients who underwent OADS surgery with a common channel 300 cm were included in the study. The weight-loss outcomes of these patients at six months and one year after surgery were retrospectively studied with respect to various perioperative variables including biliopancreatic limb (BPL) and common channel lengths. Results: At six months and one year after surgery, %TWL was 30%, 39.4%, and %EWL was 75%, 98.8%, respectively. The BMI loss, weight loss and %TWL were directly proportional to preoperative BMI and weight, while the %EWL was inversely proportional to these variables. Preoperative BMI was found to be an independent predictor of BMI loss and %EWL. The BMI loss, and weight loss were also directly proportional to BPL length. The %TWL was directly proportional to BPL length at one year after surgery. Age, gender and diabetes did not have significant effects on the weight-loss outcomes. The success rate (%TWL 25%) was 88.9% and 99.2% at six months and one year after surgery, respectively. Conclusions: OADS surgery using a common channel 300 cm appears to be highly effective for weight loss. Preoperative BMI, weight and BPL length were found to be significant predictors of weight-loss outcomes following this surgery.

A New Approach to Cloaca: Laparoscopic Separation of the Urogenital Sinus.

Introduction: Cloaca malformation repair strategy is strongly dictated by common channel and urethral lengths. Mid to long common channel cloacas are challenging and often require laparotomy for dissection of pelvic structures. The balance of common channel and urethral lengths often dictates the approach for reconstruction. Laparoscopy has been utilized for rectal dissection but not for management of the urogenital (UG) structures. We hypothesized that laparoscopy could be applied to UG separation in reconstruction of cloaca malformations. Methods: Records were reviewed for 9 children with cloaca who underwent laparoscopic rectal mobilization and UG separation. Clinical parameters reviewed included demographics, relevant anatomic lengths, operative duration, transfusion requirements, and perioperative complications. Results: Repair was perfomed at a median (interquartile range) age of 12 (7, 15) months. Common channel length as measured by cystoscopy was 3.5 (3.3, 4.5) cm. There were no intraoperative complications. Transfusion requirements were minimal. Postoperative length of stay was 6 (5, 11) days. One patient developed a urethral web and 2 developed vaginal stenosis. One patient later underwent a laparotomy for obstruction due to a twisted rectal pull-through. Conclusions: Laparoscopic rectal mobilization and UG separation in long common channel cloaca are safe and well tolerated. Laparoscopy affords full evaluation of Mullerian structures and enables separation of the common UG wall, which may ultimately enhance long-term urinary continence.

Long-Term Outcome of Proximal Versus Very-Very Long Limb Roux-en-Y Gastric Bypass: the Roux-Limb to Common Channel Ratio Determines the Long-Term Weight Loss.

The influence of the Roux limb (RL) length on weight loss in Roux-en-Y (RYGB)-type gastric bypass procedures is still unclear. This study analyzes the true impact of RL length by comparing the long-term outcomes of proximal RYGB (PRYGB) and very-very long limb RYGB (VVLL-RYGB). RL length in PRYGB was 150cm. In VVLL-RYGB, common channel length was 100cm. In both groups, biliopancreatic limbs measured 50-60cm, resulting in equal total alimentary limb lengths. To adjust for pre-operative differences between groups, and to predict the long-term outcome, a mixed model analysis was performed. Two hundred thirty-two patients with VVLL-RYGB (73.7% female, mean age 41.1 ± 10years, initial BMI 45.8 ± 6.3kg/m2) and 223 with PRYGB (83.9% female, mean age 38.5 ± 11years, initial BMI 42.9 ± 4.9kg/m2) were included. Mean follow-up was 9.4 ± 4years in VVLL-RYGB and 5.3 ± 1.9years in PRYGB. After 5years, mean BMI reduction was 15.7 ± 5.9kg/m2 in VVLL-RYGB and 11.9 ± 4.1kg/m2 in PRYGB (p < 0.001), and mean %EWL was 78.3 ± 23.1% and 70.2 ± 23.7% (p = 0.002) with a follow-up rate of 78% and 75.9%, respectively. The mixed model analysis showed a significantly higher weight rebound after PRYGB. Frequency of revisional surgery (i.e., limb length alteration, pouch banding) was similar between VVLL-RYGB and PRYGB (25 vs. 29 revisions, p = 0.463). The VVLL-RYGB has a significantly higher long-term BMI reduction and a significantly lower weight rebound. The length of the Roux limb significantly influences long-term outcome.

Does the Length of the Common Channel as Part of the Total Alimentary Tract Matter? One Year Results from the Multicenter Dutch Common Channel Trial (DUCATI) Comparing Standard Versus Distal Roux-en-Y Gastric Bypass with Similar Biliopancreatic Bowel Limb Lengths.

Although the laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is the gold-standard bariatric procedure, it remains uncertain what the optimal bowel limb lengths are to accomplish maximal weight loss while minimizing nutritional deficiencies and related gastro-intestinal complaints. The aim of this randomized controlled multicenter trial is to investigate the effect of significant lengthening of the length of the Roux limb (RL) at the cost of the length of the common channel (CC) while keeping the biliopancreatic limb (BPL) lengths the same on both study arms. Four hundred forty-four patients were randomized to receive either a Very Long Roux Limb LRYGB (VLRL-LRYGB) (variable RL length, BPL 60cm, and CC 100cm) or a Standard LRYGB (S-LRYGB) (RL 150cm, BPL 60cm, and a variable CC length). Results at 1-year follow-up for weight loss, effect on obesity-related comorbid conditions, complications, re-operation rate, malnutrition rate, and re-admission rate were investigated. Weight loss at 1-year showed no significant differences for %EWL (84.3% versus 85.3%, p= 0.72) and %TWL (34.2% versus 33.6%, p= 0.359) comparing VLRL-LRYGB versus S-LRYGB. Malabsorption requiring surgical bowel length adjustment was observed in 1.4% in VLRL-LRYGB group versus 0.9% in S-LRYGB group (p= 0.316). Significant lengthening of the RL at the cost of the common channel seems to have no effect on the weight loss at 1-year follow-up, which supports the theory that absorption of nutrients also occurs in the RL. Nevertheless, long-term results of the VLRL-LRYGB have to be awaited to draw final conclusions as part of the discussion towards optimal limb length in LRYGB surgery.

Effect of different limb lengths on quality of life, eating patterns and gastrointestinal symptoms after Roux-en-Y gastric bypass in superobese patients: randomized study.

BackgroundDistal Roux‐en‐Y gastrojejunal bypass (DRYGJB) gives better weight reduction than standard Roux‐en‐Y gastric bypass (RYGB) but at the risk of increased malnutrition side‐effects. This study compared the effects of RYGB and DRYGJB on gastrointestinal symptoms, eating patterns and health‐related quality of life (QoL).MethodsThis was a single‐blind RCT from a university‐affiliated obesity centre. Patients with a BMI of 50 kg/m2 or above were invited to participate. Treatment arms were standard gastric bypass with an alimentary limb of 150 cm and a biliopancreatic limb of 60 cm, with a variable common channel length, or DRYGJB with biliopancreatic limb of 200 cm, common channel limb of 150 cm and variable alimentary limb length. Baseline and follow‐up data to 5 years on quality of life, obesity‐related problems and gastrointestinal symptoms were collected using prospectively created and validated questionnaires.ResultsSome 140 patients were included. Those with a DRYGJB had better weight loss at 5 years (mean(s.d.) 68·3(21·8) kg versus 55·7(19·8) kg for standard RYGB; P = 0·011). Eating patterns improved, with no difference between the groups. Gastrointestinal symptoms (diarrhoea, indigestion) worsened significantly in both groups, but only patients with DRYGJB had significantly worse diarrhoea at the end of the study than at baseline (P = 0·006). Both groups had improved perceived generic QoL over baseline, and obesity‐related problems were markedly reduced.ConclusionStandard RYGB and both improved generic and disease‐specific QoL and eating behavioural pattern. Diarrhoea was increased more following DRYGJB than after RYGB. Registration number: NCT 01514799 (https://clinicaltrials.gov).

Outcomes of Duodenal Switch with a Moderate Common Channel Length and Roux-en-y Gastric Bypass: Does One Pose More Risk?

Traditional duodenal switch (DS) typically leaves a short common channel and is infrequently performed in part due to increased risk of malnutrition. We compared nutritional deficiencies between DS with a moderate channel length and standard proximal Roux-en-Y gastric bypass (RYGB). We conducted a retrospective review of 61 matched pairs who underwent DS or RYGB using our institutional database; patients were matched on sex, age, race, and BMI. DS was performed with a common channel length between 120 and 150cm. Thirty-day complications, total body weight loss (TBWL) %, and nutritional labs up to 24months were compared using paired t test and Wilcoxon rank sum tests. Weight loss was similar at each time point (all p > 0.1). DS patients had lower vitamin D levels at 6months, lower calcium levels at 6 and 12months, and lower hemoglobin at 12months and otherwise equivalent (all p < 0.05). Revision was rare (1 DS; 0 RYGB). There were no differences in short-term complications (p = 0.28). DS with a moderate common channel length is safe with a low revision rate. Weight loss and nutritional outcomes appear to be comparable to RYGB, and it may be considered an effective RYGB alternative.

Factors predicting the need for vaginal replacement at the time of primary reconstruction of a cloacal malformation

BackgroundA subset of patients with cloacal malformations requires vaginal replacement during their primary reconstruction, increasing the surgical complexity. Identifying factors which predict the need for vaginal replacement would facilitate operative planning. MethodsWe retrospectively reviewed patients who underwent primary cloacal reconstruction at our Center (2014–2018) and assessed the length of the common channel, urethra, and vagina. The presence of hydrocolpos at birth, Müllerian anomalies, sacral ratio, and tethered cord were also assessed between patients who did and did not require vaginal replacement. Results50 patients were identified. 17/50 patients (34%) underwent a total urogenital mobilization (TUM), and none required vaginal replacement. 33/50 (66%) patients underwent a urogenital separation. 19/33 (58%) required vaginal replacement. This group had a shorter vagina (4.2 cm vs 6.6 cm, p < 0.01). There was no difference in urethral or common channel length, number of cervices, sacral ratio, presence of a vaginal septum, hydrocolpos, or tethered cord between those who did and those who did not require vaginal replacement. ConclusionsUrethral and common channel lengths were used to successfully determine the operative plan (TUM or urogenital separation) to reconstruct cloacal malformations. The need for urogenital separation and a shorter vaginal length were predictive of the need for vaginal replacement. Level of evidenceLevel IV. Type of studyCase series with no comparison groups.

1331 Choledochal Cyst in an Adult Female

INTRODUCTION: The incidence of biliary cyst (BC) is 1:100,00 to 150,000 making it a rare medical condition. BC are most commonly diagnosed in the pediatric population but can occasionally present in adults. A multi-disciplinary team approach including a gastroenterologist and a hepatobiliary surgeon is ideal in treating patients with this diagnosis. CASE DESCRIPTION/METHODS: We present a case of a 38-year-old female with past medical history significant for gastroesophageal reflex disease and migraine who was admitted for evaluation of worsening epigastric pain. Patient was noted to be one week after a total abdominal hysterectomy with bilateral salpingo-oophorectomy. A comprehensive metabolic panel was ordered on admission displaying liver chemistries elevated with AST of 258 IU/L (Ref: 9-45 IU/L), ALT of 260 IU/L (Ref: 17-63 IU/L), alkaline phosphatase of 230 IU/L (45-117 IU/L) and total bilirubin of 3.2 mg/dl (Ref: 0.2-1.0 mg/dl). The patient obtained a RUQUS, which did not show any gallbladder stones or sludge. Patient was still having pain throughout her admission, so a magnetic resonance cholangio-pancreatography (MRCP) was ordered for further evaluation. The MRCP revealed a fusiform dilation of proximal half of the common bile duct (CBD) with a diameter of 15 mm and normal intrahepatic ducts. The pancreatic duct could not be visualized on MRCP and hence unable to comment on length of common channel. There was no evidence of stone or stricture in the CBD. At this point, the patient was diagnosed with Type I choledochal cyst. Patient then underwent a laparoscopic extrahepatic bile duct excision with Roux-en-Y hepatico-jejunostomy and cholecystectomy. On follow up evaluation, the patient had been doing well with normal liver chemistries. DISCUSSION: Although rare, choledochal cysts can cause many complications and need to be treated as soon as possible. These complications are due to bile stasis and/or reflux of pancreatic enzymes into the CBD resulting in recurrent cholangitis and other problems including CBD strictures, rupture, stones and secondary biliary cirrhosis. Additionally, there is an overall 10-30% risk for cholangiocarcinoma in patient's with this diagnosis. This case is a good example of successful treatment of a choledochal cyst in a young female.

Short- and Long-Term Outcomes of Duodenal Switch with a Moderate Common Channel Length

Short- and Long-Term Outcomes of Duodenal Switch with a Moderate Common Channel Length

Proximal Roux-en-Y gastric bypass: Addressing the myth of limb length

BackgroundSome studies suggest that changes in weight or metabolic outcomes are affected by the lengths of the gastrointestinal limbs in the Roux-en-Y gastric bypass. MethodsParticipants (N = 1,770) underwent primary Roux-en-Y gastric bypass and were followed ≤7 years in the Longitudinal Assessment of Bariatric Surgery-2, a multicenter US cohort study. Alimentary limb and biliopancreatic limb lengths were measured according to research protocol; common channel was measured in a subsample (N = 547). Aimentary limb, biliopancreatic limb, and common channel ratio to total small bowel length were calculated. ResultsMedian presurgery body mass index was 46 (25th–75th percentile: 43–51) kg/m2. Medians (25th–75th percentiles) for alimentary limb length were 125 cm (100–150), for biliopancreatic limb length were 50 cm (50–60), and common channel length were 410 cm (322–520). Statistics for ratios to the small bowel length were 0.23 (0.18–0.27) for alimentary limb, 0.09 (0.07–0.10) for biliopancreatic limb, and 0.69 (0.63–0.73) for common length. There were no significant associations between alimentary limb, biliopancreatic limb, common channel, alimentary limb ratio, biliopancreatic limb ratio or common channel ratio, and either weight loss or improvement in cardiometabolic outcomes. ConclusionThe common channel length in Roux-en-Y gastric bypass is highly variable between individuals. None of the limb lengths in this study, nor alimentary limb, biliopancreatic limb, or common channel ratios, seem to be related to weight loss or metabolic improvements >7 years.

Cloacal Malformations: Technical Aspects of the Reconstruction and Factors Which Predict Surgical Complexity.

Cloacal malformations are rare anomalies which occur in one in 50,000 live births. Anatomically these anomalies are defined by the presence of a single perineal orifice. There is however a substantial range in their complexity. Defining these differences is key to surgical planning and timely referral of selected cases to centers with the capabilities to manage the most challenging cases. Traditionally the common channel length as measured during cysto-vaginoscopy has been used to differentiate between patients that can be repaired with a reproducible operation and those requiring a more complex repair. The quality and range of imaging available has advanced and thus a more detailed anatomic picture is now possible to help with pre-operative planning. Cross sectional imaging with 3D reconstruction has enhanced the understanding of the anatomic variations in these patients. In addition, the sacral ratio, previously thought to only have an influence on long term continence predictions, has been shown to not only forecast the presence of urological anomalies, but also the complexity of the malformation. In principle, cloacal malformations have two major components to the reconstruction. First, the rectum needs to be separated from the urogenital tract and second, the urogenital sinus needs to be managed to create a urethral orifice and vaginal introitus. The length of the urethra has been shown to be vital in deciding between the two main surgical maneuvers; a total urogenital mobilization (TUM) and a urogenital separation. The technical demands of a urogenital separation are significant and discussed here in detail. The need for vaginal replacement adds further complexity to the care of these patients and has also been shown to be related to the length of the urethra. Predicting complexity in an accurate and non-invasive way will facilitate the care of the most complex cloacal malformations and improve outcomes.

63 – Nutritional Deficiencies and Outcomes After Duodenal Switch with a Moderate Common Channel Length and Standard Roux-En-Y Gastric Bypass: Does One Pose More Risk?

63 – Nutritional Deficiencies and Outcomes After Duodenal Switch with a Moderate Common Channel Length and Standard Roux-En-Y Gastric Bypass: Does One Pose More Risk?

The use of rotational fluoroscopy and 3-D reconstruction in the diagnosis and surgical planning for complex cloacal malformations

IntroductionCloacal malformations, a confluence of the urinary tract, vagina and rectum into a single common channel, has a broad and complex anatomic spectrum requiring an imaging tool for visualization, measurement, and surgical planning for the reconstruction of these structures. We evaluated the role of 3-D fluoroscopy for this purpose, as it offers a combination of spatial correlation with precise anatomic measurements. MethodsWe examined our imaging protocol for patients with a cloacal malformation and report our experience with rotational fluoroscopy and 3-D reconstruction in 16 consecutive patients referred for cloacal reconstruction. The length of the common channel (CC), the length of the urethra from the bladder neck to the common channel, and the height (and existence or absence) of a vagina or vaginas were determinants of the surgical procedures used for the repair. ResultsWe performed 16 consecutive 3-D cloacagrams (age range 4 months to 9 years) using a new protocol (Figure 1) that provided the following data which helped with surgical planning: Gynecologic: 3 cases with a single vagina, 5 cases with a duplicated Mullerian system (3 of which were asymmetric) and 2 cases with high vaginas requiring vaginal replacement. Colorectal: Four had a high rectum requiring an abdominal approach, and 6 had a rectum reachable via a posterior sagittal approach. Urologic: Two ectopic ureters requiring reimplantation, 3 patients had vesicoureteral reflux (1 bilateral, 2 unilateral), 1 patient had no bladder, and 7 had a normal sized bladder. Common channel length and urethral length were demonstrated in all cases and used to decide between a total urogenital mobilization or a separation of vagina(s) from the common channel, urogenital separation. ConclusionThe 3-D cloacagram can help predict the surgical plan for urologic, gynecologic, and colorectal components of the cloacal repair. It can predict the CC length as well as the length of the urethra. It helps with predicting the need for vaginal replacement and whether an abdominal approach is needed for the rectum. Its effectiveness is based on the ability to adequately distend structures and see their distal most extent, an advantage over other modalities such as MRI. Added benefits (particularly from the 3D view) include a better spatial understanding of the defect and the diagnosis of concomitant urological abnormalities such as vesicoureteral reflux and ectopic ureters. Disadvantages to this procedure include the need for general anesthesia and a higher exposure to radiation. Level of evidence3.

A174 - Longer Common Channels In Duodenal Switch Improves Vitamin A Absorption And Albumin Levels, But Can Negatively Impact Weight Loss In The Super Obese Patient: Implications For The Single Anastomosis Duodenal Switch

Background: The impact of common channel (CC) length on vitamin absorption, albumin levels, and overall weight loss is not fully known.